A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs

A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs

ASPE Generic Information Collection Request

OMB No. 0990-0421

Supporting Statement – Section A

Submitted: March 14, 2016

Program Official/Project Officer

Alana Landey

Social Science Analyst

U.S. Department of Health and Human Services

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Washington DC 20201

(202) 401-6636

[email protected]

Section A – Justification

1. Circumstances Making the Collection of Information Necessary

The Patient Protection and Affordable Care Act of 2010 (the ACA) established or expanded health insurance affordability programs that the Congressional Budget Office expects to cover an estimated 29 million people by 2016.¹ Thirteen million additional people are projected to join Medicaid and the Children’s Health Insurance Program, 16 million will receive subsidies through newly created state health insurance Marketplaces, and 24 million more people will be insured than without the law.² Enacted against a background of growing public- and private-sector interest in integrating enrollment, retention, and eligibility determination across health and human services programs, the ACA also placed new emphasis on the importance of cross-program data sharing and integrated eligibility determination and enrollment processes.³ The law encourages the use of electronic data (including data from other need-based programs) to qualify consumers for assistance whenever possible, and promotes program integration through the use of up-to-date information technology (IT) to improve consumer experience and streamline enrollment while lowering administrative costs and protecting program integrity.

Recent changes to federal rules further underline the key role of integration in achieving the goals of the ACA. HHS recently announced a permanent extension of the enhanced 90 percent federal funding for multi-program eligibility and enrollment systems modernization, as well as an extension through 2018 of cost-allocation exceptions that relieve human services agencies of the need to share the costs of IT upgrades that improve eligibility determination for both health and human services programs.⁴ HHS’ Centers for Medicare and Medicaid Services (CMS) issued guidance encouraging targeted strategies for enrolling eligible individuals in Medicaid, including the use of Supplemental Nutrition Assistance Program (SNAP) data to get SNAP recipients enrolled, an approach that is now being used by several states.⁵

The growing commitment to cross-program integration is reflected in many other efforts as well, including the American Public Human Services Association’s National Collaborative for the Integration of Health and Human Services (previously the National Workgroup on Integration),⁶ the Work Support Strategies Project supported by the Ford Foundation and other philanthropies,⁷ ACF’s National Human Services Interoperability Architecture, the OMB Partnership Fund for Program Integrity Innovation, and the National Information Exchange Model. The Center on Budget and Policy Priorities recently profiled several states that are using technology and services innovations to support multi-program integration.⁸ HHS/ASPE has invested in a body of research into cross-program integration,⁹ on which the current information collection effort will build.

Data on program population overlaps underscore the importance and potential of multi-program integration. If all states expanded Medicaid eligibility, 96 percent of (SNAP) recipients and 99 percent of Temporary Assistance for Needy Families (TANF) recipients would be eligible for Medicaid. The Earned Income Tax Credit (EITC), SNAP, and the Low Income Home Energy Assistance Program (LIHEAP) would serve 40, 39, and 15 percent of newly eligible Medicaid adults, respectively.¹⁰ These overlaps provide opportunities for targeted outreach and enrollment efforts to reduce the number of uninsured Americans and help eligible individuals get the human services benefits for which they qualify.

A number of states have achieved considerable success at integrating program arenas before, during and after the two health insurance open enrollment periods of 2014 and 2015.¹¹ As states take advantage of the extended enhanced funding and cost allocation exception and continue to evolve administrative capacity to help their low-income clients obtain a comprehensive range of supports, more states will be able to focus additional resources on integration activities. Many of the state human services agencies utilizing the cost allocation exception have carried out much of the work required to modernize shared eligibility systems.¹²

In 2015, ASPE and HHS’ Administration for Children and Families (ACF) co-funded a new project, “A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs” to assess the extent of states’ cross-program integration activities. A key component of this project is an online assessment of state human services agency officials that will collect qualitative information on the current status of states’ integration efforts, goals for further integration, and information on the kinds of technical assistance and other supports states most need from the federal government to help meet those goals. Senior political leadership in ASPE and ACF has guided the focus of this work to inform these high-priority issues. This information collection request seeks OMB’s approval to conduct the qualitative online assessment via questionnaire.

2. Purpose and Use of the Information Collection

The purposes of this data collection are to:

• Identify the extent to which state human services agencies are currently integrating their enrollment and eligibility systems and program entry processes across human services programs and with Medicaid and state health insurance Marketplaces.

• Identify plans states have to further integrate across program areas.

• Gain insight into state human services agencies’ governance and leadership approaches to sharing data across programs.

• Determine state human services agencies’ needs for technical assistance to further advance their integration efforts.

We will collect this information from state human services agency officials through a Web-based, electronic questionnaire using a mix of closed-ended and some open-ended questions. Respondents will be directors of state human services agencies or their designees, and possibly additional staff who may be asked to respond to specific items. A team of contractors will oversee administration, follow-up, and analysis of results.

This work will not be used to inform federal policy decisions. It is an effort to help HHS better understand the current status of cross-program integration and states’ ongoing challenges and technical assistance needs.

3. Use of Improved Information Technology and Burden Reduction

This information collection will use the online tool, SurveyMonkey, which minimizes respondent burden through skip options, ease of navigation, simplicity of presentation, standard Web formatting, and accessibility via the internet at the user’s convenience. Respondents can answer questions whenever they choose, and can save, close and return to the questionnaire as needed before submitting their answers. Multiple individuals can access the link if the initial respondent wants to delegate some answers to other staff members or offices.

4. Efforts to Identify Duplication and Use of Similar Information

ASPE is partnering with the leading association of state human services agencies, APHSA, to ensure complementarity with the information they collect from member agencies. The information collected by ASPE will build on and update past ASPE and other research efforts detailed in the background section, and will not duplicate them. This information collection will help federal officials better understand how states are implementing the integration elements of the ACA, one of the Administration’s highest priorities.

To our knowledge, there are no substantially overlapping information collection efforts. ASPE has identified two related information collection efforts currently being planned that touch on similar topics. One is a Department of Agriculture Food and Nutrition Service (FNS) assessment of Supplemental Nutrition Assistance Program (SNAP) agency leaders, focused on agency business and administrative practices and alignment between SNAP and Medicaid. The other is a Government Accountability Office (GAO) survey of income data matching in SNAP. Each includes a small number of questions similar to ASPE’s questionnaire, but with a specific focus on the SNAP program rather than on human services program integration and systems overall. ASPE is coordinating with FNS and GAO regarding these efforts, and the three agencies are sharing their instruments. APHSA is involved with all three projects, and is helping ensure minimal overlap in substance between the SNAP-focused assessments and the HHS assessment. The fielding periods will not overlap. We included a message in Attachment D that APHSA sent to their membership alerting them to the three questionnaires, explaining their differences, and encouraging responses.

5. Impact on Small Businesses or Other Small Entities

No small businesses will be involved in responding to this data collection.

6. Consequences of Collecting the Information Less Frequently

This request is for a one-time data collection where the data have not been previously collected elsewhere.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

There are no special circumstances with this information collection package. This request fully complies with the regulation 5 CFR 1320.5 and will be voluntary.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

This data collection is being conducted using the Generic Information Collection mechanism through ASPE – OMB No. 0990-0421, therefore no Federal Register notice is required.

9. Explanation of Any Payment or Gift to Respondents

ASPE will not provide any payments or gifts to respondents.

10. Assurance of Confidentiality Provided to Respondents

The Privacy Act does not apply to this data collection. State human services officials and any staff who answer questions will be answering in their official roles and will not be asked about, nor will they provide, sensitive individually identifiable information.

11. Justification for Sensitive Questions

No information will be collected that are of a personal or sensitive nature.

12. Estimates of Annualized Burden Hours and Costs

The estimate of burden hours is based on an average response time of 45 minutes per response. The researchers developed this estimate based on past experience with similar questionnaires, including MEF Associates’ experiences with online assessments of county TANF directors in Colorado and state refugee coordinators, and APHSA’s State Integration Self-Assessment. MEF Associates also timed a simulated questionnaire completion by project team members that demonstrated it can be completed within the estimate.

The researchers anticipate that in some states, the primary respondent (state human services program officials) will share the questionnaire with other staff, such as those responsible for IT policy, to complete some questions. We estimate that on average, two respondents will contribute to each response, for an estimate of 102 total potential respondents from the 50 states and DC. The burden estimate reflects an assumed 90 percent response rate, or 92 actual respondents.

Estimates for the median hourly wage for respondents are based on the Department of Labor (DOL) May 2014 estimates for the mean hourly wage of social and community service managers: $32.56 http://www.bls.gov/oes/current/oes119151.htm

The average is used as the hourly wage for all estimated 92 respondents. Table A-12 shows estimated burden and cost information.

Table A-12: Estimated Annualized Burden Hours and Costs to Respondents

Type of Respondent	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
State human services agency official or other employee	92	0.5	45/60	34.5	$32.56	1,123,32
TOTALS	92	0.5		34.5		1,123.32

13. Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers

There will be no direct costs to the respondents other than their time to participate in the data collection.

14. Annualized Cost to the Government

The cost of the government task order attributable to the work is $86,195.

Table A-14: Estimated Annualized Cost to the Federal Government

Staff (FTE)	Average Hours per Collection	Average Hourly Rate	Average Cost
Social Science Analyst, GS 14	30	67.00	$2,010
Estimated Total Cost of Information Collection (contract cost plus federal FTE cost)			$88,205

15. Explanation for Program Changes or Adjustments

This is a new data collection.

16. Plans for Tabulation and Publication and Project Time Schedule

The qualitative information gathered from the online questionnaire will be analyzed and summarized by ASPE’s contractor for this work, MEF Associates and their subcontractors, APHSA and RIG. The MEF team will track completion rates across respondents, do follow-ups to increase the response rate, analyze all information received, and identify main themes across states, including commonalities across lessons learned, challenges confronted and overcome, plans for further integration, and identified technical assistance needs. The contractor will produce tables presenting response frequencies and distributions of responses. Together with the project officer, the contractor team will consider how best to summarize and present this information at a webinar to which state officials and other stakeholders will be invited to learn about results and share experiences. A final research brief, which may be made public, will summarize the overall project, including results, webinar takeaways, and possible further work needed to support states’ integration efforts under the ACA.

Project Time Schedule

• March-April 2016: online questionnaire administered to states.

• April-early June 2016: Contractor team analyzes information received, prepares a codebook, and prepares draft, revised, and final versions of an internal results memo for ASPE and ACF.

• July 2016: Webinar held.

• July-September 2016: Contractor team drafts and finalizes a final report.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

We are requesting no exemption.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification. These activities comply with the requirements in 5 CFR 1320.9.

LIST OF ATTACHMENTS – Section A

Note: Attachments are included as separate files as instructed.

1. Online questionnaire

2. Copy of letter from HHS and APHSA to be sent in advance to state respondents

3. Copy of invitation email with link to questionnaire

4. Copy of APHSA message to its membership alerting them to GAO, FNS and HHS activities

1 Congressional Budget Office. Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act, April 2014 – January 2015 Baseline.

2 Ibid.

3 Dorn, Stan and Elizabeth Lower-Basch. 2012. “Moving to 21st-Century Public Benefits: Emerging Options, Great Promise, and Key Challenges. Prepared by the Urban Institute for the Coalition for Access and Opportunity.”

4 Letter from CMS to the American Public Human Services Association, October 28, 2014.

5 CMS. “Targeted Enrollment Strategies,” available at http://www.medicaid.gov/medicaid-chip-
program-information/program-information/targeted-enrollment-strategies/targeted-enrollment-strategies.html.

6 APHSA. “About the National Workgroup on Integration,” available at http://www.aphsa.org/content/
APHSA/en/pathways/NWI/ABOUT.html.

7 “Work Support Strategies: Streamlining Access, Strengthening Families.” Washington, DC. The Ford Foundation, the Open Society Foundations, and the Annie E. Casey Foundation., available at http://www.clasp.org/issues/work-support-strategies.

8 Center on Budget and Policy Priorities and Social Interest Solutions. “State Innovations in Horizontal Integration: Leveraging Technology for Health and Human Services.” Updated March 24, 2015.

9 HHS/ASPE. “Integrating Health and Human Services Programs and Reaching Eligible Individuals under the Affordable Care Act,” available at http://aspe.hhs.gov/hsp/14/integrationproject/
rpt_integrationproject.cfm

10 HHS/ASPE. “Integrating Health and Human Services Programs and Reaching Eligible Individuals under the Affordable Care Act: Final Report,” February 2015.

11 HHS/ASPE. “Examples of Promising Practices for Integrating and Coordinating Eligibility, Enrollment and Retention: Human Services and Health Programs Under the Affordable Care Act.” July 2014.

12 Jessica Kahn, CMS, personal communication with Stan Dorn, Urban Institute, 2014.

ASPE Generic Information Collection Request, OMB No. 0990-0421