Sign and Deliver: Using Technology to Speed up Eligibility and Enrollment

1. Sign and Deliver: Using Technology to Speed up Eligibility and Enrollment Web Conference Call Presentation September 30, 3:00 PM – 4:00 PM (ET) 1

2. Agenda Overview • Development, Implementation and Use of Alternative Signatures • E-signature in Alabama • Telephonic Signature in Wisconsin • Comments and Reactions with Donna Cohen Ross • Q & A

3. E-Signature in AlabamaViki Brant, DirectorProgram Operations & Professional Support DivisionBureau of Children’s Health InsuranceAlabama Department of Public HealthGretel Felton, DirectorCertification Support DivisionAlabama Medicaid Agency

4. Background • CHIP and Medicaid are in separate state agencies in Alabama • Application processing: • CHIP is centralized • Medicaid is decentralized • CHIP and Medicaid have used joint paper application since 1998; joint online application since 2006. • CHIP IT staff supports and maintains the online application.

5. E-signature? Can We or Can’t We? • Legal Issues • Initiated research to determine legal issues surrounding use of e-signature • Uniform Electronic Transactions Act passed in Alabama in 2001 • CHIP – ADPH Security Policy included use of e-signature (effective April 21, 2005) • Medicaid – updated Administrative Code to include use of e-signature (posted in Feb 2008 for effective date no sooner than April 2008)

6. How/what to capture for E-Signature? • Researched Other States • Reviewed other states’ online applications • Interviewed staff in Wisconsin and Pennsylvania (Nov/Dec 2007) • Compiled research and developed a design • Much discussion focused on how to capture name (should applicant type name or pre-populate, use last 4 digits of SSN, etc…) • Concerns about duplicate applications (not an issue for other states)

7. Modification of Online Application • E-signature page was added • Provide a line for the applicant and spouse • Applicant’s name/spouse’s name pre-populates • Assistor may key their name, but is not an E-signature • Minor script edits (FAQs and references to signature page/E-signature)

8. Alabama E-Signature Screen Shots

9. Testing and Marketing • Testing Phase • Receiving E-signature • Data transfer from CHIP IT to Medicaid (for Medicaid pre-screened applicants) • Medicaid processes developed to support workflow (decentralized); edits to checklist • Production Date – July 14, 2008 • Soft-opening • Marketed through usual outreach activities and promotion of online application (no mass media)

10. Benefits of E-Signature Low cost to implement Eliminated the need to print, sign and return the signature page Eliminated the possibility of an applicant not mailing the form or not mailing it within the allowed time frame (60 days) Eliminated the delay in receiving a mailed signature page

11. Impact of E-Signature CHIP – 106% increase in processed online applications CHIP – 37% increase in average monthly enrollments via online application

12. Lessons Learned • 30 day waiting period was adopted • Purpose: To prevent duplicate applications from being submitted while waiting for eligibility determination

13. Telephonic Signature in Wisconsin Jim JonesDeputy Director, Medicaid Vicki JessupChief Policy Section

14. Telephone Snapshot According to the Federal Communications Commission, phone penetration rate among low income Wisconsin households was 93.3% in March, 2007. Penetration rate among all households is 95.9%. Cell phone only households have grown from four percent in 2004 to 15.8 percent in 2007 (U.S. data).

15. Why did Wisconsin need a telephonic signature? Childless adults can only apply over the telephone or online (no walk-in/mail-in forms) through a central enrollment center How to set a filing date and conduct an interview for SNAP? Benefits start only from the day a valid signature is received. The earlier a person calls and signs an application, the larger amount of benefits they get for that month Good customer service and more timely application processing Reduced administrative costs (workload, postage, etc.)

16. Legal Opinion In Wisconsin statutes, “electronic record” is broadly defined to include information stored by means of electrical or digital technology that is retrievable in a perceivable form. Legal Counsel recommended that any system established to capture telephone signatures will have to comply with all aspects of the law, including the ability to make changes and correct errors.

17. Federal Law - SNAP The 2008 Farm Bill has a provision on telephonic signatures that requires a voice recording technology. The law includes the following requirements (Sec. 4190): An application may be established by providing a recorded, verbal assent over the telephone States need to record the verbal assent and the information to which the assent was given States must include safeguards against impersonation and identity theft The household’s right to apply in writing must be preserved The household must be promptly provided a written copy of the completed application with instructions for a simple procedure for correcting any errors or omissions Applicants must satisfy all requirements associated with a written signature on an application to ensure that the verbal assent triggers the effective date of the submission of the application.

18. Federal Law – Health Care Prior to CHIPRA there was no written CMS position on electronic signatures. CHIPRA amended Section 1902 (42 U.S.C. 1396a) by adding (dd) Electronic Transmission of Information: ...Any signature requirement for an application for medical assistance may be satisfied through an electronic signature, as defined in section 1710(1) of the Government Paperwork Elimination Act (44 U.S.C. 3504 note)...

19. Process After application information is obtained by phone, the eligibility worker asks if s/he wishes to sign the application over the phone. If yes, the eligibility worker captures an audio recording of the following: Key eligibility information – income, household composition, etc. Rights and responsibilities Applicant attestation of the accuracy of information provided and an understanding of rights and responsibilities

20. Process Continued • A detailed written summary that contains all information used to determine eligibility is mailed automatically to the applicant • Includes instructions to review information and contact agency within ten days if there are any inaccuracies. If we don’t hear back, we assume everything is correct. • The audio recording is stored so that it can be retrieved for any specific case.

21. Technical Details Oracle’s Call Center Anywhere software Original recording is done as a waive file; overnight batch job compresses into mp3 1 file takes about 0.3 Mb of space Start/stop recording feature

22. Future of Telephonic Signature Regional pilot projects

23. Reactions & Comments Donna Cohen Ross Senior AdvisorOffice of External AffairsCenters for Medicare and Medicaid Services

24. Questions?