Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties

Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: Dana Hughes, UCSF Institute for Health Policy Studies and Letitia Brewster, Brewster Consulting October 2004

About the Authors This report was prepared by Dana Hughes, Dr.P.H., associate professor at the University of California, San Francisco and and Letitia Brewster, M.P.H., M.B.A., of Brewster Consulting. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information, visit us online at www.chcf.org. This report was produced under the direction of CHCF s Public Financing and Policy Program, which works to create solutions to problems in publicly funded health care and safety-net programs. Visit www.chcf.org/programs/ for more information about CHCF and its programs. ISBN 1-932064-82-6 Copyright 2004 California HealthCare Foundation

Contents 2 I. Executive Summary 6 II. Introduction 8 III. Renewal Rates and Perceived Reasons for Non-Renewal 10 IV. How California Counties Conduct Annual Medi-Cal Renewal 13 V. Counties Reactions to New Eligibility Policies 18 VI. Conclusion: Ideas for Action 20 Appendix A: Data Collection and Methods 21 Appendix B: Survey Instrument 31 Appendix C: Data Graphs 43 Appendix D: Data Tables 60 Endnotes

I. Executive Summary THE ROLE OF MEDI-CAL IN CALIFORNIA IS undergoing rapid transformation. The recent downturn in California s economy has created greater demand for publicly funded health insurance coverage just as declining state revenues make it harder to maintain the state s current programs, let alone expand them to meet the needs of California s growing uninsured population. Despite growing demand, a significant number of people who are eligible for Medi-Cal and Healthy Families are not enrolled. Analysis of the 2001 California Health Interview Survey indicates that two-thirds of uninsured children, and one-fifth of uninsured adults, were eligible for coverage through Medi-Cal or Healthy Families. 1 Meanwhile, in August 2004, Governor Schwarzenegger released recommendations from the California Performance Review, a commission he established to reorganize state government to achieve efficiencies and improve effectiveness. Among the state governmental functions that the report focuses on is the administration of the Medi-Cal program. One method of improving the efficiency of Medi-Cal and Healthy Families is to keep eligible families continuously enrolled. Studies have found that churning when individuals fail to renew their coverage during the eligibility redetermination period required by the programs, but re-apply for coverage after they have been dropped from the program increases administrative costs and consumes limited staff time. 2 Moreover, the most valuable benefit of continuous coverage is beneficiaries improved quality of health care when services are not arbitrarily interrupted. Longer periods of coverage allow enrollees to obtain timely preventive and primary care, which can benefit counties by replacing costly hospitalizations and emergency room visits for uninsured county residents. 3 It is difficult to obtain timely and reliable information about the extent to which families churn in and out of the Medi-Cal program, but available data suggests variation in disenrollment rates among counties can be extreme. A 2002 study by RAND of former welfare recipients found that disenrollment rates averaged about 50 percent, but ranged from 22 percent to 82 percent across California counties. 4 With California s state plan 2 CALIFORNIA HEALTHCARE FOUNDATION

requiring that Medi-Cal policies operate uniformly statewide, it is clear that neither federal nor state policymakers intend for a family s likelihood of keeping continuous Medi-Cal coverage to depend on the county in which the family lives. To date, little has been known about counties retention practices. In the fall of 2003, a survey was conducted of California counties to learn about current approaches. With almost all counties (95 percent) completing the extensive survey, the data gathered provides a comprehensive picture of how counties conduct Medi-Cal retention practices. It also offers promising ideas about how counties can innovate to achieve higher levels of retention, as well as leads to specific state-level policy reforms that can support these efforts. The survey queried counties about various aspects of their annual Medi-Cal redetermination process, including how they conduct and promote renewal, the impact of recent redetermination-related policies, and the expected effects of California s budget crisis on each county s practices. Key Findings 1. Most California counties have initiated a variety of activities to promote Medi-Cal retention. Many counties that have not launched such efforts report that county budget constraints are to blame. In the last two years, most counties have initiated extra efforts to encourage recipients to complete and return their renewal packets (62 percent). These activities have included: Creating new and simplified print materials in the renewal packets (56 percent); Introducing specially designed mailers for the packets (50 percent); and Contacting families, through mailings and/or phone calls, to remind them of the importance of renewal (53 percent). In addition, many counties (44 percent) have launched broader initiatives to keep families covered such as: Enhancing and increasing staff contact with clients; Collaborating with community clinics and/or health plans to keep families enrolled; and Convening a retention committee to develop new strategies. Counties have demonstrated initiative and capability by developing innovative approaches to improving renewal rates. However, shrinking county budgets and increasing demands on staff time may threaten these extra efforts in the future. 2. California counties received too little support for recent Medi-Cal policy changes that greatly increased their workloads. Two recently adopted policies Senate Bill 87 (2002) and Mid-year Status Reports (2003) have forced county staff to add numerous additional tasks to their existing workload. SB 87 s primary goal was to keep eligible families enrolled despite changes in family circumstances. While the law aimed to simplify the retention process for recipients, almost all counties (89 percent) said the bill s requirements did so by placing new challenges or burdens on their staff. Eligibility workers must now use multiple sources to check clients eligibility prior to contacting them. Mid-year Status Reports (MSRs), which require some adults to renew their Medi-Cal coverage every six months, have also significantly increased county workloads. Counties major difficulties with MSRs have been in the lack of automation to manage the complex new process (66 percent), which has required counties to do manual tracking. Frustrated by the increased MSR workload, several counties turned to other counties to get ideas and sample materials to help manage the new program. Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 3

Policy development is a dynamic process in which tradeoffs are made between a proposed policy s objectives and the realities of its implementation. Although SB 87 and MSRs could be characterized as working together toward the common goal of promoting retention, in practice the policies often worked at cross-purposes because both increased county workloads significantly and competed for shrinking staff resources. The increased workload resulting from MSRs often made it more difficult for counties to find the time and resources to pursue the creative partnerships and strategies envisioned under SB 87 that would improve retention of Medi-Cal coverage among eligible beneficiaries. 3. SB 87 has not led to widespread collaboration between counties and health plans. Nonetheless, most counties believe SB 87 helps keep families enrolled in Medi-Cal. One of the objectives of SB 87 is to foster better coordination between counties and health plans participating in Medi-Cal, but only six counties reported working more closely with plans. These counties collaborate with health plans on activities such as promoting retention, sharing address changes, and clarifying coverage issues. With health plans serving Medi-Cal beneficiaries in 22 counties, many more counties could benefit by partnering with health plans on their shared goal of keeping families enrolled. Despite the additional work SB 87 demands of county staff, and the limited impact of the focus on county/health plan coordination, most counties (62 percent) say SB 87 is enabling more families to retain Medi-Cal. 4. Counties support policy changes to help them more efficiently implement the renewal process. Virtually all counties offered recommendations for policy changes to streamline the retention process. Their suggestions included: Simplify the Medi-Cal annual eligibility redetermination form (Medi-Cal Form 210RV, a three-page document that recipients must complete to retain Medi- Cal coverage); Allow recipients to renew Medi-Cal by telephone; Align state requirements with federal requirements; 5 Eliminate redetermination processes including SB 87 and ex parte reviews; Use the same reporting requirements as other public programs such as Food Stamps and CalWORKs; Eliminate asset limits for all Medi-Cal beneficiaries; Allow face-to-face redeterminations; and Automate the renewal process by pre-printing clients forms with previously reported information and asking them to indicate changes on the form. Ideas for Action In addition to the specific policy reforms outlined above, the survey results point to broader action steps that can improve the effectiveness of Medi-Cal renewal processes. 1. Elected officials and program leaders at both the state and county level should invest in efforts to identify, evaluate, and promote best practices in Medi-Cal renewal. Renewal practices vary considerably from county to county, due partly to the lack of information on the effectiveness of current renewal practices. California counties need research-based guidance on optimal approaches to Medi-Cal renewal. Research efforts should focus on identifying, evaluating, and promoting best renewal practices. In an era of leaner budgets, it is particularly important that counties use proven approaches to improve Medi-Cal renewal. For starters, counties made excellent suggestions in their survey responses. (These are presented in an accompanying document, called Keeping Eligible Families Enrolled in Medi-Cal: Promising Practices for Counties.) California policymakers should consider establishing a formal mechanism to link all 58 counties in order to leverage the innovation and creativity occurring at the county level and to disseminate effective retention strategies and practices throughout the state. The Department of Health Services and the state s County Welfare 4 CALIFORNIA HEALTHCARE FOUNDATION

Directors Association should team up to build a statewide network of key county retention staff and a process for rapidly disseminating new policies and innovative retention strategies among the counties. 2. Legislators should consult with county officials during the policy development process to better anticipate how new policy implementation will impact county workloads. Implementing new state policies can easily overburden county staff and in the end not serve their intended purpose. Counties typically have limited time to develop new procedures, train staff to manage them, and incorporate the procedures into the county s existing workload. Legislators and other state officials should proactively consider the impact of proposed policies, while still in the developmental phase, on county staff, as well as specifically examine whether new policies create or hinder efficiency for counties and whether they actually promote coverage or create additional barriers. Once a policy is adopted, DHS needs to provide counties with strategic guidance and tactical support in developing needed information systems, administrative procedures, and communication materials. Policymakers should seek county staff s suggestions as they consider ways to modify the retention process. 3. Counties and health plans should collaborate to build coordinated strategies for improving retention. Counties and health plans are natural partners that should capitalize on their common interest in keeping Medi-Cal recipients enrolled. Health plans should commit to collaborating with counties and sharing their marketing expertise to improve Medi-Cal retention rates. By combining efforts, counties and health plans can work smarter and be more effective in maximizing retention. While a seemingly obvious partnership, there are challenges. Nonetheless, counties have made progress: San Diego County created a form for health plans to notify the county when a Medi-Cal beneficiary has a change of address. The county also meets monthly with the health plans and other stakeholders to review data, policies, and procedures and to develop strategies to improve retention efforts. Los Angeles County reports that it regularly meets with the plans to identify ways they can interact with their members to alert them to new policy changes and upcoming redeterminations and to locate members who have moved. Successfully refining the redetermination process will require the leadership and collaboration of counties, the California Department of Health Services (DHS), health plans, and both county and state leadership. Counties conduct over six million Medi-Cal renewals each year. Developing more efficient and effective approaches to renewal can both expand coverage and reduce administrative costs. Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 5

II. Introduction THE ROLE OF MEDI-CAL IN CALIFORNIA IS undergoing rapid transformation. California s recent economic decline and associated budget difficulties have created a significant challenge for the state. The downturn in the economy has resulted in more people who need Medi-Cal coverage. At the same time, the decline in state revenues makes it more difficult to maintain the program, let alone expand it to meet the growing need. Meanwhile, in August 2004, Governor Schwarzenegger released recommendations from the California Performance Review, a commission he established to reorganize state government to achieve efficiencies and improve effectiveness. Among the state governmental functions that the report focuses on is the administration of the Medi-Cal program. One method of achieving cost savings is to keep eligible families enrolled in Medi-Cal. Studies have found that churning (when individuals fail to renew during the eligibility redetermination period required by the programs, but subsequently re-apply once their coverage has been dropped) increases administrative costs and consumes limited staff time. 6 Administrative efficiencies could reduce costs for both counties and the state. Moreover, while the cost efficiencies of continuous coverage are important to counties and the state, the most valuable benefit of keeping families enrolled is the continuity of care that they receive when services are not arbitrarily interrupted. With longer periods of coverage, beneficiaries are more able to obtain timely preventive and primary care and avoid unnecessary and expensive hospitalization or emergency room care. 7 It is difficult to obtain timely and reliable information about the extent to which families churn in and out of the Medi-Cal program, but available data suggests variation in disenrollment rates among counties can be extreme. A 2002 study by RAND of former welfare recipients found that disenrollment rates averaged about 50 percent, but ranged from 22 percent to 82 percent across California counties. 8 With California s state plan requiring that Medi-Cal policies operate uniformly statewide, it is clear that neither federal nor state policymakers intend for a family s likelihood of keeping continuous Medi-Cal coverage to depend on the county in which the family lives. In addition, counties are challenged by the complexities of state policies that can make promotion of retention more difficult. 6 CALIFORNIA HEALTHCARE FOUNDATION

Moreover, there is little empirical information available about the actual reasons for low rates of Medi-Cal retention. However, it likely relates, at least in part, to the multiple steps required to retain eligible Medi-Cal beneficiaries in the program. Families must be aware of the need to renew; counties must be able to locate families to communicate with them; families must be receptive to the renewal materials they receive even given the volume of information historically provided in the renewal packets; and families must return required forms and supporting documents by a deadline. The process can break down at any of these junctures. To learn what counties are doing to keep families enrolled, as well as to learn about the challenges they face in doing so, the Center for Children s Access to Care at the University of California at San Francisco (UCSF) conducted a survey of California s counties. UCSF worked closely with the Medi-Cal Retention Workgroup, the County Welfare Directors Association of California (CWDA), and RAND Corporation in developing the survey instrument and promoting county participation in the Keeping Eligible Families Enrolled Survey. This first of a kind survey, conducted over the Internet in the fall of 2003, was designed to learn from counties what the barriers to retention are from their perspective, what actions they have taken to overcome them, and what challenges remain. Researchers also sought to learn how recently implemented policy changes related to retention have affected these efforts and what additional policy reforms they would find useful. The survey was distributed to all 58 California counties. Ninety-five percent of them (55) completed the extensive survey; three small counties chose not to participate. 9 (See Appendix A for details about the survey.) The great majority of individuals who responded for their counties have extensive county experience. Ninety-three percent of respondents had worked ten years or more for their county government; the remaining respondents had at least four years of county experience. Most respondents (58 percent) had served in their current position for more than four years; another segment (35 percent) had held their current position for one to three years. Survey respondents reported a variety of job titles: the largest group of respondents (31 percent) was program managers; another 16 percent were either Medi-Cal program specialists or other program specialists. Other respondents included eligibility supervisors, directors, managers, supervisors, and analysts. Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 7

III. Renewal Rates and Perceived Reasons for Non-Renewal RESPONDENTS WERE ASKED TO ESTIMATE THE proportion of children and parents who are not approved when they come up for renewal and to share their opinions about why families don t renew. The estimates of renewal rates and perceptions of reasons for non-renewal discussed below are primarily based on respondents opinions, but may provide a useful perspective. Since the majority of respondents work with families on a daily basis, their feedback on families most common reasons for not returning renewal packets may help identify targeted approaches for more effective outreach at redetermination. To the question, What percentage of children up for redetermination is not approved? 85 percent of all survey respondents offered responses that ranged from a low of 0.5 percent to a high of 30 percent. The average response was 12 percent. 10 These responses indicate that county staff familiar with renewal believed that the great majority of children are approved at redetermination, though these figures are based on best guesses rather than on county data. Asked the same question about parents rather than children, 87 percent of survey respondents provided answers that ranged from less than 1 percent to 40-45 percent. 11 The average response for adult redeterminations was about 15 percent, a slightly higher non-renewal rate than the 12 percent rate estimated for children. In this case, one county reported that its response was based on county tracking, while the rest provided best guesses. Respondents were asked to rank four possible explanations for non-renewals in order of how common they occurred (though all are based on a best guess rather than hard data as verification). 12 Packet not returned was the primary explanation for nonrenewal; Packet is returned incomplete; county attempts to follow up for needed information or missing signature are unsuccessful was second; Post office returns the packet as undeliverable and there is no forwarding address was ranked third; and Client returns packet and is found no longer eligible was the lowest-ranked response. 8 CALIFORNIA HEALTHCARE FOUNDATION

According to the counties, the most common reasons for not returning the renewal packet among families who lost coverage for non-return of renewal packets but subsequently returned to Medi-Cal were: Lost or misplaced packet (19 percent of responses); Client has no immediate need/no longer wants Medi-Cal (18 percent); Packet not received by family or county didn t receive families submission (10 percent); Never completed or returned packet (10 percent); Change/perceived change in eligibility (10 percent); and Moved or problem with address (7 percent). Most counties (71 percent) believe that the primary reasons for not being renewed are no different for children than for adults, though 16 percent do think the reasons are different. Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 9

IV. How California Counties Conduct Annual Medi-Cal Renewal CALIFORNIA COUNTIES MUST CONDUCT AN annual eligibility redetermination process for every Medi-Cal beneficiary. While the process must be implemented according to Medi-Cal regulations, renewal approaches can vary from county to county. Counties answered several survey questions about how they conduct the annual Medi-Cal renewal process. All responding counties reported that they mail beneficiaries a renewal packet at their annual redetermination time, and the majority said that they make additional contact with families after sending out the packets. Moreover, most counties have initiated steps to promote or simplify the renewal process in the last two years. All Counties Mail Annual Renewal Packets Counties typically initiate the Medi-Cal renewal process by sending a packet of materials to enrollees that explains the steps families need to take to stay enrolled in the program. All 55 responding counties mail renewal packets to enrollees as the renewal date approaches. Most counties (95 percent) provide a letter in the packet. Eighty-two percent include a blank reenrollment form, while four counties (7 percent) send a personalized re-enrollment form listing key information previously reported by the client. Most counties (67 percent) volunteered that they include some additional materials in their county s renewal packets such as Medi-Cal and other state or county forms. 13 Counties Innovate! Four counties send a personalized renewal form listing required information reported previously by the client so that only new, or otherwise missing information, needs to be completed for renewal. Most respondents (57 percent) mail renewal packets 31 to 60 days before the client s renewal date while another 30 percent send them 16 to 30 days prior to the date. No counties send the packets out more than 90 days before the renewal date. 10 CALIFORNIA HEALTHCARE FOUNDATION

Most Counties Follow Up after Mailing Renewal Packets Most counties make additional contact with families after sending the renewal packets. About 75 percent of counties mail a reminder letter or postcard and over half (55 percent) make reminder phone calls. Large counties (71 percent) telephone clients at a greater rate than medium counties (55 percent) and small counties (47 percent). Several counties also mentioned sending discontinuance notices (that is, a note that informs the family that if the materials are not returned within a specified period of time, the beneficiary will be dropped from the program) or an extra letter as a reminder. Although most counties make additional contact, nine counties (16 percent) use the renewal packets as their only approach to contacting families at renewal time. Most counties report multiple additional attempts to contact families by letter, postcard, or telephone. The majority 34 counties (62 percent) make two to three additional attempts, while 11 counties (20 percent) make one extra contact, and one county (2 percent) makes four to five additional contacts. Counties Innovate! Inyo County makes up to four phone calls to clients due for renewal. Staff believe that calls ease their workload because clients are more likely to bring or send in necessary verifications. Most Counties Take Steps to Promote and Simplify Renewal Process The majority of California s 55 responding counties (62 percent) reported having implemented special efforts in the past two years to promote and/or simplify the annual Medi-Cal renewal process. The new efforts were most common among large counties (88 percent), while 63 percent of medium and 50 percent of small counties implement such activities. The most common practices identified included: The use of new, simplified forms, instructions, and or other materials in packets (56 percent of counties); Special contact (such as postcards or calls) to remind families of the importance of renewal (53 percent); Use of specially designed mailers or envelopes for the renewal packets (50 percent); and Reminders to families to provide agency with change of address when moving (21 percent). Counties Innovate! San Bernardino County piloted an effort to use eye-catching, color-printed labels on outgoing renewal packet envelopes and on the return envelopes. The 2003 pilot showed a significant increase in the rate of return of fully completed redetermination responses and the pilot is being implemented countywide. The outgoing renewal packet envelope labels feature color-printed multiple messages such as Important! Open Immediately/Time Sensitive/Information is needed. Both the outgoing envelope and return envelope are personalized with the due date for returning the beneficiary s necessary forms. Other special efforts to promote or simplify annual renewal include: Collaborating with health plans, community clinics, and other organizations to notify families of upcoming renewal; Completing the renewal form for clients via a telephone interview and mailing the completed packet to clients for their review and signature; Making workers available for extended Friday phone hours; Installing direct phone lines from the lobby to the main office to increase assistance; Allowing clients extra time to return the packets; Testing the concept of a dedicated retention worker; Convening a retention committee to develop strategies for increasing the number of successful renewals; and Piloting a self-declaration process for annual redetermination (under an 1115 waiver). Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 11

Counties Innovate! Amador County offers beneficiaries three ways to handle redetermination: complete and mail the form back to county; come to a county office for an in-person meeting; or speak on the phone with an eligibility worker who enters the changes. The majority (62 percent) of the 21 counties that have not initiated special efforts to promote renewal say this is due to county budget restraints and 19 percent specified state-level policy barriers (though the types of barriers were not specified). Other reasons given for not initiating special efforts included insufficient staffing and efforts not considered necessary. Counties Innovate! Merced County staff receive small SNAP cards reminding them to verify key information every time they speak with clients (not just at renewal time) to keep clients contact information current. The acronym SNAP helps staff remember to check: (S) Social Security number; (N) name; (A) address; and (P) phone number. Most Counties Attempt Telephone Contact at Redetermination Most counties (64 percent) report that they attempt phone contact at redetermination more than 50 percent of the time. Another 26 percent believe phone contact is attempted 25-50 percent of the time, while just 11 percent report attempting phone contact in less than 25 percent of redeterminations. (Eight don t know responses were excluded from these calculations.) Responses to another question on the topic of phone contact suggest that phone calls are considered somewhat effective in keeping Medi-Cal families enrolled. Asked about the percentage of required phone contacts that are successful in establishing ongoing eligibility, 41 percent picked the 25-50 percent category, while another 32 percent said 51-75 percent; 23 percent chose the under 25 percent category; and only 5 percent indicated the above 75 percent category. (Eleven don t know responses were excluded from these calculations.) Counties Innovate! Los Angeles County customized a one-page glossary of words your worker might use that provides easy-to-understand explanations of terms used in Medi-Cal forms and letters. Available in eight languages, the glossaries are included in initial enrollment packets but can also be used as a resource for redetermination cases. Counties Refer Clients to Other Health Programs All California counties refer families to other insurance programs such as Healthy Families (if the client no longer meets Medi-Cal requirements) at least some of the time. Most counties (64 percent) always make such referrals, while 31 percent of counties make the referrals if the families meet screening criteria for such programs and 3 counties (5 percent) sometimes make such referrals. Small- and medium-sized counties refer families to other programs at a significantly higher rate (80 percent and 68 percent, respectively) than large counties (13 percent). A small share of counties (15 percent) allow Medi-Cal eligibility workers to enroll families in Healthy Families or any other health program besides Medi-Cal (some of which likely refer to local Healthy Kids programs, though this question wasn t specifically asked). Generally, this requires new agreements between social services and health services agencies, as well as changes in operating procedures. However, the experiences of these counties suggest that cross referrals are achievable. Counties Innovate! All Madera County staff are cross-trained to enroll and re-enroll eligible beneficiaries in Medi-Cal, Healthy Families, CalWORKs, food stamps, and the County Medical Services Program. 12 CALIFORNIA HEALTHCARE FOUNDATION

V. Counties Reactions to New Eligibility Policies NEW STATE POLICIES DESIGNED TO PROMOTE retention in Medi-Cal have been introduced over the past several months. These include California s Senate Bill 87 (SB 87), which requires counties to take specific steps to ensure that clients who remain eligible retain their Medi-Cal coverage; and Mid-year Status Reports (MSRs), a new requirement that took effect in August 2003, which requires some Medi-Cal beneficiaries to re-confirm on a semi-annual basis that they continue to be eligible for the program. Researchers sought to understand how these two policies have affected retention and, specifically, how they have affected counties efforts to increase retention rates. Senate Bill 87 The survey asked counties several questions about implementation of SB 87, which was signed into law in September 2002 and includes a number of provisions that affect Medi- Cal s annual renewal process. The legislation s goal was to help eligible families stay enrolled despite changes in families circumstances, such as household income, composition, or age categories. Under SB 87, counties must take additional steps to ensure that clients who remain eligible retain their Medi-Cal coverage. For example, they must check for clients eligibility in other Medi-Cal categories when they are found ineligible in the original category. The legislation also requires that eligibility staff first check any available information about the family, including that found in Medi-Cal, CalWORKs, and food stamps files; and other available sources before asking the family to provide it and before disenrolling them for not providing it. Only after this ex parte review may staff contact the family. Counties may telephone families and/or send a form requesting only the specific information that is required for re-enrollment. SB 87 also encourages collaboration among counties, Medi-Cal managed care health plans, and community-based organizations to support renewal efforts. Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 13

Most Counties Believe SB 87 Helps Medi-Cal Retention Most counties (62 percent) believe that SB 87 has been helpful in enabling clients to retain Medi-Cal coverage while 22 percent do not and 16 percent say they don t know. Counties that believe SB 87 has not been helpful most commonly (4 mentions) stated that SB 87 was confusing to clients (that is, clients are unsure why they are being asked about their participation in non- Medi-Cal programs) and time-consuming for staff. Three counties commented that the process has not changed the proportion of clients that fail to provide information. Few Counties Believe SB 87 Has Promoted Collaboration One of the goals of SB 87 was to promote coordination among counties and health plans in helping families retain coverage since health plans have regular contact with families; however, only 11 percent of counties believe SB 87 has succeeded in fostering better general collaboration with health plans. Most counties (85 percent) said SB 87 has not led to a closer relationship with health plans; although many of these gave comments indicating it was not a problem to them. The relatively low rate of coordination with health plans is due in part to the delayed timing of Medi-Cal administrative support (such as development of required forms and technology issues that are being addressed) for the effort. 14 A higher proportion of large counties (38 percent) than medium (4 percent) and small (10 percent) counties believe that SB 87 has led to closer coordination with health plans. Each of the six counties that say SB 87 has led their county to work more with health plans reported that they coordinate with health plans to clarify coverage issues and share address changes. Some counties also mentioned collaboration on plans to promote retention and referrals to Healthy Families. One of the counties cited extensive collaboration including monthly meetings with health plans and other stakeholders to review data, policies, procedures, and to develop strategies to improve retention efforts. Among these six counties, four characterized their relationships with the health plans as excellent; one described its relationship as good; and another as fair. Counties Innovate! Merced County has implemented a RAP line (Rapid Assistance for Providers) a dedicated phone line for health care providers to ask questions or check on a client s Medi-Cal status. Respondents who said that SB 87 had not fostered closer coordination with health plans were asked an openended question about what barriers they have faced in working with health plans. Barriers cited include: little or no communication with the health plan; staff shortage and budget constraints; perceived confidentiality rules limiting communication; and limited ability to exchange digital data with health plans. However, some counties have established regular communications with health plans. Counties described how they meet regularly with health plans to identify families with upcoming renewal deadlines and to locate families that have moved. Most Counties Take No Steps Beyond Required SB 87 Procedures Survey respondents were asked: In addition to the required SB 87 procedures (ex parte review, phone calls, and MC 355 form), does your county take any other steps when a redetermination is triggered by a change in circumstances at a time other than the annual redetermination? Most counties (83 percent) said they take no steps beyond the required procedures. Counties were also asked, In approximately what percentage of cases do clients retain coverage when redetermination is required at a time other than annual redetermination? More than two-thirds of the counties (71 percent) answered above 75 percent while one-quarter indicated 51 to 75 percent and only one county each said 25 to 50 percent and 25 percent. 15 (Twenty don t know responses were excluded from these calculations.) Interestingly, two-thirds (63 percent) of large counties chose don t know while only 37 percent of medium counties and 25 percent of small counties did so. 14 CALIFORNIA HEALTHCARE FOUNDATION

Most Counties Agree that Administration of SB 87 Is Challenging When asked whether SB 87 has posed new challenges or burdens for the county, the great majority of counties (89 percent) said yes, while 7 percent responded no, and 4 percent reported don t know. 16 Almost all counties (94 percent) describing the challenges agreed with both the statements SB 87 requirements have imposed extra demands on staff and SB 87 requirements can make the redetermination process very long. About half of the counties (51 percent) affirmed the statement ex parte reviews are not always helpful. Less than a quarter of counties (22 percent) considered state instructions on how to conduct ex parte reviews insufficient. Similarly, less than one-third of counties (29 percent) agreed that overall state instructions on how to administer SB 87 have been insufficient. To an open-ended query about other SB 87 challenges and burdens, several counties weighed in. Five commented that the SB 87 process seemed to be of little benefit to clients and two said the process increased the workload for overburdened staff. SB 87 Ex Parte Reviews Produce Mixed Results Most counties (57 percent) said less than 25 percent of ex parte reviews reveal information necessary or useful for redetermination, while another 20 percent said that 25 to 50 percent provided such information. Only 22 percent of counties reported that more than 50 percent of ex parte reviews generate useful information. (Eleven don t know responses were excluded from these calculations.) The majority of counties (59 percent) believed less than 25 percent of ex parte reviews establish ongoing eligibility without requiring additional information and/or contact with the client. Another 28 percent chose 25-50 percent while only 14 percent believe that more than half of ex parte reviews generate useful information. (Nine don t know responses were excluded from these calculations.) As indicated by the responses to the two questions above on ex parte reviews, survey respondents are not enthusiastic about the usefulness of the ex parte reviews. Most of the counties believe that less than a quarter of the reviews reveal significant information for redetermination and that additional information and/or contact with the client is necessary in most cases. SB 87 Introduced New Form Counties were asked about their other efforts to improve Medi-Cal redetermination. Specifically, researchers asked about the Medi-Cal 355 Request for Information Form, which was developed in response to SB 87. The form is used in addition to the RV 210 form, the regular annual redetermination form, to request specific documents and/or supporting information from the beneficiary or other source. Most counties (59 percent) send the MC 355 Request for Information Form in less than half of the redeterminations. The remaining 41 percent send the MC355 in more than half of the redeterminations. (Eleven don t know responses were excluded from these calculations.) Most counties (54 percent) believed more than half of MC 355 forms are successful in establishing ongoing eligibility; the remaining 46 percent thought that MC 355 forms are successful in establishing ongoing eligibility in 50 percent or fewer redeterminations. (The multiplechoice responses included under 25 percent [12 percent of respondents chose this option]; 25-50 percent [34 percent]; 51-75 percent [22 percent]; and above 75 percent [32 percent]. While somewhat fewer counties chose the under 25 percent category, the rest of the responses were spread across the remaining ranges. Fourteen don t know responses were excluded from these calculations.) Few Counties Need More Guidance on SB 87 The survey asked, Are there any policy areas for which your county needs further guidance or assistance from the California Department of Health Services (DHS) in implementing SB 87? Only seven counties (13 percent of all surveyed counties) described needs for further guidance from DHS. Nine wrote in no or not at this point, while the remaining 40 counties didn t respond to the question, suggesting that most counties are satisfied with current guidance from DHS on SB 87 implementation. Comments from the seven counties wanting Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 15

more guidance mentioned a need for clearer policies, examples of appropriate use of new instructions, clarification of the Inter-County Transfer (ICT) procedures, and more guidance on Craig v. Bonta. There were also requests for DHS to complete question-and-answer sections on its Web site; to make additions to the Medi-Cal Eligibility Procedures Manual; and to update all DHS regulations. Finally, two respondents went beyond the discussion of needed DHS guidance: one requested additional funding for staff and the other recommended eliminating the ex parte process and revising SB 87 policy. Summary of SB 87 Results SB 87 was designed to help eligible families stay enrolled in Medi-Cal and most respondents (62 percent) believe that SB 87 has been helpful in achieving that goal. More than 70 percent of counties believed that clients retain coverage more than 75 percent of the time when redetermination is required at a time other than renewal. However, another SB 87 goal, to promote coordination among counties and health plans, has not fared so well: only 11 percent of county respondents believed that a closer relationship between counties and health plans has been achieved. Though SB 87 has had a measure of success, the great majority of counties (89 percent) said that it has posed new challenges or burdens for their counties. Even more respondents (94 percent) agreed that SB 87 requirements have imposed extra demands on their staff. The significant number of counties responding don t know to a variety of quantitative questions about SB 87 implementation suggests a need for more effective county data systems to track clients and evaluate outcomes of county contacts as beneficiaries go through the SB 87 process. Mid-year Status Reports The survey sought information about how counties were managing Mid-year Status Reports (MSRs), which took effect in August 2003 and requires adults to re-apply every six months to keep their Medi-Cal coverage (as opposed to once each year as had been the case since 2000). Under the new requirement, counties must mail the MSR form to a substantial portion of adult Medi- Cal recipients. (Several categories of Medi-Cal recipients are exempt from MSRs, such as children; recipients who are aged, blind, or disabled; CalWORKs recipients; and others.) The client needs to complete and return the MSR indicating any changes in income, resources, household composition, disability, pregnancy, or address. If the client has no such changes to report, the client is nonetheless required to sign the form and return it to the county. Counties Face Challenges with Mid-year Status Reports All 55 responding counties chose to answer the question, What are your county s biggest challenges associated with the new requirement to send MSRs? Because respondents to a lengthy survey often skip over questions requiring write-in answers, the 100 percent response rate suggests that many counties were eager to voice their concerns about implementation of the MSRs requirement. The most common challenge raised by 36 counties (66 percent) was the lack of automation for the MSR process which necessitated manual tracking; another 4 counties (7 percent) cited challenges in identifying and tracking those needing to be sent MSRs. Twenty counties (36 percent) specified lack of staffing to handle the increased workload generated by the MSR requirements. Eight counties (15 percent) spoke about the lack of clear guidance about MSR implementation from the California Department of Health Services. The lack of lead time to train staff and implement the MSR process was also identified as a challenge by eight counties. Confusion for clients was cited as a challenge by four counties and other concurrent implementation changes by two. Although almost all counties identified challenging aspects of the MSR requirements, it is worth noting that two counties (4 percent) volunteered that they did not anticipate MSR implementation to present a challenge. 16 CALIFORNIA HEALTHCARE FOUNDATION

Counties Respond to Increased Workload from MSRs When asked about their plans to meet the new workload demands, 15 counties chose push back the start date of sending MSRs from August 2003 to a later date and 12 counties selected have a dedicated staff person or unit perform the work. The dedicated staff plan was relatively common among small counties (47 percent) and somewhat less common among medium counties (23 percent). (Too few large counties answered the question, so those results are not presented.) No counties agreed with the statement out-source the work to a vendor. More than 20 counties volunteered other approaches they planned to help them meet the MSR requirements, including: Hiring additional staff; Implementing a new or modified process; Doing manual reporting; Phasing in implementation based on technical support; and Establishing a call center for redeterminations. Five counties had already implemented MSRs by the time of the survey (September to November 2003), although one of these counties noted we implemented MSRs in August [2003] requiring staff to process manually. This added more workload to an already burdened workload. Two counties found implementation of MSRs did not significantly increase the workload. Counties Innovate! Santa Cruz County gives the local Medi-Cal managed care plan a list of nonrespondents to the first MSR mailing. The plan then follows up with clients to encourage them to complete the MSRs. Thirty-six counties (65 percent of responding counties) volunteered a range of ideas that might be helpful to other counties implementing MSRs. Eleven counties developed ad hoc reports to identify clients with MSR requirements and generate mailing labels (these respons- es came from counties using several different data systems). Five counties tracked the MSR clients manually. Six counties described creating special cover letters for the MSRs, while five counties had contacted other counties for ideas, benchmarking, or best practices, and three had adapted MSR cover letters from other counties. One county has created a desk guide for the workers to use that identifies the key points of the MSR process. Counties Innovate! Santa Clara and Sacramento Counties adapted Los Angeles County s Don t Lose Your Medi-Cal Benefits MSR flyer for use in their counties. The flyers are available in English and Spanish. Most Counties Seek Tools to Manage MSR Process Finally, counties were queried about whether any tools might make sending MSRs easier. The great majority, 81 percent of respondents, expressed their need for tools to automate the generation and mailing of the reports and assist staff in managing and monitoring the return of MSRs and subsequent follow-up. It is notable that so many respondents to an open-ended question (not multiple choice) described the same needs. Automation and tracking received more than four times as many mentions as all other ideas combined. This shows how strongly many California counties feel about their need for automation and tracking tools to manage MSRs. Other responses to the question about tools included three counties (all medium-sized) recommendations that the state (rather than counties) generate and mail the MSRs to appropriate clients. Counties also suggested providing money for extra staffing; providing clearer state guidelines; allowing more flexible timeframes for implementation; requiring clients to return required verifications; and discontinuing the MSR process. One county volunteered that it has updated its county Medi-Cal handbook to include a discussion of MSR procedures. Keeping Eligible Families Enrolled in Medi-Cal: Results of a Survey of California Counties 17

VI. Conclusion: Ideas for Action CALIFORNIA IS AT A CROSSROADS. SIGNIFICANT opportunities exist to transform the Medi-Cal program through the California Performance Review and the immediate need to achieve cost savings and greater efficiencies. The results of this survey raise specific ideas about how to improve the administration of Medi-Cal to retain eligible families in the program to benefit families with continuous coverage, reduce the need to locate and re-enroll the disenrolled, and save state and county resources. The counties in the survey offered several specific policy reforms that would support their efforts: Simplify the Medi-Cal annual eligibility redetermination form (Medi-Cal Form 210RV, a three-page document that recipients must complete to retain Medi-Cal coverage); Allow recipients to renew Medi-Cal by telephone; Align state requirements with federal requirements; 17 Eliminate redetermination processes including SB 87 and ex parte reviews; Use the same reporting requirements as other public programs such as Food Stamps and CalWORKs; Eliminate asset limits for all Medi-Cal beneficiaries; Allow face-to-face redeterminations; and Automate the renewal process by pre-printing clients forms with previously reported information and asking them to indicate changes on the form. In a broader sense, the survey results point to several action steps to improve the effectiveness of Medi-Cal renewal processes. 1. Elected officials and program leaders at both the state and county level should invest in efforts to identify, evaluate, and promote best practices in Medi-Cal renewal. Renewal practices vary considerably from county to county, due partly to the lack of information on the effectiveness of current renewal practices. California counties need researchbased guidance on optimal approaches to Medi-Cal renewal. Research efforts should focus on identifying, evaluating, and promoting best renewal practices. In an era of leaner budgets, it is particularly important that counties use proven approaches to improve Medi-Cal renewal. 18 CALIFORNIA HEALTHCARE FOUNDATION