Guidelines For Collecting, Analyzing And Displaying Child .
Guidelines for Collecting, Analyzingand Displaying Child Health CoverageEligibility Outcomes DataPrepared ByVicki C. Grant, Ph.D., MSWDeputy DirectorCovering Kids National Program Office620 Sims AvenueColumbia, SC gkids.orgMarch 1999I
About Covering KidsCovering Kids is a national health access initiative for low-income, uninsured children.The program was made possible by a 47 million grant from The Robert WoodJohnson Foundation of Princeton, New Jersey, and is designed to help states and localcommunities increase the number of eligible children who benefit from healthinsurance coverage programs by: designing and conducting outreach programs thatidentlfy and enroll eligible children into Medicaid and other coverage programs;simplifying the enrollment processes; and coordinating existing coverage programs forlow-income children. Covering Kids receives direction and technical support from theSouthern Institute on Children and Families, located in Columbia, South Carolina.The views expressed in this report are those of the authors, and no officialendorsement by The Robert Wood Johnson Foundation is intendedor should be inferred.
TABLE OF CONTENTS.1STUDY TEAlM . .1INTRODUCTIONStudy Population . 2Study Units .:.3Display of Study Findings.3.STUDY DATA3Denial Reasons .4Closure Reasons . 4Additional Data . 5. .ANALYSIS AND INTERPRETATION5Changes in Caseload Size . 5Approval and Denial Rates . 5Reasons for Denial . 5Reasons for Case Closure .b .- 8Number and Percentage of Children's Cases Closed . 8.9CONCLUSIONAPPENDM A .AUTOMATIC AND NONAUTOMATIC.10APPENDM B .DATA TABLES.12APPENDIX C .EXAMPLJ3 OF DENIAL AND CLOSURE CODES.17SSIIMEDICAID STATES
GUIDELINES FOR COLLECTING,ANALYZING ANDDISPLAYING CHILD HEALTH COVERAGEELIGIBILITY OUTCOMES DATAINTRODUCTIONEligibility simplification of child health coverage programs is a majorgoal of grantees under The Robert Wood Johnson Foundation Covering Kidsinitiative.' Eligibility system data can play a major role in helping identi@simplification issues and solutions.One of the initial steps to eligibility simplification is a review of Medicaidand Children's Health Insurance Program (CHIP) eligibility data todetermine the current outcomes of the eligibility system. Eligibility outcomesdata provide states with information on the actual results of the applicationand redetermination processes, as well as the reasons for denials andclosures.The purpose of this paper is to serve as a brief "how-to" guide onconducting a children's health coverage eligibility outcomes data study. Thepaper describes who should be involved, the process and the data elementsneeded to conduct a n analysis of MedicaidICHIP eligibility outcomes.STUDY TEAMrA prerequisite for an eligibility outcomes study is the commitment andcooperation of state agency directors who have responsibility for Medicaid andCHIP, if separate from Medicaid. In states where the welfare agency is undercontract with MedicaidICHIP to provide eligibility determninati nservices, it isessential that the welfare director is also included. An eligibility outcomesstudy is a true collaborative venture where the agencies need to commit staff toparticipate in the study, provide the data for study and be willing to consideractions to remove eligibility barriers identified in the study.The recommended way to approach a study of eligibility outcomes isthrough the formation of a technical study team that has collective expertise onall facets of the eligibility process, as well as how the computer system isdesigned to support the eligibility function and sources of data and regulations.The team will meet several times during the first few weeks of design and thenwill need to hold regular meetings after data are available for analysis andinterpretation.Covering Kids: A National Health Access Initiative for Low-Income, UninsuredChildren is a 47 million program of The Robert Wood Johnson Foundation, withdirection and technical assistance provided by the Southern Institute on Children andFamilies.
The state agency directors should appoint staff to the study team t oinclude, a t a minimum, the following areas:Medicaid, CHIP and Temporary Assistance for Needy Families(TANF) eligibility policy experts;Computer systems managers and programmers; andLocal eligibility supervisors and fi-ontline eligibility staff.Child advocates who have experience in helping families meet eligibilityrequirements also should be included. While ultimate responsibility for thestudy and the study report must be assigned to one team member, all teammembers must be involved and committed to working on the design andimplementation of the study, as well as interpretation of the data.SCOPE OF STUDYStudy PopulationThe first task of the work group will be to define the population ofchildren for study. Medicaid has many eligibility categories and avenues forentry, including TANF and Supplemental Security Income (SSI). Theprimary focus of the study should be on the eligibility process, over which thestate has significant decision making authority.The groups of children that should be included in the study aredescribed below.,Medicaid children, including poverty related children and CHIPchildren eligible under a Medicaid expansion;Children eligible for CHIP coverage in states operating CHIP as aseparate and distinct program from Medicaid;Medicaid children in families receiving Transitional Medicaid; andChildren in TANF families who are automatically provided Medicaidwithout filing a separate Medicaid application. For this group ofchildren, the TANF eligibility data system will need to be 'incorporated into the study.Another Medicaid eligibility group is composed of low income, disabledchildren who receive cash assistance through SSI. In 32 states and theDistrict of Columbia, the Social Security Administration, rather than localeligibility workers, determines eligibility for disabled children under SSI, andchildren eligible for SSI are automatically eligible for Medicaid. In the 18states where Medicaid eligibility is not automatic for SSI children, thesechildren must apply for Medicaid coverage and be determined eligible in thesame local eligibility system as other children. A decision should be made as
t o whether to include SSI children in a study with other Medicaid children orto conduct a separate study of the Medicaid eligibility process for SSI children.(See Appendix A for a table on automatic and nonautomatic states.)Study UilitsThe study data should be collected for each county so that county bycounty comparisons can be made in addition to comparisons with statewidedata.2 Local level data are important to have in order to determine the range ofdata findings across the state. This level of analysis helps in determining ifspecial attention is needed in specific areas of the state.Display of Study FindingsBefore the data are gathered, the study team should decide how it willdisplay the data. Designing the data tables in advance helps the team clarifyexactly how the data should be gathered and what specific data are needed tocomplete a table.Appendix B provides examples of data tables used in reports oneligibility outcomes. The tables are designed to communicate effectively withpolicymakers and to answer questions of interest to them.S r n Y DATAWhen an application for children's Medicaid is filed, it is reviewed alongwith required verification documents, and a determination of eligibility ismade. Determinations of initial Medicaid eligibility result in one of threeoutcomes:Approved;Denied; andWithdrawn at request of the applicant.Although a withdrawn application results in the applicant not receivingMedicaid, it differs from a denial because it is an applicant decision, not anagency decision. For this reason, withdrawn applications are separated fromagency denials for purposes of analysis.Redeterminations of Medicaid eligibility result in one of three outcomes:Approved;Closed; and2If data are not available on a county by county basis, then another unit of local datashould be used.
Withdrawn at request of the recipient.Although Medicaid is lost when a child's case is withdrawn, withdrawn casesare separated from closures because withdrawn cases are recipient decisionsrather than agency decisions for purposes of analysis.Denial ReasonsEach state determines the computerized codes eligibility workers use fordesignating the reason for a denial of an initial application. Because thenumber of these specific denial codes may be large, it is necessary to group thedenial codes. The following five basic categories of denial reasons relate toeligibility policy and are a helpful way to group data for analysis. These are:Excess income;Age not within eligibility criteria;Excess resources (in states with a resource/assets test);Failure to comply with procedural requirements, such as missing anappointment for an eligibility interview or failure to return requiredverification documents within the required time frame; andOther basic eligibility criteria, such as, undocumented alien, notdeprived of parental support, and the applicant moved or cannot belocated.IClosure l3easonsEach state determines the computerized codes eligibility workers use fordesignating the reason a case is closed. As with denial reasons, there aremany specific closure codes, and it is helpful to group them into basiccategories. Closures can be grouped into the following categoGes:Excess income;Age not within eligibility criteria;Excess resources (in states with a resource/assets test);Failure t o comply with procedural requirements, such as missing anappointment for a redetermination interview or failure to returnrequired verification documents or reports within the time frame;andOther basic eligibility criteria, such as, transitional period expiredand the recipient cannot be located.Appendix C shows an example of denial and closure codes ascategorized for a recent study on eligibility outcomes for TANF and Medicaidchildren.
Additional DataMore than likely, the study will indicate some areas in need of additionalstudy. For example, a review of a random sample of case records may beneeded to identify policy and procedural barriers to eligibility, especially whenattempting to identify verification issues. Case file reviews should beconducted using a review guide to assure the collection of essentialinformation on a consistent basis.Another method of gaining in-depth information into areas identified bythe analysis of eligibility outcomes data is to interview denied applicants orformer recipients. Their experience with the eligibility system is an invaluablesource of information. As with any data gathering effort, protection ofconfidentiality is paramount.ANALYSIS AND INTERPRJETATIONChanges in Caseload SizeChanges in caseload size are determined by the net effect of the numberof approvals and the number of closures within a time period. Currentoutreach efforts to enroll uninsured children are typically designed to increasethe number of applications.The number of children covered by Medicaid can decline in the face ofincreasing applications, if systemic efforts are not directed at retaining eligiblechildren on Medicaid. Declines in Medicaid coverage for children as a resultof welfare reform can probably be traced t o the lack of systemic efforts toprevent children from losing Medicaid when the family was no longer eligiblefor cash assistance under the welfare program.Approval and Denial RatesAn effective eligibility system results in approval for children whoqualify under the eligibility criteria and denial for children who do not qualify.A basic data finding is the approval or denial rate of applications. The desiredor appropriate denial rate should be determined for use as a benchmark asdenial rates are monitored over time. Table B-1 in the appendix shows a modelfor displaying the rates.Reasons for DenialIn order to understand why children are denied, the denial reasonsshould be analyzed. The question to be answered is: "Are children deniedbecause they are not eligible due t o excess income or other eligibility criteria, orbecause they did not comply with a procedure within the eligibility system?"The denial reason of "failure to comply with procedural requirements"points to system barriers. A truly simplified eligibility process should producealmost no procedural denials.
There are two major reasons for procedural denials. These reasons are:Missing a n appointment for a n eligibility interview, commonlyknown as no-show; andFailing to return requested verification documents.Denials for procedural reasons do not indicate whether or not a childqualifies under the eligibility criteria. One study documented the likelihood ofeligibility after examining a representative sample of 100 case records deniedfor failing to return verification documents. The case records were reviewedand income and resource eligibility were determined from the information inthe record. It was found that 76% of these cases were probably eligible if therequested verification been returned and if it substantiated the informationstated by the a p p l i a n t . ProceduralDenials Due toNo ShowsIf a relatively high number of procedural denials can be traced to "noshows," then a number of policy options can be examined. Face to faceinterviews are a state option. Many states are discontinuing the practice,particularly in light of more applicants having full work schedules and beingunable to leave work during the typical 8:OO-500 day. The following list ofquestions is not intended to be complete but to stimulate thinking about theprocess of appointments:Are applicants given a choice about appointment times, or are theysent a time and date in the mail?What is the readability level of the appointment notice?IAre applicants given a specific and dedicated time for a n interview,or are they given a time to check in and then wait for a n interview ona first-come, first-serve basis?Are interviews scheduled before or after regular office hours and onweekends?Are interviews held at locations other than the eligibility office?Are local telephone systems adequate and user-friendly?If face to face interviews are required, is there a n adequate andreliable transportation system for applicants to use to get to theeligibility office?Sarah C. Shuptrine, Vicki C. Grant, and Genny G. McKenzie, I m r o v i nAccess toMedicaid for Pregnant Women and Children, prepared for The Robert Wood JohnsonFoundation and Grady Memorial Hospital (Columbia, SC: Sarah Shuptrine andAssociates, February 1993) p. 37.6
Is there a purpose for the face-to-face interview that cannot be met inother ways?Procedural Denials Due to Failure to Return VerifcationIf a relatively high number of procedural denials is for failure to returnverification documents requested by the eligibility worker, then verificationpolicies and procedures should be examined. Because this is an area wherepolicy and practice are not always congruent, it is important to understandwhich documents are not being returned. The following list of questions is notintended to be complete but to stimulate thinking about verification and theprocess:Do eligibility workers request more verification than required bypolicy?Are eligibility workers requesting applicants to submit documentsthat the eligibility worker can obtain fkom other agency files?Are standardized, multi-program checklists given to applicants thatlist documents to provide the eligibility worker, or are applicantsasked to bring only required verification documentation specific totheir application and circumstances?Is it easy or difficult to actually speak to eligibility workers by callingthe eligibility office?0Do office policies require eligibility workers to offer and provideassistance to applicants in obtaining the required verification? rWhat verification documents are most likely not to be returned?How much time are applicants given to return verificationdocuments?F'rocesshy TimeTypically, eligibility workers must make a decision on eligibility within45 days or less from the date the application was filed. In many areas,processing time has been judged as too long and policies have been enacted toshorten the time. The time it takes to make an eligibility decision should bebalanced against the potential impact on denial rates. A n unintendedconsequence of placing too much emphasis on reducing processing time isthat denials can increase because required verification documents are notreturned in shortened time periods.Table B-2 in the appendix shows a model for displaying denial reasons.
Reasons for Case ClosureAt some point after children are approved, their eligibility for continuingcoverage must be redetermined. For most children, a redetermination mustbe made at least every 12 months, but a state can choose to redetermineeligibility more frequently. Except in states that have adopted the continuouseligibility option, recipients are required to report immediately any changes inincome or household size so that eligibility can be redetermined.To better understand the outcomes of the redetermination process, thereasons for closure should be analyzed. Reviewing the reasons for closure isan important step to assure that cases are being closed only when children nolonger qualify under eligibility criteria. Similar to denials, system barriersmay be present when a high percentage of closures are due to failure to complywith procedural requirements or failure to return required reports. Table B-3in the appendix shows a model for displaying closure reasons.Number and Percentage of Children's Cases ClosedAn important measure of the eligibility process is the number ofchildren who have their cases closed and the percentage of the children'scaseload that is closed. It is administratively inefficient, as well as disruptiveto families and providers, when eligible cases are closed and families have toreapply.A recent study of closures showed that in 12 months, a state closed61,133 children's Medicaid cases. Of these total case closures, 32,514 wereclosed only once, and a number were closed more than once, resulting iq thechurning p h e n m e n o n . If the extent of churning is high, the possible causesshould be investigated. In this state's case, 57% of Medicaid infants wereautomatically closed upon reaching their first birthday because of a computercode that automatically generated closure action. As pointed out in the study,"Churning is costly, as well as disruptive to families and providers."Churning can be minimized by adoption of 12-month continuous eligibility and,implementation of practices and procedures to assure that children'seligibility is determined under all Medicaid categories before a closure actionis taken, as required by federal law.If the data are reviewed over a n extended time fkame, such as 12months, duplications should be removed to determine the extent that childrenare losing Medicaid and then returning. The unduplicated set of numbersgives a count of cases or children closed without counting a child more thanonce. The set of numbers that are not unduplicated gives a count ofcaseworker or system actions to close cases, including cases that are closed,reapply and receive Medicaid coverage again, and later closed again.Sarah C. Shuptrine and Genny G. McKenzie, South Carolina Medicaid EligibilityStudy, prepared for the South Carolina Children's Hospital Collaborative (Columbia,SC: Sarah Shuptrine and Associates, December 1998) p. 7-8.8
Table B-4in the appendix shows a model for displaying the percentageand number of children's cases closed.CONCLUSIONA study of eligibility outcomes data is an excellent way to gain anobjective view of the eligibility process a t application and redetermination.Eligibility outcomes data provide states with information on the actual resultsof the application and redetermination processes, as well as the reasons fordenials and closures. Such a study creates a baseline for monitoring changeover time, especially as simplification reforms are implemented.
APPENDIX AAUTOMATICAND NONAUTOMATIC SSUMEXlICAID STATES
Distribution of States on Whether Medicaid Is Automatically Providedto SSI Recipients or Separate Medicaid Application Must Be FiledAutomatic States(33 States)Nonautomatic Medicaid StatesSeparate ApplicationSeparate ApplicationSame Eligibility CriteriaMore Restrictive EligibilityCriteria (11 States)(7 t of ColumbiaUtahNorth DakotaFloridaNew piMontanaNew JerseyNew MexicoNew YorkNorth CarolinaPennsylvaniam o d e IslandSouth CarolinaSouth DakotaTennesseeTexasVermontWashingtonWest VirginiaWisconsinWyomingI
APPENDIX BDATATAB-
TABLE B-1APPROVAL AND DENIAL RATES OF CHILDREN'S MEDICAIDAPPLICATIONSAGE 18 AND UNDER, BY COUNTY AND STATETIME PERIODAreaStateNumberPercentage ofof ApplicationsChildren's MedicaidApproved and DeniedApplicationsApproved#Percentage ofChildren's MedicaidApplications Denied%%County 1County 2County 3County 4County 5County 6County 7County 8County 9County 10Source:I
TABLE B-2MEDICAID APPLICATION DENIALS FOR CHILDRENAGE 18 AND UNDER, BY COUNTY AND STATETIME PERIODAreaStatePercentage of Applications Denied By ReasonPercentage of Number of Number ofFailure t oExcessExcessApplicationsIndividualsComply withApplicationsOtherIncome ResourcesDeniedDeniedDeniedProceduresAge%##%County 1County 2County 3County 4County 5County 6County 7County 8County 9County 10Source:-%%%%
TABLE B-3CASE CLOSURES FOR MEDICAID CHILDRENAGE 18 AND UNDER, BY COUNTY A N D STATETIME PERIODPercentage of Case Closures By ReasonAreaStateCounty 1County 2County 3County 4County 5County 6County 7County 8County 9County 10TotalTotalNumber OfCaseClosures Children##ExcessIncomeExcessResources%%AgeFailure ToComply WithProceduresOther BasicEligibility Criteria%%%Notes: 1) The data are not unduplicated. 2) The estimate of individuals is based on 1.68 persons per Medicaid case. 3) "Other"includes cases where a determination cannot-be made because the family did not respond, cases where the family has moved orcan't be located, cases where the postpartum period has ended, cases where the certificate period has ended, cases withdrawnby recipients, cases with no eligible child and non-residents.Source:
TABLE B-4PERCENTAGE AND NUMBER OF MEDICAID CHILDREN'SCASE CLOSURES, AGE 18 AND UNDERBY COUNTY AND STATETIMOE PERIODAreaPercentage of MedicaidChildren's CaseloadClosedTotal Number ofMedicaid ChildrenCase ClosuresState%#County 1County 2County 3County 4County 5County 6County 7ICounty 8County 9County 10Note: The data are unduplicated cases.Source:
APPENDIX CEXAMPLE OF DENIAL AND CL0SUR;E CODES
CHIPCODE,. ".'gf"k-.x&"&Zre;',- GJ[ ;' :c"- DESCRIM'ION*" /2;"*'b* *-:t - ' :"'" ."; 7 :. " '\ -AFDCDENIALCLOSUREREASON.::"''-, ?', CMCXChild Support Extended MedicaidNYCExc IncomeChild support FI Extended MedicaidYYCExc IncomeDMDisregard loss - Extended MedicaidNYCExc IncomeDXDisregard loss - FI Extended MedicaidYYCExc IncomeEMEarned income - Extended MedicaidNYCExc IncomeEXEarned income - FI Extended MedicaidYYCExc IncomeIEIncrease - earned incomeNYCExc IncomeINEarned income limits -no MedicaidNYCExc IncomeIUIncrease - income/pensions, etc.NYCExc IncomeIUUnearned income limits - no MedicaidNYCExc IncomeLSLump sum ineligibility before 6130197NYCExc IncomeRTRemoval of 30 113NYCExc IncomeRTRemoval of disregardNYCExc IncomeSISupport - pension inside homeNYCExc IncomeSOSupport - pension outside homeNYCExc IncomeWMWage supp. - Extended MedicaidYYCWMWage supp. - Extended MedicaidYYCExc IncomeWSWage suppJno Extended MedicaidYYCExc IncomeDPDeemed parent incomeNYDExc IncomeIGIncome (gross) exceeds limitsNY'DExc IncomeINIncome (net) meetslexceeds requirementsNYDExc IncomeSTStepparent income'LeE&& &6/& 9 ." "-3--FI'' - Lni*L",' ?", * . ",r"x-l" - ,A" " "" A. : ."-7-*",,wA A ansferDfTe OUt.CeSz: .2:::A, *;A-Y'iy' "ls'* -Nh ' ;?'*;p"pAbc,,5-;I.i*Ly;.;.1 : :x: l.," %,, 3%4;.: ;m J 2amO-s!' I-", *'miI ,; "u3, ' "-"c:pq" e s"2 X ", I:,r: , :,,j: . C'?;- A,?*A-11D-5: %:':'AExc Income,-C,. "-D/G/. ,d:B/C.,Exc IncomeA:f ,A1 - EG Bsomces,.' k g & e s m & -I , ,ATFailed to participate in druglalcohol programYYCFTCFAFailed to comply wlagreement (ISSP)YYCFTCFRFailed to complete reviewNYCFTCLDMRLoss of disregards - sanctionedNYCFTCFailed to file MRNYCFTCFailed t o cooperate with QCNYCFTCAFDC semi annual not completeNYCFTCQCSAPage 1 of 1AEXC &ources:
untary quit a jobNYCFTCWCWage supp. - noncooperative with CSYYCFTCWRWork reg - refuselfail to complyNYCF"rCFCFailed to complete interview (Sys-Generated)NYDFTCFPFailed to provide information (Sys-Generated)NYDFTCJSInitial job search not completedYYDFTCJSInitialjob search not completedYYDFTCPBPossible benefit - failed to applyNYDFTCSRSpec. Rel. Not verifiedNYDFTCPage 2 of 2
CISCODE-DENIALCLOSUREDESCRIPTIONREASONCCBudget period expired-closed by computerCCAManual closureCMEMedicare eligibleC98Terminated from community long term care expandedservicesCTUComputer closure deemed babyC1st BirthdayB1Infant has reached first birthdayC1st Birthday95Child has reached first birthday (or 19th)C1st Birthdaym w g x & g @ ; .: .,, ; .: g": j; &FjF & ; :;?'?:!;"& :'" :c& :; :: : .i., ' :;?;:;:i ":::.,. ;: :?y,:&T :;?,y:? :.3;j:(?;; i,y: ic&? l&,a e2:.: ,- .,.,,. .,.*,::.:a,,*., . .;,; ;g ;;; y: ,;;.4 ;,.fi.b?"Y; s,:*: ,.,.,,v,,: ,&.*kc ,.,;:*;,: ;.::.:. . ,, ,,, ,,.,.,, ,.yy,. :;, . " ,, .A,,3,. .: : . .,,,a.#: : ,: .: , ; , , ,:*:.A*,,,liil.i ,,,, . : , , . ,%.,.,. ,"r%,,.A. ",' .D2Removal of 30 1/3 or 30 earned income disregardCExc Income70Remains in foster care, no longer financially eligible forMedicaidCExc IncomePage 3 of 3,
CHIP is the AFDC and Food Stamp computer system.CIS is the Medicaid Client Information System.Page 4 of 4
GUIDELINES FOR COLLECTING, ANALYZING AND DISPLAYING CHILD HEALTH COVERAGE ELIGIBILITY OUTCOMES DATA INTRODUCTION Eligibility simplification of child health coverage programs is a major goal of grantees under The Robert Wood Johnson Foundation Covering Kids initiative.' Eligibility system data can play a major role in helping
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