Creating a Streamlined Service Center for California s Health Subsidy Programs

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1 Creating a Streamlined Service Center for California s Health Subsidy Programs Prepared by John Connolly December 10, 2012 The California Health Benefit Exchange, in coordination with the Department of Health Care Services (DHCS), will launch a new service center in 2014 to provide individuals and families with a unified eligibility determination and enrollment portal. This service center will allow consumers to learn about their coverage options and simultaneously apply for subsidized Exchange and Medi- Cal coverage. The Affordable Care Act created the impetus for this effort by requiring that states create a streamlined, no- wrong- door, eligibility application for all health subsidy programs, including Exchange coverage, Medicaid (known as Medi- Cal in California), and CHIP. California has chosen to meet this requirement by establishing a service center with the capability to either enroll individuals in the Exchange or directly transfer individuals, when appropriate, to county service centers that will enroll them in Medi- Cal. This arrangement preserves the counties role of enrolling eligible individuals in Medi- Cal. The ability of the service center and county enrollment call centers to knowledgeably answer potential applicants questions and to handle enrollment in a timely and accurate fashion will be a critical component of creating a first- class consumer experience. In fact, the ACA stipulates that this streamlined application process must not require applicants to provide unnecessary or duplicative information. The effectiveness with which the Exchange service center and the counties enrollment lines are able to coordinate transfers of calls and applicants data will also be a critical element of creating a unified enrollment portal envisioned in the ACA. Moreover, these capabilities will be particularly important with the large expected volume of new enrollees in To ensure the success of this vital element of California s subsidized health programs under health reform, this brief outlines some important considerations and potential performance metrics for the Exchange, DHCS, and the counties to include in their ongoing coordination, improvement, and implementation efforts related to their service centers. ITUP recommends the following performance measures and goals: ITUP supports Covered California s goal of answering 80% of incoming calls within seconds, with no busy signals. Customers should not wait on hold for assistance for more than five minutes. ITUP recommends a performance goal of two minutes or less for hold times because this aspect of performance will likely be one of the most essential to successfully processing eligibility and enrollment casework. ITUP additionally recommends that service centers provide a service center call- back option, similar to that of the California Department of Motor Vehicles (DMV) customer service center. With this feature, an automated response unit would prompt customers with the option to have the DMV return his or her call when wait times exceed five minutes. ITUP recommends a goal of no more two automated response prompts per call for directing consumers to the appropriate destination. Further, units should always serve to reduce wait times and direct calls to the customer service representative that is most skilled in handling a particular application or question.

2 Enrollment calls may be justifiably lengthy, while representatives may respond to caller requests for information quite quickly. Call centers should utilize post- call surveys and maintain audio recordings to identify what questions (required application information, benefits of different plans, provider networks, etc.) or issues (multi- program households or changes in household financial circumstances, for example) consumers present in calls of varying lengths. This information would allow service centers to identify different types of calls and assess the productivity of the time that consumers spend on the phone, given the varying requests that they present. We support Covered California s goal of having a call abandonment rate of less than 3%. Regarding call center representatives level of knowledge and helpfulness, representatives should be able to definitively answer questions about the information that callers must provide when submitting an application. Representatives should also have the ability to answer specific questions about the benefits that their respective plans offer, and Exchange representatives should be able to explain the different cost- sharing structures and overall costs of its plans. Representatives should also be able to report whether or not specific providers are in plans networks, and whether or not plans cover specific prescription drugs. Additionally, they should be able to provide customers with comparative quality ratings for offered health plans (e.g. wait- times for appointments, use of electronic health records, and other established best practices and outcomes measures commonly used to asses quality). Representatives should always be responsive to consumers concerns and questions while maintaining respectful, patient, and courteous tone. A post- call survey would be an effective way to allow consumers to indicate their level of satisfaction with representatives performance. ITUP supports Covered California s goal of having 80% of calls that its service center transfers to the counties answered within 20 to 30 seconds. Reducing the eligibility determination error rate to as near zero as possible should be the service centers unified goal and the metric of success for CalHEERS. ITUP urges formal, ongoing quality assessments by independent quality review organizations to evaluate the service centers ability to handle the enlarged volume of casework. Evaluators from these organizations could pose as callers and present a range of questions and applications to service center representatives, and the evaluators would provide performance reports regarding the metrics outlined above. The remainder of the brief describes the current infrastructure and knowledge about service center performance in California, and the following discussion presents the main considerations that motivate these recommendations for service centers as health reform implementation continues. Building on Existing Infrastructure The Exchange and DHCS will be coordinating the statewide Exchange service center with the county welfare offices service centers. Therefore, building a coordinated eligibility gateway that is as seamless as possible by January 2014 will require a great deal of advance planning and process improvement for 2

3 all entities involved. County service centers current ability to enroll new Medi- Cal applicants is limited by existing program rules that require more detailed paperwork for determining eligibility, a process that must often be handled in person as a result. Yet, the process for determining eligibility for many groups eligible for the program will be more manageable for county service centers with the new, simplified rules under the ACA that base eligibility on Modified Adjusted Gross Income (MAGI). 1 Some counties also currently struggle with wait times and call abandonment, which are issues that will be of great concern with the increase in applicants in The County Welfare Directors Association in coordination with the California Health Benefit Exchange released a survey of human resource operations that examined service center performance, and the results indicate some clear areas in which certain counties will need to improve. While call abandonment rates were quite low in some counties, the more populous counties with larger populations applying for Medi- Cal and other assistance programs had rates that were as high as nearly 18%. Similar trends appeared in the data about average call wait times. 2 To prepare for an influx of applicants for health subsidy programs in 2014, counties will need to hire and train additional staff, in addition to increasing operating hours and overall staff capability to process applications and handle enrollment over the phone. A recent Health Access study of DHCS, Major Risk Medical Insurance Board (MRMIB), California Department of Insurance (CDI), and Department of Managed Health Care (DMHC) customer service lines revealed some additional concerns about wait times and their capacity to answer questions. The data from the study indicate that the average caller to the DHCS service line encounters more than two automated response prompts, 44% of calls reach no customer service representative, and the average wait time to speak with a customer service representative was nearly 8 minutes. 3 Each of the other three agencies received higher scores on these measures, with 8% - 16% of calls not reaching a customer service representatives and wait times slightly below 2.5 minutes. These results should prompt some quality improvement effort in preparation for the Medi- Cal expansion in 2014, especially given the much larger call volumes that may result from the Medi- Cal eligibility expansion that begins on January 1, Although counties and the Exchange service centers will handle the majority of customer service, enrollment, and eligibility questions, the DHCS customer service line will also likely field a large volume of inquiries, particularly with the considerable changes to California s health subsidy programs under ACA implementation. Toward a First- Class Consumer Call Experience Building a seamless eligibility portal that can accommodate the large number of new applicants and process applications accurately and efficiently in 2014 and beyond will require substantial effort and resources from all entities involved. The effort to build and improve service center capabilities at both the state and county levels should be informed by quality and performance measures for customer assistance, eligibility determination, and enrollment functions. The Exchange service center, DHCS, and 1 County Welfare Directors Association California County Customer Service Operations: Survey of Current Human Service Operations. Available at: 20Centers%20Survey%20Report%20Final%20Draft.pdf 2 Ibid. 3 Health Access Foundation Putting All the Ingredients Together: A Recipe for Getting Ready for Health Reform, Base on Results from a Consumer Assistance Assessment Survey of California State Health Agencies. Available at: access.org/files/advocating/haf.consumerassistancesurvey.pdf 3

4 county service centers will need to take consumers experiences into account as they test and implement the new service center infrastructure and technology. Several aspects of a call to the service centers will be critical to their ability to process the large number of enrollment applications and to assist individuals simply seeking information about the state s new and modified health programs. The remainder of this brief discusses some key metrics to consider and performance goals that might serve to inform service centers operations as they meet these considerable challenges. Time to first connection The amount of time a consumer waits on the phone is the first dimension of quality that a consumer experiences when calling to apply for a program, or to ask a question and gather information. The Exchange staff have set a goal of answering 80% of incoming calls within seconds, with no busy signals. 4 The recent Health Access Foundation study showed that DHCS calls were answered within 8.6 seconds, on average. Reaching this goal seems both central to keeping consumers on the line, and very attainable with call center technology. Yet, this measure would have little effect on the overall time that consumers would have to commit to a service center call if an automated answering service places them on hold for an inconveniently, or unreasonably, great amount of time. As a result, other quality metrics may be both more challenging and greater priorities for service center planning. Wait time for a live customer service representative One of the most important elements of customer satisfaction, and very likely a determinant of call abandonment rates, is how long a consumer has to wait to speak with a live customer service representative. Individuals have many demands on their time, and the efficiency with which the service center can handle calls will be critical. Counties report widely varying wait times to speak with customer service representatives at their service centers. 5 With the increase in applicants in 2014, the Exchange, DHCS, and counties may face a considerable challenge in maintaining wait- times brief enough to keep consumers on phone lines, and to achieve a high level of user satisfaction. While the increased volume may be a challenge for service centers, asking customers to wait on hold for more than five minutes for assistance seems likely to have a considerable negative impact on both the call abandonment rate and the customer satisfaction level. Furthermore, we recommend that the service centers set a performance goal of two minutes or less for hold times because this aspect of call center performance will likely be one of the most essential to its ability to successfully process eligibility and enrollment casework. Adding a service center call- back option, similar to that of the California Department of Motor Vehicles (DMV) customer service center, offers another option to prevent customers from spending unnecessary time on hold. With this feature, an automated response unit prompts customers with the option to have the DMV return his or her call when wait times exceed five minutes. 6 Since a state department already 4 California Health Benefit Exchange Service Center Status Update. Available at: erboardpresentation_ pdf 5 County Welfare Directors Association California County Customer Service Operations: Survey of Current Human Service Operations. Available at: 20Centers%20Survey%20Report%20Final%20Draft.pdf 6 California Deparment of Motor Vehicles. Available at: 4

5 uses this technology, Exchange and DHCS officials should discuss this option with their counterparts at the DMV. Number of automated response units, calls when no live customer service representative reached The number of automated response units encountered and a caller s ability to reach a live customer service representative are key elements of the consumer experience for service centers to track. Automated response units are important tools that can boost call center efficiency by directing calls appropriately, prioritizing consumers needs, and more quickly answering less complex consumer questions. However, they can also be sources of caller frustration when individuals are directed inappropriately, placed in multiple lengthy customer service queues, or ultimately never reach a live customer service representative as a result. The Health Access study found that calls to DHCS, MRMIB, CDI, and DMHC averaged between 1.2 and 2.6 automated response units. Two automated response prompts seems to be a reasonable number for directing calls to the appropriate destination. However, more than three transfers to different automated response units seems excessive, and units should always serve to reduce wait times and direct calls to the customer service representative that is most skilled in handling a particular application or question. One indispensible characteristic of automated call units for consumers should be the option to transfer from automated response units to a live customer service representative at any time. The share of calls that never reached a customer service representative varied from 8% for CDI to 44% for DHCS. Counties and the Exchange should strive to prevent this outcome entirely if a consumer wishes to reach a live representative. Since many programs will be new and issues related to insurance and health subsidy programs can be quite technical and complex, every consumer should be able to speak with and receive assistance from a customer service representative if s/he desires. Moreover, call centers should continually assess the level of helpfulness and effectiveness of automated response units for consumers. Overall call length The total amount of time that consumers spend on the phone will also be an important piece of the service center performance. This factor depends on many of the other metrics discussed in this brief, including wait times to speak to a customer service representative, number of transfers among automated response units, as well as the level of knowledge, efficiency, and accuracy of customer service representatives. Therefore, overall call length may be a secondary performance measure because it is the product of several others, but it is a useful broad metric of consumer experience when assessed in the context of different customers needs. For example, one consumer may call with a relatively simple question that an automated response unit can answer with 2 minutes of total call time; a consumer may call with a few complex coverage questions that could require around 15 minutes; and an enrollment call could span 30 minutes or more. In fact, a customer may call to enroll a family member in Medi- Cal coverage and herself in Exchange coverage a process that would potentially involve representatives from two different service centers. While calls may be justifiably lengthy, call centers should utilize post- call surveys and maintain audio recordings to identify what questions (required application information, benefits of different plans, provider networks, etc.) or issues (multi- program households or changes in household financial circumstances, for example) consumers present in calls of varying lengths. This information would allow service centers to identify these different types 5

6 of calls and to assess the productivity of the time that consumers spend on the phone, given the varying requests that they present. Call abandonment rates Call abandonment provides a key measure of the customer experience because it is usually the result of a consumer waiting on hold, being transferred, or struggling with an automated response unit to an extent that s/he feels is unsatisfactory and hangs up. The Exchange has set a goal of having an abandonment rate of less than or equal to 3%. 7 This metric will also very likely depend on the metrics discussed above, including the wait time for a customer service representative, number of automated response units, and overall call length. Therefore, it will be important to focus on the above performance measures to meet the performance goal the Exchange has set with regard to call abandonment. Knowledge and helpfulness of customer service representatives The level of mastery and helpfulness of customer service representatives will be one of the most crucial elements of performance for the Exchange and DHCS to monitor. While these aspects of customer service are more qualitative than some others, they can greatly influence the consumer s overall evaluation of a call. As a result, the Exchange, DHCS, and counties should both measure these elements of their service center representatives performance and uphold standards of quality. With regard to the level and types of knowledge that call center representatives should have, they ought to be able to definitively answer questions about the information that callers must provide when submitting an application. Moreover, Medi- Cal and Exchange service center representatives should have the ability to answer specific questions about the benefits that their respective plans offer, and Exchange representatives should be able to explain the different cost- sharing structures and overall costs of its various plans. Representatives should also be able to tell consumers whether or not specific providers are in plans networks, and whether or not plans cover specific prescription drugs. Additionally, they should be able to provide customers with comparative quality ratings for offered health plans (e.g. wait- times for appointments, use of electronic health records, and other established best practices and outcomes measures commonly used to assess quality). To ensure a first- class consumer experience, training about the new programs, specific eligibility and enrollment protocols, and the specific plans offered should be a very highly prioritized activity for service centers. If ongoing quality assessments reveal that certain representatives are unable to accurately answer the questions above, they should be required to review preparation materials or attend additional training sessions before receiving a certification that demonstrates mastery of these topics. Nevertheless, it is plausible that certain individuals circumstances may be complicated, and questions about the particular costs and benefits of plans may be complex. If a representative is unable to provide a caller with a prompt answer in some unusually complicated cases, supervisors should be on hand and able to assist representatives. 7 California Health Benefit Exchange Service Center Status Update. Available at: erboardpresentation_ pdf 6

7 The manner in which customer service representatives handle and respond to consumers is another critical piece of callers experience. Representatives should always be responsive to consumers concerns and questions while maintaining respectful, patient, and courteous tone. A post- call survey would be one way to allow consumers to register their level of satisfaction with these elements of call representatives performance. Such a survey should ask consumers whether or not they felt that they were treated respectfully and with patience. This dimension of customer service should also be included in any formal service center quality assessment program, in which evaluators can rate the level of respectfulness and patience that representatives exhibit. As implementation begins, formal, ongoing quality assessments will be essential to understanding how well the Exchange and the counties service centers are able to handle the enlarged volume of casework. Assessments should include quality evaluations conducted by independent quality review organizations. Evaluators from these organizations could pose as callers and present a range of questions and applications to service center representatives, and the evaluators would provide performance reports to the Exchange, DHCS, and the counties. These evaluations should measure all of the elements of quality, both quantitative and qualitative, discussed in this brief. In sum, the Exchange and DHCS should be vigilant about maintaining a first- class customer experience with call centers, and these entities should use the terms of their contracts with counties and vendors to achieve this objective. Referral wait times when transferred to counties Counties will retain responsibility for enrolling individuals who are eligible for Medi- Cal under ACA implementation, while the Exchange will have a separate service center to handle applications for its coverage offerings. If the Exchange service center receives calls from individuals who are likely eligible for Medi- Cal, it will directly transfer those calls, along with any relevant data collected, to county service centers. County service centers will additionally have the ability to enroll individuals who are eligible for Exchange coverage. While this two- touch system of call routing raises some logistical challenges, the Exchange has set a goal of having 80% of calls that its service center transfers to the counties answered within 20 to 30 seconds. To reach this goal, it will be pivotal for the Exchange, counties, and DHCS to ensure that all systems, employees, and protocols are connected and coordinated as possible to maximize accuracy and efficiency. Rate of accuracy of determinations The accuracy of the service centers eligibility determinations will be another crucial dimension of the consumer experience that will affect many of the elements of quality discussed above. The California Healthcare Eligibility Enrollment and Retention System (CalHEERS) will have the capability to determine whether someone is eligible for the Exchange or Medi- Cal if individuals are applying for coverage under modified adjusted gross income (MAGI) criteria. Reducing the eligibility determination error rate to as near zero as possible should be the service centers unified goal and the metric of success for CalHEERS. This objective is critical because errors could send applicants through multiple eligibility paths and service center queues an outcome that will likely have a substantial adverse effect on enrollment and call abandonment rates, as well as customer satisfaction. The issue of accuracy is particularly important for the Exchange service center because it will transfer applicants to a county service center once a representative determines that an applicant is likely eligible for Medi- Cal. If this initial assessment is incorrect, this transfer may unnecessarily result in the customer 7

8 waiting on hold in a second queue until a county customer service representative can process the enrollment. Since the county service centers will have the ability to handle Exchange enrollment, consumers unnecessarily transferred would still be successfully enrolled, but with a greater time commitment and a less positive experience. Therefore, to increase the accuracy of this initial determination the Exchange service center should collect enough data to make a full assessment of eligibility. This approach would use the new CalHEERS information technology available through the ACA to maximize the accuracy and efficiency of eligibility determinations. Further, representatives can transfer the information collected in this assessment to the counties to initiate the Medi- Cal enrollment process. Tracking Performance To evaluate many of the performance metrics outlined above, it will be crucial for the state and county service centers to have the capability to track the path of each call and each application. The Exchange technology staff have indicated that they plan to assign unique identifiers to calls to track call paths and outcomes. 8 These unique identifiers should enable the service centers to know how long a consumer waits on hold before speaking with a customer service representative, how many automated response units the caller encounters, whether or not a consumer is able to speak with a live representative, overall call length, and whether or not the consumer abandoned the call. We strongly support the use of unique identifiers and feel that this feature will be a vital component of quality assessment. In addition, evaluators ought to have the capability to track calls across service centers to assess all of these performance metrics for an applicant who is transferred from one call center to another. It will be essential for the service centers to know how seamless the transfers between the state and county service centers truly are. These data will be essential to officials understanding of the effects of the structure of and relationship between state and county service centers on workloads, the quality of customer service, and improvements that might be necessary. Data Sharing The ACA stipulates that the streamlined Medi- Cal and Exchange application processes must not require applicants to provide unnecessary or duplicative information. Therefore, the transfers of data between CalHEERS and the counties Statewide Automated Welfare System (SAWS) databases and between the state and county service centers will be critical to meeting this requirement. This capability will be very important when individuals apply for assistance through one portal and are transferred to another. Further, information stored in these databases could potentially increase efficiency and accuracy when individuals circumstances change, causing transitions between the programs. If systems can readily transfer and share data from various health subsidy and other assistance programs, a more efficient and accurate eligibility and enrollment system would reduce the burden on beneficiaries, as well as potentially increase retention rates and create more consumer- friendly programs as a result. 8 California Health Benefit Exchange. Available at: erboardpresentation_ pdf 8

9 Summary The ACA explicitly requires states to create a streamlined, seamless, no- wrong- door eligibility portal for all health subsidy programs. This requirement recognizes the importance of a consumer- friendly eligibility and enrollment process that reduces the burden on the applicant as much as possible. This aim will serve to maximize enrollment and retention rates in health subsidy programs, reduce duplicative administrative work and expense, and ultimately increase beneficiaries access to and continuity of care. Ensuring that this eligibility and enrollment portal becomes a reality in California requires quality assessment and improvement measures that are informed by continuous data collection. This brief outlines a set of measures that will be important for the state and counties to track to gain an understanding of the consumer experience and how effectively these new systems are meeting the objectives of the ACA. As the state and counties implement new ACA programs and systems in 2014, these quality metrics will enable officials to understand how well the systems are performing and what steps might be necessary for continuous quality improvement a process that should continue through the months and years following the initial implementation of the new enrollment portal in January