| Statement of J. Ruth Kennedy, Medicaid Deputy Director, Louisiana Department of Health and Hospitals, Baton Rouge, Louisiana Testimony Before the Subcommittee on Health
of the House Committee on Ways and Means May 03, 2007
Chairman
Stark, Ranking Member Camp and distinguished members of the Health Subcommittee:
Good morning. My name is Ruth Kennedy and for the past seven years I have been
a Deputy Medicaid Director for the Louisiana Department of Health &
Hospitals. In that position, I am responsible for Medicaid and SCHIP
eligibility and enrollment in our State. During those seven years, we have made
a concerted effort to increase enrollment of eligible seniors and people with
disabilities into our Medicare Savings Programs. Most recently, one of the immediate
goals of Governor Kathleen Blanco’s 2004 Health Care Reform Plan included
increasing participation of eligible but unenrolled persons in the Medicare
Savings Programs (MSP).
I
want to thank the Committee for the invitation this morning to share some of
the methods and strategies that have proven successful in substantially
increasing enrollment in the Medicare Savings Programs in Louisiana. In the
period from January 2000 to April 1st of this year we have seen
enrollment in the Medicare Savings Programs increase by just under 43,000
individuals, which for us represents a 44% increase. The biggest percentage
increases were in our Pure SLMB and QI-1 Programs: 161% and 401%
respectively. I make mention of this because nationally, the SLMB and QI-1 have
lower take up rates than QMB.
Background
Louisiana first began to focus on increasing
enrollment in MSP in late 1999 in response to correspondence from CMS [at that
time HCFA] which urged states to take pro-active steps to increase
participation of eligible but unenrolled people into the Medicare Savings
Program.
For
MSP qualifying seniors and people with disabilities, the current $93.50
increase in their monthly Social Security check represents as much as a 17%
increase in “spendable” dollars. Now that MSP enrollees are also automatically
eligible for Extra Help with out-of-pocket costs and immediate enrollment into
a Medicare Prescription Drug Plan, the value of MSP participation is even
greater.
The
increase in enrollment in Louisiana has resulted from a combination of
administrative simplification and intensive, ongoing outreach. Outreach alone
is of limited usefulness unless both the application and renewal
processes are streamlined and simplified.
Application
Simplification
Low
literacy levels, poor eyesight, hearing impairments, memory loss and other
health care problems are barriers to enrollment which we have identified and
are working to mitigate. We designed a simplified Application Form specifically
for the Medicare Savings Programs, eliminated the requirement for a
face-to-face or telephone interview, relaxed verification requirements, and we
use less restrictive methods when calculating countable resources. These are
all options allowed the States by CMS. Information and application assistance
is readily available through a widely publicized toll-free MSP hotline that is
manned by knowledgeable Medicaid eligibility professionals.
Focus
on Retention
The
annual renewal process has been addressed as well, since we found in our State
that many enrollees were having their cases closed not because they were
no longer eligible for MSP, but solely because they did not return the required
paperwork. We began conducting ex parte reviews where possible, i.e.,
using our inquiry rights to other systems such as Food Stamps to verify income
and resources. When an ex parte renewal is not possible, caseworkers
can complete the review of circumstances subject to change by telephone,
without the need for a signed renewal form. These procedures have resulted in
less than ˝ percent of our enrollees having their case closed for failure to
return a renewal form.
Beginning
in July, we are further simplifying MSP renewals by adopting the technique used
by the Social Security Administration to conduct renewals for Low Income
Subsidy. We will mail letters advising enrollees of the income and resource
information on our records and request that they contact us only if our
information is incorrect or their income or resources has changed. Otherwise
they need not do anything. A careful review of our administrative data revealed
that our MSP cases are almost never closed at renewal because of increased
income or resources so we believe this is responsible public policy.
We
know that keeping eligible people enrolled— or plugging the holes in the
bucket—is an important key to increasing Medicare Savings Program
participation. Reducing closures at renewal for purely procedural reasons and
simplifying the renewal process have resulted in significant administrative
savings for the Department as well.
[1]
Closures
at renewal can result in undue hardship for this vulnerable population. Persons
closed at renewal are often not aware that their case has been closed until
they
discover that the amount of the Social Security check directly deposited into
their checking account is ~$280 less than anticipated. The retroactive and
current premiums due to SSA were automatically deducted.
Importance
of Outreach
We
have made substantial administrative changes. But the reality is without help,
many people in our target population are unable to navigate even our “kinder,
gentler” bureaucracy. The only way to reach them is through intensive
outreach and face-to-face interaction—contact with them, but also with their
sons and daughters, with their grandchildren, with their nieces and nephews,
with caring friends and neighbors, and with sources of information they
trust.
Community
Partners
We
have forged partnerships with hundreds of those sources of information: SHIP
outreach workers, the Social Security Public Affairs Specialists in Louisiana, community organizations, medical providers, and local social service agencies.
They are valuable partners for identifying and disseminating information to
potential enrollees, many who are homebound or live in rural areas. These
local partners have day-to-day contact with our target audience and have
credibility and the trust of their communities. We have found that the
messenger is very important. Our targeted population responds well to a
representative at the local Social Security Office, Council on Aging, Meals on
Wheels, their doctor, pharmacist, or home health provider. Without question,
the MSP partners we have engaged have been instrumental in helping raise
awareness and increasing enrollment.
Role
of Medicaid Eligibility Employees
Medicaid
eligibility employees who work in the 45 local Medicaid eligibility offices
throughout the state have spearheaded our MSP community outreach efforts,
logging literally thousands of hours. These employees—caseworkers, supervisors,
and managers-- live in the cities, towns, and communities where they are
conducting outreach. They understand the culture. They can identify those
trusted sources of information in the community and recruit partners. They
have the knowledge and experience to assist with application completion and answer
questions about MSP. Our eligibility offices have recruited community
partners, distributed and kept stocked MSP applications in “Take One” holders,
given presentations about MSP, and conducted special direct mail initiatives.
They have raised awareness of MSP and provided one-to-one assistance at
hundreds of events and locations, with much of the activity taking place after
normal working hours and on weekends.
This
past month for example—April of 2007—some of the settings in which our
eligibility staff conducted MSP outreach were the Gusher Days Festival in Oil
City, a Walgreens Pharmacy in New Iberia, the Etouffee Festival in
Arnaudville, a community health center in Luling, the Delta Music Festival in
Ferriday, a Family Life Conference in Hammond, heath fairs at places of
worship in Baton Rouge and Monroe, and a senior citizen’s center in eastern
New Orleans.
Our
initiative to empower and provide opportunities for eligibility staff to
conduct outreach for the Medicare Savings Programs is the same model we had
earlier used beginning in late 1998 to increase enrollment of children in our
Medicaid and SCHIP Programs. Their performance has greatly exceeded our
(high) expectations. Our employees have demonstrated a strong commitment to
helping seniors and people with disabilities who have limited income and
resources. They have proven to be creative, imaginative, and passionate about
outreach and they believe that what they are doing is important and deserving
of their time and effort. Staff engaged in outreach work tirelessly to
maintain their regular workload while also engaging in MSP outreach efforts.
[2]
Funding
MSP Outreach
The
outreach model we have employed is relatively low cost. But without monetary
investment in outreach, we could not have achieved increases of this magnitude
Medicare Savings Programs enrollment. In our case, funding for outreach as well
as valuable technical assistance was provided by the Robert Wood Johnson
Foundation through a three year State Solutions grant ($140,000
annually) and a subsequent, one year, “post-Katrina” grant. We were able to
claim federal matching funds for Medicaid administration (50% FFP).
With
that funding we held annual conferences for staff involved in MSP outreach at
which they shared promising practices, heard from national subject matter
experts and networked with local MSP partners. We purchased promotional items,
which we found to be essential for generating interest at our outreach events.
We provided compensation to employees for travel and for work performed outside
normal working hours and on weekends, we printed posters and flyers, we paid
for radio commercials, and we paid for follow up mailing to individuals identified
through the Social Security Administration’s “leads” file.
I
must acknowledge the Rutgers Center for State Health Policy which, in
conjunction with the State Solutions grant, provided technical
assistance, guidance, and support. They provided important expertise and
additional resources such as opportunities to network with other States and
organizations who are working to increase enrollment in MSP
It
is important to evaluate outreach activities to assure that we are getting “the
biggest bang for the buck.” We closely monitor the number of phone calls
requesting MSP information or an application and the actual number of new
applications received as well as enrollment and retention trends in each
geographic region of the State so that we can quickly and make adjustments as
needed.
Program
Costs in Louisiana
While
the costs for outreach have been relatively modest, the same cannot be said for
the impact of increased enrollment on the Medicaid Budget. A 44% increase in
enrollment translates to a 44% increase in our budget for Medicare Buy-In, at
the same time that Medicare Part B premiums have been sharply increasing.
Unlike regular Medicaid budget cuts, in which reductions in payments to
providers is an option, we do not have the latitude to reduce our state match
for the “fixed” Medicare Part B premium.
I
previously alluded to the rapid growth in enrollment in our QI-1 program. In
FFY 05, our QI-1 allotment was not sufficient to continue enrollment beyond
March. We were unable to enroll additional eligible individuals for five months
while CMS was working to get us a supplemental appropriation.
Conclusion
We have found effective outreach for the Medicare Savings Programs to be more
challenging than outreach to enroll uninsured children. Our target population
is more likely to view government-funded programs with fear and mistrust, and
stigma is certainly a factor.
Nevertheless,
largely as result of Louisiana’s aggressive and sustained Medicare Savings
Program outreach and administrative simplification initiative, 43,000 more Louisiana
citizens with limited income and resources are now receiving much needed help
with Medicare costs than received help in 1999. We had the infrastructure in
place to actively participate in outreach for the Medicare Prescription Drug
Program Low Income Subsidy and did so. Reducing the number of people eligible
for, but not enrolled in MSP has reduced the number of people eligible for, but
not enrolled in or receiving Extra Help with a Medicare Prescription Drug Plan.
For
all our success in connecting with and enrolling additional people into these
programs, we have reason to believe that thousands of other people in
Louisiana who would greatly benefit from enrollment in MSP are not yet
enrolled.
They still don’t realize that help through the Medicare Savings Programs
is available. If they do, they’re not aware that we have simplified the
application and requirements for enrollment. Their perception is that
the application process is onerous and that it is highly unlikely that their
application would be successful. We’ve all heard the axiom “perception is
reality”. We’ve changed the reality and we are working to change the
erroneous perception-- for the sake of needy Louisiana citizens who
qualify for, but are not yet enrolled and receiving the benefits, of the
Medicare Savings Programs.
Thank
you for the opportunity to share with your our experience.
[1]
Summer, Laura Administrative Costs Associated with Enrollment and Renewal
for the Medicare Savings Programs: A Case Study of Practices in Louisiana,
2004 http://www.statesolutions.rutgers.edu/Reports/LA_CaseStudy_v1.pdf
2 Sofaer,
Shoshanna , Assessing the Louisiana State Solutions Project, May 2006
http://www.statesolutions.rutgers.edu/Reports/Shoshanna%20Brief.pdf
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