Legislation Aims to Improve, Update Medicaid’s Eligibility Process

Lilo H. Stainton | September 13, 2018 | Health Care
Lawmakers, healthcare advocates push to update application process and more

crowded hospital waiting room
New Jersey lawmakers are pushing the state to modernize and improve its system for determining who is eligible to receive Medicaid and getting people enrolled, a process that has undergone some upgrades but is still criticized as burdensome and inefficient for both patients and administrators.

The Senate Budget Committee will review legislation Thursday that would require the state to create a new digital application for Medicaid, also known as NJ FamilyCare, and a way to track those submissions and reward government agencies that successfully enroll people. It also calls for an ombudsman to help individuals navigate the system.

The measure, sponsored by Senate Health Committee Chairman Joseph Vitale Jr. (D-Middlesex) and Sen. Fred Madden Jr. (D-Camden), draws from recommendations contained in the Medicaid 2.0 Blueprint for the Future, a March 2017 report published by the New Jersey Health Care Quality Institute. Among other things, it called for a full review of the state’s Medicaid intake system, as well as other reforms.

Suggestions include Medicaid ombudsman

The Quality Institute’s plan recommends a number of ways the state’s program could be updated to better meet the needs of its low-income patients and New Jersey taxpayers. This includes the creation of an electronic application system to better monitor the enrollment process and identify problems, along with the appointment of a system-wide enrollment advocate, or ombudsman.

“This is an ambitious bill that we fully support. The IT piece has been a challenge for more than twenty years,” said Linda Schwimmer, the Quality Institute’s president and CEO. In the institute’s Medicaid blueprint, “we specifically called for a comprehensive assessment of the entire intake system, and a way to hold the state-contracted entities that process Medicaid applications accountable for their performance. This bill provides for both,” she said.

On right: Carole Johnson, commissioner, Department of Human Services
Human Services Commissioner Carole Johnson, whose department oversees the state’s Medicaid program and other social services, said her staff is also reviewing the proposal. Johnson has taken several steps to expand Medicaid coverage, modernize the program, and improve transparency — including the creation of a new data dashboard, another priority for the Quality Institute.

There is now a single website, NJHelps, that serves as a portal for multiple social service applications, including FamilyCare, Johnson noted. “We are committed to continuing to build on and enhance our online tools and platform to improve the application process and experience for New Jerseyans,” she said.

Medicaid currently covers more than 1.7 million Garden State residents, or roughly one in five, nearly half of whom are children. While the program has grown slowly in the past year, current members must submit new financial data annually to continue to qualify for the insurance coverage, which is funded by a mix of state and federal dollars.

Disqualifying clients

According to a Quality Institute analysis of Medicaid data from 2013 through 2016, tens of thousands of residents lose coverage each month when they are determined to be ineligible — including several thousand who may still qualify for the program, but could not be reached because they moved, or changed phones, as well as those unable to provide the proper paperwork in time.

“As a direct result of the complexity of the system, beneficiaries who are otherwise eligible lose coverage and then need to be reenrolled — a process referred to as “churn,” the institute notes in its Medicaid 2.0 report. These patients are sometimes forced to seek medical services elsewhere and don’t have the continuity of care provided by regular visits to the same primary-care provider.

The eligibility-processing problems are grounded in the state’s outdated computer system, outdated regulations and contracts, and the complexity of the current process, the Quality Institute noted. As it is, eligibility is now determine by county officers, who handle much of the in-person enrollment, a state contractor that processes the data, and federal officials, who process certain applications as part of the Affordable Care Act.

“The current assortment of entry points is not only confusing to the Medicaid applicant, but places an administrative burden on the State, as it is labor intensive and prone to error. The comparative performance of the entities that process applications is not regularly tracked or reported by the State,” the QI wrote.

To address these concerns, the bill (S-499) — first introduced in November — calls for the DHS to work with the state’s Office of Information Technology to develop a modern online application that could be used by all those involved in enrollment. It also calls for a tracking system to enable state officials to identify hurdles in the sign-up process and monitor the agencies involved, as well as a penalty and reward system to encourage positive results.

In addition, the measure, which passed the Senate Health Committee in March, calls for the DHS to appoint an ombudsman to assist the process, noting that such an advocate exists for those covered by commercial health insurance plans. The bill aims to standardize the process across public agencies, simplify the steps for patients and staff, and create a platform that could also be used to link beneficiaries with other income-based social services, like food stamps or public support.

Long evident to lawmakers

A number of these concerns have long been evident to lawmakers as well. The Assembly Human Services Committee held hearings in 2014 on the state’s efforts to replace what was then a 1980s-era information technology system when it became evident that poor and low-income residents were not able to obtain the services they were qualified for — particularly Medicaid and food stamps, now called the Supplemental Nutrition Program or SNAP.

The state’s efforts to overhaul this system date back to 2007, when a company contracted to modernize its social service IT system for $83 million. But unseen problems arose and costs escalated as the benefit programs were flooded with applicants as a result of the recession. The contract was transferred several times before former Gov. Chris Christie fired the firm in 2014; the state had lost $10 million on the deal and the federal government was out $56 million.

Incremental progress has been made since then. The DHS has received federal waivers that provide additional flexibility within the Medicaid program, which has enabled officials to make some changes to the application process. In 2017 the state also launched NJHelps, the portal for multiple social services, but each program requires a distinct application — even though many low-income families qualify for several — and each application is processed independently.

Ultimately, Johnson said, “individuals can complete our online Medicaid application (on the NJHelps site), which allows for more timely eligibility determinations and assists the Department in better tracking and processing of applications.”