Sunday, August 16, 2015

DHS letters to Medicaid beneficiaries were vague, confusing and poorly marked; almost 50,000 lost coverage

Posted By on Sun, Aug 16, 2015 at 3:41 PM


Our cover story this week looks at the Arkansas Medicaid eligibility verification mess. Almost 50,000 Arkansans face termination of their health insurance because they didn't manage to get paperwork back to the Department of Human Services and processed in time, even though many or most are eligible for the program according to the state's own data. One thing worth highlighting is how poor the outreach effort was to communicate with these beneficiaries to begin with, starting with the vague, confusing, poorly marked communications sent out by DHS. 

Look at that letter above. Consider that the letter refers to a brand new program for hundreds of thousands of Arkansans. Consider that the letter was sent to the state's lowest-income residents, many of whom have health insurance for the first time in their adult lives. Consider that the letter was sent as part of a brand new renewal process that beneficiaries had no idea was coming and likely knew nothing about. Consider that most beneficiaries probably do not know exactly what paperwork they're even being asked for. Consider that this nondescript letter was in fact urgent, that beneficiaries had a 10-day deadline to respond (with some extra days of wiggle room) before a cancellation notice of their coverage was sent out. Consider the stakes: that eligible beneficiaries were receiving this confusing letter about a confusing new process, and could end up losing their health care coverage — including access to vital medication — if things didn't go smoothly. 

This vague, poorly explained letter — written in bureacratese, with very little information either about what to do immediately or the options in case coverage does end, not to mention about what's even going on in the first place — does this look like the kind of communication likely to be successful if the state's goal was a smooth renewal process?

Keep in mind the 10-day response deadline. Keep in mind the inherent challenges of this new process. Keep in mind the human stakes. 

DHS officials have said they are working on revising the letter to make it more clear and add additional information (some newer communications that have gone out actually include a more detailed explanation of what paperwork is needed actually needed for verification, since the examples in the letter above are vague and don't apply to everyone). Likewise, while the initial communications were in envelopes easily mistaken for junk mail, newer letters feature the DHS logo on the envelope and are marked as urgent. Which is all good news! Mistakes and glitches happen, and state agencies should aim to make improvements in real time as problems are discovered. 
Unfortunately, the Hutchinson administration's policy of putting a 10-day deadline on replies — a failed policy that the governor refuses to reconsider — meant that sorting out these kinks came too late, after a massive wave of cancellations and terminations of coverage. Note that the letter above was the only communication that beneficiaries received before a cancellation letter went out. Best practices for these sorts of renewal processes depend on multiple communications to make sure the beneficiary knows what's going on (worth noting that private companies doing renewals typically have at least a 30-day window and always send multiple communications if the first one doesn't get a reply). That was impossible given the 10-day window. 

The cancellation letters were no better (again, DHS officials say they are working on revising them to make them more clear and offer more information). Here is one of the cancellation letters (name and Medicaid ID redacted): 

click to enlarge dhs_cancellation_2.png

State officials have noted, correctly, that beneficiaries have 90 days after coverage termination to send in their information and get it reinstated without having to start all over with a new application. But there is nothing in the cancellation letter to explain that to beneficiaries. Nor is there any information about options for beneficiaries who really have transitioned out of the program. All they get is this: "Your Health Care Independence Program was closed because you did not provide the proof needed to verify your reported change." With no indication, by the way, of what that "reported change" even is to confused beneficiaries trying to figure out what the heck is going on...and of course, now we know that some of them had no change at all, they simply make no income. 

Additional information on the back of the cancellation letter has nothing about the 90-day window to get reinstated; instead there is confusing information about an appeals process. The original income-verification also highlights the appeals process without mentioning anything about the 90-day window. Unfortunately, the appeals process is really only relevant to situations in which a beneficiary has been found ineligible and wishes to contest the finding. That's not what happened here — instead beneficiaries are being cancelled for failing to turn in paperwork in time, but have an additional time frame to follow up, get their paperwork in, and be reinstated. None of this is explained, at all. 

I have every reason to believe that both the governor's office and state officials at DHS wanted this process to go smoothly. They wanted people to respond to the income-verification letters. They wanted people who were legitimately eligible for the program to go through the renewal process without gaps in coverage. Unfortunately, the actual communications sent to beneficiaries look like something that would either end up in the trash or leave beneficiaries deeply confused. That's on top of the fact that many of the addresses were bad, that there was nothing close to an adequate outreach program in place to get in touch with this hard-to-reach population, that DHS was woefully unprepared to handle the volume of responses, etc. Again, mistakes happen! But add in an unreasonable and unworkable 10-day deadline, and you have a process doomed to failure. 

To get a sense of how all of this looked to beneficiaries, let me share the following account, which I got from a private option beneficiary in Little Rock:

I received the request for verification from DHS (dated June 23) on June 26, a Friday. The composition of the letter was completely confusing. For example, in bold type at the top of the letter the date July 23 was given as the deadline for appeal, but in the body of the text, the actual deadline to provide verification was July 3! Since it was after close of business Friday when I initially opened the envelope, I had to wait until Monday 7/29 to try to reach DHS with questions. When I called first thing Monday the lines were down and I wasn’t able to get through all morning. So, in a bit of a panic, I made a stab at what kind of verification was needed and mailed the letter off that afternoon.

I should tell you that I am self-employed and my income fluctuates from year to year. I sometimes earn well above the poverty line, and sometimes earn nothing. I applied for healthcare through insureark during a low income year and qualified for Blue Cross through the Private Option. At the end of the first year’s coverage I reapplied with an update to my income, which had risen somewhat but not enough to disqualify me from the program. Once again I qualified.

Here is where I get confused. If each of us is required to reapply every year and to provide income tax information on the application, why is there even a need to verify income in the middle of the year? And why is that request for verification so vague? There was no mention of copies of tax returns in the verification letter. The letter requests verification of current income, which I read to mean this year’s income thus far. So, I sent copies of invoices through June 29. In your article in the Times today, you mention that self-employed people should be sending income tax returns, but that wasn’t in their request. 

Here's another account of the confusion from one of the beneficiaries covered in our cover story: 

The envelopes containing the notice of income verification were plain and nondescript with no indication that they contained a very important document with a time limit for response. The return address was the Access Arkansas Processing Center in Batesville (rather than the Arkansas Department of Human Services, which would have gotten my attention) and that did not make any impression on me whatsoever since I have worked only with Ambetter of Arkansas since we got our insurance. I was only on the Access Arkansas web site one time to get to and complete the application for the Affordable Care Act two years ago and have not been on that site since. The envelopes looked like junk mail and I honestly thought they were a solicitation from some television cable outfit.

State officials have said that it was the responsibility of beneficiaries to respond. Fair enough. But if the governor actually wants a renewal process that works as opposed to a chaotic mess of plan cancellations, he might want to look at his administration's own policies and practices. 

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