The Missouri Department of Social Services is trying to transform its benefits application form before potentially hundreds of thousands of people become eligible for Medicaid in July.
In August, Missouri voters approved Medicaid expansion after a successful petition campaign got the issue placed on the ballot. It is estimated expansion to MO HealthNet, the state's Medicaid program, will increase it by about 230,000 people.
But, even before voters approved expansion, it was clear the state's application process for benefits was flawed and overly bureaucratic. The state notoriously has 63 pages of forms a person would have to fill out to apply for all the services DSS offers.
When Gov. Mike Parson appointed Todd Richardson to helm MO HealthNet, he charged Richardson with bringing the rising costs of the program under control and improving sustainability. Simplifying and streamlining the application process will save time and money, so the state partnered with Civilla, a design studio dedicated to changing the way the public service institution works to evaluate its eligibility process.
Civilla has worked with other states to help them simplify processes.
The first step, according to Kirk Matthews, chief transformation officer for the Office of Medicaid Transformation, was to try to understand the challenge and research how Missouri's application process worked. That research took about six months, he said.
Civilla staff visited call centers and 19 Family Support Division field offices. They interviewed 44 DSS front-line people and 65 programs participants. Research ranged through the urban, suburban and rural areas, Matthews said.
"We realized, because we have a field office in every county, we could not get to every office," Matthews said.
He asked Civilla to expand its research using surveys. The organization conducted about 1,000 surveys with staff and community partners.
"We wanted to understand the challenge thoroughly," Matthews said.
Earlier this month, the state released Civilla's report and recommendations for changes to the system.
"The report will be a guideline for (how the application process changes)," Matthews said. "It will inform. We have to not only redesign the application to make it more user-friendly for both participants and field staff, but we have to make sure it passes legal muster."
It has to meet regulatory requirements, and federal authorities must sign off on it, he said.
The Civilla report "Missouri Benefits Enrollment Transformation: Transforming the Enrollment Process for End Users" may be found at dss.mo.gov/docs/civilla-missouri-research-report.pdf.
It is intended to "create a faster, simpler and more human-centered enrollment process for Missouri's safety net programs," it states.
The transformation report makes five recommendations:
- Create an integrated application.
- Create a standardized interview guide.
- Simplify verifications.
- Produce clear and consistent correspondence.
- Modernize case management.
The integrated application goes to the center of the problem. With the current application process, "participants have to navigate complex legal language and redundant questions to enroll," according to the transformational report.
Integrated and streamlined applications will be faster, simpler and more efficient.
DSS front-line staff told Civilla more than 50 percent of participants apply for multiple programs - especially concerning food or medical applications, according to the report.
A streamlined application would integrate six separate benefit programs into a single application - including Food Assistance, Family Medical, Adult Medical, Cash Assistance, Child Care and the Low Income Home Energy Assistance Program.
The application would have three components - a core application asking for information that is shared across programs, such as household composition, home income, assets and expenses.
"We envision the core application to be between seven and 10 pages," Matthews said. "We believe that we can get the total number of pages - the core plus the supplements - to the 13- to 15-page range."
The second component is supplemental applications, which are only to be completed for the programs for which they are applying.
The third component is to produce an information booklet, providing information about programs and applicants' rights and responsibilities.
The second recommendation the transformation report makes is for standardized interview guides.
Interviews for benefits currently range 35-60 minutes per program. And because front-line staff are specialized, program participants must conduct multiple interviews if they apply for multiple programs.
"It also makes it difficult for front-line staff to apply best practices consistently across programs. A standardized guide that pairs with the application would provide a tool for eligibility specialists and create a more consistent experience across the state for participants, while reducing the length of interviews," the report says.
The standardized guide would also allow specialists to cover more complex questions during the interview process.
Additionally, standardization of case notes assures documentation is consistent, decreasing chances for errors and making the transition to another staff member easier, should that be necessary.
Standardized interview guides would improve the consistent transfer of quality information and help prevent mistakes.
The third recommendation is to find a way to simplify verification processes. "Verifications" are documents the state requires - such as pay stubs, bank statements, leases, identification cards and bills - to prove household information.
"Verifications result in a significant burden for front-line staff and high error rates for the department," the transformation report says. "These documents are hard for many participants to provide - requiring them to travel, pick up documents, make copies and either fax, mail or submit them in person."
If participants are able to collect the requested documents, the information is often incomplete, causing the DSS to reject them.
"Improving the verification process and retraining front-line staff on department policies to ensure they are being applied consistently will alleviate stress on the call center and decrease the time it takes to determine eligibility," according to the report.
The fourth recommendation is to produce clear and consistent communications. Missouri forms intended to communicate information about program enrollment or what must be done for someone to maintain benefits are "confusing and poorly designed."
"This makes it hard for participants to complete the required actions and hampers eligibility specialists' ability to make efficient determinations on each case," the report says. "When correspondence fails to give participants the information they need, it falls on eligibility specialists to fill in the gaps."
That causes participants to call the office or visit in person to ask questions about requirements, deadlines and confusing correspondence. These unnecessary interactions take time and cause stress for everyone involved.
"By redesigning correspondence and enabling faster feedback loops through text message reminders, DSS could improve the participant experience and decrease the administrative burden," it says.
It suggests simplifying language in correspondence and changing renewals so they don't look on the outside like other correspondence from the DSS that might not be read.
Case action notices must be simplified and legal jargon must be removed, the report says. It confuses staff and participants. There is currently no difference between informational case action notices and those that require further action.
"The notices for the medical programs can be especially confusing and vague," the report states. "One notice arrives with the heading, 'Great news!' only to say that a participant has been denied benefits."
The fifth recommendation is that DSS improve technology, particularly technology that allows participants to more easily use self-service options.
"A simple, intuitive case management system designed to be accessed on a mobile device would allow participants to update their case and find important information on their own," the report says. "Developing this mobile-first online case management services would also provide important worker relief for front-line staff by giving them an easy place to point participants for information."
The next phase of transformation - to redesign the application process and make it more user-friendly - has already begun, Matthews said.
DSS received the first suggested iteration for the changes from Civilla last week.
Matthews said DSS will receive documents, look at them internally, suggest edits and return them to Civilla, who will make changes and return them to DSS.
"We are shooting for - although it's going to be difficult - to have the application implementation beginning in the second quarter next year," Matthews said. "To have it fully redesigned."
Some field staff will be brought in for trials to see if there are holes in the process or if there continue to be duplications.
"Our target is to try to have it ready to go by July 1," he said. "We realize that's a challenge. Some of our field offices are understaffed, closed or working remotely. It's an enormous effort."