Children's Medicaid Simplification - Senate Bill 43
Proposed Implementation Outline
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In addition to the project implementation plan outlined below, the following attachments are included for review:

• Draft - Joint Application for Children's Health Insurance (pdf document). This is the revised TexCare Partnership application that will be used for children applying for Medicaid and CHIP through either the TexCare Partnership or through DHS.
• Timeline for Publication of DHS rules - These are the DHS rules that would implement the key components of Senate Bill 43.
• Draft - Script for Health Care Orientation (pdf document). This is the material that will be used by Texas Health Steps (THSteps) staff and contractors, and participating community-based organizations (CBOs) for the Health Care Orientation required by Senate Bill 43.
• Health Care Orientation - Application for Interested CBOs (pdf document) - This is the application and agreement between THSteps and CBOs interested in volunteering to deliver the Health Care Orientation.

Introduction/Background

SB 43 requires major changes in Medicaid eligibility policy for children under age 19. The law does not make any Medicaid eligibility changes for children age 19 and 20. The legislation's primary focus is to make children's Medicaid simpler and more like the CHIP program by unifying the application process and streamlining eligibility approval processes. The bill's Eligibility Transition provisions require the elimination of gaps in coverage when children are moving between CHIP and Medicaid. Two provisions in the bill -- the Health Care Orientation requirement and the THSteps provisions -- require the development of new processes and additional system and staff effort to ensure better utilization of preventive care and the health care system in general.

The bill's requirements fall into four major areas:

• Application Simplification
• Continuous Eligibility and Eligibility Transition with CHIP
• Health Care Orientation (HCO)
• Participation in THSteps

Outline of Proposed Components and Processes

A. Application Simplification (Phase I)

• The TexCare Partnership (TCP) and the DHS children's Medicaid application will become a joint application.
• DHS mailed-out applications or applications obtained in person from DHS will omit the TCP 1-800 number at header and will omit the U.S. DHHS civil rights number in the Rights and Responsibilities section. Phone numbers for assistance and civil rights (at local DHS office) will be addressed in DHS cover letter.
• These two differences recognize that sending families to TCP for assistance with an application obtained from DHS is likely to be confusing and that DHS local offices have an internal civil rights process, unlike TCP.
• The assets questions and additional questions for Medicaid will be included on the joint application and will not be asked as a second step. This process and the additional questions and items will improve and speed the processing of all applications, whether applicants eventually enroll in CHIP or Medicaid.
• DHS applicants wanting TANF, Food Stamps or adult Medicaid will still use the DHS form. If applicants want children's Medicaid in addition to any of these other program benefits, they will complete both the DHS and the TCP simplified children's health insurance application. However, if applicants mail in ONLY the old DHS form and intend to apply for children's Medicaid, DHS will process that form for children's Medicaid eligibility.
• Any applications distributed in bulk in the community by DHS will be the TCP application folder and will be mailed to TCP.
• The header on application will be "TexCare Partnership Application."
• A social security number (SSN) or documentation of application for a SSN will be required on the joint application. A SSN is considered essential for a "seamless" application system between CHIP and Medicaid and is also useful in improving child support and medical support efforts (per Senate Bill 236).
• Assistance in applying for a SSN will be offered. Currently, about 75% of TCP applicants already provide SSNs on the submitted application.
• As an interim approach, TCP will discontinue/recycle existing TCP application stock and start sending out the new joint application. For an interim period, the application may be black and white with updated instructions for SSN.
• The online application will be changed to be consistent with the written application and the SSN change.
• TCP will continue to process any old stock applications. If a SSN is not provided, the family will get a missing information letter (similar to any of the other missing information letters).
• For Phase I, DHS mailed-out applications or applications provided at DHS offices will be mailed to DHS. TCP applications will be mailed to TCP. This process will be reviewed for Phase II.
• All of the above are interim steps to implement key provisions of SB 43. Additional consolidation and changes may be made as Phase II changes after field testing and further reengineering of TCP and/or DHS business processes.

B. Medicaid Process Simplification and Continuous Eligibility

New DHS Policies

• Initial applications and renewals for children's Medicaid may be processed by mail or telephone.
• Children under 19 are certified for 6-month periods, and remain continuously eligible regardless of changes in household composition, income and resources.
• A Medicaid renewal form asking the same questions as the CHIP form will be sent to the family in the 4th month of their 6-month continuous eligibility period. The form includes an option to state there have been no changes and to return the form without completing the entire renewal form.
• Applications may be accepted at any health and human services agency.
• Applications may be filed at hospitals, county health departments, and federally qualified health centers (FQHCs). List of FQHCs
• Each DHS region will contract with hospitals, health departments and FQHCs to accept applications. Contracts will specify the length of time by which the provider must get the applications to the DHS office for processing.
• Documentation and verification procedures for children under 19 will be the same as the requirements for CHIP. Assets questions are the same and do not require verification.

C. Eligibility Transition

Background

DHS and Birch and Davis (the TCP administrative services contractor) business processes will be reengineered to eliminate gaps in coverage for children moving between CHIP and Medicaid. For families whose eligibility periods "straddle" the January 1 start date, DHS may manually extend Medicaid eligibility for 1-2 months as needed. For families whose Medicaid continuous eligibility periods begin on or after January 1, the system reprogramming will prevent system-caused gaps in coverage.

New DHS Policy

• Medicaid renewal packets will be mailed at the beginning of the 4th month of a child's 6-month eligibility period. Completion of the renewal process by the middle of the 5th month will allow sufficient time to "deem" (or automatically enroll) a child to CHIP when he/she is no longer eligible for Medicaid due to income or assets. Eligibility for Medicaid continues through the end of the 6th month. The family receives an enrollment packet as soon as the deeming process occurs. If the enrollment packet is received at TCP by the middle of the 6th month, enrollment in CHIP is effective the first of the 7th month (no gap in health coverage).
• It will be important for families to promptly return Medicaid renewal packets to DHS, and to promptly return the enrollment packet to CHIP after deeming, to ensure no gap in coverage. If there is a delay due to Birch & Davis or DHS error, Medicaid eligibility may be extended 1 or 2 additional months to allow the family time to complete the process and still retain coverage.
• Reminders will be mailed to families about importance of keeping Medicaid coverage, and the availability of CHIP, at beginning of 5th month if renewal form hasn't been received.

TCP / Birch and Davis System Changes - Eligibility Transition:

• A "Medicaid end date" field will be added to the daily DHS electronic "deem to CHIP" file. This change will better coordinate the ending date (for a child leaving Medicaid) with the child's start date in CHIP.
• The existing TCP Enrollment Confirmation and Enrollment packet/welcome letters will be revised to accommodate the change described above.
• As of January 1, 2002, the TCP process will look for a SSN (or proof of application to SSA for a SSN) for every applying child.
• For applications lacking a SSN, a missing information letter that addresses both the need on the part of the family to submit SSN information and that explains the reason for this change will be developed.
• TCP will develop a process to assist families with SSN applications.
• A reminder letter will be developed for families to forward SSN (for those families that supplied verification of application for SSN).
• TCP will develop new CBO training materials to reflect the new SSN requirement and provide training to CBOs on SSN application assistance.

D. Health Care Orientation (HCO) for Parents and Guardians of Medicaid-enrolled
     Children

Components:

• Generally, the HCO requirement is a one-time requirement.
• Only parents or guardians whose children are newly Medicaid certified after January 1, 2002, are subject to the HCO requirement.
• Families with prior Medicaid coverage, but with gaps in service greater than two years will need to meet the HCO requirement.
• Children who become eligible for Medicaid through an application to the Social Security Administration for SSI or SSI-related Medicaid programs are not subject to the HCO requirement.
• There will be multiple opportunities to meet the HCO requirement. The parent or guardian may:
  • attend an in-person HCO provided by THSteps or volunteer CBO in a group setting, or in a one-on-one session in an office or the caretaker's home;
  • take the child to a THSteps medical check-up or for a medical visit for any reason. Medical visits to an emergency room will not qualify as an HCO (this system requires no extra effort on the medical provider's part);
  • get the HCO over the phone by THSteps staff and concurrently in the mail as an insert in the DHS notification of certification letter; or
  • get the HCO in a DHS office with a DHS caseworker at the time of application or at a face-to-face renewal visit.
• Although HCOs can be accomplished with CBOs, through medical visits, medical check-ups, and at DHS offices, THSteps (including MAXIMUS in contracted areas) is ultimately responsible for assuring that caretakers receive the HCO.
• THSteps will offer the telephone HCO on the first telephone contact with all parents and guardians, yet still encourage the caretaker to make an appointment for a face-to-face HCO.
• It the parent or guardian does not complete the HCO requirement, they may be required to renew the child's Medicaid in person at a DHS office. If this occurs, he/she will receive the HCO from DHS at that time, which will fulfil the one-time HCO requirement.
• Only medical visits and medical check-ups will fulfill the HCO requirement; dental visits or dental check-ups will not fulfill this requirement.
• If the caretaker reports to THSteps or DHS that the child has been to a medical appointment or THSteps medical check-up since the initial certification for Medicaid, the HCO requirement will be completed. DHS will verify the THSteps medical check-up visit at a later date, through the claims processing system.
• When a THSteps worker assists a family in scheduling a medical check-up appointment, or if a caretaker reports to the worker that he/she has scheduled the medical check-up or a medical appointment, the worker will credit the family as having completed the HCO.
• The HCO will be developed in English, Spanish, and Vietnamese. Clients speaking other languages will be referred to the THSteps call center for AT&T translation services. Caretakers with hearing impairments can contact THSteps through the Relay Texas system.
• THSteps outreach staff and CBOs will coordinate with MAXIMUS enrollment broker staff to include health plan-specific information as an area-specific addendum to the statewide training curriculum. This will allow the caretaker to attend only one HCO to learn about THSteps, appropriate use of health insurance, and how to enroll in a health plan, where appropriate.
• THSteps will test the HCO script in at least two areas of the state (rural and urban) and make subsequent revisions to the script before producing the final version for publication.
• DHS will begin mailing an updated Medicaid User's Guide to parents and guardians statewide when it becomes available. Caretakers will also receive a one-page summary of HCO content in their notification letter, as well as a resource page of important phone numbers as a handout at the time of the HCO.
• CBO participation in the HCO program will be on a voluntary basis.
• CBOs will designate a HCO contact person, who will attend a train-the-trainer session. This contact person will be responsible for assuring that other CBO staff and volunteers are trained before offering HCOs.

E. Participation in THSteps

Proposed SB 43 Process

• Similar to the current THSteps process for TANF families, the SB 43 THSteps requirement will be applied to children starting at age 2. Children under age 2 typically have high compliance.
• Generally, children over age 2 are required to have an annual THSteps medical check-up visit. Medical check-ups are not required for ages 7 and 9.
• Following initial certification for Medicaid, THSteps staff will contact the family (see HCO section) and encourage and assist (if needed) the family to schedule a medical check-up visit for the child or children.
• If no medical check-up is indicated on the DHS eligibility system at the time the Medicaid renewal process begins, the family is notified and given the opportunity to self-declare that the child has had the medical check-up, the child is currently scheduled for the medical check-up, or has good cause reason (using current THSteps good cause policy) for not completing the medical check-up.
• Good cause reasons include:
  • Medical - A medical provider may decide that for medical reasons a check-up is not required (e.g., the child is ill or has a chronic illness; doctor documentation of recent medical check-up visit; or provider discretion based on health status of the child, etc.)
  • Religion - The family has a religious belief that does not allow the child to have a medical check-up.
  • No medical provider or transportation - There is no medical provider or transportation available within the family's geographic area.
• If the family indicates that the child has had the medical check-up or is scheduled for the medical check-up, or had a good cause reason, the DHS advisor updates the DHS eligibility system and the family can renew Medicaid eligibility by mail.
• If the child is overdue for the medical check-up and there is no self-declaration otherwise or a good cause exception, the family will be required to renew Medicaid coverage in person at a DHS office.

Improvement to Data Systems:

The current data systems for capturing THSteps medical check-up information do not adequately capture all completed medical check-ups. This necessitates a flexible self-declaration process when the system does not indicate a medical check-up. Planned improvements to data systems include:

• Improved data on Medicaid managed care claims.
• Manually verified medical check-up dates.
• Acceptance of data from other sources.
• Expansion of database to include filed as well as paid and adjudicated claims.