Chapter 1
Executive Summary

Prior to this study, anecdotal evidence in Iowa indicated that applications to the hawk-i and Medicaid programs frequently ended with applicants being denied enrollment into these health care programs. Evidence provided by the Iowa Department of Human Services suggested that the most common reason that an application was denied was failure on the part of the applicant to provide all of the information needed to complete the application process. To better understand the barriers to applying for the Iowa Medicaid and hawk-i programs, the Iowa Department of Human Services contracted with the University of Iowa Public Policy Center to conduct a Wellmark Foundation-supported study of the difficulties applicants face trying to enroll in these programs, with an emphasis on reasons why applicants who start the application process have trouble supplying all of the requested information.

Research topics

This executive summary presents information obtained from varied sources to
provide an overview of:

Data sources

Data for this study were obtained from the following sources:

5. Applicant perceptions of barriers to applying for the programs, as well as other information about the application process, obtained from written surveys administered to a) hawk-i applicants, b) Medicaid applicants and c) applicants who originally applied to hawk-i but were referred to Medicaid because their income was too low to qualify for hawk-i (see Chapter 6). The samples included applicants who successfully enrolled in the programs as well as those who did not submit all of the requested information.

Enrollment process

Eligibility for the Medicaid and hawk-i programs extends to all children in Iowa with family incomes of up to 200% of the federal poverty level (FPL). Medicaid covers all children up to age 1 and children up to 133% of the FPL from ages 1 to age 19. The hawk-i program covers children ages 1 to 19 from 134% to 200% of the FPL.

The application process is different for the hawk-i and Medicaid programs in a number of important ways: therefore

4) No personal interview is required for acceptance into hawk-i. Personal
interviews are also not required when applying for Medicaid health care
coverage for children. However, if adults are included in the application, or if
other programs such as Food Assistance are being requested, a personal
interview is required. If the parent does not complete the personal interview
and all other supporting materials have been submitted, Medicaid coverage
for children should not be denied, although adults would still be denied in
such a case.

New applicant/applications and dispositions

Applicant Denials

Administrative data for a four-month period (April to July 2005) was used to analyze the initial application process and the relative extent to which failure to provide requested information was a problem among all denied applications (Table E-1). The results for this 4-month period were multiplied by 3 to approximate the results for a 12-month period. The results are for new applicants only (i.e., the first time an applicant had applied in at least one year) and only for those who applied to a single program during that time. If a person had been referred from hawk-i to Medicaid during the 4-month period, they were put into the Referred group and removed from the hawk-i or Medicaid numbers.

There are limitations to this analysis because researchers only requested data from the hawk-i program for applicants who were denied for failure to respond to the request for information (i.e., the group of interest for the survey). Due to the
approximations in these estimates, number of applicants was rounded to the
appropriate whole number.

Table E-1. Unduplicated number of applicants to the hawk-i and Medicaid programs and their disposition for an estimated 12-month period

	Medicaid	hawk-i	Referred
New applicants per year	52,000	*	4,300
Accepted applications	31,000	1,200	2,700
Total Denied applications	19,00	*	*
Denied for failure to respond to request for information	9,500 (50% of all denied applicants)	2,100	1,600

*Data for this analysis was derived from administrative data used to draw the sample for the surveys. The survey was only sent to people who were either accepted into the program or were denied for failure to respond to requested information; information regarding the total number of unduplicated applicants and denials for the hawk-i program were therefore not available.

Application Denials

The disposition of applications to the Medicaid and hawk-i program from May 2003 to April 2004 are presented in Table E-2. The numbers differ from Table E-1 because applicants may have submitted more than one application during the study period (e.g., the first application was denied, so a new application process was begun). Administrative data about Medicaid applications provided by the Iowa Department of Human Services was used to evaluate the specific reasons for the program denials. During the 12-month period from May 2003 to April 2004, about 30% of the 24,833 applications to the Iowa Medicaid program were denied enrollment into the program. Of the applications that were denied, the most common reason was failure to return requested information. Other reasons for denial are shown in Table E-1.

Table E-2. Main reasons for Medicaid denial of applications (children),
May 2003 - April 2004

	Number of denied applications	Percent of denied applications
Medicaid application - didn’t return requested information	8,123	33%
Income over Medicaid limits	3,780	15%
hawk-i application referred to Medicaid - didn’t return requested information	1,938	7%
Didn’t attend interview*	1,625	7%
Applicant request to withdraw application	1,491	6%
Did not meet requirements: e.g., age, have dependent child, not disabled/pregnant	1243	5%

*Interviews are not supposed to be required when applying only for a child

Between January 2004 and April 2004, about 74% of the 7,616 applications to the hawk-i program were denied enrollment. This number includes 2,776 applicants who were denied enrollment into hawk-i because their family income was below the hawk-i FPL. These applicants were referred to and ultimately enrolled in Medicaid. When this group is removed from the denominator, the application denial rate for hawk-i is 47%. Table E-3 presents the main reasons listed in the administrative data for denials to hawk-i.

Table E-3. Main reasons for hawk-i application denial, January 2004 - April 2004

Reason for denial	Number of denied applications	Percent of denied applications
Receiving Medicaid	2,776	36%
Failure to provide information	1,916	25%
Medicaid non-compliant (failure to provide information to the Medicaid program after referral to determine eligibility)	1,297	17%

These data show that failure to provide information is a major reason why children are not accepted into these health care programs. However, the nature of the information requested but not provided, the methods used to ask for this information, and how well applicants understood what was being asked for cannot be determined from the basic administrative data.

Barriers to enrollment

As the numbers indicate, one of the most important reasons that initial applications for enrollment in the hawk-i and Medicaid programs are denied is that the applicant does not submit all of the information requested to support the application.

General Barriers

Important barriers identified in this study include:

3) Stigma of applying for public health care coverage

Communication misunderstandings or lack of clarity between the program and the applicant

In general, applicants did not understand the application process for hawk-i or Medicaid very well. Applicants indicated a general sense that the application process was one, long, on-going process. This was different from the perspective of DHS staff, which viewed each application and associated deadlines as discreet processes that are opened and closed depending on the receipt of requested information. This misunderstanding was further increased by written correspondences from both programs that were confusing, vague, and often required further clarification by talking with DHS or hawk-i staff.

Specific examples of unclear correspondence from the Medicaid program included:

1. The letter requesting further information varied by local DHS office. Some used a vague checklist that gave no specific information on how to respond to the request, others developed their own letter that was a little more clear but still may not have detailed exactly what applicants needed to send in, still others wrote personalized letters to applicants.

2. The letter denying coverage in Medicaid: this letter—which was written sideways on legal paper—was poorly formatted, very difficult to understand, and written using legal terminology that made it difficult for applicants to figure out why they were not accepted into the program or what other options they had, if any.

Specific examples of poor correspondence from the hawk-i program included:

1. The letter requesting proof of the cancellation of insurance. The hawk-i application form did not mention that applicants whose children had existing insurance would need to submit a specific form indicating cancellation of this insurance prior to being enrolled in hawk-i. Applicants viewed the letter requesting this information as vague and difficult to understand in terms of what information would satisfy this requirement.

2. The letter requesting further income verification requests pay stubs for 30 days, which was often confused with the pay stubs for one month. Applicants actually needed to submit five weeks of pay stubs.

The amount of time necessary for obtaining and returning requested information

Following a request for information, Medicaid applicants are given 10 days to respond (14 days for hawk-i). The entire application must be processed by Medicaid and hawk-i within 30 days of the application being received (otherwise a new application must be started). The time period was a reported problem for many, especially when requests for income verification meant employers needed to be contacted to complete forms. Applicants can request an extension to this time period, but many were not aware of this. DHS staff also have some flexibility on when they close an application, but this varied by staff person and office.

Stigma of applying for public health care coverage

Although there was some reported stigma associated with applying for either public health care coverage program, there was higher stigma associated with applying for Medicaid than for hawk-i. Sixty percent of all applicants reported that they were strongly or somewhat uncomfortable applying for a government health care coverage program for their child. Medicaid enrollees were most likely to believe that doctors and nurses treat enrollees differently than those with private insurance. Over half of Medicaid applicants thought enrollees had a harder time finding a doctor who would accept them than those with private insurance.

Barriers to responding to the request for information

The information requests that were the primary barriers to enrollment for applicants
who were asked to submit additional documentation to the hawk-i program were:

1. Income verification

2. Cancellation of insurance verification

3. Other Medicaid-specific issues

Income verification

Income verification was requested of about half of those who did not complete the
Medicaid application process and about one-third of those denied for hawk-i (from administrative data, Chapter 3). This included not returning pay stubs, employer statement of earnings, and tax return information.

Problems identified for responding to this request include: 1) difficulty
understanding what needed to be submitted as proof, 2) time to get employersupplied information, 3) difficulty knowing how to submit proof for seasonal and one-time payments, and 4) variation in the amount of assistance provided by offices in obtaining this proof. For example for Medicaid applicants, some offices contact "the Work Number"1 for the applicants, others require the applicant to get the proof themselves.

Verification of the cancellation of insurance

Verification of the cancellation of insurance is a hawk-i-specific issue. Over 40% of the incomplete hawk-i applications only required proof of cancellation of insurance for the child to complete the process, and only a few cases responded to this request during the 30-day time period (source: enrollment file chart abstraction). This was the most frequently requested piece of information for hawk-i applicants who did not complete the process on time.

Barriers to responding to this request included: 1) not clear what form to use to meet the request, and 2) the necessity of canceling insurance prior to enrollment caused a perceived gap in coverage for the child. This is additionally problematic because hawk-i coverage is not retroactive to the beginning of the month as Medicaid coverage is.

Other Medicaid-specific issues

1) Child support issues—For Medicaid, Child Support Recovery must be notified that the applicant is requesting public assistance. This can stop some applicants from finishing the process because they do not want the non-custodial parent to be contacted.

2) Family application issues—Medicaid requires that family applications that include adults provide information on assets such as bank accounts; a personal interview is also required. These requirements do not affect the enrollment of children in the family, but this is not stated on the Medicaid application. Thus, it is unclear if applicants who were applying for adults did not submit any of the requested materials, even those that would have made the child eligible, because they did not want to follow through about assets or come in for the interview.

Policy Recommendations

The following recommendations are being made based on the results from the
different components of this study, as well as on research findings in the literature.
Some of these recommendations may be relatively easy to implement while others may be extremely difficult or require changes in federal or state law or regulations.

1) Philosophical issues

Problem 1-1: Between half and three-quarters of applicants to the hawk-i and
Medicaid programs who are initially denied for failure to respond to requested
information are later accepted into the program following reapplication. These
unnecessary reapplications create a very inefficient and unnecessarily costly process for both the applicant and DHS.

Recommendation 1-1: Review the approach taken to the application process
generally, including regulations (state and federal), time frames, and the philosophies of the DHS offices (local and central offices) and field staff toward assisting applicants. Introducing a more assistive approach generally (rather than a regulatory approach) would both help eligible applicants receive the public health care coverage for which they will eventually qualify and save administrative time and effort associated with reapplications and reopening case files. Specific detail relating to these general comments follow in more specific recommendations.

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Problem 1-2: Local DHS offices vary significantly in their philosophy about how
much assistance they will provide clients with the application process. For example, some offices assist applicants a great deal with getting information from employers or getting health care information, while others do not.

Recommendation 1-2: Standardize the amount of assistance offered to clients with the goal of making the process as efficient as possible to decrease unnecessary reapplications and reduce barriers to children receiving health care coverage for which they are eligible. This may have implications for staffing and support at the local DHS offices and the hawk-i central office.

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Problem 1-3: The importance of being able to apply for only Medicaid vs. all DHSadministered public assistance programs was viewed differently at different DHS offices, which led, in part, to some of the differences identified in the previous two problem statements (1-1 and 1-2). Some DHS IMWs believe that Medicaid should be made available to families with as independent an application process as possible (i.e., less contact with the DHS office) while others believe the client is better served by having more contact with the local office staff. The DHS office can then assist clients with the application and make sure they are aware of all programs for which they may be eligible (e.g., FIP, Food Assistance). Although personal interviews are no longer required when applying just for Medicaid for children, most clients do either call or contact a local DHS office to get a Medicaid application and complete the process. It is appears from the survey that contact with a local DHS office improves the chances that a client will submit all requested information and finish the application process.

Recommendation 1-3: Apply a consistent approach within DHS to providing Medicaid to children. An internal discussion of the pros and cons of a centralized application process for Medicaid, separate from the other public assistance programs should be conducted. Centralizing Medicaid applications, (with improved written correspondence), could make the workload in local DHS offices more manageable, giving local DHS IMWs time to better answer client questions pertaining to the application process and helping clients get the necessary information. It might also allow more time for interviews for family applications to be conducted. However, disconnecting the process from local offices entirely might make the process more difficult by providing less client support.

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Problem 1-4: There is an indirect relationship between hawk-i and Medicaid. It is
difficult for applicants to sort out which program they are eligible for prior to applying. Applicants may not be aware that they can use the more readily available hawk-i application to apply for Medicaid. Making the application process for the two programs similar (e.g., one application form, centrally processed, market both as public health care coverage programs) might help make the program more efficient. It is possible, however, that this would also discourage some higher income families who would be eligible from applying for the hawk-i program.

Recommendation 1-4: Conduct an internal discussion of the pros and cons of combining application processes for hawk-i and Medicaid. These might includ developing an application that clearly states it is for both programs, and determining where administrative functions related to the application process might best be used for both programs.
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2) Improvements in communications

a) Written communication

Problem 2-1: Letters from the Medicaid and hawk-i programs regarding the income verification requirements, reasons for denial and the time frame for returning requested information are often difficult to understand (e.g., non-paginated denial letter sent from the central office [See Appendix 4], checklist of information to return with little specification as to how to meet expectations).

Recommendation 2-1: Conduct a systematic review of all correspondence sent to applicants, emphasizing clarity and literacy level. An important criterion for judging the appropriateness of the letters that request further action would be how well the applicant could respond to the content of the letter without needing to contact the program for clarification of the request.

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Problem 2-2: Not all hawk-i forms are in Spanish.

Recommendation 2-2: Have a Spanish language version of all hawk-i forms
available within the next 6 months.

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b) Phone communication-system adequacy

Problem 2-3: Some local DHS offices do not have enough phone lines to handle the number of incoming calls from applicants and other clients. It is unclear if this is also true for the hawk-i office. This problem appeared to be worse in rural DHS offices where travel distances are longer, a larger percentage of application requests are received by phone, and the offices may only be open part-time. Some local DHS offices currently monitor the amount of time it takes to return client calls, which is one important component of phone communication but not necessarily an indication of the adequacy of the phone system. Offices do not, to our knowledge, have the ability to track calls that are missed due to clients hanging up or because they are unable to speak with the desired person.

Recommendation 2-3: Conduct a study of the phone system at each local DHS
office and the hawk-i office over a specified time period (e.g., 2 weeks). The study would evaluate issues beyond number of calls received and call-back time to include the number of abandoned calls, number of busy signals, length of time callers had to wait on hold, etc.
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c) Phone communication-office efficiency

Problem 2-4: A significant amount of clarification of requests for supporting
materials for hawk-i and Medicaid applications occurs by phone. However, the ability of callers to speak with a IMW or other appropriate person varies significantly from office to office. As mentioned, some local DHS offices track calls that reach the IMW, as well as how quickly calls are returned. Many clients, however:

4) do not have a phone

5) are not at a phone number consistently

6) are not available

This can be a critical factor for time-sensitive issues such as returning requested materials within the given time limit. There were discrepancies in the perceptions of applicants and DHS and hawk-i staff about how easy it is to get through to the appropriate person at DHS or hawk-i.

Recommendation 2-4: After studying the adequacy of the phone system, evaluate the process by which calls are received and triaged to determine who would be the appropriate staff person to receive the call.

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d) Internal communication-hawk-i to Medicaid

Problem 2-5: DHS local office staff were concerned about the lack of communication from the DHS IMW at the hawk-i office about certain applications, especially those for which the local DHS staff may have had some background on the family situation. They were also concerned about how long it takes files to be transferred from hawk-i to Medicaid if they needed to help a client with information that was in the file. The 30-day limit for an open application could also be affected by the amount of time it can take a file to arrive in the DHS office.

Recommendation 2-5: Implement a computer-generated referral system from hawk-i to Medicaid similar to the one that is available from Medicaid to hawk-i (single press of the F5 key). Encouragement of more phone and e-mail contact between DHS staff in the hawk-i office and DHS field staff when questions arise would also be helpful.

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3) Medicaid computer system

Problem 3-1: The current Medicaid computer system is:

1) outdated

2) provides little flexibility at the local level

3) produces correspondence to applicants that is unintelligible

Recommendation 3-1: Modernize enrollment computer system to provide more rapid evaluation of the applicants’ program eligibility, provide information to IMWs in a more timely manner (perhaps while an applicant is in the office) and to generate correspondence that applicants can understand.

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4) Responding to request for information

a) Time to respond to request for information

Problem 4-1: Applicants frequently indicated difficulty in getting the information
about their income from employers within the 10-day time limit for Medicaid and 14-day limit for hawk-i. Applicants may or may not be aware that extensions are possible. As a result, applications are often denied for failing to respond and a new application has to be submitted.

Recommendation 4-1: Implement a time limit for receiving requested information in a manner similar to that used by the Food Assistance program. Applicants are given 60 days to respond to a request. If they respond within the first 30 days, their eligibility begins retroactive to the first day of the month of their original application. If they respond during the second 30 days, they become eligible on the first day of the second month. This would decrease the need to reopen many applications for families whose income is very unlikely to change drastically during a 60-day period.

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b) Income and insurance verification-clarification of responsibilities
for obtaining proof

Problem 4-2: The process for verifying income and insurance coverage is not consistent between local DHS offices or between hawk-i and Medicaid. Some local DHS offices will use “The Work Number” to verify income, some will accept a signed release to contact an employer as adequate verification, others (and the hawki office) require the applicant to provide all verification. Similarly, for insurance, some will use The Work Number, some refer to Health Insurance Premium Program (HIPP)2 or third party liability and consider that adequate verification, and others (including hawk-i) require the client to get all of the information.

Recommendation 4-2: Institute a standard approach to income and insurance verification with recommendations for what is minimally acceptable. Also determine to what extent DHS and hawk-i offices should assist clients in obtaining supporting materials. Having the applicant sign a release for DHS to contact the employer seems to be the most efficient and successful way to obtain the information.
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c) Income and insurance verification-cancellation of insurance

Problem 4-3: People have to verify the cancellation of insurance prior to being able to qualify for hawk-i. This causes parents to be concerned that their child will have a gap in insurance coverage and so they may not finish the application process once they become aware of this problem.

Recommendation 4-3: Investigate getting a waiver that allows families to provide proof of the cancellation of insurance within the first month of enrollment in hawki, rather than prior to acceptance. This should eliminate parents’ perception of a coverage gap for the child during the application process.

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d) Income and insurance verification-clarification of what is requested

Problem 4-4: The correspondence requesting income and insurance verification is unclear and difficult to respond to without further contact with hawk-i or Medicaid staff.

Recommendation 4-4: It is essential that clear guidance be given to both applicantsand Medicaid and hawk-i office staff regarding what is required and whose responsibility it is to obtain the information (as noted in problem 4-2 above).

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e) Income verification-clarification of variable, seasonal and one-time income

Problem 4-5: Applicants reported difficulty with knowing how to submit verification for income that was not consistent throughout the year, or even within a pay period. This included people who had temporary or seasonal jobs and one-time lump sum payments.

Recommendation 4-5: Provide clear guidance to the applicant regarding how to
report this income on the application. Medicaid and hawk-i office staff should also receive guidance about such income should be reported.
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5) Stigma of government-sponsored health care coverage

Problem 5-1: It is relatively easy to locate a hawk-i application and comparatively
difficult to locate a Medicaid application. Medicaid applications are primarily available by calling or stopping in at a DHS office or by going to the DHS website. hawk-i applications, in contrast, are in school packets, on display boards, available in provider offices, etc. hawk-i is promoted as health care coverage for children, while Medicaid is not promoted this way, if promoted at all. The difference in the availability of applications for hawk-i and Medicaid may add to the stigma associated with being in the Medicaid program.

Recommendation 5-1: Promote Medicaid as health care coverage for children in the same way as hawk-i. Could also consider a name change for the program, as has already been done in many states, to reduce the stigma of Medicaid with both providers and clients (along with other substantive improvements). Consider broader distribution of a Medicaid-specific application form; also indicate more clearly on the hawk-i application that it too can be used for Medicaid. As indicated in Problem 1-4, combining the applications is not without some concerns of its own (e.g., adding stigma to the hawk-i program).

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Problem 5-2: Many indicated that it was difficult requesting public health care
coverage for their family. Some of the local DHS offices are in disrepair (e.g., unfriendly cage-like reception areas, 30-year-old worn out furniture, huge pot holes in parking lots) with little external signage to indicate it is a DHS office and little internal signage to indicate where to go for assistance once inside. These issues were reported to compound the difficulty of requesting assistance.

Recommendation 5-2: Place reasonable signs on the outside of DHS offices. Make sure internal signs are clear about where to go for assistance. Ensure that offices are maintained in a reasonable manner for a public building.

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Problem 5-3: Families still receive monthly paper Medicaid cards even though their children are eligible for 12 months (unless their family situation changes). The paper cards can cause problems to those trying to receive services if they do not arrive on time, and they add to the stigma of being on a public insurance program. The paper cards are also expensive to generate on a monthly basis. Verification of eligibility by providers is still seen by many as a barrier to care.

Recommendation 5-3: Issue plastic, rechargeable Medicaid and hawk-i cards similar to those used by the Food Assistance program. Eligibility could be updated monthly. Providers could have a swipe system (similar to credit cards) to determine eligibility instantly. It would also reduce the cost of monthly printing and mailing.

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6) Other program consistency issues

Problem 6-1: Child Support Recovery rules were reported to be an issue for some families applying for Medicaid. Medicaid applicants are required to submit the name of non-custodial parents so that Child Support Recovery can track child support payments and contact non-custodial parents who are behind in payments. Having DHS contact a non-custodial parent could potentially cause an awkward or dangerous situation and was reported to stop some applicants from completing the process. Reporting to Child Support Recovery is not a requirement for hawk-i.

Recommendation 6-1: Receive a waiver that would allow the child support recovery rules for Medicaid be the same as for hawk-i so that the children are not further punished by not being able to receive health care coverage.

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Problem 6-2: hawk-i applications are not retroactive to first of the month in which
they are received. This creates gaps in insurance for families having to cancel
insurance policies. Medicaid does not have this policy.

Recommendation 6-2: Make hawk-i applications retroactive to the first of the
month in which the application is successfully processed, similar to Medicaid.

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Problem 6-3: hawk-i requests 30 work days of pay stubs rather than a standard
month (28 work days). Medicaid allows for one month.

Recommendation 6-3: Allow hawk-i applicants to submit the pay stubs for four
work weeks (if paid weekly) or one month (if paid monthly).

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7) Other program barriers discussed during study

Problem 7-1: hawk-i does not allow for electronic transfer of premium payments at the beginning of each month.
Recommendation 7-1: Develop a system to allow monthly automatic electronic
transfer of premiums.

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Problem 7-2: Medicaid applicants are not allowed to submit an application to a
DHS office that is not in their local area. This was reported to be a problem for an applicant who was trying to get help in a DHS office in which they felt more comfortable than in their local office

Recommendation 7-2: Allow Medicaid applications to be submitted to any DHS office and then they can be routed to the correct office via internal mail.

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1 The Work Number is “an income and employment verification service used by social service workers nationwide to determine eligibility for TANF, food stamps, low-income housing, welfare-to work programs, cash assistance, Medicaid and other benefits.” For more information go to http://www.theworknumber.com/AboutUs/SocialServices/

2 The HIPP program helps people on Medicaid get insurance or keep insurance they already have by paying for the premiums when it is cost effective. http://www.dhs.state.ia.us/dhs2005/dhs_homepage/medical_assistance

/medicare/state_pays.html

Chapter 1 Executive Summary

Research topics

Data sources

Enrollment process

New applicant/applications and dispositions

Applicant Denials

Application Denials

Barriers to enrollment

General Barriers

Communication misunderstandings or lack of clarity between the program and the applicant

The amount of time necessary for obtaining and returning requested information

Stigma of applying for public health care coverage

Barriers to responding to the request for information

Income verification

Verification of the cancellation of insurance

Other Medicaid-specific issues

1) Philosophical issues

2) Improvements in communications

a) Written communication

b) Phone communication-system adequacy

c) Phone communication-office efficiency

d) Internal communication-hawk-i to Medicaid

3) Medicaid computer system

4) Responding to request for information

5) Stigma of government-sponsored health care coverage

6) Other program consistency issues

7) Other program barriers discussed during study

Chapter 1
Executive Summary