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Policy Innovation Profile

Online System Speeds Enrollment in Medicaid and Children’s Health Insurance Program, Significantly Reduces Operating Costs, and Contributes to Decline in Number of Uninsured


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Snapshot

Summary

The Oklahoma Health Care Authority, which administers Medicaid and the Children’s Health Insurance Program in the state, offers a real-time enrollment system for both programs. Enacted in response to an expansion in the eligible Medicaid population and Congress’s reauthorization of the Children’s Health Insurance Program, the system performs real-time data review (verifying information through other State databases) and then immediately enrolls new applicants and renews benefits for existing beneficiaries if they appear to meet eligibility requirements, employing an “enroll-first, verify-later” approach for those in which eligibility cannot be confirmed. Various sources of support are available to assist those unable to complete the application process on their own. Since its introduction, the system has rapidly become the dominant method of applying for or renewing coverage, has dramatically reduced the time it takes for an individual to enroll and start receiving benefits, has contributed to a decline in the number of uninsured in the state, and has saved an estimated $1.5 million in operating costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the time required to review and process applications for Medicaid and CHIP under the SoonerCare program; trends in the proportion of uninsured children in Oklahoma; post-implementation estimates of the cost savings generated by the program; and post-implementation reports from families on their satisfaction with the system.
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Developing Organizations

Oklahoma Health Care Authority
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Date First Implemented

2010
Planning for the system began in 2007, with implementation in September 2010.begin pp

Patient Population

Vulnerable Populations > Children; Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

The application and eligibility verification process used by Oklahoma for Medicaid and the Children’s Health Insurance Program (CHIP) was fraught with long delays, inconsistent application of eligibility rules, and a significant social stigma associated with applying for and receiving benefits. As a result, many eligible adults and children did not apply, thus exacerbating the problem of uninsured individuals in the state.

  • Multiple problems with application and verification process: Various problems plagued the Medicaid and CHIP application and eligibility verification process used in Oklahoma, as outlined below:
    • Long enrollment delays: The typical applicant for SoonerCare (the name for Oklahoma’s Medicaid and CHIP program) waited nearly 3 weeks for the application to be reviewed and enrollment finalized. The lengthy process stemmed from overtaxed case workers and the inability to use automated systems to reduce their workload and to process applications outside of normal working hours, including weekends, holidays, and during periods of bad weather when State offices closed. In addition, submitted paper applications often were not complete, forcing staff to follow up with applicants to obtain missing data.
    • Inconsistent application of eligibility rules: Significant variations existed across Oklahoma’s 77 counties in how eligibility rules, including income verification, were applied. These variations stemmed from differences in caseworker training and human judgment.
    • Stigma associated with applying in person: Potential enrollees sometimes decided not to apply for benefits because of the significant stigma associated with visiting a county office to apply for “welfare.” Many eligible individuals did not use other similar programs offered by the state, and hence felt reluctant to apply for health care benefits.
  • Resulting in many eligible individuals not applying for benefits: The obstacles outlined above led many of Oklahoma’s 600,000 uninsured residents (out of 3.3 million total residents, giving the state the eighth-highest rate of uninsured in the country) not to apply for Medicaid or CHIP coverage, despite the fact that many of them were eligible for the programs, including 100,000 residents made eligible for Medicaid when Oklahoma received a Federal waiver for that program in 2007.1

What They Did

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Description of the Innovative Activity

The Oklahoma Health Care Authority offers a real-time, online enrollment and renewal system for both Medicaid and CHIP. The system performs real-time data review (verifying information through other State databases) and then immediately enrolls new applicants and renews benefits for existing beneficiaries who appear to meet eligibility requirements, employing an “enroll-first, verify-later” approach for those in which eligibility cannot be confirmed. Various sources of support are available to assist those unable to complete the application process on their own. Key components of the program include the following:
  • Eligible users: The vast majority of eligible populations for SoonerCare can be enrolled through the online system, including children ages 19 years and younger who live in households with an income less than 185 percent of the Federal poverty level (FPL); women who are pregnant and live in households that earn up to 185 percent of the FPL; adults with minor children living in households earning up to 37 percent of the FPL; anyone 19 years and older seeking family planning services who lives in a household that earns up to 185 percent of the FPL; anyone seeking behavioral health services who lives in a household that earns up to 200 percent of the FPL; and some individuals who also qualify for Insure Oklahoma, a State program for low-income working adults.
  • Quick, easy-to-complete online application to enroll or renew benefits: The online system can be accessed 24 hours a day, 7 days a week by anyone seeking to enroll for the first time or renew benefits (even before the end of the current enrollment period). Current enrollees with an approaching expiration date receive an electronic reminder to access the system to renew benefits, along with an accompanying personal identification number. The new or renewing applicant enters the requisite information needed for the system to determine eligibility, including income, citizenship, and other data. They can also upload any needed documents (e.g., proof of citizenship) to be included with their application. Applicants also select a primary care provider, eliminating the need for later assignment and helping the state implement the medical home concept. The entire process takes roughly 30 to 45 minutes for new applicants, depending on family size, and 5 to 8 minutes for renewals.
  • Available support through call center, partner agencies: Although most individuals complete the online application process on their own, those unable to do so can go to a local office to apply in person or contact a centralized call center staffed by those trained to assist with the enrollment process. In addition, staff at other agencies that serve similar populations have been trained to assist applicants in completing the online application in their offices, using an agency-based version of the system. These entities include public health agencies, tribal organizations, community health centers, and other community-based organizations. Staff in these agencies can also directly input additional data from their databases into the application, can submit completed applications directly to the Oklahoma Health Care Authority, and can track their disposition. In addition, hospital staff can use a separate online portal to enroll eligible newborns in the system and hence provide the family with a SoonerCare identification number for the child before discharge, thus removing the previous requirement for the family to apply in person after the birth.
  • Submission of (only complete) applications: After completing the process, the applicant (or assisting agency) hits the submit button to transfer the application to the Oklahoma Health Care Authority. If information is missing, the system will not transmit the application and instead alerts the applicant of the need to provide any missing data. As noted, before implementation of this program, paper applications often did not include all needed information, thus increasing the time between application and enrollment and requiring staff time to follow up on missing information.
  • Real-time review and decision, using “enroll-first, verify-later” policy: Everyone who completes the process receives a real-time initial enrollment decision based on the information provided. During the month of February 2013, approximately 52 percent of new applications and 93 percent of recertifications were approved. Those approved automatically receive a member identification number online, permitting them to access services immediately if needed. (A membership card is also subsequently sent by mail.) If not all information can be verified, the system employs an “enroll-first, verify-later" policy. In other words, the applicant will be enrolled in the program, and later disenrolled if the unverified information on the original application turns out to be inaccurate and hence disqualifies the person from eligibility. This new policy fundamentally changed the traditional process, which required verification of income and other eligibility criteria (such as confirming a pregnancy) before the individual was enrolled. To make the decision, the system uses the following steps:
    • Verification of information via other State databases: The system conducts a behind-the-scenes review to verify self-reported income, citizenship, and other information by accessing other State databases that may contain this information, including databases maintained by the Social Security Administration, the Oklahoma Employment Security Commission, the Oklahoma State Department of Health, and the Oklahoma Department of Human Services. Program leaders estimate that roughly 80 percent of applicants have personal information in databases from these and other programs. If information in the databases differs from the self-reported data, the family receives a letter and is given time to provide documentation using the upload function available in the system.
    • Rules engine to standardize application of criteria: The enrollment software relies on a standardized, algorithm-based rules engine to ensure uniform application of eligibility criteria in counties throughout the state. These rules typically come in “if/then” form—for example, if the person’s income is at or below a certain amount, then he or she is eligible for enrollment. An eligibility unit makes determinations in exceptional cases that the automated rules engine cannot handle.

Context of the Innovation

The Oklahoma Health Care Authority runs SoonerCare, which administers the state’s Medicaid and CHIP programs, and oversees Insure Oklahoma, a premium subsidy program that helps small- and medium-size businesses purchase coverage for low-income workers. SoonerCare currently covers roughly 780,000 Oklahomans, approximately 20 percent of the state’s population.4

The impetus for this program began in 2007, when Medicaid enrollment in Oklahoma totaled roughly 600,000 individuals. At that time, an additional 600,000 State residents did not have health coverage, giving Oklahoma the nation’s eighth highest percentage of uninsured residents. To increase the number of insured residents, the state applied for and received a Medicaid waiver to extend the program to certain adults whose income was less than 200 percent of the FPL. With the prospects for 100,000 additional enrollees, leaders of the Oklahoma Health Care Authority began planning for the development of an online system that could cope with the influx without increasing administrative costs and simultaneously make it easier for qualified individuals to enroll.

Did It Work?

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Results

Since its introduction, the system has rapidly become the standard method of applying for and renewing coverage, has dramatically reduced the time it takes for an individual to enroll and begin receiving benefits, has contributed to a decline in the number of uninsured in the state, and has saved an estimated $1.5 million in operating costs.2,3
  • Already the dominant method to apply: In the 3 years since its introduction, the online system has become the dominant method of applying for coverage, with just 5 percent of applications being submitted on paper.
  • Much faster enrollments and renewals: The online system has reduced the average time to complete and process an application to just a few minutes. By contrast, before implementation of the system, the average paper application took 20 days to process for a new beneficiary (even longer if the family also applied for other benefits) and 15 days for a renewal.
  • Fewer uninsured: Program leaders believe the online enrollment and renewal process has increased retention rates in Medicaid and CHIP, and reduced the proportion of uninsured children in the state, which fell from 11.8 percent in 2008 to 7 percent in 2011.3 It is not clear how much of this decline is due to the electronic enrollment system, because, as noted earlier, expanded eligibility requirements in 2007 also led to an increase in the number of individuals eligible for Medicaid.
  • Significant cost savings: Staff time for processing applications has been dramatically reduced, as online applications typically require little if any staff time to process. Overall, 55 percent of new applications and 80 to 85 percent of renewal applications submitted through the online system require no staff time to process. Even for those applications in which staff need to be involved, the amount of time required tends to be much less than for a traditional paper application. Overall, program leaders estimate net savings of $1.5 million a year, calculated as $4.4 million in savings due to less staff time needed to review and process applications, less $2.9 million in additional costs to staff the call center and maintain new information technology (IT) systems.
  • High beneficiary satisfaction: In focus groups, families using the system expressed appreciation for the time and money saved as compared to the paper application process, which often required out-of-pocket expenditures for copying and mailing or time spent bringing documentation to a local Oklahoma Department of Human Services office.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the time required to review and process applications for Medicaid and CHIP under the SoonerCare program; trends in the proportion of uninsured children in Oklahoma; post-implementation estimates of the cost savings generated by the program; and post-implementation reports from families on their satisfaction with the system.

How They Did It

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Planning and Development Process

Key steps included the following:

  • Establishment of interagency task force: The online enrollment process entailed coordination between the Oklahoma Health Care Authority and the Oklahoma Department of Human Services, which historically reviewed and processed the paper applications. Consequently, a task force was formed, made up of representatives from both agencies. The Oklahoma State Department of Health and the Oklahoma Department of Mental Health and Substance Abuse Services joined the task force subsequently.
  • Conceptual development and analysis of requirements: The task force developed conceptual objectives for the online system, along with a detailed analysis of the system requirements. This work led to the compiling of more than 200 “change orders” needed to create an application and rules engine that could work with existing electronic systems.
  • Transfer of responsibility for enrollment: Through a change in the State administrative code, the Oklahoma Health Care Authority took over responsibility for eligibility determinations, enrollment, and management of affected populations from the Oklahoma Department of Human Services (which still can process paper applications). With this change, approximately 20 employees transferred to the Oklahoma Health Care Authority.2
  • Establishing workgroups: The Oklahoma Health Care Authority created several workgroups made up of representatives from stakeholder agencies, including federally qualified health centers, tribal entities, and community action groups. The workgroups allowed these agencies to be involved in the planning process in a structured way. Separate workgroups were formed to focus on systems (particularly programming and data issues); applications (including designing a prototype user interface); and infrastructure and operations (to address various issues, including creating a telephone help desk and correspondence units).
  • Forging data-sharing agreements: Before launching the system, the Oklahoma Health Care Authority established data-sharing agreements with the Social Security Administration, the Oklahoma Employment Security Commission, the Oklahoma State Department of Health, and the Oklahoma Department of Human Services. As noted, these agreements facilitated the ability to perform real-time eligibility checking in the majority of cases.
  • System testing and refinement: To test and refine the interface, the Oklahoma Health Care Authority developed prototypes of the consumer and agency versions of the online application. The consumer version was tested with applicants at multiple locations, including a county health department clinic, an urban Indian clinic, a private clinic, and the Authority’s main offices. Applicants provided feedback on the wording of questions, application flow, and general ease of use, with system refinements made in response to this input. Staff from partner agencies similarly tested and gave feedback on the agency-view application.
  • Call center creation: To accommodate the anticipated customer inquiries, the Authority established a call center that at its peak had 45 employees. (Under the previous system, which relied on in-person applications, the Oklahoma Department of Human Services did not maintain a call center.) Since that time, demand for call center support has declined as consumers get used to the new system, and consequently current staffing has fallen to 32 employees, including the 20 transferred from the Oklahoma Department of Human Services.
  • Redesigning paper application: Since applicants can still use the paper application, it was redesigned to facilitate scanning and rapid data entry into the online system through the use of optical character recognition software.
  • Ongoing planning for enhanced capabilities: The Oklahoma Health Care Authority recently began planning the creation of a member portal that enrollees will use to manage not only enrollment and renewals, but also appointments, health records, and other correspondence pertaining to their health care. Going forward, program leaders hope that the system can become a platform for eligibility determination and enrollment for all State services, and serve as a mechanism to connect residents with other sources of coverage under the provisions of the Affordable Care Act.

Resources Used and Skills Needed

  • Staffing: During the planning process, eight employees worked on the system requirements and design. During the development period, the project required 64 individuals supplied by contractor Hewlett-Packard over an 18-month period. On an ongoing basis, roughly 45 individuals work on program-related activities, including the 32 call center staff.
  • Costs: Development and implementation costs totaled approximately $15 million, not including costs borne by other agencies. Annual operating costs average roughly $2.9 million; as noted earlier, however, the program saves an estimated $1.5 million a year, even after factoring in these operating costs.
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Funding Sources

Centers for Medicare and Medicaid Services
The Centers for Medicare and Medicaid Services provided a $6.15 million Medicaid Transformation Grant. The balance of the $15 million cost was funded through an administrative funding match from The Centers for Medicare and Medicaid Services.end fs

Tools and Other Resources

The state of Oklahoma has given The Centers for Medicare and Medicaid Services the system's infrastructure design, requirements, and rules, and this information is available for other developers through The Centers for Medicare and Medicaid Services 's Collaborative Application Lifecycle Management Tool.

Adoption Considerations

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Getting Started with This Innovation

  • Obtain buy-in from involved agencies: The Oklahoma Health Care Authority and the Oklahoma Department of Human Services experienced some “turf issues” during the transition of the enrollment process between the two agencies, and some tension could have been alleviated with better communication early in the project.
  • Design systems for flexibility: The enrollment system must communicate with other systems, and the volume and variety of those communications will increase with the advent of health insurance exchanges and other reforms included in the Affordable Care Act.
  • Delay implementation if necessary: The system should not be launched until it has been fully tested and proven ready to serve end users. It is better to delay the launch date than to go live with a system that is “not ready for prime time.”
  • Plan for adequate call center staff, other support: Some beneficiaries will always be more comfortable with telephone-based or in-person support, and others will need such support during the transition to the electronic system. Consequently, program leaders should anticipate and plan for a significant initial surge in call center volume after the system becomes operational. Slightly more than one-third of applicants need some personal support, some because of language difficulties. Staff can also tell applicants why their application was denied, a capability that is not currently available online.2,3

Sustaining This Innovation

  • Piggyback on other systems: Once online Medicaid enrollment is in place, the system can be used to set up “express lane eligibility,” in which an enrollee who has qualified for one benefit program can enroll in others (such as the free school lunch program) without repeating the eligibility verification process. Oklahoma does not currently use express lane eligibility, but has the flexibility to do so.
  • Provide for document uploads: Initially documents could not be uploaded directly to the online system, but this feature was added in 2012. It has caused some confusion because the system doesn't immediately acknowledge receipt, but a confirmation message is being added.2,3

Spreading This Innovation

Thirty other states have requested and received information on the system, including several that have sent representatives to meet with the Oklahoma development team.

More Information

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Contact the Innovator

Derek Lieser
Director of Information Services
Oklahoma Health Care Authority
2401 NW 23rd Street, Suite 2B
Oklahoma City, OK 73107
(405) 522-7101
E-mail: Derek.Lieser@okhca.org

Innovator Disclosures

Mr. Lieser reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Weiss AM. Hard work streamlining enrollment systems pays dividends to the sooner state. Health Affairs. 2013;32(1):7-10. [PubMed]

Oklahoma Medicaid/CHIP Web site. Available at: http://www.okhca.org/.

The Pacific Health Policy Group. State of Oklahoma, Oklahoma Health Care Authority, “No Wrong Door” online enrollment independent evaluation, final report. 2011 Mar. Available at: http://www.okhca.org/research.aspx?id=88.

Hoag S, Swinburn A (Mathematica Policy Research). CHIPRA express lane eligibility evaluation: case study of Oklahoma’s SoonerCare online enrollment system, final report. Washington (DC): U.S. Department of Health and Human Services. 2013 May 31. Mathematica Reference No.: 06988.830. Available at: https://www.statereforum.org/sites/default/files
/mathematica-_case_study_of_oklahomas_online_enrollment_system_5_31_13.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 Weiss AM. Hard work streamlining enrollment systems pays dividends to the sooner state. Health Affairs. 2013;32(1):7-10. [PubMed]
2 Hoag S, Swinburn A (Mathematica Policy Research). CHIPRA express lane eligibility evaluation: case study of Oklahoma’s SoonerCare online enrollment system, final report. Washington (DC): U.S. Department of Health and Human Services. 2013 May 31. Mathematica Reference No.: 06988.830. Available at: https://www.statereforum.org/sites/default/files
/mathematica-_case_study_of_oklahomas_online_enrollment_system_5_31_13.pdf
.
3 The Pacific Health Policy Group. State of Oklahoma, Oklahoma Health Care Authority, “No Wrong Door” online enrollment independent evaluation, final report. 2011 Mar. Available at: http://www.okhca.org/research.aspx?id=88.
4 SoonerCare Fact Sheet. 2013. Available at: https://www.okhca.org/individuals.aspx?id=11698&menu=40&parts=7453.
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Original publication: September 11, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.