A Blueprint for the Future Executive Report

Transcription

1 MODERNIZING ENROLLMENT IN CALIFORNIA S HEALTH PROGRAMS FOR PREGNANT WOMEN AND CHILDREN A Blueprint for the Future Executive Report Prepared for: Blue Shield of California Foundation California HealthCare Foundation The California Endowment The David and Lucile Packard Foundation August 10, 2007 Eclipse Solutions, Inc River Plaza Drive, Suite 320, Sacramento, California Phone: (916) Info@EclipseSolutions.com Fax: (916)

2 Table of Contents Introduction & Purpose... 1 Background...1 Project Scope and Approach... 3 Findings / Business Problems... 4 Policy Environment... 9 Piecemeal and Conflicting Legislation...9 Funding Availability...9 Program Silos...9 Multiple Agency Oversight...10 State versus County Eligibility Administration...10 Specific Legislation...10 Lessons Learned from Other States Other State Summary...12 Recommendations The Future State...14 Interim Recommendations...19 Improving Self-Service to Increase Enrollment...19 Enhancing the CHDP Gateway to Streamline Enrollment...21 Better Facilitating Continuous Coverage...24 Conclusions Executive Report August 10, 2007 Page ii

3 List of Figures Figure 1 Shared Services on the ESB...15 Figure 2 High-Level View of the Self-Service Enrollment Process in the Future State...16 List of Tables Table 1 Summary of Findings / Business Problems...5 Table 2 Comparison of Ongoing Efforts to Streamline Enrollment Processes...12 Table 3 Estimated Program Look-Up / Inquiry Development Costs...18 Table 4 Estimated Enrollment Development Costs...18 Table 5 Interim Recommendations and Estimated Costs...27 Executive Report August 10, 2007 Page iii

4 Introduction and Purpose

5 Introduction & Purpose In August 2006, the Blue Shield of California Foundation, the California HealthCare Foundation, The California Endowment, and the David and Lucile Packard Foundation (collectively, the Foundations ) contracted with Eclipse Solutions, Inc. (Eclipse) to conduct an independent assessment of California health and social services program requirements and associated information technology (IT) systems to develop a blueprint for achieving the goal of a more streamlined, integrated and efficient approach to enrollment and retention. Streamlined, integrated and efficient are defined as follows: Streamlined: Reducing the need for consumers to share information more than once. Integrated: Sharing information electronically with minimal human intervention. Efficient: Minimizing redundant activities and supporting ongoing operations with on-line, real-time connections. It is within this framework that the findings and recommendations are organized and presented in this Executive Report. A more complete description of this programmatic and technical assessment, along with its results, is contained within a separate document, Modernizing Enrollment in California s Health Programs for Children Report Appendix. Background Enrollment processes for California s health and social service programs are complex and disconnected. Based on a recent study conducted by the UCLA Center for Health Policy Research, more than half of California s uninsured children were eligible for public programs in 2005, but were not enrolled 1. While the number of uninsured children decreased in 2003 due to extensive local and statewide efforts and resources invested in outreach and enrollment by Medi-Cal and Healthy Families and locally funded Healthy Kids programs, numbers since then have remained static. As California s population has grown in size and diversity, so have its programs that serve children and pregnant women. Indeed, the programs designed to serve that population have become more numerous and more complex; in addition, local programs for children are isolated from other programs designed to serve similar populations. Complex eligibility requirements and siloed enrollment processes supported by stand-alone systems can act as barriers to the uninsured seeking coverage and care. Finding it difficult to maneuver through the public health insurance maze, prospective beneficiaries can be discouraged from applying for services. Many programs that have been designed to address their needs require the same or similar sets of information to determine eligibility. Redundancies and inefficiencies are sometimes the norm rather than the exception. In an effort to make it easier to apply to California s programs that serve children and pregnant women and streamline the enrollment process, the California Legislature passed Senate Bill 24 (SB 24) in October This bill required the California Department of Health Care Services (DHCS) to establish two new electronic gateways the Newborn Hospital Gateway, which 1 UCLA Center for Health Policy Research, October Of the three-quarters of a million children (763,000) who were uninsured at the time of the 2005 California Health Interview Survey (CHIS 2005), nearly one-half million children (447,000) were eligible for either Medi-Cal or Healthy Families under current rules for enrollment but they were not enrolled. Executive Report August 10, 2007 Page 1

6 would enable hospitals to electronically submit enrollment data for infants automatically eligible for Medi-Cal from birth through age one year because their mothers had Medi-Cal coverage for the delivery, and the Prenatal Gateway, which would enable pregnant women to apply for Medi- Cal with a new, simplified application form from a provider s office, start coverage the same day, and keep coverage until a final eligibility determination is completed by the Medi-Cal program. Women over-income for Medi-Cal (over 200% of poverty) are to be referred under SB 24 to the Access for Infants and Mothers (AIM) program (300% of poverty). Finally, SB 24 stipulated that none of the above would occur until funding and staffing were available to DHCS; once the new enrollment mechanisms are in place, the state is responsible for health care costs and all program administration. In response to the passage of SB 24, DHCS began researching an approach to implementing the bill and continues to assess its options for accommodating the requirements of this and other related bills. DHCS also requested the Foundations to support its efforts to implement the bill. The Foundations, in turn, have chosen to offer not only proposed solutions to the mandates of SB 24 but also a comprehensive blueprint for streamlining enrollment and retention of eligible individuals in California s health and social services programs serving children and pregnant women. Executive Report August 10, 2007 Page 2

7 Project Scope and Approach

8 Project Scope and Approach The California health and social services programs that were assessed in this study included: Access for Infants and Mothers (AIM); Child Health and Disability Prevention Program (CHDP); Healthy Families (HF); Medi-Cal for Children (MCC); and the Women, Infants and Children (WIC) Supplemental Nutrition Program. Eclipse also reviewed the Express Lane Eligibility (ELE) process that allows children who qualify for the National School Lunch Program (NSLP) to apply for Medi-Cal and HF, and the Single Point of Entry (SPE) unit that screens and processes joint HF and MCC applications and forwards the applications to the counties or the HF enrollment contractor for eligibility determinations on behalf of the DHCS 2. The supporting technologies included in this review were the CHDP Gateway (GW), which provides an automated pre-enrollment process for uninsured children seeking a health assessment at their CHDP provider s office to receive ongoing health care coverage through Medi-Cal or HF; Health-e-App, an Internet application that electronically transmits applications, signatures and supporting documents from local enrollment sites to SPE for processing and eligibility determination for HF, screening of applications for Medi-Cal, and referral of Medi-Cal applications to the counties for eligibility determinations; and One-e-App, a web-based application that enables users to access publicly-funded health and social service programs including Medi-Cal, HF, county indigent programs, and Healthy Kids (county-sponsored coverage expansion programs). In addition, Eclipse obtained an understanding of the systems of records that support the programs in this review. This includes the administrative vendor s (MAXIMUS) proprietary system (MAXe 2 ), which supports AIM and HF, the Integrated Statewide Information System (ISIS), utilized by the WIC program, and the respective system interfaces to California s Medi-Cal Eligibility Data System (MEDS). To conduct this assessment, Eclipse reviewed written materials and interviewed subject-matter experts. We also spoke with local program representatives and other states to gather comparative data. In addition, we met with a representative of the State Chief Information Officer (CIO) to ensure that our recommendations are consistent with the State s information technology vision and future direction. We also reviewed recently passed legislation that relates to the scope of this project. During this assessment, we validated the data we gathered with representatives of DHCS, the Managed Risk Medical Insurance Board (MRMIB), and The Center to Promote HealthCare Access to ensure that our understanding of the programs and IT solutions included in the assessment was accurate. Based on this assessment, Eclipse has developed both interim and future state recommendations that, taken together, offer a blueprint for streamlining the enrollment process for health and social services programs that serve children and pregnant women in California. 2 HF and AIM is administered by the Managed Risk Medical insurance board (MRMIB). MRMIB is responsible for overseeing various aspects of the program, including eligibility, enrollment, and oversight of MAXIMUS, the administrative vendor. Executive Report August 10, 2007 Page 3

9 Findings / Business Problems

10 Findings / Business Problems This assessment identified several issues and observations about how individuals apply for, and enroll in, programs that serve children and pregnant women in the State of California 3. Program eligibility is defined differently in each program. Processes and systems that support these functions have evolved over time and are neither streamlined, nor well integrated in most instances. Without a holistic approach, opportunities to coordinate functions across programs and to realize efficiencies are minimal. Currently, applicants are generally unable to learn about, or electronically apply for, more than one program at a time 4 unless local agencies provide them with extensive assistance and do much of the application process on behalf of an applicant. The issues and observations identified in this assessment are captured into five overarching findings / business problems. These include: 1. Lack of a Unified Agency-Wide Approach. The Health and Human Services Agency (HHSA) has not taken an enterprise-wide approach to develop, implement, and streamline enrollment processes for California s health and social services programs in order to eliminate IT strategies that focus on the implementation of a single program and pose barriers or limit the exchange of information with other programs that provide complementary services to recipients. 2. Minimal Data Sharing Between Programs. The extent to which California s health and social service programs share data is minimal. Applicants wishing to apply for multiple programs provide the same information more than once, which leads to errors that make it difficult to establish the full range of services an applicant may be eligible to receive. 3. Enrollment Processes are not Always Consumer Friendly. Current enrollment processes are not always consumer-friendly (e.g., confusing application forms), which discourages eligible persons from applying for services they could rightfully receive. 4. Outdated and Disparate Technology. Some of DHCS major IT systems use dated and disparate technology, making it difficult to enhance them to support the current business need to exchange and use common data. 5. Reliance on Manual Processes. Many activities that support enrollment processes for California s health and social services programs are manually performed which is expensive, time consuming and error prone. Each finding, with summary observations and examples from the current environment that illustrate the business problem, is presented in the table below. 3 See Program and IT Solutions Overviews, Executive Report Appendix for additional information. 4 Applicants can apply for two programs using the join Medi-Cal/Healthy Families mail-in application form. They can also apply for CalWORKS, Food Stamps, and Medi-Cal using the SAWS 2 application form. Executive Report August 10, 2007 Page 4

11 Table 1 Summary of Findings / Business Problems # Finding/Business Problem 1 Lack of a Unified Agency-Wide Approach Summary Observations No coordinated HHSA-wide approach. Discrete funding streams. Multiple program silos. Stand-alone enrollment processes. Examples There are no federal / state mandates that require coordination across all the programs included in this assessment. Funding streams are often designated for a specific program, limiting their use for cross-program coordination. Programs are housed in different divisions serving the same population. There is no comprehensive approach to simultaneously capturing data and determining eligibility across multiple programs. Separate systems are used to determine program eligibility (e.g., Medi-Cal and HF). Program eligibility varies due to complex set of policy rules. While ISIS, the CHDP GW and MAXe 2 interface with MEDS, they do not interface with each other. Health-e-App does not directly interface with MEDS. Each program has its own application form (except the Joint Application and ELE/NSLP). Systems do not support electronic client referrals to other programs. Single sign-on functionality (i.e., the ability to sign on once to access more than one gateway) does not exist for providers who access the DHCS gateways (i.e., the CHDP GW, the Breast and Cervical Cancer Treatment Program [BCCTP GW]. Executive Report August 10, 2007 Page 5

12 # Finding/Business Problem 2 Minimal Data Sharing between Programs Summary Observations No common front-end for data capture and screening. No common backend for eligibility determination and routing. Limited real-time access to MEDS. Minimal interfaces to regulatory agencies. Absence of standard data elements and layouts. Examples The Joint Application and Health-e- App collect information for HF and MCC but do not gather sufficient data to enable counties to determine eligibility for adult Medi-Cal programs. Eligibility re-determinations for HF and MCC are not automatically supported by technology, which limit opportunities for sharing previously provided data. 50% of the applications received at SPE are for re-determinations. DHCS/HHSA has not developed enterprise-wide technology standards across its different applications and system implementations (ISAM, Assembler, Flash, COBOL, DB2, etc.). Less than 10% of the HF applications received in SPE are submitted through Health-e-App, limiting the opportunity to share data that is provided online. While a DHCS system interface with the Employment Development Department (EDD) exists, the payroll information from EDD is dated; efforts to reliably verify income are manually performed (e.g., request/view pay stubs). Data-sharing delays are experienced when data is transferred from One-e- App to Health-e-App when user password updates fail to occur at the same time. In most instances, the process of providing supporting documentation is manual; matching supporting documentation to applications presents opportunities for error. Executive Report August 10, 2007 Page 6

13 # Finding/Business Problem 3 Enrollment Processes are not Always Consumer Friendly 4 Outdated and Disparate Technology Summary Observations No public access. Limited ability to determine eligibility for multiple programs. Confusing application forms. Complex eligibility requirements. Multi-stepped process for continuous Medi-Cal coverage. Some systems are using dated technology. Technology not extensible and may be difficult to maintain Minimal system integration Technology environment cannot efficiently support ever-changing policy environment and legislative demands. Examples Clients cannot currently access programs online (via the Internet) to apply for coverage from their homes or other remote locations. (Note: the Governor announced in 2006 that the State would make Health-e-App accessible to the public.) Presumptive eligibility application processes (through the CHDP GW, ELE) do not support the process of attaining continuous coverage without the collection of additional information for those who may be eligible. Due to the lack of a look up tool into MEDS - ELE spends significant time attempting to enroll clients who are already enrolled in Medi-Cal (forty four % of applicants through ELE are already enrolled in Medi-Cal). Applicants go to multiple locations to apply for the different programs. System access is usually limited to mutually exclusive user populations, as required by some programs. Some systems have been extensively modified and may be difficult to maintain (e.g., MEDS). It is difficult to find staff to maintain systems using dated technology. Current technology does not support electronic self-service. Degree of system integration is minimal. Executive Report August 10, 2007 Page 7

14 # Finding/Business Problem 5 Reliance on Manual Processes Summary Observations Paper applications are completed manually and rekeyed into systems. Documents are routed via USPS and overnight mail. Cross-program referrals are manual. Eligibility redeterminations are not supported by technology. File clearance activities require manual intervention. Examples Programs collect the same or similar data elements multiple times, which utilizes resources inefficiently and increases the opportunity for data discrepancies. Routing of Medi-Cal applications between SPE and the counties is manual (printed, batched and sent via overnight mail). Routing of applications from AIM to the counties is manual (printed, batched and sent via overnight mail). Routing of applications from the schools to SPE is manual (printed and mailed). Applications (some application data) that SPE routes to the counties are re-keyed into the county welfare systems. The AIM application process is entirely paper-based. The concept of bridging is manually performed counties mail Medi-Cal re-determination applications to SPE for HF eligibility when Medi-Cal income limits are exceeded. In most school districts the ELE process is paper-based. The absence of the Benefits Identification Card (BIC) number on joint application requires manual processing and increases workload levels in SPE. Executive Report August 10, 2007 Page 8

15 Policy Environment

16 Policy Environment In government, policy drives programs. Many of the state s health programs must comply with federal rules for the state to receive federal funding. In addition to the federal government, the primary policy-makers are the Legislature and the Governor, while the role of the state agencies and departments is to implement the policies mandated by these elected officials. In the health care arena, the policy landscape has become more and more complex over time, making it increasingly difficult to obtain and provide health care services in a seamless and integrated fashion. Indeed, as the population of California has grown, health and social services programs have become more numerous, more complex and some have become more isolated from other programs designed to serve similar populations. The following paragraphs summarize the various ways in which this complexity can impact health care policy. Piecemeal and Conflicting Legislation Legislators introduce bills in response to concerns presented by their constituencies. In some cases, each legislator, or each constituency, has a different perception as to what kind of legislation will best address the identified concerns. Because each legislator wishes to take affirmative steps to address problems, several legislators may introduce legislation to tackle one or more aspects of the same issue. Further, because each health care program has its own advocates, and their interests do not necessarily overlap with the interests of the advocates of other health care programs, legislators may introduce bills that only affect one program when the same problem affects multiple programs. This can result in piecemeal legislation that may either have differing and possibly conflicting impacts on the same program, or may make changes to only one program when those same changes would make sense for other programs. Funding Availability Over the years, federal as well as state legislation has often been introduced that contains inadequate funding to implement its provisions, yet the State has generally been expected, and has been able, to do so anyway. Since FY , the number of Medi-Cal eligibles (individuals receiving services paid for by Medi-Cal) has increased dramatically, from an average of 5,024,700 to 6,664,700 each month in FY , an increase of nearly 33 percent. During that same time period, the total cost of the program has grown at an even faster pace, by nearly 74 percent, from just over $20 billion to nearly $35 billion annually. In the face of these increases combined with periodic budget deficits, it has become common for the Legislature and the Governor to enact legislation that contains no funding at all for implementation of new legislation. Program Silos California s health care programs have become remarkably complex over time, complicating the ability of everyone involved in the health care process to ensure that patients receive comprehensive, integrated health care services that address the full range of their health care needs. Instead, programs generally develop on a stand-alone basis, creating a silo effect in which programs have little or no interaction with one another. This generally happens because it is simply too difficult for either policy-makers or policy implementers to figure out how to create and implement program changes that take other programs into consideration. Executive Report August 10, 2007 Page 9

17 Multiple Agency Oversight Each health care program administered by the State of California is subject to a variety of mandates that are often conflicting. The State Legislature and advocacy groups work to create a vision of a health care system that serves patients with needed care in a seamless manner. Federal oversight agencies establish a variety of eligibility and administrative requirements that ensure accountability and protect patients, but may conflict with the State s overarching policy goals. For example, federal requirements related to verification privacy, citizenship documentation and obtaining approval to expend federal funds may impede the State s ability to allow the data sharing necessary to create a truly seamless system. Further, federal and state governments often view their own requirements as more important than those of the other, making it difficult to obtain consensus on the best approach to implementing needed changes. State versus County Eligibility Administration In some states, eligibility determination for Medicaid and other federal programs is handled at the state level, with local offices staffed by state employees who report directly to the state agency responsible for overall program administration. In California, many key health and human services programs, including Medi-Cal, are administered by county agencies, making it difficult to implement policy changes uniformly throughout the state, particularly if those changes are viewed as not being in the best interest of the county. In this project, this situation plays itself out in the manner in which the Statewide Automated Welfare System (SAWS) operates in California. County administration of programs allows flexibility but may also mean that each county operates its programs in its own way. In this environment of distributed responsibility (the Medi-Cal rules are established by the State, not the counties), it is difficult to gain consensus on a single process or system. The SAWS in California is actually comprised of four separate systems, ISAWS, CalWIN, LEADER and C-IV. Los Angeles has its own independent system, LEADER. Four counties formed a consortium and agreed to share business processes through the C-IV system. Eighteen counties formed a consortium to purchase CalWIN as a shared system that is actually customized for each county. ISAWS is used by the remaining smaller counties and is slated for elimination, with the affected counties moving to C-IV. A significant challenge with these disparate systems is information-sharing in a manner that is consistent with consumers legitimate expectations of privacy and confidentiality. Specific Legislation There are a number of bills, either already enacted or proposed, which seek to streamline enrollment processes, improve access to services, or expand coverage. 5 While several of the bills passed during the most recent legislative session have the potential to make health care program enrollment and retention processes for low-income children, and for others, more streamlined, integrated and efficient, there are several programmatic, fiscal and IT impediments to their implementation. DHCS is seeking resources for each of these bills but is unable to move toward implementation until resources are provided. Further, as the Governor s newly proposed health care reforms seek to expand eligibility for public programs that serve lowincome children and adults, even greater demands will be placed on existing enrollment systems. In the face of these challenges, Eclipse proposes recommendations in this document that may assist DHCS in meeting some of the requirements included in these bills. 5 An analysis of the legislation that was reviewed in this project can be found in the Executive Report Appendix. Executive Report August 10, 2007 Page 10

18 Lessons Learned from Other States

19 Lessons Learned from Other States Eclipse researched five other states that have implemented systems to streamline their enrollment process in order to identify approaches that might prove effective in the California environment. As a part of our research, we interviewed staff from each state. Our interviews focused on the types of systems other states have implemented to integrate and streamline services as well as the organizational and procedural changes required to support those changes. The states interviewed were: Pennsylvania, Texas, Massachusetts, Louisiana, and Arizona. General observations of lessons that California can learn from other states include the following: Many other states are facing the same challenges California is confronting in attempting to create a more streamlined, integrated and efficient approach to enrollment and retention. Solutions that have been developed by other states often involve a combination of systems working together to support their enrollment processes. Executive-level sponsorship is critical to support the development of an IT infrastructure that facilitates the exchange of information across programs and to streamline enrollment processes. This level of support assures for a top-down view of the programs and their inter-relationships, assigns a high level of priority and visibility to the project, provides for the necessary resources, and maintains the momentum to support and implement the future state. A strong, empowered governance structure must be created to serve as the framework for making informed IT decisions and to ensure that IT resources are allocated appropriately to meet business needs. This governance structure must also serve as the forum for involvement from multiple stakeholders and cross-departmental/divisional cooperation and teamwork. Most of the five states we studied have already, or are currently moving toward web-based applications that offer online application and enrollment functionality, and shared services to multiple programs. Federal matching funds are available to states that are developing new information systems to streamline their application and enrollment processes. Some states have streamlined processes for programs that extend beyond those included in this review, and are enhancing their existing statewide eligibility systems that are comparable to MEDS as part of their effort to streamline eligibility and enrollment. Executive Report August 10, 2007 Page 11

20 Other State Summary A comparison of efforts to streamline enrollment processes in other states is summarized in the following table. Table 2 Comparison of Ongoing Efforts to Streamline Enrollment Processes State Department(s) System Programs Supported Pennsylvania Texas Massachusetts Public Welfare Health and Human Services MassHealth, DHHS COMPASS TIERS, YourTexas Benefits.com The Virtual Gateway Medicaid, FS, LTC, SCHIP, NSLP, Communitybased Services, Low-Income Home Energy Assistance Program FS, TANF, Medicaid, SCHIP (planned) WIC, Health Insurance and Health Assistance Programs, Substance Abuse, FS, Child Care Subsidy, Veterans Services, Community Services and Longterm Functions Supported Web application that allows individuals and CBOs to screen, apply for, view and renew a broad range of social services. Serviceoriented architecture supports online eligibility determination and enrollment available to the public. Web application that provides online screening, referral and intake services for multiple programs at the same time. Information is shared among existing Year of Inception Funding secured in TIERS implemented in 2003; YourTexas Benefits.com implemented in Vendor contract cancelled in Implemented in Executive Report August 10, 2007 Page 12

21 State Department(s) System Programs Supported Support Functions Supported legacy eligibility systems. Year of Inception Louisiana Health and Hospitals, Social Services ACESS Medicaid, other health and human services programs; plans to support its statewide automated child welfare information systems (SACWIS) and entitlement programs Recently purchased Cúram Software s commercialoff-the-shelf (COTS) Social Enterprise Management (SEM) system to provide the public with web-based benefits screening across multiple programs. Purchased Cúram application in Arizona AZ Health Care Cost Containment System Health-e- Arizona Medicaid programs, SCHIP, Long-term care, SSI, Food Stamps, TANF Web-based enrollment application that screens for eligibility and submits electronic applications. Implemented in Executive Report August 10, 2007 Page 13

22 Recommendations

23 Recommendations The purpose of this project was to develop a blueprint for achieving the goal of a more streamlined, integrated and efficient approach to enrollment and retention for California s health and social services programs that serve children and pregnant women. Creating more opportunities for applicants to learn about, and apply for multiple programs at one time will significantly impact their ability to access services they could rightfully receive. Sharing information across programs will not only make the application process easier for applicants, but improve data accuracy and reliability. Reducing manual activities that are redundant will save time and resources. To that end, the recommendations for addressing these challenges in the long-term (Future State) and near future (Interim Recommendations) are presented below. The Future State The ideal future state has been designed to streamline enrollment, increase efficiency and integrate systems so that information can be shared electronically 6 with minimal human intervention. The future state encompasses the following set of improvements: A governance structure to provide a framework for ensuring that IT organizational resources are targeted to deliver maximum business value. This will be: A framework that drives decisions related to IT direction, policies and investments. A multi-stakeholder organization that includes CHHSA, DHCS, CDSS, MRMIB, Department of Public Health (DPH), Counties, State CIO representatives and consumer representatives to direct cross-program activities. A comprehensive technology solution that is consistent with state and federal IT direction and that streamlines and integrates the enrollment process through the combination of: A common front-end, that allows consumers to input basic information into an online screening tool and apply for services via the Internet. This web-based self-service will allow consumers to screen for many programs from many locations and submit online applications directly to programs, in which they are interested. A common messaging infrastructure, that will serve as the platform on which to build common back-end services, control access and authorization, and route information to existing systems. Built utilizing modern enterprise architecture, this model incorporates the creation of an Enterprise Service Bus (ESB) that will make available the common services and serve as a central repository of shared business rules and processes. This enables authorized to perform a multi-program applicant search, verify program eligibility status, enroll and re-enroll in multiple programs online, and provides the basis for additional shared services. 6 Assumes the applicant has given informed and voluntary consent to sharing information with other programs for the purpose of determining eligibility. Executive Report August 10, 2007 Page 14

24 Enhanced system integration, to connect existing and future systems to each other via the ESB, allowing current applications to interface to the new architecture and services, including the ability to validate an applicant s status (e.g., income, birth records) online. The figure below presents a graphic representation of the ESB. Figure 1 Shared Services on the ESB Key business features will include: Applicants will share information only once, regardless of the number of programs for which they are applying; Applicants will be able to apply for services from any door; Information is electronically shared via online, real-time connections; Consumers can receive assisted application support if desired, and can be directed to the service location that is closest to them; and Supporting documentation is verified online, to the extent permitted by program policy. Figure 2 graphically presents the future state approach, followed by a description of an enrollment scenario from the consumer s perspective. Executive Report August 10, 2007 Page 15

25 Figure 2 High-Level View of the Self-Service Enrollment Process in the Future State Applicant search function is performed to determine if applicant is already enrolled in any programs Do not retain data Screen Laptop Apply to programs? Yes Application form is prepopulated Applicant accesses front-end tool Applicant enters basic information into an online screening application Front-end tool informs applicant of potential program eligibility Application and Routing Applicant completes and submits application for desired programs Send data to desired programs via ESB Front-end tool notifies applicant that applications have been submitted Resident systems Data is validated against regulatory agency files Eligibility Determination and Enrollment Eligibility is determined Updates are sent to multiple programs via the ESB Applicant is enrolled in multiple programs and receives services Redetermination req d? No Services continue Yes Laptop Applicant accesses front-end tool Applicant enters basic information online Executive Report August 10, 2007 Page 16

26 Self-Service Enrollment A mother logs onto the Internet in the evening from home to research health and social services programs that she heard discussed on the radio. The menu-driven website walks her through a series of simple questions regarding household income and family composition. Based on the information she provides, the website checks to see if she is already enrolled in any of the programs and shows her the programs for which each family member may qualify. She is also provided with a link to obtain more information about each program. Based on that information, she can choose to apply online for the programs in which she is interested. If she needs assistance to complete the application, the website will help her to find a Certified Application Assistant (CAA) in her area. In this scenario, the mother is pregnant and applies for Medi-Cal for herself and her one-yearold; HF for her 7 year old child, and WIC for eligible family members. Whether she applies online or seeks assistance from a CAA, she will only be required to supply information above and beyond what she has already provided. Since she has started the application process for WIC, the website informs her of the WIC office that is closest to her home and she is presented with a list of possible appointment times. Based on that information, she selects a time that fits her schedule to complete the WIC enrollment process. Her application is then submitted online and is routed to Medi-Cal, Healthy Families and WIC at the same time. Once the programs receive her application, they send her an electronic confirmation. When her application is received, the information provided on the application is checked against the online files of regulatory agencies (e.g., Vital Statistics, Department of Motor Vehicles, as appropriate) to validate residency citizenship or immigration status, residency, and other eligibility requirements. 7 Once the information is validated and signatures are provided. is, the mother and her children are enrolled in the programs for which they are eligible, and begin to receive services. If there is a change in her circumstances, the mother can access the website to update her information online. If she is still receiving services at the time of re-determination, the system will automatically notify her that she must update her information to continue to receive services. When this occurs, she can again access the website or go to her CAA to provide any updates to the required information, which is automatically checked with the consent of the applicant against other records/files (e.g., FTB) to determine whether benefits will continue. 7 Under the new DRA requirement, some citizens and nationals will need to present a birth record to the county office. Executive Report August 10, 2007 Page 17

27 Future State Costs This section provides information about the development costs associated with two key components of the future state: Program Look-Up and Enrollment. In the future state, system users will be able to conduct queries to identify an enrolled applicant. The Program Look-Up, or Inquiry, service determines if a program or programs knows an applicant. Further, users will be able to enroll an applicant in programs. The Enrollment service submits the applicant s information to a program or programs. We have also included development costs for a web-based application tool for consumers to apply for programs. The estimated development costs provided below were developed by Eclipse. These estimated development costs are not the complete costs for the future state. They do not include any costs associated with contract or procurement activities, purchase of additional software or hardware necessary to host the solution, securing additional bandwidth or network usage, conducting statewide roll-out or training activities, any county customizations, or ongoing maintenance and operations. Further, the estimated costs for the web-based tool are illustrative only. Finally, we note these cost estimates are based on the knowledge available at the time; any changes to the basic system information, program requirements and mandates, organization and governance, software and hardware platforms, etc. will invalidate the costs as presented. In addition, our estimates assume the California Chief Information Officer s (CIO) California Enterprise Architecture Program (CEAP) will take the following actions: The CEAP initiative to procure and implement an ESB will occur and access will be granted to the programs listed; and The CEAP Identity Management initiative will provide the basic structures needed for authorization and authentication needed to secure access to the ESB. 8. Table 3 Estimated Program Look-Up / Inquiry Development Costs System / Program Development Development Timeframe Cost AIM $ 184,500 Up to 6 months SPE software $ 166,500 Up to 5 months MEDS $ 184,500 Up to 8 months ISIS / WIC $ 40,500 Up to 3 months SAWS Not estimated Not estimated Total Inquiry Development Costs $576,000 Table 4 Estimated Enrollment Development Costs System / Program Development Cost Development Timeframe Web-based tool $3,703,500 Up to 21 months AIM $ 711,000 Up to 9 months SPE software $ 972,000 Up to 9 months 8 For more information about the State CIO and CEAP, please see the Executive Report Appendix. Executive Report August 10, 2007 Page 18

28 System / Program Development Cost Development Timeframe ISIS / WIC $ 693,000 Up to 8 months SAWS Not estimated Not estimated Newborn $ 562,500 Up to 10 months Prenatal $ 554,500 Up to 10 months Total Enrollment Development Costs $7,002,000 Total Inquiry Development Costs $576,000 Total Estimated Development Costs $7,578,000 Interim Recommendations It will take time to put the pieces in place to implement the future state recommendations. The policy environment is dynamic, however, and the state needs to be able to respond to existing requirements in the meantime. Accordingly, we recommend the state pursue a number of shorter-term, interim recommendations, which are discussed below. The interim recommendations have been designed to meet the study goals in the near-term by: Improving self-service to increase enrollment; Enhancing the CHDP Gateway to streamline enrollment; and Better facilitating continuous coverage. Further, the interim recommendations address the requirements of SB 24 and recently passed legislation that was included in this assessment. The criteria that were used to select the interim recommendations are listed below: The interim step addresses a problem associated with the enrollment process that is related to the goal of being streamlined, integrated or efficient; The interim step can be pursued with existing IT resources / staff; The interim step does not step on the DHCS planned / ongoing Feasibility Study Reports (FSRs), which will result in a level of analysis that is more in-depth than what this project allows; and The interim step does not exceed the HHSA s delegated spending authority. Each interim recommendation is described below and summarized in Table 5 with their associated development costs. Similar to the caveats presented above regarding the future state costs, the estimates provided for the interim recommendations are also limited and do not reflect the total costs of implementation. We have identified the limitations of our estimates in the discussion below. We also note that these estimates have not be reviewed or approved by the State. Improving Self-Service to Increase Enrollment 1. Develop an Informational Website The statewide portal ( has recently been updated to reflect a new look-andfeel and structure. As part of this effort, HHSA will lead the development of the health service center to provide health-related information on such issues as public health programs and Executive Report August 10, 2007 Page 19

29 managed care. In addition to that, we recommend that HHSA provide further outreach assistance and develop an informational section that: Provides a single access point through which an applicant can learn about multiple programs, available in the State s threshold languages, for which they might be eligible. Based on providing anonymous information, visitors can identify assistance programs that may meet their needs; and Links those visitors to the specific program websites, enrollment applications, or service locations based on their initial search. The estimated development costs for this type of informational website are approximately $210,000 with a development schedule of up to 6 months. These are strictly development costs and do not take into account any associated costs for contracts or procurement, scope definition, compliance with HIPAA privacy and security requirements, additional hardware and software needed for hosting the solution, additional bandwidth requirements or network usage, or ongoing maintenance and operations costs. 2. Evaluate One-e-App s Re-Use Potential in the Future State As each program has its own online screening and application tool, but none of them have a multiple program screening tool, we recommend that the State investigate and evaluate One-e- App. The One-e-App application could serve as the basis of an online screening/application tool for the future state. The future state process would have applicants information entered once and provided to multiple programs for their individual application processes. As the rules for each program vary, the ability to isolate and update those rules independently while minimizing any changes to software programs that utilize those rules would be very useful. The One-e-App application has created a business rules engine that provides this type of functionality. As the State contemplates the future state, it should evaluate the One-e-App rules engine as a possible asset to be leveraged. While Eclipse believes the One-e-App rules engine should be considered as a reusable asset, the State should be mindful of feedback received from consumer advocates regarding One-e-App, surrounding limitations in error correction functionality, the lack of uniformity on important core eligibility and procedural issues among participating counties, and a cumbersome consumer interface. As shown in our analysis, other states are facing enrollment and retention challenges that are similar to California s. Approaches and solutions to these challenges vary. Eclipse also believes that it would be prudent for the State to conduct an alternatives analysis of other similar tools in the marketplace that automate and streamline the enrollment process for the purpose of comparing functionality and identifying the best fit for the State s needs. 3. Create a Public Enrollment Application for AIM The application process for AIM is entirely manual. If the program is continued 9, we support MRMIB s current efforts to develop an electronic application for AIM by adding AIM to the new public version of Health-e-App. We also note that under the SB 24 Prenatal Gateway, women 9 This recommendation is predicated on the continuation of the AIM program which is recommended to sunset in the Governors Health Care plan released in January Executive Report August 10, 2007 Page 20

30 screened ineligible for Medi-Cal but potentially eligible for AIM must be referred to MRMIB for that program; inclusion of AIM in Health-e-App would provide for a more efficient way of making such referrals from the Prenatal Gateway. The estimated development costs for creating a public enrollment application for the AIM program by including it into Health-e-App are approximately $266,000 with a development schedule of up to 9 months. As mentioned above, these are strictly development costs and do not take into account any associated costs for contracts or procurement, scope definition, compliance with HIPAA privacy and security requirements, additional hardware and software needed for hosting the solution, additional bandwidth requirements or network usage, or ongoing maintenance and operations costs. Enhancing the CHDP Gateway to Streamline Enrollment 4. Improve Beneficiary Data Integrity During our interviews, data integrity was one of the most frequently mentioned shortcomings of the CHDP Gateway. The current matching algorithm determines a match based on the data input. This process, known as file clearance, needs to be more accurate and robust. Further, even when the provider knows that the match is incorrect, the provider is not permitted to modify the result. This can lead to an incorrect association between a person and a MEDS record, or the creation of a MEDS record with incorrect data that may be entered to trick the system in order to enroll an applicant in CHDP. To address this problem, CHDP Gateway users need to be able to edit or update beneficiary information they enter into the system. Lastly, the recipient s BIC number should be included on the Joint Application. Including the BIC number on the Joint Application would allow the user to query beneficiary records in MEDS based on the BIC number 10. This would help to minimize the possibility of either creating duplicate records in MEDS, or incorrectly merging beneficiary records in MEDS. Using the BIC number to identify a beneficiary s record in MEDS will allow the user to update the beneficiary s presumptive record, rather than erroneously creating an entirely new record. The estimated development costs for improving the beneficiary data integrity cannot accurately be estimated. Analysis of the MEDS/SCI systems was not specifically within the scope of this engagement. However, previous assessments of the MEDS system provided estimated costs to modernize MEDS. Modernizing the MEDS system or systems would allow for the use of more modern technologies for beneficiary searching and matching based on the diverse California ethnic population. Creating a long-term solution for beneficiary data integrity improvement will require a more thorough business process review of the procedures and analysis of existing code that support the processing of multiple possible matches made during a CHDP transaction. It is apparent that the current process of resolving multiple records does not meet user expectations and creates additional workload for both the users and MEDS personnel. In the future state, automated file clearance should be a service available though the ESB for all programs. The cost for adding the BIC number to the Joint Application form is not provided. 10 As of the DHCS review of this draft report, Eclipse was informed that a new version of the Joint Application will be produced in 2007 that will include a field for the BIC number. Executive Report August 10, 2007 Page 21