State Medicaid and CHIP Programs in the Examining Room: Diagnosing What Works to Get and Keep Eligible Children Enrolle

1. State Medicaid and CHIP Programs in the Examining Room: Diagnosing What Works to Get and Keep Eligible Children Enrolled Web Conference Call Presentation March 3, 3:30 PM – 4:30 PM (ET) 1

2. Agenda 2 • Welcome and Overview Catherine Hess, Maximizing Enrollment for Kids/NASHP • Diagnostic Assessment Findings Alice M. Weiss, Maximizing Enrollment for Kids/NASHP • Reaction and Federal Perspective Victoria A. Wachino, Director, Family and Children’s Health Programs, Centers for Medicare and Medicaid Services • Discussion with Maximizing Enrollment Grantees Cathy Caldwell, Alabama Ruth Kennedy, Louisiana James Jones, Wisconsin • Open Q&A

3. What is MaximizingEnrollment for Kids? $15 m. Robert Wood Johnson Foundation Initiative 8 Grantees receiving funding and technical assistance Launched February 2009 NASHP is National Program Office (NPO) Goals: Move the needle on kids’ enrollment Share models/lessons to maximize enrollment nationally Document what works 3

4. Maximizing Enrollment Program Design Focus is on state systems, policies, procedures to identify, enroll, retain kids Program design based on: literature/evidence review state and national expert opinion Theory: No silver bullet Diagnostic Assessment a tool to help states understand baseline strengths/opportunities TA, peer-to-peer exchange will help states make improvements 4

5. MaxEnroll Grantee States 5

6. Maximizing Enrollment for KidsDiagnostic Assessment Findings Alice M. Weiss Maximizing Enrollment for Kids/NASHP 6

7. Diagnostic Assessment 7 • Foundational phase of Maximizing Enrollment • Goals: • Identify individual and common strengths, challenges, and opportunities • Support development of grantee’s improvement plans and identify technical assistance needs • Provide stronger understanding of best practices and areas of improvement for states, federal policymakers

8. Diagnostic Assessment Methodology 8 • NASHP contracted with Health Management Associates (HMA) to partner in developing and conducting assessments in eight grantee states. • Protocol based on literature review and expert opinion: • collection of background information from states • development of process maps by states • 2 day site visits with state officials and stakeholders • Information synthesized and analyzed to identify strengths, challenges, and opportunities

9. Diagnostic Assessment Context 9 • Period of assessment (February to June 2009) • Deep recession increased pressure on programs • High unemployment increased coverage demand • State budgets facing record shortfalls • New federal policies enacted February 2009: • Children’s Health Insurance Program Reauthorization Act (CHIPRA) • American Recovery and Reinvestment Act (ARRA)

10. Process Improvement and Paperwork Reduction: Simpler for families, more efficient for the state

11. Process Improvement & Paperwork Reduction Strengths Application and renewal available online Reduced documentation (e.g., E-signature, self-declaration of income, third-party data matching) Electronic case records No wrong door policy Streamlined renewal (e.g., administrative, ex parte, annual, and off-cycle renewals) 12 months continuous eligibility

12. Process Improvement & Paperwork Reduction Opportunities • Focus on retention strategies to decrease churning • Use process maps (flow charts) to identify duplicative, slow, or problematic steps. • Study effectiveness of processes or recent changes • Estimate system costs for process “bottlenecks” • Learn from families which steps are most challenging; involve them in redesign • Use plan-do-study-act model to pilot change • Invest in changes with high productivity payoff (e.g., address corrections to reduce returned mail)

13. Data Analysis and Integration: Necessary to monitor and improve coverage, find eligible but uninsured children, and streamline documentation

14. Data Analysis and IntegrationStrengths Having an infrastructure for data analysis Actionable performance measures Using data to monitor effects of process and trends (standard and ad hoc reports) Use of a single identifier across programs Collection of detailed information on reasons for denial and reasons for termination/non-renewal Single or compatible information system across sites Electronic case records

15. Data Analysis and IntegrationOpportunities Measure what you can, and share information to build constituencies for change, including better data Set an analytic agenda for information needs and create measures to support it Create partnerships with IT, program staff, academics, and foundations to fill in data gaps Develop cross-agency initiatives and seek administration/legislative leadership and support Seek federal funds through CHIPRA, ARRA/HITECH Target children known to the system for outreach

16. Leadership, Agency Capacity, Coordination, and Culture: Leaders and cross-state and local agency connections - alignment supports staff efficiency and process improvements

17. Leadership and Agency Capacity, Coordination, and Culture: Strengths Governor’s commitment to children’s coverage Dynamic, visionary state leaders Single agencies (administering Medicaid and CHIP) Centralized functions ease implementation challenges Alignment of Medicaid/CHIP rules, staff, resources Good communication between involved agencies Technology/processes supporting coordination Accountability/recognition for performance Culture of continuous quality improvement

18. Leadership and Agency Capacity, Coordination, and Culture: Opportunities Foster political/agency leadership (including mandate for coordination) and build support Invest in inter-agency relationship-building Consider centralizing enrollment/retention functions Implement simplifications that save staff time Monitor transfers between Medicaid and CHIP Adopt ELE, ex parte renewal, other inter-agency strategies to identify, enroll or renew eligible children Define and communicate expectations - add contractual, accountability measures if possible

19. Consumer, Community, and Stakeholder Engagement: Regular interactions critical to gain insights from families’ perspectives, help families enroll and renew, and support policy improvement 19

20. Consumer, Community, and Stakeholder EngagementStrengths • Engaging CBOs, health plans and providers to assist in outreach, enrollment and renewal (some with financial support) • Providing an environment and infrastructure to support policy discussion among stakeholders • Seeking consumer input regularly • Sharing data, goals and milestones with advocates, providers and other stakeholders 20

21. Consumer, Community, and Stakeholder EngagementOpportunities • Collaborate with stakeholders to shift resources/energy to renewal (assess opportunity for medical homes role here) • Schedule periodic stakeholder meetings to exchange information • Seek/maximize outreach funding through CHIPRA, foundation grants • Renew, strengthen, fund community partners • Obtain family input on enrollment and renewal 21

22. Online self- assessment toolkit available this Spring Based on diagnostic assessment Interactive New tool to promote states’ self-awareness of strengths, challenges, opportunities Maximizing Enrollment for Kids/NASHP will be sharing lessons learned with all states Visit www.maxenroll.org for more information Diagnostic Assessment Opportunities for All States

23. Conclusions 23 Creativity, perseverance, and challenging the status quo have resulted in more kids covered in every state Even leading states with successes can make improvements to reach more eligible children Measuring the impact of improvements can have multiple benefits and audiences Lessons learned here can have broad applicability as states expand coverage role and seek to streamline enrollment Alignment of this program’s goals, economic environment, and new federal policies and resources create a window for very big changes – states can make major strides forward.

24. Reaction and Federal PerspectiveVictoria A. Wachino, Director Family and Children’s Health ProgramsCenters for Medicare and Medicaid Services 24

25. Discussion with Maximizing Enrollment for Kids Grantees 25 Cathy Caldwell, Bureau of Children’s Health Insurance Director Alabama Department of Public Health James Jones, Deputy Medicaid Director Wisconsin Department of Health Services Ruth Kennedy, Deputy Medicaid Director and CHIP Director Louisiana Department of Health and Hospitals

26. Contact Information 26 Catherine Hess Director, Maximizing Enrollment for Kids Senior Program Director, NASHP 202-903-0101 chess@nashp.org Alice Weiss Deputy Director, Maximizing Enrollment for Kids Program Director, NASHIP 202-903-0101 aweiss@nashp.org Maximizing Enrollment for Kids Website: www.maxenroll.org