CHIPRA Express Lane Eligibility Evaluation
ELE Program Case Study Site Visit
State Medicaid/CHIP Program Officials - Key Informant Protocol
Thanks very much for agreeing to meet with us. We have been funded by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (HHS) to conduct a national evaluation of the new state policy option under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for health coverage, despite programs’ different methods of assessing income or otherwise determining eligibility.
This Congressionally Mandated Evaluation of ELE is composed of four components: monitoring state programs and policy; analysis of ELE impacts on enrollment; a descriptive study of costs, enrollment, and utilization; and case studies of states that have adopted ELE or other approaches to streamlining enrollment and/or retention. We’re here as part of this latter qualitative/case study component of the project, which involves site visits to the following states that have implemented ELE— Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina.
While we’re here onsite, we will gather information from a broad range of key informants. At the state level, we are meeting with officials responsible for administering CHIP and Medicaid, Express Lane partner agencies, policy makers such as key legislative staff, and family and child advocates, among others. At the local level, we will meet with such informants as: county social service administrators, frontline eligibility workers, local offices for Express Lane agencies, and community-based organizations involved with outreach and application assistance. We will also be conducting two focus groups in each state with parents of children who enrolled or renewed coverage via ELE.
During these interviews, we will discuss a wide range of issues including: the broader eligibility policy features of your state’s Medicaid and CHIP programs; the process your state went through to consider and develop ELE policy; ELE implementation; outcomes of ELE related to enrollment, retention, and access to care; and the role that ELE may play in your state’s implementation of federal health reform coverage expansions under the Affordable Care Act.
Information gathered during our site visit will be used in a series of state-specific case study reports, as well as a final cross-cutting Report to Congress that will synthesize findings from across the study states. Importantly, none of the information you share with us today will be quoted without your permission. We’ll be taking notes during our discussion, but if it’s okay with you we would also like to record this interview, as a backup to those notes.
Do you have any questions?
Do we have your consent to proceed with our interview?
Do we have your permission to record?
BACKGROUND AND OVERVIEW
To start with, please give us some background information on your agency/organization and tell us about the role you play in the Medicaid and CHIP programs.
Probes:
How long have you worked at this agency/organization?
What are your current responsibilities?
MEDICAID AND CHIP PROGRAM FEATURES
[Note to reviewers: we will have an extensive set of background materials from other data collection efforts, including this project’s 51 state survey and first set of quarterly calls that will both be fielded prior to this, as well as from other publicly available sources such as the Kaiser Family Foundation and the CHIP annual reports, among others. Any data and/or program characteristics that we have will be summarized and shared with state officials prior to our site visits, so that we won’t need to burden them unnecessary questions during our interviews. For example, much of the information sought in sections II.A. and II.B. below may be known in advance of our case studies and thus may not have to be collected during our visits. ]
Before we begin talking about Express Lane Eligibility, I want to be sure we have a good understanding of broader Medicaid/CHIP policies related to enrollment, retention, and outreach. My next set of questions explores that context.
Enrollment
Putting ELE to the side for the moment, can you summarize for us some of the basic characteristics of your state’s enrollment process, and the various ways in which parents can enroll their children in Medicaid and CHIP?
What is the application like? How long is it? Can families apply for coverage together on the same application? Is there a joint Medicaid/CHIP application? Is there a joint application for medical and human services (TANF, SNAP) programs?
What kinds of verification do you require as part of the application (income, assets, age, residency, identity)?
Can parents apply online? How does that work exactly: do parents have to print the application out and mail it, or can they file it online? If they can submit it online, does other data need to be sent by mail (income documents, for example)?
Can applications be submitted by mail or over the phone? By fax?
Is a face-to-face interview with an eligibility worker required?
Is community-based application assistance provided? How? Where? Can you describe this process
Do providers or health plans help enroll consumers? If so, how?
What steps has your state taken to simplify or streamline enrollment into Medicaid and CHIP for children?
Have you eliminated the assets test from the application?
Have you reduced or eliminated any other verification requirements?
Do you conduct administrative verification of income or other information (through data matches)?
Do you have presumptive eligibility for children? What types of providers or organizations are permitted to conduct presumptive eligibility? How does the follow up process work for getting individuals enrolled?
Do you have 12-month continuous eligibility?
Are there other simplification strategies we should know about?
Did your state qualify for a CHIPRA “performance bonus” by adopting at least five qualifying simplification strategies, and meeting enrollment targets? How did you qualify (which strategies), and how much was your bonus?
Please highlight for us any key difference between the Medicaid and CHIP applications or enrollment policies/procedures.
B. Renewal
Let’s turn to eligibility redetermination, or renewal. Can you tell us about how families renew coverage for their children?
How is the family informed that they need to renew their child’s coverage?
What form, if any, is required to be completed? Is a signature required?
Does a parent need to meet, face to face, with anyone?
Can the process be completed online, or by phone, or through the mail? [obtain a yes/no for each issue in this question]
What verification, if any, needs to be submitted?
Is community-based application assistance provided for renewals? How? Where? Can you describe this process?
What would you highlight as the most important renewal simplifications that your state has implemented under Medicaid and CHIP?
Do you pre-print forms with information already in the system?
Is renewal “passive” (i.e., are children renewed if you don’t receive changed/updated information from families)?
Do you conduct administrative and/or ex parte renewal (i.e., when states use other data available to them, such as wage or labor records, to determine if a child is still eligible for the program)?
Do you allow “rolling” renewals (i.e., any time a family updates their information, the state automatically extends their coverage forward for an additional set of months, up to 12 months) ?
Anything else?
Once again, please highlight for us any key differences between the Medicaid and CHIP renewal processes.
C. Outreach
With regard to outreach and public education:
Please provide an overview of your outreach and education activities. Where do you focus most of your efforts (in terms of dollars)? (For example, do you concentrate resources on state-level outreach, or community-based outreach?) Which special populations (if any) do you focus on?
Has your state engaged in any large scale, statewide media campaigns to publicize the availability of coverage for children? How recently? Was there any particular focus on simplified procedures for applying?
Does your state support any notable community-based outreach strategies, such as application assistance or grants to CBOs to support outreach and enrollment assistance? If so, what types of organizations are involved? Are providers, health plans, or school-based clinics involved?
Did your state receive any CHIPRA outreach grants, or other federal grants to support outreach for children’s coverage? If so, please describe.
Which outreach strategies have you found to be most effective? How have you assessed or measured this?
How has outreach in your state been affected by funding uncertainties?
EXPRESS LANE ELIGIBILITY
The remainder of our questions are about the specifics of Express Lane Eligibility. We begin with questions related to your state’s decision to adopt ELE. We continue with questions about the “nuts and bolts” operations of ELE. We then turn to any evidence you may have regarding the impacts of ELE on enrollment, retention, access to care, and administrative costs.
A. ELE Policy Development
Why did your state decide to implement ELE? What were your original goals in adopting ELE? Have these changed at all?
Were CHIPRA bonuses an incentive to implement ELE?
Where did the support for adopting this simplified approach come from – the Governor’s office, legislature, advocacy community, other?
Did you rely on/learn from the experiences of other states that had implemented ELE? Which ones?
Do you use ELE to determine initial eligibility, renewal eligibility, or both? What were the various factors that played into that decision? What aspect of eligibility does ELE determine (ELE can be used for any factor except citizenship; aspects could include income, age, etc.)?
What benefits or advantages did this option add to your system, above and beyond the strategies we’ve already discussed?
Did you need new state-level statutory authority to adopt ELE?
How was adoption of ELE framed in terms of your agency’s budget (i.e., budget-neutral, costly but advantageous, or money-saving)? Has this proven to be true?
How easy or difficult was it to gain federal approval from CMS for your state plan amendment?
What was the timeline for ELE design and implementation? Did it take more, or less, time than you anticipated?
Were there any particular factors that facilitated your adoption of ELE? Conversely, were there any particular obstacles or challenges that you had to overcome?
Did you have any concerns or worries about ELE and, if so, how did you address them?
B. ELE Implementation and Operations
Who is your partner organization (or organizations, if more than one) for ELE? How did you select this agency/agencies as your partner(s)? Please describe for us the conversations you had with this agency/agencies when planning ELE.
(If more than one other agency partner, ask probes below for each agency involved.)
What was the partner agency’s initial attitude toward ELE? Were they immediately in favor of adopting ELE, or did they have concerns?
If there were concerns, were these about the administrative resources required for policy development? For IT? For the effort that would be demanded of local social services staff? Were there any legal issues or concerns they had?
How did you address these concerns?
Did they see any advantages of ELE, from their perspective?
How did you secure their cooperation?
What approval did this agency need before proceeding?
Please tell us, in detail, how the mechanics of ELE work in your state. [Note, we will have detail from the cost and enrollment study underway already in 6 of the ELE states to build on in this section.]
What population(s) do you target with ELE? Does the child need to have been “known” to Medicaid/CHIP previously? (In other words, previously enrolled in or previously applied to programs?)
How do you match Partner Agency records with those of Medicaid/CHIP? How complex has that been to accomplish? How do you avoid duplicate enrollment?
Do parents have to give permission to the agency to share these records (for example, by “checking” a box, or otherwise indicating that they would like to have their information shared)? Do parents need to “opt in” or “opt out” of the system used to authorize data matching?
Are matches performed automatically by the agencies’ systems, or do you sometimes have to perform manual matches/reviews? Why? How often is a manual review involved?
How do you inform families that their child has been found eligible for health coverage through ELE?
Do families have to “do” anything to consent to this coverage? What constitutes “affirmative consent” in your program?
How and when does a family receive a Medicaid/CHIP card demonstrating their enrollment?
What information is shared with families to help them identify a primary care provider for their child, or a health plan in which to enroll their child?
What systems do you have to monitor whether or not a family has enrolled their child in a health plan, or with a PCP?
Beyond the ELE process, are other data matches performed as well during eligibility or renewal determination, for example, with citizenship or third-party-liability databases?
Has the process always been this way, or has it evolved since implementation?
What are the major differences between the Express Lane Agency’s eligibility methodologies and the normal Medicaid/CHIP methodologies?
Any differences in household composition?
How income is defined?
What deductions or disregards apply?
The relevant time period for determining eligibility?
Any differences in what families need to attest to? Any differences in what families need to document?
Any other differences we have not mentioned?
Have these differences, if any, posed challenges for state policy development? For local social services offices? Have they created any concerns about program integrity
Let’s turn to renewal (if applicable). Please tell us, in detail, how the mechanics of ELE renewal work in your state.
Do you use ELE to renew all Medicaid/CHIP recipients, regardless of how they originally enrolled? Or only those who enrolled, initially, through ELE?
If both, do the procedures for how ELE is used to renew coverage differ?
What data matching, consent, and follow-up communications with families occur under ELE renewal?
We imagine that adoption and implementation of ELE must have involved a significant “culture change” among both state and local officials.
Would you agree with that observation? If so, how did that change in mindset come about?
Did state officials do anything in particular to prepare local officials for this change?
What feedback have you received from local officials?
Did your state conduct any broad outreach or public education effort related to the implementation of ELE (to inform families receiving, for example, SNAP that they could now be automatically enrolled in Medicaid/CHIP)? Please describe.
If needed (if not already obtained through the cost and enrollment study in 6 ELE states, but will not have been collected yet in Georgia & South Carolina): What kind of staff and financial investment did ELE design and implementation require? How did your state cover these costs?
What staffing or organizational changes were required? Describe the type and level of effort for those changes.
Did you have to train/re-train staff? How many and what types of staff were trained?
How did the systems and processes change in your agency? Describe the type and level of effort for those changes.
What IT or Data system changes were required from your department in order to implement ELE?
Did your state receive any technical assistance in designing and implementing ELE? (For example, from the MaxEnroll program?) Please describe.
C. Outcomes of ELE Program
Let’s turn to some of the various outcomes that you may have experienced as a result of ELE implementation. Have you evaluated your ELE program? If so, are there findings you can share with us? Are you planning any future evaluation activities?
Can you differentiate ELE enrollees from non-ELE enrollees in your systems (i.e., can you identify those who came in through the ELE path in your data)?
If so, how many children have been enrolled into Medicaid/CHIP via ELE since the initiative was launched?
What proportion of all children enrolled during this period does this represent?
Is this higher, or lower, than expected?
Do you know, among ELE enrollees, the number and percentage who subsequently renewed at the renewal period? Is their pattern of renewal similar/different than other enrollees? If so, how so?
How would you characterize these ELE enrollees? Do they differ, demographically, than other children in the program? How so?
How many children have renewed Medicaid/CHIP coverage via ELE since the initiative was launched?
What proportion of all children renewed during this period does this represent?
Is this higher, or lower, than expected?
What is the retention rate of ELE enrollees vs. other enrollees? Do you see evidence that ELE improves retention rates?
Do you track service utilization rates for ELE enrollees, separate from all other enrollees? If so, what does the utilization profile of these children look like?
Do ELE enrollees use the same types and amounts of services as the general population of enrollees?
Or, do the data indicate any cause for concern? For example, if utilization rates are low, might this indicate that enrollees/families may not understand that they have coverage? Or could it mean that they are not being connected with health plans or PCPs?
Have you calculated whether or not ELE is resulting in administrative savings to your program?
Can you tell us the ‘per case’ cost of traditional eligibility determination, versus ELE determination?
Can you tell us the ‘per case’ cost of traditional eligibility renewal, versus ELE renewal?
What feedback have you received from clients? From community groups? From other stakeholders?
Have you done any program integrity reviews of ELE? If so, what have you learned from any program integrity reviews you’ve done?
Are there any other outcomes of ELE that we haven’t talked about? If so, what are they?
D. Role of ELE under Health Care Reform
Will ELE policies or processes change in any way as a result of the implementation of health care reform?
Will new enrollment systems cause ELE for children to change or go away?
Will ELE-like enrollment systems be extended to new populations under reform (for example, adults receiving SNAP who will now gain coverage under Medicaid?)?
Do you think that, by designing and implementing ELE, you’re any better prepared to launch automated enrollment systems (for Medicaid or the Health Insurance Exchange) under reform?
How so? Did practice gained from developing new data matching algorithms help you design new data-driven eligibility systems under reform?
Have Medicaid/CHIP and ELE partner agencies had to work together to implement the Affordable Care Act, and did the ELE effort help prepare for this collaboration?
To what extent are the changes you made because of ELE changes that you would have needed to make any way to prepare for implementation of the Affordable Care Act
What lessons from your experience with ELE do you think could be helpful to national and state policymakers involved in implementing the Affordable Care Act?
IV. LESSONS LEARNED
What would you say are the most important lessons that you have learned by adopting, designing, and implementing ELE?
What worked well in implementing ELE? What were the best planning or policy decisions that your state made?
Given what you know now, what would you have done differently?
What would you tell policymakers in other states who are considering ELE?
What do you see as the biggest advantages and disadvantages of adopting ELE?
Would you recommend any changes in the federal government’s rules for ELE? Have any particular federal policies posed a challenge?
CHIPRA Express Lane Eligibility Evaluation
ELE Program Case Study Site Visit
High Level Policymakers - Key Informant Protocol
Thanks very much for agreeing to meet with us. We have been funded by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (HHS) to conduct a national evaluation of the new state policy option under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for health coverage, despite programs’ different methods of assessing income or otherwise determining eligibility.
This Congressionally Mandated Evaluation of ELE is composed of four components: monitoring state programs and policy; analysis of ELE impacts on enrollment; a descriptive study of costs, enrollment, and utilization; and case studies of states that have adopted ELE or other approaches to streamlining enrollment and/or retention. We’re here as part of this final qualitative/case study component of the project, which involves site visits to the following states that have implemented ELE— Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina.
While we’re here onsite, we will gather information from a broad range of key informants. At the state level, we are meeting with officials responsible for administering CHIP and Medicaid, Express Lane partner agencies, key legislative staff, and family and child advocates, among others. At the local level, we will meet with such informants as: county social service administrators, frontline eligibility workers, local offices for Express Lane agencies, and community-based organizations involved with outreach and application assistance. We will also be conducting two focus groups in each state with parents of children who enrolled or renewed coverage via ELE.
During these interviews, we will discuss a wide range of issues including: the broader eligibility policy features of your state’s Medicaid and CHIP programs; the process your state went through to consider and develop ELE policy; ELE implementation, outcomes of ELE related to enrollment, retention, and access to care; and the role that ELE may play in your state’s implementation of federal health reform coverage expansions under the Affordable Care Act.
Information gathered during our site visit will be used in a series of state-specific case study reports, as well as a final cross-cutting Report to Congress that will synthesize findings from across the study states. Importantly, none of the information you share with us today will be quoted without your permission. We’ll be taking notes during our discussion, but if it’s okay with you we would also like to record this interview, as a backup to those notes.
Do you have any questions?
Do we have your consent to proceed with our interview?
Do we have your permission to record?
BACKGROUND AND OVERVIEW
To start with, please tell us a little bit about yourself and your relationship to your state’s Medicaid and CHIP programs.
Probes:
How familiar are you with the state’s Express Lane Eligibility program for Medicaid/CHIP? What does ELE mean to you?
What has been your role in adopting or implementing ELE?
MEDICAID AND CHIP ELIGIBILITY AND ENROLLMENT - GENERAL
Before we begin talking about Express Lane Eligibility, I want to get a sense of your state’s approach to Medicaid/CHIP policies related to enrollment, retention, and outreach. My next set of questions explores that context.
Putting ELE to the side for the moment, can you summarize your state’s overall approach to Medicaid and CHIP enrollment and renewal processes? Has the state actively pursued ways to simplify or streamline enrollment into Medicaid and CHIP for children? How has it done this?
Is there support for simplifying and streamlining Medicaid and CHIP enrollment for children among state policymakers? Has there been any opposition to simplification or streamlining efforts? Please describe.
Are the Medicaid and CHIP enrollment, or renewal policies/procedures different at all? How?
How would you characterize your state’s approach to outreach for and public education about Medicaid and CHIP coverage? Is there support among policymakers for outreach and public education?
Are you aware of any large scale, statewide media campaigns to publicize the availability of coverage for children? How recently?
Are you aware of any community-based outreach strategies, such as application assistance or grants to community-based organizations to support outreach and enrollment assistance?
Did your state receive any CHIPRA outreach grants, or other federal grants to support outreach for children’s coverage? If so, please describe.
EXPRESS LANE ELIGIBILITY
The remainder of our questions are specifically about Express Lane Eligibility. We begin with questions related to your state’s decision to adopt ELE. We then turn to any evidence you may have regarding the impacts of ELE on enrollment, retention, access to care, and administrative costs.
A. ELE Policy Development
Why did your state decide to implement ELE? What were the state’s original goals in adopting ELE? Have those goals changed at all?
Were CHIPRA bonuses an incentive to implement ELE?
Did the state rely on/learn from the experiences of other states that had implemented ELE? Which ones?
What did this option add to your state’s system, above and beyond the strategies we’ve already discussed?
Did policymakers consider other simplification routes vis a vis ELE? If so, which other routes? Were any implemented?
What was the timeline for ELE design and implementation? Did it take more, or less, time than you anticipated?
Were you involved in the ELE design process (e.g., selecting the partner agency for the ELE effort, or deciding whether to use ELE for initial eligibility determination, renewals, or both)? What factors influenced the decisions about ELE design?
Were there any particular factors that facilitated the state’s adoption of ELE? Conversely, were there any particular obstacles or challenges it has had to overcome?
Did policymakers have any concerns or worries about ELE and, if so, how did you address them?
Were there concerns about ELE effects on the state budget? Or on program integrity?
Were there any concerns about issues related to consent (i.e., parents having to authorize the sharing of eligibility information across Medicaid/CHIP and the ELE partner agency)? How were these addressed?
Was state statutory authority required to adopt ELE? What was this process of authorizing the option like—did it go smoothly or was it challenging?
How easy or difficult was it to gain federal approval from CMS for your state plan amendment?
We imagine that adoption and implementation of ELE must have involved a significant “culture change” among both state and local officials.
Would you agree with that observation? If so, how did that change in mindset come about?
Did state officials do anything in particular to prepare local officials for this change?
What kind of staff and financial investment did ELE design and implementation require? How did your state cover these costs?
B. Outcomes of ELE Program
Let’s turn to some of the various outcomes that you may have experienced as a result of ELE implementation. First, how would you define a successful ELE program?
Has the state evaluated its ELE program?
Overall, how do you think the ELE program has been performing since it was implemented? How do you get information about ELE performance?
How many children have been enrolled into Medicaid/CHIP via ELE since the initiative was launched? Is this higher, or lower, than expected?
Do you have any sense of whether ELE enrollees differ, demographically, from other children in the program? How so?
How many children have renewed Medicaid/CHIP coverage via ELE since the initiative was launched? Is this higher, or lower, than expected?
Do you see evidence that ELE improves retention rates?
Has the state examined service utilization rates for ELE enrollees, separate from all other enrollees? If so, what does the utilization profile of these children look like?
Has the state calculated whether or not ELE is resulting in administrative savings to Medicaid and CHIP?
Can you tell us the ‘per case’ cost of traditional eligibility determination, versus ELE determination?
Can you tell us the ‘per case’ cost of traditional eligibility renewal, versus ELE renewal?
Are there any other outcomes of ELE that we haven’t talk about?
C. Role of ELE under Health Care Reform
Will ELE policies or processes change in any way as a result of the implementation of health care reform?
Will new enrollment systems cause ELE for children to change or go away?
Will ELE-like enrollment systems be extended to new populations under reform (for example, single adults receiving SNAP who will now gain coverage under Medicaid?)?
Do you think that, by designing and implementing ELE, the state is any better prepared to launch automated enrollment systems (for Medicaid or the Health Insurance Exchange) under reform?
How so? Did practice gained from developing new data matching algorithms help you design new data-driven eligibility systems under reform?
Have Medicaid/CHIP and ELE partner agencies had to work together to implement the AFFORDABLE CARE ACT, and did the ELE effort help prepare for this collaboration?
Has having the ELE option had any influence (positive or negative) on state policymakers’ support for other simplification and streamlining efforts, including those required and/or authorized by the AFFORDABLE CARE ACT?
IV. LESSONS LEARNED
What would you say are the most important lessons that the state has learned by adopting, designing, and implementing ELE?
What worked well in implementing ELE? What were the best planning or policy decisions that your state made?
Given what you know now, what would you have done differently?
What would you tell policymakers in other states who are considering ELE?
What do you see as the biggest advantages and disadvantages of adopting ELE?
What lessons from your experience with ELE do you think could be helpful to national and state policymakers involved in implementing the Affordable Care Act?
CHIPRA Express Lane Eligibility Evaluation
ELE Program Case Study Site Visit
ELE Partner Agency (Non-Tax Agencies) Key Informant Protocol
Thanks very much for agreeing to meet with us. We have been funded by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (HHS) to conduct a national evaluation of the new state policy option under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for health coverage, despite programs’ different methods of assessing income or otherwise determining eligibility.
This Congressionally Mandated Evaluation of ELE is composed of four components: monitoring state programs and policy; analysis of ELE impacts on enrollment; a descriptive study of costs, enrollment, and utilization; and case studies of states that have adopted ELE or other approaches to streamlining enrollment and/or retention. We’re here as part of this latter qualitative/case study component of the project, which involves site visits to the following states that have implemented ELE— Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina.
While we’re here onsite, we will gather information from a broad range of key informants. At the state level, we are meeting with officials responsible for administering CHIP and Medicaid, Express Lane partner agencies, policy makers such as key legislative staff, and family and child advocates, among others. At the local level, we will meet with such informants as: county social service administrators, frontline eligibility workers, local offices for Express Lane agencies, and community-based organizations involved with outreach and application assistance. We will also be conducting two focus groups in each state with parents of children who enrolled or renewed coverage via ELE.
During these interviews, we will discuss a wide range of issues including: the broader eligibility policy features of your state’s Medicaid and CHIP programs; the process your state went through to consider and develop ELE policy; ELE implementation; outcomes of ELE related to enrollment, retention, and access to care; and the role that ELE may play in your state’s implementation of federal health reform coverage expansions under the Affordable Care Act.
Information gathered during our site visit will be used in a series of state-specific case study reports, as well as a final cross-cutting Report to Congress that will synthesize findings from across the study states. Importantly, none of the information you share with us today will be quoted without your permission. We’ll be taking notes during our discussion, but if it’s okay with you we would also like to record this interview, as a backup to those notes.
Do you have any questions?
Do we have your consent to proceed with our interview?
Do we have your permission to record?
BACKGROUND AND OVERVIEW
To start with, please give us some background information on your agency/organization and your role within that agency.
Probes:
How long have you worked at this agency/organization?
What are your current responsibilities?
PARTNER AGENCY PROGRAM FEATURES
Before we begin talking about Express Lane Eligibility, I want to be sure we have a good understanding of broader policies related to [SNAP, free and reduced school lunch, etc., whichever area the agency focuses on] enrollment, retention, and outreach. My next set of questions explores that context.
Enrollment
Putting ELE to the side for the moment, can you summarize for us some of the basic characteristics of the enrollment process for your program, and the various ways in which parents can enroll their children in [SNAP, free and reduced school lunch, etc.]
What is the application like? How long is it? Is there a joint application for medical and human services programs in your state?
What kinds of verification do you require as part of the application (income, assets, age, residency, identity)?
Do you use any form of data matching to verify citizenship or income eligibility? To verify any other eligibility factors?
Can parents apply online? How does that work exactly: do parents have to print the application out and mail it, or can they file it online? If they can submit it online, does other data need to be sent by mail (income documents, for example)?
Can applications be submitted by mail or over the phone? By fax?
Is a face-to-face interview with an eligibility worker required? If so, how long does that interview typically take?
Is community-based application assistance provided? How? Where? How is it funded?
Have there been any recent efforts to streamline the enrollment process in your agency? If so, please describe.
B. Renewal
Let’s turn to eligibility redetermination, or renewal. Can you tell us about how families renew or maintain their eligibility for this benefit?
How is the family informed that they need to renew their child’s coverage?
What form, if any, is required to be completed?
Does a parent need to meet, face to face, with anyone? Or can the process be completed online, or by phone, or through the mail? [obtain a yes/no for each issue in this question]
What verification, if any, needs to be submitted?
Is community-based application assistance provided for renewal? How? Where? Can you describe this process? How is it funded?
Do you conduct data matches to establish eligibility automatically, without requesting information from the family? Have you taken other steps to streamline the renewal process?
C. Outreach
With regard to outreach and public education:
Has your state engaged in any large scale, statewide media campaigns to publicize the availability of [SNAP, free and reduced lunch program, etc.] for children? How recently?
Does your state support any community-based outreach strategies, such as application assistance or grants to CBOs to support outreach and enrollment assistance?
EXPRESS LANE ELIGIBILITY
The remainder of our questions focus on your agency’s role in the implementation of Express Lane Eligibility for CHIP. We begin with questions related to your state’s decision to adopt ELE and your agency’s role in this decision. We continue with questions about the “nuts and bolts” operations of ELE, and any changes that may have affected your agency’s operations. We then turn to any evidence you may have regarding the impacts of ELE on enrollment, retention, access to care, and administrative costs.
A. ELE Policy Development
Why did your state decide to implement ELE? What were the original goals in adopting ELE? Have these changed at all?
How involved was your agency in the decision to implement ELE? To what extent/in what capacity?
Where did the support for adopting this simplified approach come from – the Governor’s office, legislature, advocacy community, other?
Did you rely on/learn from the experiences of other states that had implemented ELE? Which ones?
Did you have any concerns or worries about ELE and, if so, how were they addressed?
Do you use ELE in your state to determine initial eligibility, renewal eligibility, or both? What were the various factors that played into that decision?
Did this option add any advantages or benefits to your system? If so, what were they?
Did you need statutory authority to adopt ELE?
Who covered your costs to implement ELE– your budget, or the Medicaid/CHIP agency? How significant were those costs?
How was adoption of ELE framed in terms of your agency’s budget (i.e., budget-neutral, costly but advantageous, or money-saving)? Has this proven to be true?
What was the timeline for ELE design and implementation? Did it take more, or less, time than you anticipated?
Were there any particular factors that facilitated your adoption of ELE? Conversely, were there any particular obstacles or challenges that you had to overcome?
Did you have any concerns or worries about ELE and, if so, how did you or others address them?
B. ELE Implementation and Operations
Please describe for us the conversations you had with CHIP/MEDICAID officials when planning for ELE. What approval did your agency need before proceeding?
How did this option change your systems and procedures, above and beyond the strategies we’ve already discussed?
Please walk us through the new process. How has implementation of ELE in your state affected your agency’s enrollment and renewal processes?
Did you need to modify your agency’s application?
Have you held any staff training to promote understanding of new processes?
Have you put into place any sort of monitoring or quality assurance checks to ensure that processes are working appropriately?
Do families have to “do” anything to consent to the data sharing that occurs under ELE? (What constitutes “affirmative consent” in your program?) Do parents opt “in” or “out” to consent to participate?
When are data matches performed automatically by the agencies’ systems? When do you or others have to perform manual matches/reviews?
Does ELE matching happen at initial enrollment and at renewal?
How did the initial ELE enrollment process unfold?
Was the transition smooth? What enabled this?
Were there bumps along the way?
What are some of examples of challenges encountered? How were they addressed?
Has the ELE process evolved since implementation?
Did ELE adoption and implementation require any notable change in your agency’s “culture”?
If yes, can you describe these changes? How did these changes evolve?
Did your agency receive training or technical assistance to smooth the adoption of ELE and facilitate “culture” change?
Did your agency provide technical assistance or training to county-level agencies and staff to promote business process improvements?
Did your agency conduct any broad outreach or public education effort related to the implementation of ELE (to inform families that they could now be automatically enrolled in Medicaid/CHIP)? Please describe.
Did your agency conduct any community-based outreach or application assistance to help families through ELE?
C. Outcomes of ELE Program
Do you have a sense of how many children have been enrolled into Medicaid/CHIP via ELE since the initiative was launched?
Is this higher, or lower than expected?
Are ELE enrollees any different from your typical program enrollees? In other words, is ELE allowing your agency (in tandem with Medicaid/CHIP) to reach new populations that heretofore have not enrolled in health coverage?
Do you know this from discussions with Medicaid/CHIP partners, or does your program’s system track these data?
Have you heard feedback from your clients?
What are they saying about the process?
Are there any other outcomes of ELE that you would like to mention?
D. Role of ELE under Health Care Reform
Will ELE policies or processes change in any way as a result of the implementation of health care reform?
Will ELE-like enrollment systems be extended to new populations under reform (for example, adults receiving SNAP who will now gain coverage under Medicaid?)?
Have you discussed these issues with the state?
IV. LESSONS LEARNED
What would you say are the most important lessons that you have learned by adopting, designing, and implementing ELE?
What worked well in implementing ELE? What were the best planning or policy decisions that your state made?
How do you think this would work with other agencies or programs?
Given what you know now, what would you have done differently?
What would you tell policymakers in other states who are considering ELE?
What do you see as the biggest advantages and disadvantages of adopting ELE?
What would you tell federal policymakers who are considering whether to continue the ELE option and, if so, whether to change the federal rules?
What lessons from your experience with ELE do you think could be helpful to national and state policymakers involved in implementing the Affordable Care Act?
CHIPRA Express Lane Eligibility Evaluation
ELE Program Case Study Site Visit
ELE Tax Partner Agency – Key Informant Protocol
Thanks very much for agreeing to meet with us. We have been funded by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (HHS) to conduct a national evaluation of the new state policy option under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for health coverage, despite programs’ different methods of assessing income or otherwise determining eligibility.
This Congressionally Mandated Evaluation of ELE is composed of four components: monitoring state programs and policy; analysis of ELE impacts on enrollment; a descriptive study of costs, enrollment, and utilization; and case studies of states that have adopted ELE or other approaches to streamlining enrollment and/or retention. We’re here as part of this latter qualitative/case study component of the project, which involves site visits to the following states that have implemented ELE— Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina.
While we’re here onsite, we will gather information from a broad range of key informants. At the state level, we are meeting with officials responsible for administering CHIP and Medicaid, Express Lane partner agencies, policy makers such as key legislative staff, and family and child advocates, among others. At the local level, we will meet with such informants as: county social service administrators, frontline eligibility workers, local offices for Express Lane agencies, and community-based organizations involved with outreach and application assistance. We will also be conducting two focus groups in each state with parents of children who enrolled or renewed coverage via ELE.
During these interviews, we will discuss a wide range of issues including: the broader eligibility policy features of your state’s Medicaid and CHIP programs; the process your state went through to consider and develop ELE policy; ELE implementation; outcomes of ELE related to enrollment, retention, and access to care; and the role that ELE may play in your state’s implementation of federal health reform coverage expansions under the Affordable Care Act.
Information gathered during our site visit will be used in a series of state-specific case study reports, as well as a final cross-cutting Report to Congress that will synthesize findings from across the study states. Importantly, none of the information you share with us today will be quoted without your permission. We’ll be taking notes during our discussion, but if it’s okay with you we would also like to record this interview, as a backup to those notes.
Do you have any questions?
Do we have your consent to proceed with our interview?
Do we have your permission to record?
BACKGROUND AND OVERVIEW
To start with, please give us some background information on your agency/organization and your role within that agency.
Probes:
How long have you worked at this agency/organization?
What are your current responsibilities?
PARTNER AGENCY PROGRAM FEATURES
Before we begin talking about Express Lane Eligibility, I want to be sure we have a good understanding of broader issues policies related to state income taxation. My next set of questions explores that context.
Income tax returns
Putting ELE to the side for the moment, can you summarize for us some of the basic characteristics of income tax filing in your state?
What are state income tax forms like? As with federal income tax returns, do you have long and short forms, with supplemental forms to provide additional information? Are they all available on line?
How many taxpayers complete each of the various forms?
How is federal tax return information used in the state income tax filing process? What information comes to you from the federal system or federal forms, rather than the taxpayer’s filing of state income tax returns? How do you obtain federal tax return data? From the taxpayer or the IRS?
How are erroneous state income tax returns corrected? Are there any “up-front” checks (such as for math errors)? Are state tax returns cross-checked against information returns provided by employers, banks, etc.? When does that take place during the year? What process if followed?
Continuing to put ELE aside, in what other ways have state income tax forms changed in recent years? How costly are such changes to implement? What kind of lead time is typically required? What do you typically do to educate tax preparers and software vendors about those changes and other state income tax developments? Have you observed any impact of tax return form changes on taxpayer compliance with tax filing requirements? Do additional questions reduce the number of returns that are filed?
Tax filers
How, if at all, do the thresholds for required tax filing differ at the state and federal levels?
Does the state offer any refundable credits that might encourage low-income households to file returns? What is the amount of such credits? How many taxpayers claim them?
What information do you have available about the income distribution of state income tax filers?
What proportion of returns are filed electronically? Could you please walk us through that process? Is information available showing how many state income tax returns for low-income residents are filed electronically?
What information do you have about the proportion of state income tax returns that are filed with the aid of a tax preparer or other assister? Does such information show the prevalence of assisted return filing among taxpayers with various income levels?
Tax agency conditions and procedures
How would you characterize staffing levels at your agency? How have staffing levels changed in recent years? Have staff limits created challenges for the agency? If so, how have those challenges been addressed?
How would you characterize information technology used by your agency? Has it been modernized substantially in recent years? Have limits on information technology resources created challenges for the agency? If so, how have those challenges been addressed?
How does your agency approach taxpayer privacy?
Why is such privacy important?
If a taxpayer wants to have his or her state tax return information shared with a third party, how does your agency approach the consent process? What legal constraints apply to such information sharing?
What limits apply to sharing tax return information that comes from sources other than the taxpayer, such as information that comes from the federal government and employers? How, if at all, can a consumer consent to the sharing of such information?
EXPRESS LANE ELIGIBILITY
The remainder of our questions focus on your agency’s role in the implementation of Express Lane Eligibility for CHIP. We begin with questions related to your state’s decision to adopt ELE and your agency’s role in this decision. We continue with questions about the “nuts and bolts” operations of ELE, and any changes that may have affected your agency’s operations. We then turn to any evidence you may have regarding the impact of ELE.
ELE Policy Development
Why did your state decide to implement ELE? What were the original goals in adopting ELE? Have these changed at all?
How involved was your agency in the decision to implement ELE? To what extent/in what capacity? How involved was your agency in shaping the details of ELE implementation?
Where did the support for ELE come from – the Governor’s office, legislature, advocacy community, other?
Did you rely on/learn from the experiences of other states that had implemented ELE? Which ones?
Did you have any concerns or worries about ELE and, if so, how were they addressed?
Do you use ELE in your state to determine initial eligibility, renewal eligibility, or both? What were the various factors that played into that decision?
Which eligibility factors were established by ELE? Income, state residence, other things?
Did this option add any advantages or benefits to your system? If so, what were they?
Did you need statutory authority to adopt ELE?
Please describe the state legislation that resulted in changing tax returns to provide information about child health coverage. What are the most important features of such legislation? How has it changed over time? What were the arguments and concerns that surfaced during the legislative discussion? Which arguments and concerns did you believe were well-taken?
Who covered your costs to implement ELE– your budget, a special state appropriation, or the Medicaid/CHIP agency? How significant were those costs?
How was adoption of ELE framed in terms of your agency’s budget (i.e., budget-neutral, costly but advantageous, or money-saving)? Has this proven to be true?
What was the timeline for ELE design and implementation? Did it take more, or less, time, effort, and cost than you anticipated?
Were there any particular factors that facilitated your adoption of ELE? Conversely, were there any particular obstacles or challenges that you had to overcome?
Did you have any concerns or worries about ELE and, if so, how did you or others address them?
ELE Implementation and Operations
Please describe for us the conversations you had with CHIP/MEDICAID officials when planning for ELE. What approval did your agency need before proceeding?
How did this option change your systems and procedures, above and beyond the strategies we’ve already discussed?
Please walk us through the new process. How has implementation of ELE in your state affected your agency’s procedures?
Did you need to modify the state tax return?
Have you held any staff training to promote understanding of new processes?
Have you undertaken any outreach to the tax preparer community or tax software vendors?
What agency funds the mailings to families? What kinds of families are targeted? What agency sends out the mailings?
Have you put into place any sort of monitoring or quality assurance checks to ensure that ELE processes are working appropriately?
Under what circumstances are tax return data shared with the state health agency?
Do families have to “do” anything to consent to the data sharing that occurs under ELE? (What constitutes “affirmative consent” in your program?) Do parents opt “in” or “out” to consent to participate?
When are data matches performed automatically by the agencies’ systems? When do you or others have to perform manual matches/reviews?
Does ELE matching happen at initial enrollment into health coverage? Does it happen when people enrolled in health coverage have such coverage renewed?
How did the initial ELE enrollment process unfold?
Was the transition smooth? What enabled this?
Were there bumps along the way?
What are some of examples of challenges encountered? How were they addressed?
Has the ELE process evolved since implementation?
Have health-related questions on state income tax returns been modified? If so, how? What led to such changes?
How has outreach to tax preparers and software vendors changed over time? What misunderstandings required correction?
How has the process for identifying mailing targets changed over time? Have there been any other changes to the mailing process?
How have taxpayer consent procedures changed over time?
Did state officials consider giving taxpayers the ability to consent, on the tax return, to sharing tax return information with the state health agency to see if uninsured children qualify for subsidized health coverage, eliminating the need for mailings? If so, what did officials see as the advantages and disadvantages of direct data sharing, following taxpayer consent? Why was it ultimately not undertaken?
Did ELE adoption and implementation require any notable change in your agency’s “culture”?
If yes, can you describe these changes? How did these changes evolve?
Did your agency receive training or technical assistance to smooth the adoption of ELE and facilitate “culture” change?
Did your agency conduct any broad outreach or public education effort related to the implementation of ELE? Please describe.
Outcomes of ELE Program
Do you have a sense of how many children have been enrolled into Medicaid/CHIP via ELE since the initiative was launched? Of how many applications resulted from mailings to taxpayers, triggered by the state’s ELE initiative?
Were these results higher, or lower than expected? What do you think was responsible for any differences between expectations and actual performance?
Do you know about these results from discussions with Medicaid/CHIP partners, or does your program’s system track these data?
What kinds of taxpayers have been affected by the ELE initiative? Primarily low-income households? Are there any other distinguishing characteristics of affected taxpayers?
Have you heard feedback from taxpayers or tax preparers?
What are they saying about the process?
Did any of your worries about ELE implementation come to pass? Was the reality better or worse than you feared?
How, if at all, has ELE affected the following?
Your agency’s administrative costs
Burden on your agency’s staff
Burden on your agency’s IT systems
Taxpayer privacy rights
The cumbersomeness of tax return forms
Taxpayer compliance with tax return filing requirements
Role of ELE under Health Care Reform
Will ELE policies or processes change in any way as a result of the implementation of health care reform?
Will ELE-like enrollment systems be extended to new populations under reform (for example, adults)?
Have you discussed these issues with the state health agency?
IV. LESSONS LEARNED
What would you say are the most important lessons that you have learned by adopting, designing, and implementing ELE?
What worked well in implementing ELE? What were the best planning or policy decisions that your state made?
Given what you know now, how should ELE have been approached differently?
What would you tell policymakers in other states who are considering ELE?
What do you see as the biggest advantages and disadvantages of adopting ELE?
What would you tell federal policymakers who are considering whether to continue the ELE option for child health coverage beyond its current 2013 sunset date, if so, whether to change any of the applicable federal rules?
You may have heard that, in the health reform law, federal income tax information will play a central role in establishing eligibility for Medicaid and other subsidies for health insurance. What advice would you give federal policymakers about how to approach this, given your state’s experience with ELE?
What other lessons from your experience with ELE do you think could be helpful to national and state policymakers involved in implementing the Affordable Care Act?
CHIPRA Express Lane Eligibility Evaluation
ELE Program Case Study Site Visit
County or Local Social Services Agencies Conducting Eligibility Determinations/Application Processing - Key Informant Protocol
Thanks very much for agreeing to meet with us. We have been funded by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (DHHS) to conduct a national evaluation of the new state policy option under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for health coverage, despite programs’ different methods of assessing income or otherwise determining eligibility.
This Congressionally Mandated Evaluation of ELE is composed of four components: monitoring state programs and policy; analysis of ELE impacts on enrollment; a descriptive study of costs, enrollment, and utilization; and case studies of states that have adopted ELE or other approaches to streamlining enrollment and/or retention. We’re here as part of this latter qualitative/case study component of the project, which involves site visits to the following states that have implemented ELE— Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina.
While we’re here onsite, we will gather information from a broad range of key informants. At the state level, we are meeting with officials responsible for administering CHIP and Medicaid, Express Lane partner agencies, policy makers such as key legislative staff, and family and child advocates, among others. At the local level, we will meet with such informants as: county social service administrators, frontline eligibility workers, local offices for Express Lane agencies, and community-based organizations involved with outreach and application assistance. We will also be conducting two focus groups in each state with parents of children who enrolled or renewed coverage via ELE.
During these interviews, we will discuss a wide range of issues including: the broader eligibility policy features of your state’s Medicaid and CHIP programs; the process your state went through to consider and develop ELE policy; ELE implementation; outcomes of ELE related to enrollment, retention, and access to care; and the role that ELE may play in your state’s implementation of federal health reform coverage expansions under the Affordable Care Act.
Information gathered during our site visit will be used in a series of state-specific case study reports, as well as a final cross-cutting Report to Congress that will synthesize findings from across the study states. Importantly, none of the information you share with us today will be quoted without your permission. We’ll be taking notes during our discussion, but if it’s okay with you we would also like to record this interview, as a backup to those notes.
Do you have any questions?
Do we have your consent to proceed with our interview?
Do we have your permission to record?
BACKGROUND AND OVERVIEW
To start with, could you please give us some background information on your agency/organization and tell us about the role you play in the Medicaid and CHIP programs.
Probes:
How long have you worked at this agency/organization?
What are your current responsibilities?
What kinds of interactions do you have with state Medicaid and CHIP administrators?
On what kinds of issues do you generally talk to with state officials about? How often?
MEDICAID AND CHIP PROGRAM FEATURES
Before we begin talking about Express Lane Eligibility, I want to be sure we have a good understanding of how families typically enroll their children into Medicaid or CHIP, as well as a characterization of any outreach efforts that exist in your state.
Enrollment
First, could you walk us through the process that a parent would follow to apply for Medicaid or CHIP for their children?
Probes:
What is the application like? How long is it? Can families apply for coverage together on the same application? Is there a joint Medicaid/CHIP application? Is there a joint application for medical and human services (TANF, SNAP) programs?
What kinds of verification do you collect as part of the application (income, assets, age, residency, identity)?
Can parents apply online? How does that work exactly: do parents have to print the application out and mail it, or can they file it online? If they can submit it online, does other data need to be sent by mail (for example income documents)?
Can applications be submitted by mail or over the phone? By fax?
Is a face-to-face interview with an eligibility worker required? (If so, how long does such an interview typically take?)
Is community-based application assistance provided? How? Where?
Do providers or health plans help enroll consumers? If so, how?
Renewal
Next, could you please walk us through the process that a parent would follow in order to renew their child’s Medicaid or CHIP coverage?
How is the family informed that they need to renew their child’s coverage?
What form, if any, is required to be completed? Is a signature required?
Does a parent need to meet, face to face, with anyone? Or can the process be completed online, or by phone, or through the mail? [obtain a yes/no for each of these]
What verification, if any, needs to be submitted?
In your view, how easy or hard is the process for families?
Thinking back to before the implementation of ELE, can you describe any other major changes or simplifications that have taken place with Medicaid/CHIP eligibility during the last ten years? [prompts if needed: for example, pre-printed forms, a single form for applying for Medicaid and CHIP, enroll or renew online, etc.]
Probes:
What do you think are the most important such changes? Why?
Was it easy for eligibility and enrollment staff to adjust to those changes? Why or why not?
How have those changes affected clients?
Outreach
Has your state engaged in any large scale, statewide media campaigns to publicize the availability of coverage for children? How recently? Was there any particular focus on simplified procedures for applying?
Does your state support any notable community-based outreach strategies, such as application assistance or grants to CBOs to support outreach and enrollment assistance? Are providers, health plans, or school-based clinics involved? Is your agency involved?
Did your state receive any CHIPRA outreach grants, or other federal grants to support outreach for children’s coverage? If so, please describe. Are you involved in a CHIPRA outreach grant project?
EXPRESS LANE ELIGIBILITY
Now, let’s change gears and talk about the specifics of Express Lane Eligibility. We begin with questions related to your state’s decision to adopt ELE. We continue with questions about the “nuts and bolts” operations of ELE.
Policy Development
When did you first learn about Express Lane Eligibility? How did you hear about it?
When you first heard about ELE, what did you think?
Probes:
Did you have any concerns or worries about ELE, and if so, how did you address these?
Did you or your colleagues at the local level have the opportunity to weigh in during the development of the state’s ELE policy, or was planning and decision making a state-level exercise?
Eligibility And Enrollment Process
Could you please describe your understanding of [state]’s ELE’s approach to enrolling uninsured children?
How did you and your colleagues prepare to enroll children through ELE?
Probes:
Did any of this preparation require a lot of work?
Did anything lead to resistance or confusion? If so, how was that addressed?
When it came time to enroll the first group of children through ELE in [Month, Year], what happened? Could you describe how things unfolded?
How have your eligibility and enrollment processes at the local level changed due to the implementation of ELE?
Probes:
What is the same?
What is different?
Have ELE enrollment procedures changed since the first group of children was enrolled via ELE in [Month, Year]?
Probes:
If so, how?
How do you think the new ELE approach to eligibility and enrollment compares to the processes in place before ELE implementation?
Probes:
Is it more, or less work for local-level agencies and staff?
Is it more, or less accurate, in terms of program integrity?
Is it more, or less work for families with children?
Is it more, or less, understandable for parents?
Have you heard any reactions from clients to the new ELE process?
Probes:
If so, what?
Renewal Process
Could you please describe your understanding of [state]’s ELE’s approach to renewing coverage for children in Medicaid and CHIP?
How have renewal processes changed due to the implementation of ELE?
Probes:
What is the same?
What is different?
Have ELE renewal procedures changed since the first group of children was enrolled via ELE?
Probes:
If so, how?
Have you heard any reactions from clients to the new ELE renewal process? If so, what feedback have you received, good or bad?
Outreach
Was any outreach or public education conducted to promote the availability of ELE to families in your state? Please describe that for us.
Why do you think the remaining eligible, uninsured children haven’t yet enrolled into coverage?
During outreach efforts, have you seen any effects of ELE implementation?
Have outreach strategies changed as a result of ELE implementation?
If so, how?
OUTCOMES AND EFFECTS OF ELE PROGRAM
Next, I’d like to discuss some of the outcomes of ELE implementation on enrollment and possible effects on your agency.
Medicaid/Chip Enrollment
Do you have a sense of how many children have been enrolled into Medicaid/CHIP via ELE in your state? What about in your county?
Probes:
Is this higher or lower than expected?
How do you track ELE enrollment?
How would you characterize these children enrolling through ELE? Are they children who have previously been enrolled in Medicaid/CHIP, or are they “new” children without previous experience on the program?
Organization-Level
Some have described ELE as involving a major culture change for eligibility determination. Do you think that’s true? If so:
Probes:
How did state officials help people make this change? (Was there any formal training or technical assistance to change county-level business processes?)
How effective were such efforts?
Is more work along these lines still needed, in your opinion? What else, if anything, do you think the state should do?
What other kinds of organizational changes have occurred as a result of ELE implementation?
Probes:
Have you had staffing changes?
Have you had to conduct additional staff trainings?
Have you had to other make any changes to your IT systems or business processes?
Has the implementation of ELE allowed you to shift resources to other efforts?
V. LESSONS LEARNED AND BEST PRACTICES
What do you think worked well in implementing ELE? What were the best planning or policy decisions you think your state made?
Given what you know today, what do you think the state should have done differently? What might have made ELE adoption and implementation smoother at the county/local level?
What would you tell policymakers in other states who are considering ELE implementation?
Probes:
What are the advantages of the strategy?
Are there any disadvantages?
What have been your greatest challenges at the local level, and how have you overcome them?
What barriers to eligibility/enrollment and renewal remain for Medicaid/CHIP clients, and how might these be overcome?
CHIPRA Express Lane Eligibility Evaluation
ELE Program Case Study Site Visit
Community Based Organization Involved in Outreach/Application Assistance or Enrollment- Key Informant Protocol
Thanks very much for agreeing to meet with us. We have been funded by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (HHS) to conduct a national evaluation of the new state policy option under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for health coverage, despite programs’ different methods of assessing income or otherwise determining eligibility.
This Congressionally Mandated Evaluation of ELE is composed of four components: monitoring state programs and policy; analysis of ELE impacts on enrollment; a descriptive study of costs, enrollment, and utilization; and case studies of states that have adopted ELE or other approaches to streamlining enrollment and/or retention. We’re here as part of this latter qualitative/case study component of the project, which involves site visits to the following states that have implemented ELE— Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina.
While we’re here onsite, we will gather information from a broad range of key informants. At the state level, we are meeting with officials responsible for administering CHIP and Medicaid, Express Lane partner agencies, policy makers such as key legislative staff, and family and child advocates, among others. At the local level, we will meet with such informants as: county social service administrators, frontline eligibility workers, local offices for Express Lane agencies, and community-based organizations involved with outreach and application assistance. We will also be conducting two focus groups in each state with parents of children who enrolled or renewed coverage via ELE.
During these interviews, we will discuss a wide range of issues including: the broader eligibility policy features of your state’s Medicaid and CHIP programs; the process your state went through to consider and develop ELE policy; ELE implementation; outcomes of ELE related to enrollment, retention, and access to care; and the role that ELE may play in your state’s implementation of federal health reform coverage expansions under the Affordable Care Act.
Information gathered during our site visit will be used in a series of state-specific case study reports, as well as a final cross-cutting Report to Congress that will synthesize findings from across the study states. Importantly, none of the information you share with us today will be quoted without your permission. We’ll be taking notes during our discussion, but if it’s okay with you we would also like to record this interview, as a backup to those notes.
Do you have any questions?
Do we have your consent to proceed with our interview?
Do we have your permission to record?
BACKGROUND AND OVERVIEW
To start with, could you please give us some background information on your agency/organization and tell us about the role you play in the Medicaid and CHIP programs.
Probes:
How long have you worked at this agency/organization?
What are your current responsibilities?
What is the work that your organization does, and which populations does your organization serve?
For advocates: What issue areas do you advocate for?
What kinds of interactions do you have with state Medicaid and CHIP administrators?
On what kinds of issues do you generally talk to with state officials about? How often?
II. ENROLLMENT AND RETENTION PROCESSES
Let’s begin by discussing your state’s traditional eligibility and renewal policies and procedures, as a precursor to our discussion of the new Express Lane Eligibility system.
In the discussions we have had with state officials, we learned a great deal about enrollment and retention policies. But now that we are at the local level, it would be helpful if you could walk us through the process that a parent would follow to apply for CHIP for their children.
When people come in to apply, about how long do they have to wait before meeting with an eligibility worker/application assistor? Is there a place for their kids to play? If they go out to lunch, do they lose their place in line?
How much time do workers/assistors spend with each applicant?
What forms must be filled out? How long are they? (May we have a copy?)
What verification is needed?
Do families usually have everything they need to apply with them? What proportion of families typically need to follow up by submitting additional documents and other verification?
Do they have to come in, in person, to do this, or can they submit such material by mail?
Does your state offer on-line applications? Are you able to help families fill out their applications on line?
Can families fill out their applications at home (either on-line of in paper and mail them in to you), or must they come in for a face-to-face interview?
What proportion of applicants do you never hear from again?
What do you do if a family doesn’t speak English?
What would you do if a father told you he was in the country illegally?
Have any of the processes you described change in the past year or two? If so, what has changed? In your view, has this change made it easier or harder for families, or to families was this change invisible and only affected workers here?
Do you also process Medicaid applications? Is the process the same? If not, can you walk me through the application process for Medicaid?
Does your state have a joint application for these two programs (Medicaid and CHIP)? If not, are you aware of any plans to create one?
Can you describe for me the “screen and enroll” process that you use?
How do you/your staff refer applicants who appear to be Medicaid eligible to the Medicaid agency, and vice versa?
Do families have to indicate that they want their applications referred to Medicaid, or is this done automatically?
Now I’d like to talk with you about the process after applications are completed.
Are you authorized to make “official” eligibility determinations or do you forward completed applications to another agency?
If the latter, to whom? Is this a central “clearinghouse” for processing or are there multiple such sites around the state?
How long does processing of applications take for CHIP and Medicaid (i.e. how much time elapses from when a form is completed/submitted, and when a notification of approval or denial is sent to a family)? Is there any priority given to children’s applications?
Can we get a copy of the letter families receive when they are notified of approval?
Can you walk us through how the renewal process works for families?
How often must eligibility be redetermined?
When and how often are families notified?
Do you offer automatic renewal?
What forms are required to be completed? Are forms pre-populated or do they need to be filled out? (May we have a blank copy?)
Can the forms be mailed in, or is a face-to-face interview required?
What assistance is provided to fill out the form?
What verification requirements must be submitted?
How long do families have to comply before their children are disenrolled?
Are there any differences between Medicaid and CHIP redetermination processes? If so, what are they?
III. EXPRESS LANE ELIGIBILITY
Now, let’s change gears and talk about the specifics of Express Lane Eligibility. We begin with questions related to your state’s decision to adopt ELE. We continue with questions about the “nuts and bolts” operations of ELE. It is OK if you do not know much about ELE.
Policy Development
When did you first learn about Express Lane Eligibility? How did you hear about it?
When you first heard about ELE, what did you think?
Probes:
Did you have any concerns or worries about ELE, and if so, how did you address these?
Did you or your colleagues at the local level have the opportunity to weigh in during the development of the state’s ELE policy, or was planning and decision making a state-level exercise?
Eligibility And Enrollment Process
Could you please describe your understanding of [state]’s ELE’s approach to enrolling uninsured children?
Did you and your colleagues need to do anything to prepare to enroll children through ELE?
Probes:
Did any of this preparation require a lot of work?
Did anything lead to resistance or confusion? If so, how was that addressed?
When it came time to enroll the first group of children through ELE in [Month, Year], what happened? Could you describe how things unfolded?
Have your eligibility and enrollment processes at the local level changed due to the implementation of ELE?
Probes:
What is the same?
What is different?
Have ELE enrollment procedures changed since the first group of children was enrolled via ELE in [Month, Year]?
Probes:
If so, how?
How do you think the new ELE approach to eligibility and enrollment compares to the processes in place before ELE implementation?
Probes:
Is it more, or less work for local-level agencies and staff?
Is it more, or less accurate, in terms of program integrity?
Is it more, or less work for families with children?
Is it more, or less, understandable for parents?
Have you heard any reactions from clients to the new ELE process?
Probes:
If so, what?
Renewal Process
Could you please describe your understanding of [state]’s ELE’s approach to renewing coverage for children in Medicaid and CHIP?
How have renewal processes changed due to the implementation of ELE?
Probes:
What is the same?
What is different?
Have ELE renewal procedures changed since the first group of children was enrolled via ELE?
Probes:
If so, how?
Have you heard any reactions from clients to the new ELE renewal process? If so, what feedback have you received, good or bad?
IV. OUTREACH
Was any outreach or public education conducted to promote the availability of ELE to families in your state? Please describe that for us. How recently was this? Was there any particular focus on simplified procedures for applying?
Why do you think the remaining eligible, uninsured children haven’t yet enrolled into coverage?
Setting ELE aside for a minute, do you conduct outreach at your organization? If so,
Can you describe your outreach activities?
Do you target special populations?
How is your agency funded to do outreach – do you receive state support?
Has funding for outreach been a problem in recent years? How has your agency dealt with funding challenges?
During outreach efforts, have you seen any effects of ELE implementation?
Have outreach strategies at your agency changed as a result of ELE implementation? If so, how?
Did your state receive any CHIPRA outreach grants, or other federal grants to support outreach for children’s coverage? If so, please describe. Are you involved in a CHIPRA outreach grant project?
V. OUTCOMES AND EFFECTS OF ELE PROGRAM
Next, I’d like to discuss some of the outcomes of ELE implementation on enrollment and possible effects on your agency.
Medicaid/CHIP Enrollment
Do you have a sense of how many children have been enrolled into Medicaid/CHIP via ELE in your state? What about in your county?
Probes:
Is this higher or lower than expected?
How do you track ELE enrollment?
How would you characterize these children enrolling through ELE? Are they children who have previously been enrolled in Medicaid/CHIP, or are they “new” children without previous experience on the program?
Organization-Level
Some have described ELE as involving a major culture change for eligibility determination and enrollment. Do you think that’s true? If so:
Probes:
How did state officials help people make this change? (Was there any formal training or technical assistance to change county-level business processes?)
How effective were such efforts?
Is more work along these lines still needed, in your opinion? What else, if anything, do you think the state should do?
What other kinds of organizational changes have occurred as a result of ELE implementation?
Probes:
Have you had staffing changes?
Have you had to conduct additional staff trainings?
Have you had to other make any changes to your IT systems or business processes?
Has the implementation of ELE allowed you to shift resources to other efforts?
LESSONS LEARNED AND BEST PRACTICES
What do you think worked well in implementing ELE? What were the best planning or policy decisions you think your state made?
Given what you know today, what do you think the state should have done differently? What might have made ELE adoption and implementation smoother at the county/local level?
What would you tell policymakers in other states who are considering ELE implementation?
Probes:
What are the advantages of the strategy?
Are there any disadvantages?
What have been your greatest challenges at the local level, and how have you overcome them?
What barriers to eligibility/enrollment and renewal remain for Medicaid/CHIP clients, and how might these be overcome?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Courtot, Brigette |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |