State of Utah: Improving Food Stamp, Medicaid, and SCHIP Participation: Strategies and Challenges....

Contract No.: 282-98-0021 MPR Reference No.: 8661-204

State of Utah Improving Food Stamp, Medicaid, and SCHIP Participation: Strategies and Challenges Final Report May 7, 2002 Jessica Mittler* Gary Hyzer†

Submitted to:

Department of Health and Human Services Administration for Children and Families Office of Planning, Research and Evaluation 370 L’Enfant Promenade, SW, 7th Floor Washington, DC 20447

Project Officer:

Michael Dubinsky

Submitted by:

Mathematica Policy Research, Inc. 600 Maryland Ave., SW, Suite 550 Washington, DC 20024-2512 Telephone: (202) 484-9220 Facsimile: (202) 863-1763

Project Director: LaDonna Pavetti

*Mathematica Policy Research, Inc. †American Management Services, Inc.

PAGE IS INTENTIONALLY LEFT BLANK TO ALLOW FOR DOUBLE-SIDED COPYING

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ACKNOWLEDGMENTS

This report would not have been possible without the cooperation and support we received from staff at all levels in each of the study states. Program administrators fielded many questions from us about formal policies and procedures, and local staff talked openly with us about how those policies and procedures play out in practice and let us observe them as they went about their daily routines. Clients shared their thoughts on both the benefits and costs of applying for public benefits. We would like to thank everyone who graciously shared their time with us and for making this report possible.

We would also like to thank staff from the U.S. Departments of Health and Human Services

and Agriculture for providing guidance and feedback throughout this project. As project officer, Michael Dubinsky guided the project from beginning to end. Ann McCormick, Ann Burek, Penny Pine and Margaret Andrews also provided useful feedback throughout the project.

Stacy Dean, Dottie Rosenbaum, and David Super from the Center on Budget and Policy

Priorities helped us to gain a better understanding of the intricacies of the Food Stamp Program and the options available to states to simplify the application and recertification processes for families. Vicki Grant and Nancy Gantt from the Southern Institute for Children and Families worked with us to coordinate our work with the Robert Wood Johnson Foundation’s project, Supporting Families After Welfare Reform.

The work for this project was completed as a team effort, involving staff from multiple

organizations. At Mathematica Policy Research (MPR), LaDonna Pavetti directed the project. Robin Dion, Megan McHugh, Angela Merrill, Jessica Mittler, and Charles Nagatoshi conducted site visits and wrote the state site visit summaries. As a consultant to MPR, Liz Schott contributed to virtually every aspect of the project. She conducted site visits, wrote several of the site visit summaries, and reviewed those she did not write. Her extensive knowledge of TANF and the Food Stamp and Medicaid programs helped all of us to do a better job on this project. Margaret Boeckmann, also a consultant to MPR, conducted several site visits and helped to synthesize the information collected. Julie Osnes of the Rushmore Group, Inc., helped us to identify potential sites and reviewed all of the reports. Ruchika Bajaj managed the project. Brianna Stanton helped us to prepare the data we collected for analysis. Daryl Hall coordinated the editing of the reports and Donna Dorsey provided ongoing and consistent administrative support. Staff from our survey division helped us to recruit clients for the focus groups.

Our subcontractors, George Washington University Center for Health Services Research

(GWU) and American Management Services, Inc. (AMS), participated in all aspects of the project. Kathleen Maloy acted as project director at GWU, supervising project staff and reviewing all reports. Her extensive knowledge of Medicaid for families helped everyone to better understand the intricacies of Medicaid enrollment and retention. Jennifer Stuber and Michelle Posner conducted site visits. Lea Nolan and Julie Darnell, a consultant to GWU from Northwestern University, conducted site visits and wrote the state site visit summaries. Soeurette Cyprien provided administrative support. At AMS, Gary Hyzer acted as project director. Along with Allison Logie, Lara Petrou Green, and Ben Marglin, he conducted site visits and authored the state site visit summaries. AMS staff also helped to develop the methodology to document the case flow in each of the sites and to assess the use of automated systems.


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CONTENTS

Chapter Page

EXECUTIVE SUMMARY............................................................................................ix I CONTEXT ......................................................................................................................1

A. INTRODUCTION ...................................................................................................1 B. BACKGROUND ON STATE PROGRAMS ..........................................................2

1. Utah’s TANF Program: Family Employment Program...................................2 2. Utah’s FSP .......................................................................................................4 3. Utah’s Medicaid Program for Children and Families ......................................4 4. Utah’s State Children’s Health Insurance Program (SCHIP) ..........................7

C. THE DWS: A NEW MODEL FOR SERVICE DELIVERY ..................................8

1. Employment Centers........................................................................................9 2. Eligibility Service Centers .............................................................................11 3. Automated Management Information Systems .............................................13

D. WORK FLOW AT THE SOUTH COUNTY EMPLOYMENT CENTER...........14

1. Front Desk and Screening Procedures ...........................................................14 2. Application Processes ....................................................................................15 3. Ongoing Casework.........................................................................................15

II FINDINGS ....................................................................................................................17

A. PROGRAM MARKETING AND OUTREACH ..................................................17

1. Promising Practices—Strategies to Increase Participation............................17 2. Areas for Improvement ..................................................................................18

B. FRONT DESK.......................................................................................................18

1. Promising Practices: The Expedited Eligibility Screen.................................18 2. Areas for Improvement ..................................................................................19

CONTENTS (continued) Chapter Page

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II (continued)

C. ELIGIBILITY AND THE INTAKE PROCESS ...................................................20 1. Promising Practices That Support Initial Enrollment in the FSP and

Medicaid .........................................................................................................20 2. Areas for Improvement ..................................................................................21

D. ONGOING ELIGIBILITY PROCESS ..................................................................23

1. Promising Practices........................................................................................23 2. Areas for Improvement ..................................................................................24

III CONCLUSIONS AND FUTURE CONSIDERATIONS.............................................27

A. INITIAL ENROLLMENT IN FOOD STAMPS AND MEDICAID ...................27

1. Use of ECs Creates a Strong Focus on Work but May Inhibit Initial Access to and Enrollment in Food Stamps and Medicaid ...................27 2. Eligibility Services Are Provided in a Supportive Manner that Promotes

Access to Food Stamps and Medicaid ...........................................................28 3. FEP Application Process May Discourage Enrollment in Food Stamps

and Medicaid..................................................................................................28 B. RETENTION IN FOOD STAMPS AND MEDICAID.........................................28

1. ESC Both Facilitates and Inhibits Retention in Food Stamps and Medicaid..................................................................................................28 2. DOH Outstationed Workers Facilitate Ongoing Program Retention ............29 3. Medicaid Issues Result from Two-Tiered 1931 Medicaid Program..............29

C. OUTREACH..........................................................................................................29 D. AUTOMATED SYSTEMS ...................................................................................30 E. COORDINATION BETWEEN DWS AND DOH................................................30 F. POLICY CONSIDERATIONS ............................................................................31

1. Simplify Eligibility and Reporting for the FSP .............................................31 2. Consider and Address Consequences of Two-Tiered Family Medicaid .......31 3. Eliminate Asset Test for Medicaid .................................................................32

CONTENTS (continued) Chapter Page

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III (continued)

G. FINAL CONCLUSIONS.......................................................................................32

REFERENCES..............................................................................................................33 APPENDIX A: RESEARCH METHODS ....................................................................35 APPENDIX B: WORK FLOW DIAGRAMS ..............................................................37 APPENDIX C: CUSTOMER FOCUS GROUP SUMMARY .....................................41

APPENDIX D: APPLICATIONS.................................................................................49


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EXECUTIVE SUMMARY

Each year since the enactment of federal welfare reform in 1996, participation in the Food Stamp Program (FSP) and Medicaid, two of the nation’s most important safety net programs, has declined nationwide. Although large numbers of cash assistance recipients have transitioned from welfare to work, research suggests that in some states, many low-income families with children are not receiving the FSP and Medicaid benefits they for which they are eligible, and which provide important nutritional and medical support as families transition to self-sufficiency. Federal and state policymakers are concerned that enrollment has indeed been affected by changes in cash assistance programs.

In response to these concerns, the U.S. Departments of Health and Human Services and Agriculture contracted with Mathematica Policy Research, Inc. (MPR) to identify innovative state policies, practices and operational procedures that appear to promote enrollment and enhance ongoing participation in these programs, and identify potential areas for improvement. We selected Utah for this study because of its new employment-centered approach to delivering services. In most states, cash assistance is the centerpiece of the service delivery model, with Medicaid, food stamps, and employment built around it. In Utah, however, employment services are the keystone around which all other human and supportive services are organized, and the state has restructured its offices at the state and local level to reflect this. Due to the uniqueness of this model, and the fact that many other states are considering moving in this direction, Utah can provide valuable insight into understanding the program access and retention issues that may arise in an employment-centered service delivery model. This case study documents Utah’s experience with access to and participation in the Food Stamp, Medicaid, and SCHIP programs post welfare-reform and since the adoption of the employment model.

A. METHODS

To learn about Utah’s experience, the MPR team visited Department of Workforce Services (DWS) sites in the Salt Lake City area. These were the South County Employment Center and the Eligibility Service Center. We collected data from a wide range of informants, including state and local program and policy officials, caseworkers, community-based organizations, and current and former recipients of public assistance. The team also looked closely at barriers to participation that could have arisen or become magnified as a result of specific welfare reform policies (i.e., diversion, sanctions, time limits, and work requirements).

B. ADMINISTRATIVE STRUCTURE

In 1997, the state combined responsibility for employment and job security services with human services programs, including the Family Employment Program (FEP is Utah’s Temporary Assistance for Needy Families program) and food stamps, under the newly created Department of Workforce Services (DWS). At the state level, DWS is responsible for establishing FEP and FSP policy.

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For Medicaid and SCHIP, the Department of Health (DOH) is responsible for program policy, administration, and oversight. Responsibility for administering Medicaid is split between DWS and DOH: DWS determines eligibility and completes ongoing case management for clients also receiving FEP or food stamps, and DOH determines eligibility and completes ongoing case management for clients only receiving Medicaid, and for all clients receiving SCHIP, regardless of whether those clients are also receiving any other services.

There are two primary vehicles for the delivery of services: employment centers and eligibility service centers:

• Employment Centers (ECs) At the “one-stop” ECs, customers can receive employment services, and apply for supportive services including FEP, food stamps, and Medicaid. The South County EC has three teams of employment counselors and one team of eligibility specialists. Employment counselors work with customers who receive a program benefit with a work-related requirement, such as TANF or FSP Employment & Training, to develop employment plans. Eligibility specialists conduct the initial eligibility determinations for customers seeking public assistance benefits, including FEP, FSP, and Medicaid benefits. They authorize benefits for eligible customers. While eligibility specialists do not provide ongoing case management support (this is provided by ESCs), they do conduct yearly reviews with customers when face-to-face interviews are required. (DOH eligibility and caseworker staffs are also located at ECs to determine eligibility and provide ongoing case management for SCHIP and Medicaid-only clients.) There are approximately 50 ECs throughout the state’s five service delivery regions that are organized like the South County EC

• Eligibility Service Centers (ESCs) ESCs provide ongoing eligibility support for

FEP, food stamps, and Medicaid, and enable customers to obtain information on their cases, and conduct regular ongoing activities (conducting recertifications, reporting changes, etc.) exclusively by telephone and the mail. The South County ESC provides ongoing case management services for most customers receiving FEP, food stamps, and Medicaid. Customers receiving only Medicaid, SCHIP, or other medical insurance programs offered by DOH are not served at ESCs. Instead, their cases are managed by ongoing Medicaid caseworkers. Most caseworkers at the ESC are formally classified as employment counselors. They are assigned to teams that work together to manage individual cases. There are eight ongoing casework teams at the South County ESC, each with about six to eight employment counselors. Since July 2001, ESC caseworkers have assigned caseloads. Previously, teams and employment counselors were not assigned to specific cases.

C. FINDINGS

With DWS’s creation, Utah refocused its vision by helping customers attain lasting self-sufficiency through meaningful employment. DWS’s efforts have proven successful in this regard, and it has created a model for helping customers re-enter the labor market with the assistance of supportive services such as food stamps and Medicaid. However, eligibility

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services are now a secondary focus of the service delivery process, used to support customers’ transition to work. This has created a unique set of program access and retention issues for those seeking benefits from FSP and Medicaid.

1. Initial Enrollment in Food Stamps and Medicaid

a. The use of ECs creates a strong focus on work but may inhibit initial access to and enrollment in the FSP and Medicaid

The primary focus of the employment centers is to help customers re-enter the labor market, through the provision of employment and training services. The centers are noted for providing employment-related services for all citizens, regardless of socioeconomic status, and there appeared to be little stigma attached to using the centers’ employment services. By co- locating the application sites for food stamps and Medicaid with employment services, ECs offer customers one-stop centers and provide information to employment-seekers who may be eligible for food stamps and/or Medicaid, but who otherwise may not have learned about the programs.

However, there are some features of ECs that may inhibit initial access to food stamps and

Medicaid. There is a general lack of Medicaid and FSP information in the centers; front desk workers emphasize work and employment services in customer interactions; front desk workers often discuss food stamps and Medicaid only when customers specifically inquire about these programs; and the universal customer registration form customers must initially fill out focuses on work skills and employment history. These factors may lead some customers to conclude incorrectly that work or work-search activities are a prerequisite for receiving food stamps or Medicaid. There may be instances when customers interested in or potentially eligible for food stamps and/or Medicaid may never make it past the front desk because they are unaware of the programs or assume they are ineligible.

b. Eligibility services are provided in a supportive manner that promotes access to food stamps and Medicaid

The eligibility specialists provide services in a supportive and nonthreatening manner. Workers observed during initial eligibility interviews seemed committed to fully assessing customers for food stamps and Medicaid eligibility, and enrolling them whenever possible. They did not discourage participation in food stamps and Medicaid, although they did frequently counsel FEP applicants about using cash assistance wisely (Utah has a 36 month lifetime limit on FEP assistance). In instances when applicants decided not to pursue FEP, in order to save the benefits for times of greater need, eligibility workers took necessary steps to ensure that all eligible customers were enrolled in food stamps and Medicaid.

c. The FEP application process may discourage enrollment in food stamps and Medicaid

The application process for FEP is significantly more complex than for food stamps and Medicaid, requiring customers to meet several times with various workers. These meetings often occur on separate days, requiring multiple trips to the EC. Due to the number of required meetings and the ongoing focus on work and FEP program requirements, some customers may be discouraged from continuing the FEP application, which also may result in the abandonment

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of the Medicaid and food stamps applications. Moreover, because the eligibility interview typically occurs after the initial meeting with the employment counselor, it still is possible that some customers who drop their FEP applications also may not complete the application process for food stamps and Medicaid.

However, one promising practice in Utah is that once an eligibility interview is completed and a customer is determined eligible for food stamps and Medicaid, benefits are authorized and initiated, regardless of the customer’s FEP application status. (In some states, the authorization of food stamps and Medicaid benefits is delayed until the FEP benefits are either approved or denied).

2. Retention in Food Stamps and Medicaid

a. ESCs both facilitate and inhibit retention in food stamps and Medicaid

The ESC promotes ongoing participation in FEP, Food Stamp, and Medicaid programs by making the ongoing eligibility process more user- friendly. It provides customers with a toll- free number and serves as a single point of contact for customer issues, questions, concerns, and case changes. Extended hours of operation make it easier for working families to reach the ESC. While this has made the logistics of maintaining eligibility in food stamps and Medicaid more straightforward, many customers stated that they prefer working with an assigned eligibility worker, rather than a team of workers where any worker on the team may get involved with the case. Customers said relying on one worker usually results in stronger working relations, which gives workers and customers the chance to work harder together to achieve compliance with program requirements and ongoing eligibility requirements, and remain in food stamps and Medicaid longer. ESC managers also indicated there are benefits to having a single worker assigned to a case, and they said they are moving in this direction. Since the visit, workers are assigned a caseload, so a single worker has responsibility for specific cases.

b. DOH outstationed workers facilitate ongoing program retention

As in other states, DOH’s outstationed eligibility workers have helped to increase enrollment in Medicaid. But Utah is unique in that outstationed Medicaid workers also provide full case management services, and conduct redeterminations for ongoing Medicaid eligibility. This facilitates ongoing enrollment in Medicaid, as customers who are receiving only Medicaid are able to receive all Medicaid services at a community location that often is the same health clinic where they receive their primary health care services. The only potential drawback is that many customers also are potentially eligible for food stamps or other benefits, but applications for these services are not provided nor accepted by outstationed Medicaid workers.

c. Medicaid issues may result from the two-tiered 1931 Medicaid program

In Utah, there are two Family Medicaid (Section 1931) programs with slightly different eligibility requirements: one for families on FEP and another for families not receiving FEP. In some respects, the two–tiered family 1931 Medicaid program treats income more generously for families receiving FEP. This results in different income triggers for Transitional Medical Assistance (TMA). The lower income standards potentially create a shorter period of Medicaid

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eligibility for non-FEP families, since they move more quickly into TMA. There also may be some implications for families who reach the FEP time limit whose income is too high to qualify for the non-FEP Family Medicaid, but low enough to qualify for Family Medicaid while on FEP.

The different standards and treatment of the two tiers of Family Medicaid adds a level of

complexity for workers that could affect ongoing access. The current automated information system treats the two programs differently, so caseworkers must complete a manual work-around to redetermine a customer’s Medicaid eligibility when a FEP case closes.

3. Outreach

Over the past several years, Utah has aggressively marketed SCHIP and, for the past two years, has surpassed enrollment targets. Part of the state’s success may be attributable to its decision to position SCHIP as health insurance, as opposed to a welfare program. While SCHIP marketing and outreach has been successful, the state has not yet launched a food stamp and Medicaid outreach campaign, and overall enrollment in these programs continues to decline. A food stamps outreach committee recently was formed, and the state may wish to consider how to transfer the tactics and strategies of SCHIP’s outreach effort to the food stamp campaign. The state may also wish to consider refocusing public opinion of food stamps and Medicaid so it no longer views them as welfare programs, but as nutritional assistance and health insurance programs.

4. Automated Information Systems

Utah has several effective practices regarding the use of automated systems to support enrollment and retention in food stamps and Medicaid. The state’s automated eligibility system helps determine eligibility for FEP, food stamps, and Medicaid. This is notable because many other states rely on multiple systems, and, in some cases, still rely on manual processes to determine eligibility for some programs, usually Medicaid. The document imaging system allows workers to make and store digital records of static documentation, such as birth certificates and social security cards, and relieves customers of the burden of providing this information every time they apply for services. The proposed eligibility-screening module that integrates with the current automated information system can provide customers with enhanced program information.

There are some remaining challenges, however. While the automated information system

supports initial eligibility determination, it is not fully automated. Workers must manually input codes for program categories. This process is somewhat prone to error, in that only a limited number of program codes can be tested concurrently, and workers must continually retest customers’ eligibility in other program categories. Although there were mixed opinions, workers we interviewed generally said they thought there were cases in which individuals were improperly denied Medicaid because of workers’ failure to properly test customers for eligibility against all Medicaid codes. In addition, improvements can be made to ensure that the automated information system fully supports ongoing participation in food stamps and Medicaid.

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5. Coordination between DWS and DOH

Workers from DWS and DOH are co- located in the ECs, which is helpful during initial eligibility determination. Customers who wish to apply for FEP, Medicaid, and food stamps can see DWS workers, whereas those who wish to apply only for Medicaid services can be seen by DOH workers. This eliminates the need for referrals to other locations for applicants seeking specific types of services. For customers deemed ineligible for cash assistance or food stamps but eligible for Medicaid, their cases can be immediately transferred from DWS workers to DOH workers.

There may be room for improvement in terms of coordination between DWS and DOH,

however. DOH workers said they sometimes receive cases from DWS in which Medicaid eligibility was not determined correctly or was improperly discontinued. This may be due in part to program complexity resulting from the state’s decision to continue its two-tiered 1931 Medicaid program, in which varying Medicaid eligibility standards exist depending on whether customers are receiving FEP. Several workers said that while case transfers typically happen quickly, there are often varying qualities in the notes attached to the cases, making it difficult sometimes to understand histories of cases transferred between DWS and DOH. Improved training and communication may alleviate this issue.

D. POLICY CONSIDERATIONS

There are a number of policy options available to states that may provide enhanced program access for eligible families and at the same time simplify the administration of the Food Stamp and Medicaid programs. 1. Simplify Eligibility and Reporting for Food Stamps

The U.S. Department of Agriculture is offering states new opportunities to adopt food stamp procedures that make the program more regulations more friendly toward working families. The new semi-annual and quarterly reporting options (authorized by November 2000 regulation) Under the semi-annual option, customers’ benefits are “frozen” for six months and do not change based on income fluctuations. Recipients are required to report income changes above 130 percent of poverty, which would result in their ineligibility, and they may report losses in income that would result in an increase in benefits. Recipients’ six-month reviews are limited to questions about the previous month (rather than the entire previous six-month period). Stated do not get penalized for payment “errors” if income changes go unreported. Utah is considering implementing the six-month reporting option. Since Utah currently has a three month certification period for most families with earned income, the six-month reporting option has the potential to enhance access to and support ongoing participation in the Food Stamps Program.

2. Consider and Address Consequences of Two-Tiered Family Medicaid

As discussed, Utah’s two-tiered Family Medicaid policies create some administrative and program complexities that may inhibit ongoing participation in both 1931 Medicaid and Transitional Medicaid. In addition to these complexities, the two-tiered Family Medicaid policies also have implications for Utah’s FEP program. This is because, in order for Utah to continue with operating the two-tiered Family Medicaid program as authorized under the state’s

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AFDC demonstration waiver, the state must continue to meet conditions of the waiver. This restricts any changes to FEP, giving the state little flexibility to shape the program to address emerging needs. Given these issues, the state may wish to re-examine the current two-tier system, and weigh the advantages of having one Family Medicaid program, which include simplification of the ongoing eligibility process, reduction of administrative burden, and greater flexibility in setting program policy.

3. Eliminate Asset Test for Medicaid

In a recent 10-state research study (Smith, Ellis and Chang 2001), representatives from the participating states noted that the Medicaid asset test was “cumbersome” to administer, “onerous” for applicants and therefore a potential barrier to applying, and in the end, kept few families from meeting Medicaid eligibility requirements. The states also found that eliminating the Medicaid asset test resulted in significant benefits including the ability to streamline the eligibility determination process, improve productivity of eligibility workers, establish Medicaid’s identity as a health insurance program distinct from welfare, and achieve Medicaid administrative cost savings. Utah may wish to consider whether the elimination of the asset test for its Family Medicaid program would result in similar benefits, and would thereby facilitate the application process for families seeking medical insurance coverage.

E. CONCLUSIONS

When DWS was created in 1997, Utah implemented a new model for delivering employment and social services to its residents. The institution of ECs has created an overarching focus on providing customers with a package of short-term assistance and benefits they need to re-enter the labor force and attain long-term self-sufficiency. While co- locating employment services with social services, such as food stamps and Medicaid, has made it easier for clients to apply, challenges remain in ensuring that all customers are informed of the programs for which they may be eligible and that the availability of food stamps and Medicaid is not overshadowed by overarching emphasis on work.


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I. CONTEXT

A. INTRODUCTION

One of the unexpected consequences of the 1996 federal welfare law has been the nationwide decline in participation in the Food Stamp and Medicaid programs by low-income families. Although large numbers of cash assistance recipients have transitioned to work, research suggests that in some states many eligible low-income families with children may not be receiving the food stamp and Medicaid benefits they need and for which they qualify.

To examine the barriers and enhancements to initial and continuous participation in the Food

Stamp Program (FSP), Medicaid, and the new State Children’s Health Insurance Program (SCHIP), the U.S. Department of Health and Human Services and the U.S. Department of Agriculture commissioned a research project involving case studies of the implementation of these programs at the state level. As part of this project, we chose to study Utah’s promising practices and potential program improvements with respect to access to and participation in FSP, Medicaid, and SCHIP. The aim of this case study was to profile innovative policies and practices that enhance participation in these programs, and identify potential areas for improvement.

We selected Utah because of its new employment-centered approach to delivering services.

In most states, welfare is the centerpiece of the service delivery model, with Medicaid, food stamps, and employment built around it. In Utah, employment services are key, and the state has restructured its offices at the state and local level to reflect this. In 1997, the state combined responsibility for employment and job security services with human services programs, including Temporary Assistance for Needy Families (TANF) and food stamps, under the Department of Workforce Services (DWS). At the local level, welfare offices were replaced by “one-stop” employment centers (ECs) and eligibility service centers (ESCs). ECs offer employment services, TANF, food stamps, and Medicaid. ESCs provide ongoing eligibility support for TANF, food stamps, and Medicaid exclusively by telephone. Because the employment-centered delivery model is one that many states are examining, we were especially interested in Utah’s experience with access to and participation in the Food Stamp, Medicaid, and SCHIP programs.

We visited the South County Employment Center and the ESC in the Salt Lake City area

because they support a large urban and suburban population, have high customer traffic (in person and over the phone), and are highly functioning sites that provide an opportunity to identify good models of implementation practices and ongoing operations. Appendix A provides more detail about our research methods.

This report describes Utah’s state- level policies and procedures as well as implementation

practices and processes observed at the EC and ESC. The remainder of Chapter I provides an overview of state- level policies and procedures in the TANF, Food Stamp, and Medicaid programs, and an overview of the structure and environment of the South County EC and ESC. Chapter II presents our findings, which outline Utah’s promising practices and areas for improvement with regard to enrolling and retaining eligible individuals in the Food Stamp and Medicaid programs. Chapter III presents our conclusions and future considerations.

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B. BACKGROUND ON STATE PROGRAMS

Utah’s DWS is responsible for setting policy for TANF and food stamps and for administering these programs through ECs and ESCs. Electronic benefit transfer accounts provide clients with TANF and food stamps.

For Medicaid and SCHIP, the Department of Health (DOH) is responsible for program

policy, administration, and oversight. Responsibility for administering Medicaid is split between DWS and DOH: DWS determines eligibility and completes ongoing case management for clients also receiving TANF or food stamps, and DOH determines eligibility and completes ongoing case management for clients only receiving Medicaid and for all clients receiving SCHIP. DOH eligibility and caseworker staffs are at ECs so they are in fact “one-stop” centers that provide access to all programs. A more detailed discussion of ECs, work flow, and operational responsibilities is in the next section.

1. Utah’s TANF Program: Family Employment Program

Utah’s Family Employment Program (FEP) provides cash assistance under the TANF block grant to low-income families with dependent children. It makes available TANF cash assistance, support services, other support such as diversion payments, and a range of work activities. FEP operates under pre-TANF waivers initially obtained in 1993 that allow Utah to use an expanded definition of work participation activities, impose full family sanctions (allowed nationally with the 1996 Personal Responsibility and Work Opportunity Reconciliation Act), and keep TANF linked to Medicaid. Utah’s TANF caseload has decreased 46 percent between 1996 and 2000. In April 2001, Utah had about 5,300 FEP cases. We refer to TANF cash assistance benefits interchangeably as TANF or FEP benefits throughout this report.

a. Eligibility and Benefits

Customers apply for FEP at an ESC by submitting a 10-page combined form that serves as an application for all benefits (See Appendix D). The maximum FEP benefit in Utah is $451 for a family of three, or 37 percent of the 2001 federal poverty guidelines. In determining eligibility and computing monthly benefits, Utah disregards $100 of earnings for applicants and $100 plus 50 percent of earnings for recipients. Earnings cut-offs are $551 for applicants and $1,002 for recipients for a family of three. Utah excludes the value of a car up to $8,000 and any excess counts toward an asset limit of $2,000.

b. Time Limits

Utah adopted a 36-month lifetime limit on the receipt of cash assistance that became effective January 1997. The first families reached this time limit in January 2000. In April 2001, about one percent of the FEP caseload (roughly 35-55 cases) was closed because those

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cases had reached the time limit. This figure has remained consistent over the last two years. Extensions are granted for families who reach the time limit and are fully participating in FEP.1

c. Work Requirements

Utah requires eligible FEP recipients to comply with an employment plan developed with their employment counselor. Recipients must participate in work activities for at least 30 hours per week, with some exceptions and modifications made on an individual basis. Work activities include activities such as job search, standard employment, education and training, and substance abuse treatment.

d. Sanctions

Recipients who do not comply with work requirements have their TANF benefits reduced by $100 for two months. If a recipient does not comply within these two months, a full family sanction is imposed: the entire TANF cash grant is terminated, and the TANF case is closed. Utah allows customers to return to FEP at any time after sanctions have been imposed as long as they show compliance with work requirements. In April 2001, about 10 percent (or 80 actual cases) of FEP cases were under sanction.

e. Cash Diversion

Utah has a cash diversion program that allows single-parent families with no FEP history to receive a cash lump sum equal to up to 3 months of the maximum benefit for temporary crisis needs. Families receiving a lump sum payment are categorically eligible for food stamps and Family Medicaid for 3 months.2 The payment counts for 1 month against a customer’s 36-month FEP time limit, but the state is planning to rescind this policy. If families reapply for FEP within the 3-month period and are approved, the cash benefits are prorated accordingly. The number of families in any month participating in the diversion program is small, ranging from 70 to 100 families. In April 2001, 83 families were participating, compared to more than 5,300 families receiving FEP.

1 State policy allows time -limit extensions to be granted if a recipient meets the criteria in one of three

categories: (1) hardship, which includes a parent being under age 19, medically unable to work or unable to work because she or he is fulfilling medical needs of a dependent, and being in the middle of job-related education or training; (2) abuse, where a family member has been battered or subjected to extreme cruelty, and implementation of the time limit would make extrication from the abusive situation more difficult; (3) full participation, which means the parent has complied with work requirements and meets this standard: the parent was employed for no fewer than 80 hours in the last month and no fewer than 80 hours a month during at least 6 of the 24 months. For this last category, extensions are limited to 24 months, although a recipient may qualify for further extensions under the first two categories (SPDP 2000 a, b). Federal policy allows extensions to be extended for up to 20 percent of the state’s average monthly caseload (Pavetti 2000).

2 This provision for Medicaid is authorized by a state waiver.

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2. Utah’s FSP

The FSP is a federal entitlement program administered through the states for low-income people. In Utah, DWS administers the program. Federal rules governing eligibility for food stamps require recipients to have incomes below 130 percent of the federal poverty level and meet asset tests and other procedural requirements. (As of July 1, 2001, Utah adopted the more generous FEP standard of $8,000 for one vehicle.)

Customers apply for food stamps at ECs using the 10 page combined application that covers

all available benefits. Families with earned income are certified for food stamp benefits for three months, and families with a stable situation and no earned income, such as non-working individuals on Supplemental Security Income (SSI), are certified for up to 1 year. Utah is considering new federal options that allow 12-month certification periods with semi-annual reporting for working families. The full TANF benefit (or diversion payment) is counted in computing a family’s food stamp benefit even if the benefits have been reduced or terminated as a result of noncompliance with TANF work requirements.

Recertifications are completed by mail and phone through ESCs. All recipients, regardless

of certification period, must have one face-to-face review per year at an EC (unless waived on an individual basis due to hardship). Between reviews, food stamp recipients must report changes within 10 days.

Utah has adopted a full family sanction for head of household noncompliance with the food

stamp work requirement. (Noncompliance by other household members results in an individual sanction.) The sanction is applied for escalating periods and remains in place until the individual complies with the work requirement or becomes exempt. For the initial occurrence, the sanction is applied for one month; for the second occurrence, three months; and for the third occurrence, six months (DWS 2001).

3. Utah’s Medicaid Program for Children and Families

Medicaid is a federally matched medical assistance program that provides health insurance coverage for low-income families and children as well as elderly and disabled persons. Utah’s Medicaid and SCHIP policies are summarized in Table 1 and described below.

a. Medicaid Under Section 1931—Family Medicaid.

The 1996 federal welfare law established a new Medicaid eligibility category for low-income families. It replaced the previous category under which families receiving Aid to Families with Dependent Children (AFDC) automatically qualified for Medicaid (and frequently lost Medicaid eligibility when losing eligibility for AFDC). This low-income families category, established by adding Section 1931 to the Social Security Act, sets as a base line for family-based Medicaid coverage certain AFDC policies of a state that were in effect on July 16, 1996. A state can adopt less restrictive methodologies for consideration of income and resources so it can expand family-based Medicaid eligibility beyond the July 16, 1996, baseline.

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TABLE 1

SUMMARY OF UTAH’S PRIMARY MEDICAL PROGRAMS FOR FAMILIES AND CHILDREN

Medicaid Section 1931 & TANF— Family Medical

(FM)

Medicaid Section 1931 & no

TANF— Family Medical-Other

(FM-O)

Children’s Medicaid

(up to age 6)


(ages 6-18)

Separate SCHIP

Program

Income eligibility limit

Applicants: 45% FPLa

Recipients: 82% FPLa

Applicants: 55% FPLb

Recipients:b

0-4 months: 82% FPL

5-12 months: 58% FPL

>12 months: 55% FPL

133% FPL 100% FPL 200% FPL

Earnings disregards

TANF standard:

Applicants: $100

Recipients: $100 plus 50%

Applicants: $90

Recipients: $90 + $30 + 1/3 remainder for 4 months; $30 for next 8 months

Applicants: $90

Recipients: $90 + $30 + 1/3 remainder

Applicants: $90

Recipients: $90 + $30 + 1/3 remainder

All income of a child

Asset tests Applicants: TANF standard of first car if value less than $8,000 and any excess toward $2,000 limit

Applicants: First car (if value less than $15,200) and asset limit of $3,025

No Applicants: First car (up to $1,500 equity value) and asset limit of $3,025

No

Self-declaration of income

No No No No Noc

Certification periods

Up to 12 months Up to 12 months Up to 12 months

Up to 12 months 12 months of continuous eligibility

Application form

Combined application for all benefits (TANF, food stamps, etc.)

Combined application for all benefits or

Separate Medicaid-only application


Separate Medicaid-only application or

Separate SCHIP application with Medicaid addendum


Separate Medicaid-only application or

Separate SCHIP application with Medicaid addendum

Separate SCHIP application or

Separate Medicaid-only application

TABLE 1 (continued)

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Medicaid Section 1931 & TANF— Family Medical

(FM)

Medicaid Section 1931 & no

TANF— Family Medical-Other

(FM-O)


(up to age 6)


(ages 6-18)

Separate SCHIP

Program

Locus of eligibility determination

DWS Employment Center

DWS Employment Center or

DOH at DWS Employment Center or

Outstationed locations







Interview required

Yes, can be conducted on the phone





aThese figures represent the countable income cut-off for a family of three of $551 for applicants and $1,002 for recipients receiving TANF as a percentage of the 2001 federal poverty level (FPL). bThese figures represent the countable income cut-off for a family of three ($673 for applicants; $995 for recipients 0-4 months; $702 for recipients5-12 months; $673 for recipients more than 12 months) as a percentage of the 2001 federal poverty level (FPL). cSCHIP applicants must provide income verification, but Utah accepts self-declaration of income at renewal if there has been no change in employer.

Utah has two categories of Medicaid coverage for families under Section 1931: one for

families receiving TANF, and one for families not receiving TANF. For families receiving TANF, Utah calls its Medicaid coverage category under Section 1931 Family Medicaid (FM). All families receiving TANF are automatically eligible for FM, which means the treatment of earnings for FM conforms to its overall less restrictive treatment of earnings for TANF. The result is a net income cut off of $1,002 (82% FPL) for a family of three. The state also uses the TANF standard of disregarding the first car up to $8,000 and imposes a limit of $2,000 on other assets.

For families not receiving FEP, Utah calls its Medicaid coverage category under Section

1931 Family Medicaid Other (FM-O). To be eligible for FM-O, a family must have at least one age-eligible child living in the home who is deprived of parental support, must meet assets tests, and must pass two income tests (gross income and net income standard test). FM-O has slightly more restrictive treatment of earnings than TANF. For applicants, the state disregards $90; for recipients, the state disregards $90 of earned income plus $30 and one-third for four months, after which the disregard drops to $90 plus $30 for the next eight months. This results in a net income limit of $673 (57% FPL) for applicants and $995 (82% FPL) for recipients for a family of three for the first four months. The income limit then drops to $702 (58% FPL) for the next eight months, and then to $673 (57% FPL) for the remainder. The treatment of assets for FM-O became slightly more generous than TANF in July 2001, when the state elected to disregard a first car up to $15,200 and impose a $3,025 limit on other assets.

Families applying for Medicaid and either TANF or food stamps use the 10 page combined

application for all benefits, and they apply at ECs. DWS staff at ECs determines eligibility, and

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ongoing case management is completed at the ESCs. Families only applying for Medicaid use a separate Medicaid application and have their eligibility determined and cases managed by DOH staff located at ECs or at outstationed community sites (see Appendix D). [In the Salt Lake area, DOH staff is outstationed at about 30 community sites, including county health centers, federally qualified health clinics (FQHCs), and Women, Infants and Children (WIC) clinics.] For Medicaid, customers do not need to apply for benefits in-person at an EC or community site or meet with their eligibility worker face-to-face; applicants can complete their application interview over the phone. Benefits can be certified for up to 12 months, but most staff indicated that certification is often for 3- or 6-month periods.

b. Transitional Medicaid Assistance

In accordance with federal law, Utah provides Transitional Medical Assistance (TMA) for up to 12 months to families who lose eligibility for 1931 Medicaid (FM or FM-O) due to earnings and for 4 months to families who lose eligibility for FM-O due to increased child support income or alimony. To be eligible for TMA, families must have received FM or FM-O in at least 3 of the last 6 months (or a FEP diversion payment) and have become ineligible due to increased earnings, increased work hours to more than 100 per month, or lost the time-limited $30 and one-third disregard for FM-O (BES 2000). (The income trigger for TMA is different for FM and FM-O because the income standards are different for the two categories.) In July 2001, Utah implemented a new policy for families who lose 1931 eligibility due to earnings that disregards 100 percent of earnings for 12 months, followed by 12 months of TMA, effectively creating 24 months of TMA coverage. TMA eligibility is reviewed every 6 months.

c. Children’s Medicaid

In Utah, children’s Medicaid is divided into two eligibility groups: children under age 6, and children 6 to 18 years old. Children under age 6 are eligible for medical coverage in families with incomes up to 133 percent of the poverty level and are not subject to an asset test. Children age 6 to 18 are eligible for medical coverage in families with incomes up to 100 percent of the poverty level and must meet an asset limit of $3,025, with the first $1,500 of a car disregarded. For both groups, the state treats income the same. It disregards $90 of applicants’ earnings, and $90 and $30 and one-third of recipients’ earnings. The process of applying for children’s Medicaid follows the same protocol as applying for family Medicaid categories.

4. Utah’s State Children’s Health Insurance Program (SCHIP)

Utah operates a separate SCHIP program for children ages 0 through 18 who are ineligible for Medicaid but are in families with incomes less than 200 percent of the federal poverty level. The separate program, launched in 1998, has similar but not identical benefits as Medicaid. There is no asset test, 12 months of continuous eligibility, no face-to-face interview requirement, and a separate mail- in application (Ross and Cox 2000). Even though it is separate from Medicaid, DOH’s Bureau of Eligibility Services (BES) administers SCHIP. So regardless of other benefits a family is receiving, BES caseworkers manage the SCHIP case. Families can apply at any DOH location, including outstationed community sites. If a family submits a Medicaid application and is deemed ineligible for Medicaid but is potentially eligible for SCHIP, DWS sends a note to DOH to review the application. The family does not need to fill out the

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separate SCHIP application. Conversely, if a family submits a SCHIP application and appears to be eligible for Medicaid, a separate addendum is added to the application to collect the additional information for Medicaid eligibility. Applicants can supply the additional information over the phone or by mail. At redetermination, families are sent a pre-filled out form to correct and return. If a family has not changed employers, the state accepts self-declaration of income. Otherwise, income changes must be re-verified by caseworkers. Utah anticipated that the total program enrollment would be 21,000, but it rose to about 27,000 by the end of 2001 (AHL 2002). The state has subsequently closed enrollment to the program (Jones 2002).

C. THE DWS: A NEW MODEL FOR SERVICE DELIVERY

In 1997, Utah created DWS, a statewide department responsible for delivering services under all of the state’s employment and training programs as well as many public assistance programs, including food stamps, Medicaid, SCHIP, and FEP. DWS was created through the merger of several agencies, including:

• Department of Employment Security, which managed Utah’s employment services and Unemployment Insurance (UI) programs and maintained the state’s labor-market information

• Office of Family Support, which coordinated and managed several major public assistance programs, including FEP and the FSP

• Office of Job Training, which managed the Job Training Partnership Act and other training programs and initiatives

• Office of Child Care, which administered the state’s numerous child care programs

• Turning Point, a program for displaced homemakers

The creation of DWS represented a renewed focus on helping Utahans maintain meaningful participation in the labor force through a spectrum of employment, training, and work supportive services.3 The overarching principle in this new model of service delivery is to help customers re-enter the labor market through state-provided training and development opportunities designed to upgrade customer’s skills over time. The ultimate goal is to help customers attain long-term self-sufficiency through meaningful employment. Program services, including those for food stamps, Medicaid, SCHIP, and FEP, are coordinated primarily through employment centers (ECs) and eligibility service centers (ESCs), as explained below.

1. Employment Centers

ECs qualify as the one-stop service centers required under the 1998 Workforce Investment Act (WIA). They offer employment services, including job search and placement assistance, skills assessment and testing, and access to local and national labor market information,

3 State of Utah Department of Workforce Services Overview, internal publication.

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information on education and training opportunities, and assistance with unemployment insurance claims. They also offer customers information about state’s public assistance programs, including food stamps, Medicaid, and FEP. In addition, the centers serve as application sites for the state’s major public assistance programs, including unemployment insurance, FEP, food stamps, Medicaid, SCHIP, and child care and veterans services. Customers seeking only Medicaid or SCHIP may apply fo r benefits without visiting ECs. Initial eligibiity interviews are also conducted at ECs. Once eligibility has been authorized for one or more public assistance programs, customers are transferred to ESCs. There are approximately 50 ECs throughout the state’s five service delivery regions.

a. Services Provided

Each EC offers the same set of services to help customers find employment and to help them access and enroll in the work supportive services needed to retain employment. The centers also work closely with the employer community to help identify and hire qualified applicants from among the EC customer base. The following are the primary services provided by ECs.

Core Services. These services are targeted to customers seeking employment and

employers seeking qualified candidates. Core services include registration for services, assessment of customers’ skill sets and work history, skills testing, career counseling, and such employment-related activities as assistance with resume preparation, job search, job referrals, and interviewing. ECs provide labor market information and offer a variety of free workshops on such topics as pre-employment skills, job searching, job retention and upgrade, life management, and communication skills.

Intensive and Training Services. These services are targeted at customers in more dire

circumstances than those using only core services. Intensive and training services include comprehensive assessments of customers’ situations, needs, barriers to employment, work experience, and employment-related skills. In-house social workers help customers identify social and rehabilitative services that may be needed. Mental health, substance abuse, and specialized vocational assessments are conducted as necessary.

Eligibility Services. These services are provided for customers seeking support through

state and federal assistance programs, and support the core employment services available at ECs. State and federal assistance programs coordinated through the ECs include FEP, food stamps, Medicaid, SCHIP, and General Assistance. Utah also has a cash diversion program available to potential FEP applicants. Eligibility specialists, who provide these services, are DWS employees with training and skills related to eligibility determinations for programs offered by the state.4 DOH’s BES also has eligibility workers permanently located at each EC. BES workers deal exclusively with customers applying solely for Medicaid and SCHIP. This is true regardless of whether customers are in search of labor-exchange services offered by the centers.

4 Eligibility specialists are formally classified as employment counselors. We refer to them throughout the

report as eligibility specialists, in order to distinguish them from the employment counselors that help customers manage the work activities and requirements related to their cases.

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b. South County Employment Center

The South County EC is the largest and busiest of four centers in the greater Salt Lake City area. Its high traffic flow is most likely attributable to the facility’s quality, attractiveness, and location near a major intersection in a busy suburb. Approximately 800 people visit South County daily. During our July 2001 site visit, the staff told us that about 80 percent of customers seek employment-related services and the remainder is interested in public assistance programs, including FEP, food stamps, and Medicaid.

Physical Plant. The center is easily accessible from a variety of major roads and bus routes.

It is modern and well maintained. Many customers said they prefer this center because it is the nicest building, is easy to reach either by car or public transportation, and provides ample free parking.

Upon entering the facility for the first time, customers must register at the front desk. The

front desk is where customers can inquire about available services and the application process. We observed that the front desk staff served customers quickly, and most customers did not have to wait long to speak with a staff member. Customers who previously have been to the center can use the business express desk, where they can pick up and drop off applications for assistance or return required verification without waiting in line. The express desk is immediately to the right of the front desk and is easily seen by customers.

The center has space reserved for employment-related information and activities. There is a

large listing of job opportunities in the lobby that customers can peruse before registering at the front desk. There are ample computers, phones, and fax machines, all of which are available to customers searching for jobs. There is a skills testing room, where customers can take self-directed word processing and typing tests.

The center is open from 7:30 a.m. until 5 p.m. While this is not a DWS standard, managers

said most other ECs keep the same or similar hours. Staffing. Many customers said they prefer this center because the staff is very

knowledgeable and helpful in accessing employment information and creating job referrals. There are three teams of employment counselors and one team of eligibility specialists. Each team of employment counselors consists of 1 supervisor, 1 lead counselor, and between 10 and 12 counselors who maintain a full load of casework activities. The team of eligibility specialists consists of 1 supervisor, 2 lead specialists, and about 12 specialists.

Employment counselors work with customers who receive a program benefit with a work-

related requirement, such as FEP or FSP Employment & Training. They help customers understand program requirements and develop employment plans. They coordinate work, training, and supportive activities designed at helping customers find jobs and become self-sufficient. Counselors maintain an average ongoing caseload of about 50 cases. There is some variation on caseload depending on experience and complexity of cases. While counselors qualified to manage any type of case, some specialize in certain types of cases, such as FEP, General Assistance, or FSP.

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Eligibility specialists conduct the initial eligibility determinations for customers seeking benefits in public assistance programs, FEP, the FSP, and Medicaid. They authorize benefits for eligible customers. While eligibility specialists do not provide ongoing case management support (this is provided by ESCs), they do conduct yearly reviews with customers when face-to-face interviews are required. Typically, an eligibility specialist keeps a case only until eligibility has been determined. Once approved, the case is transferred to an ESC.

2. Eligibility Service Centers

ESCs provide ongoing case management services for most customers receiving FEP, food stamps, and Medicaid. Customers receiving only Medicaid, SCHIP, or other medical insurance programs offered by DOH are not served at ESCs. Instead, their cases are managed by ongoing Medicaid caseworkers assigned to their cases by BES. Once those cases have been transferred to ESCs after initial determination of eligibility, ECs are no longer the contact point for customers with questions. ESCs have toll- free numbers that customers use to report case status changes, ask questions, and obtain information on other public assistance programs. ESC workers conduct all ongoing eligibility reviews for all programs.

a. South County Eligibility Service Center

The South County ESC provides ongoing case management for customers receiving benefits from public assistance programs, such as FEP, the FSP, Medicaid, and SCHIP. All cases initially authorized for benefits (except those receiving only medical assistance) are transferred from ECs to ESCs. ESCs then assume responsibility for conducting case reviews (recertifications and redeterminations), maintaining relations with customers, and serving as the first line of response for all customer questions. There is no in-person contact with customers at ESCs—all customer contacts are made on the phone. The centers’ local and toll- free numbers are provided on all program notices.

Physical Plant. The South County ESC is a large, open facility with sufficient room for

staff. The building is not accessible to customers. Center managers have created a collegial environment that workers say is very supportive. It is open from 7 a.m. until 6 p.m. but takes phone calls only until 5 p.m.

Organization and Operations. Most caseworkers at the ESC are formally classified as

employment counselors. They are assigned to teams that work together to manage individual cases. There are eight ongoing casework teams at the South County ESC, each with about six to eight employment counselors. During standard business hours, two counselors from each team work the phones. They answer incoming phone calls for their teams, respond to customer questions, and as appropriate, refer callers to their specific employment counselors, even if those counselors are not currently working the phones. Typically, employment counselors working the phones only take calls from customers assigned to workers on their teams.

When customers call the ESC, they are greeted with an automated voice response system.

They must enter their names and the workers’ team numbers, which are provided on all the notices. Customers then are directed to the appropriate worker from their team that is working the phone that day. Workers from each team are assigned to answer phones about twice a week

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for four hours a day. They serve as backup the other four hours on days they are assigned to work the phones. For example, if the other two workers are both on the phones or otherwise unavailable, the backups handle any overflow calls.

Call Management. An ESC supervisor monitors and manages overall phone traffic. This

individual uses tracking software that lets her view the number of employment counselors on the phones, call volume, how many callers are on hold and their wait time, and the average wait time for all callers. The supervisor can determine how many workers are on “Aux/Work,” a button counselors push to redirect all calls. This function allows workers to complete case updates related to their last calls. The software collects other statistics used for reporting purposes, such as how long workers have been on the phones, average length of calls, average length of time spent on Aux/Work, and total number of calls taken. These statistics are available for each worker and can be aggregated at the team or center level.

Workers understand that there are no set benchmarks regarding the number of phone calls a

worker should receive or the amount of time they should spend on each call. Rather, the goal is to provide each customer with outstanding service and to ensure accuracy, regardless of time spent on the phone. The tracking software is used to maintain a steady and consistent call volume, to redirect calls to other workers as necessary, and to determine if additional workers need to be on the phones at any given time.

Recent Organizational Change. A significant organizational change had just occurred at

ESC before our July 2001 site visit. Each caseworker is now assigned a caseload and is responsible for managing those cases. Previously, teams and employment counselors were not assigned to specific cases. Staff said the change was designed to decrease the incidence of customers referred to as “shoppers.” They are customers who call ESC repeatedly with the same questions until they get a worker who agrees to handle the issue in accordance to the customers’ wishes. Despite this change, a strong team concept remains in place at ESC. When individual workers are unava ilable, customers may discuss their case status with other counselors on the same team. Those counselors can take an action on a customer’s case if the primary worker is unavailable. This depends on individual standards in place with each team, as well as the severity of the action to be taken.

Workers we interviewed had mixed opinions about the organizational change. Several

workers said the shift contradicts ESC’s original philosophy that customers could call and speak to any available workers about their cases. Workers expressed concern that the change could impede the delivery of timely responses to customers’ questions and erode quality of service. Some were upset that the change was made without input from caseworkers and predicted that the accuracy rate may be adversely impacted. However, other workers said the change was positive, because it would result much improved accuracy with fewer workers “touching” each case. Primary workers could develop closer working relationships with customers. Virtually every worker interviewed, even those who disliked the change, said the switch to assigning caseloads would almost certainly reduce the prevalence of “shoppers.”

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3. Automated Management Information Systems

DWS uses two primary management information systems to deliver labor exchange and work supportive services: Public Assistance Case Management Information System (PACMIS) and Utah’s Workforce System (UWORKS). PACMIS is Utah’s statewide family assistance management information system (FAMIS) that is federally certified by the Department of Health and Human Services for use in the management and automation of TANF, Food Stamp, Medicaid and other human services programs. UWORKS is Utah’s statewide one-stop operating system (OSOS), which supports the labor exchange and work force development activities of ECs.

a. PACMIS

PACMIS is a mainframe information system used by caseworkers to execute the core eligibility determination, benefit calculation, and benefit issuance functions of 24 of the state’s major human services programs. These include FEP, the FSP, all categories of Medicaid, SCHIP, General Assistance, and other related financial and in-kind assistance programs.

PACMIS automates a substantial portion of the eligibility determination process, eliminating

the need for workers to remember detailed requirements for each program. However, unlike the FAMIS systems in some states, PACMIS does not automatically determine eligibility for all programs on its own. To initiate the eligibility process, workers must enter program codes into PACMIS for programs in which a customer has expressed interest. PACMIS then runs the workers through a series of authorization sequences based on eligibility requirements for the selected programs. PACMIS supports ongoing, eligibility-related case management functions, including automation of the recertification process.

b. UWORKS

UWORKS supports the coordination and delivery of employment-related activities in ECs and offers functionality for both caseworkers and customers. Employment counselors use UWORKS to conduct initial and comprehensive customer assessments, create employment plans, coordinate work and training activities, and track customers’ progress in meeting goals. Customers can access UWORKS directly to register for services, conduct initial self-screening, obtain program information, search the database for available jobs and training opportunities, access provider information, acquire labor market information, and conduct pre-applications for some labor exchange and assistance programs. UWORKS is available to customers on EC computers and on the Internet.

The system exchanges basic client demographic and program participation data with

PACMIS and ensures that common customer information remains synchronized between the two systems. UWORKS interfaces with other external systems to obtain labor market information, gather provider and partner data, and collect information related to customers’ participation in training courses and other employment activities coordinated by ECs.

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c. Document Imaging System

Utah has invested in a document management system that allows workers to create computer images of customer documentation and verification information. The images are stored as part of case records in PACMIS and can be viewed by workers with access to case records. Although the system is relatively new, workers say it has been extremely useful in reducing the burden on customers to repeatedly provide the same pieces of documentation, such as birth certificates and drivers’ licenses.

d. Eligibility Screening Tool

State Management Information Systems (MIS) managers said they are searching for a front-end system for PACMIS that would enable customers to conduct basic, high- level eligibility screening without the aid of a caseworker or other DWS employee. The information and referral tool would be available on the Internet and would enable customers to enter basic demographic and household data and receive a list of assistance programs for which they may be eligible. Customers could print the list and find out where to apply.

D. WORK FLOW AT THE SOUTH COUNTY EMPLOYMENT CENTER

This section describes the work flow and case processing practices at the South County EC. Although this is just one of many ECs in Utah, all have comparable design, layout, and case processing standards. Detailed work flow diagrams are in Appendix B.

1. Front Desk and Screening Procedures

Upon entering an EC, all customers must register with the front desk, which is staffed by employment counselors trained to quickly identify customers’ needs and direct them accordingly. Front desk staff conducts a brief, informal customer assessment, asks customers to complete universal customer registration forms, and provides them with whatever application forms are needed (see Appendix D). Customers seeking public assistance benefits, either exclusively or in combination with employment services, are provided with the appropriate application information. They are then directed to the appropriate worker, which varies depending on whether cash assistance was requested.

Customers interested in public assistance programs, such as food stamps, Medicaid or FEP,

must complete an application and turn it into the business express desk. When customers submit their applications, express desk workers make appointments for them with eligibility specialists and conduct mandatory screens to determine whether the information on the applications render the customers eligible for expedited food stamps.

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2. Application Processes

a. FEP Applicants

Customers seeking FEP benefits typically meet with on-call employment counselors during their first visit to the center. The counselors discuss application and program requirements for FEP, review other available assistance, and ask customers to sign a Family Employment Agreement. This is a standard agreement that discusses customers’ rights and responsibilities for receiving cash assistance and requires customers to indicate their willingness to comply with all FEP requirements. Counselors and customers may begin to develop self-sufficiency plans, which detail the activities that customers will undertake to find employment and become self-sufficient.

After this meeting, applicants return, usually on a different day, for a scheduled appointment

with an eligibility specialist. The eligibility specialist will review the customer’s application, discuss program requirements, complete the eligibility determination, and ensure that the Family Employment Agreement is signed. If customers qualify for very small FEP benefits, workers often may encourage diversion assistance or rejecting the grant, because the months on assistance—regardless of the grant amount—counts toward customers’ lifetime limits.

b. Non-FEP Applicants

Customers seeking benefits other than FEP return to the center for their scheduled interviews to complete the eligibility determination process with the eligibility specialists assigned to their case. If customers are eligible for food stamps and are subject to some form of the Food Stamps Employment and Training rules, then they meet with employment counselors to review work-related requirements and develop self-sufficiency plans.

If, during the course of the interview, a customer requests cash assistance, then an eligibility

worker completes the eligibility determination, including the cash assistance portion, and authorizes the food stamp and Medicaid portions of the application, assuming the customer has qualified. The customer must then meet with an employment counselor to satisfy FEP application requirements before FEP benefits are authorized.

c. Medicaid-Only Applicants

If a customer only wishes to apply for medical coverage, then he or she meets with a BES caseworker, usually on the same day the customer first visits the center. DOH maintains a team of workers at each EC who serve as full-service case managers for customers receiving only medical services. These workers determine eligibility, calculate benefits, and manage all of the ongoing casework related to the medical cases assigned to them.

3. Ongoing Casework

Once a customer’s eligibility for benefits has been authorized, the case is transferred to the ESC, where ongoing casework is managed. The only exceptions are customers who have been

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authorized for SCHIP or only for medical assistance programs. The ongoing case management for the SCHIP program and Medicaid-only cases are maintained by DOH caseworkers.

Reviews. ESC conducts all recertifications for the case. Customers with earned income

have three-month recertification periods for food stamps and FEP and are required to have yearly face-to-face interviews at ECs. The redetermination period for Medicaid-only customers depends on the category for which they are participating. We were told it is every three months for customers with earned income, or every six months to one year if there is no earned income. Face-to-face interviews are not required for any medical assistance program; they may be conducted over the phone.

At least one month before reviews are due, customers receive pre-printed letters that contain

the most current case data on income, household composition, and other relevant information. Customers indicate what information has changed, sign the form, and submit it with whatever verification is required, such as pay stubs. When customers fail to return the reviews on time, PACMIS automatically closes their cases and sends termination letters. Case closure alerts are generated and sent to workers.

Although ESCs are responsible for reviews, customers sometimes go ECs to apply for

additional benefits. When customers apply for an additional benefit during a month when a review is scheduled, the eligibility specialists at the EC typically conducts the eligibility determination (for the new program) and performs the regularly scheduled reviews (for the programs the customer is currently receiving) at the same time. Eligibility specialists then make the appropriate changes to customer’s case in PACMIS and enter comments in the case records to indicate that they met with the individuals in person. Then ESC staff will understand that the required reviews have been completed. Our interviews with workers indicate that this is a fairly common occurrence.

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II. FINDINGS

Our findings from our site visit to South County EC are grouped in four major areas: program marketing and outreach; front desk; initial eligibility and the intake process; and the ongoing eligibility process. In each section, we discuss promising practices and areas for improvement.

A. PROGRAM MARKETING AND OUTREACH

1. Promising Practices—Strategies to Increase Participation

a. Program Outreach and Marketing Efforts

In the past several years, Utah has conducted an aggressive marketing campaign for SCHIP. It has coordinated a variety of efforts ranging range from multilingual media campaigns to toll-free information numbers to partnerships with community-based organizations, all of which have been contributed to the state exceeding its SCHIP enrollment targets in the past two years. Like many other states, Utah decided to market SCHIP as health insurance, rather than a welfare program. The state believes this helps increase SCHIP enrollment by eliminating the stigma that many customers may feel when applying for programs typically thought of as welfare, such as FSP and Medicaid. The customer focus group confirmed this. Most SCHIP customers we interviewed reported no feelings of shame or embarrassment in receiving SCHIP benefits.

b. Outstationing Medicaid Workers in Community Organizations

DOH places caseworkers in community organizations, which it says has helped increase Medicaid enrollment. While the Centers for Medicare and Medicaid Services (CMS) requires that all states use outstationed Medicaid workers to accept applications, Utah’s model goes further. Outstationed workers in Utah also perform eligibility determination, redeterminations, and case management for individuals receiving only Medicaid.5 Medicaid applications at these sites have grown quickly and steadily in the past several years. Utah says the use of outstationed workers has proven particularly effective, as the state’s FEP and food stamp caseloads have decreased. With more individuals leaving FEP and food stamps, providing a more convenient, community-based location where Medicaid customers can receive case management services is an important factor in their decision to continue benefits.

5 There are a few exceptions to the full case management model. In a few hospitals, outstationed workers are

employed by the hospitals. These workers are only authorized to take Medicaid applications; they do not determine eligibility or provide ongoing case management.

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2. Areas for Improvement

a. Initiate an Outreach and Media Campaign to Promote Enrollment in the Food Stamp and Medicaid Programs

During our site visit, we saw little printed information and visible signage about FSP and Medicaid at the EC. Materials we examined focused primarily on eligibility criteria and program requirements, rather than benefits of increased food and nutritional security for families or the value of health insurance. A comprehensive marketing campaign could promote participation in FSP and Medicaid. This campaign could include new brochures, posters, printed program information, a media campaign (using the SCHIP campaign as a possible model), and creating a toll- free number that provides important program information. Discussions with DWS workers and customers indicated that many view FSP and Medicaid as welfare programs, a label that carries negative connotations for potential customers and workers. Therefore, new marketing materials should promote FSP and Medicaid as nutritional assistance and health insurance programs, respectively, and discuss the extent to which these programs help the transition to employment.

b. Increase Partnerships with Community Agencies

A key to developing a successful marketing campaign is distributing information widely enough to reach families who should be but are not actively seeking government assistance. DWS can accomplish this, at least in part, by strengthening its partnerships with community organizations. This may result in reaching customers who do not visit ECs or even realize they are potentially eligible for government assistance. Strategies to strengthen existing partnerships could include providing information and training for community workers about FSP and Medicaid, supplying applications at community agencies, and placing applications in food orders filled by local food banks and food pantries.

c. Provide Applications for Food Stamps at the Sites with Outstationed Medicaid Workers

Outstationed Medicaid workers said many customers express interest in FSP and frequently request applications. However, outstationed sites do not carry food stamp applications. This policy exists to avoid confusion about where food stamp applications can be filed. (They must be filed at ECs). But with appropriate instructions and training, outstationed workers can learn to help families follow correct application procedure.

B. FRONT DESK

1. Promising Practices: The Expedited Eligibility Screen

It was clear that all customers who expressed interest in food stamps were immediately screened for expedited services. DWS established the expedited screen as an automatic process that must happen whenever customers mention food stamps, and our interviews with and observation of workers demonstrated that the standard has been implemented effectively. While all states are required to screen customers for expedited food stamps, Utah is notable for the

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degree to which this process is supported. Staff is provided with a list of items to discuss with customers during the expedited screen, and a sample script is available to guide the workers and ensure they cover all relevant information. The expedited screen is not limited to the front desk. Business express desk staff also performs a screen for expedited services when it receives completed applications, and other workers often use the script during phone conversations with customers to discuss food stamps benefits.


a. Provide More Information on the FSP and Medicaid

Front desk workers do not routinely provide customers with information about all of DWS’s relevant assistance programs. Furthermore, potentially eligible customers for food stamps or Medicaid are not always provided with applications unless they specifically ask about a program by name. There are also instances where the staff may not work with customers carefully enough to determine the programs for which the customer may be eligible. The state may wish to consider these strategies:

• A standard script or protocol could be developed that contains a list of items to be covered with all customers expressing interest in supportive services or those potentially eligible for food stamps and Medicaid. Front desk staff could be required to always ask if customers have or need health insurance and/or nutrition assistance.

• More brochures, posters, and program fliers could be placed near the front desk area and on information racks for customers waiting in line.

• The information and referral tool that DWS hopes to implement could be made available at kiosks in the front desk area so customers can gain access to information and screen themselves for potential program eligibility.

• Universal customer applications that are used to register with DWS could contain more information about food stamps and Medicaid. There could be a tear-off sheet for customers that explains how to obtain more program information.

b. Provide Information on Verification Requirements

Many focus group participants expressed frustration at not being told what information is needed for eligibility interviews. DWS says it does not provide this detailed information during the customer’s first visit to avoid discouraging customers when they discover how much verification information is required. DWS is concerned that this knowledge could result in some customers not returning for their eligibility interviews. However, customers clearly stated that they prefer to be informed of verification requirements immediately, so they could start collecting the information well before the eligibility interview.

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c. Adopt a Consistent Approach to Universal Customer Application

Front desk workers have inconsistent approaches to making potential food stamp and Medicaid customers register as universal customers before distributing information and applications for food stamps and Medicaid. While state policy does not require food stamp applicants to first complete the universal customer application, many workers insist this be done before providing customers with food stamp, Medicaid, or combined applications. Given the application’s emphasis on work skills and employment history, some customers may think they must register for or participate in work activities as a condition for receiving assistance. This may inhibit some customers from applying for food stamps or Medicaid. DWS could eliminate this misconception by not requiring the universal application or by modifying the form so there is less emphasis on work and a greater emphasis on supportive programs and services, such as food stamps and Medicaid.

d. Provide Enhanced Hours of Operations at ECs

Customers told us that hours of operations were not always convenient, especially for working parents. Extending hours on one or more days each week may allow more working parents to visit ECs to apply for benefits. This would give them more opportunities to utilize the centers’ employment-related services.

C. ELIGIBILITY AND THE INTAKE PROCESS

1. Promising Practices That Support Initial Enrollment in the FSP and Medicaid

a. EC Model

The state’s use and implementation of the employment centers significantly facilitates the application process for programs such as food stamps and Medicaid by enabling customers to learn about and apply for all of the services they may need in one location. Visiting an employment or welfare office is often traumatic, particularly for individuals needing financial assistance because of life-changing experiences, such as losing a job, death of a spouse, or suffering from domestic violence. ECs are “one-stop” centers that offer all types of employment-related services. This includes job searches, such supportive benefits as FEP, FSP, and Medicaid, and strategies for self-sufficiency. The centers also provide space for caseworkers from other departments, such as DOH, to give non employment-seeking customers access other services they may need.

ECs are also effective at attracting potentially eligible customers who may be underserved.

In many states, “one-stop” centers required by WIA are located separately from offices that coordinate public human services programs, making it more difficult for people to access information about and apply for assistance programs, such as FSP and Medicaid. Co-locating the WIA “one-stop” with the office responsible for coordinating low-income human services benefits greatly improves the ability for customers to access information and apply for all of the programs for which they may be eligible.

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b. Eligibility Specialists Committed to Supporting Clients Needs

In general, eligibility specialists we interviewed and observed seem committed to helping customers access and enroll in programs for which they were eligible. Specialists made sincere and thorough efforts to qualify customers during eligibility interviews. For example, we noted one worker using different budgeting techniques to try to qualify a customer for FEP. Specialists were also concerned for customers’ long-term well-being, and were particularly careful to ensure that customers use their 36 months of FEP eligibility wisely.

c. Ensuring That Workers Are Trained and Knowledgeable

Another component of the Utah service delivery model is having knowledgeable workers with the right skills, tools, and training to effectively complete the eligibility process. Several eligibility specialists said legislative changes in recent years have made it challenging to remember all the program and eligibility rules for FEP, food stamps, and Medicaid.

To help train and better prepare its workers, DWS created in 2000 a training academy,

which consists of a three-month immersion program that teaches new employees about the state’s assistance programs. Participants receive in-depth training on PACMIS and UWORKS. Many said the academy provides new workers with a solid understanding of the state’s major assistance programs. In addition, there are three dedicated DWS trainers who provide the staff with ongoing development, focusing on evolving regulations, policies, and operational issues. Trainers develop materials that include memos, alerts, “cheat sheets,” videos, and workshops. Of particular interest is “Stop the Bleeding,” which focuses on improving eligible low-income families’ abilities to enroll and stay on Medicaid (see next section for more detail).

d. Simplified Applications

As a result of a recent simplification effort, Utah’s applications for assistance are shorter and easier to understand. The combined application for assistance is 10 pages. However, the application for medical assistance is only 6 pages, 2 of which are the rights and responsibilities section, which does not require customers to complete any information. The SCHIP application is 1 page, front and back. All applications are available in English and Spanish. There are also a number of pre-printed verification forms to help customers obtain proper verification.


a. Assist Customers Who Have Come to the Wrong Employment Center

If customers try to apply for supportive services at ECs that do not serve their zip codes, they cannot submit their applications. They are redirected to the appropriate EC, where they must re- initiate the application process. During the focus group, many customers said this creates a burden on customers and might inhibit people from applying. Utah could remedy this by allowing customers to submit food stamp applications at any EC. Workers could schedule eligibility interviews for customers at the appropriate center, or they could ask customers to call a hot line number to schedule their own appointments.

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b. Enhance Support from Automated Programs

One limitation of PACMIS is that it can only concurrently determine eligibility for six programs. If a customer does not meet eligibility requirements for the first set of six programs, or he or she expresses interest in more than six programs, the caseworker must run multiple eligibility sequences. Many workers said this was not an issue, because there are written procedures outlining the order in which eligibility sequences must be run. Others said they knew of instances where customers had been initially denied Medicaid eligibility because workers did not carefully follow procedure. Given that some of the workers expressed concern that this limitation in PACMIS adversely impacts Medicaid eligibility, the state may wish to investigate the true magnitude of this problem.

c. Decrease the Number of Required Visits for FEP Applicants

Customers may have to visit ECs multiple times to apply for food stamps and Medicaid. This includes the initial contact with the front desk, the eligibility interview, and interviews with ORS and employment counselors. These repeated visits may be a deterrent, particularly for customers whose situations are only marginally improved by supportive services. To reduce the number of visits, DWS could encourage customers to call to request eligibility appointments and schedule ORS appointments at the same time. ECs might consider changing the system so the employment agreement and employment plan are completed the same day as the eligibility interview.

d. Continue Simplifying Applications

Although applications have been shortened considerably in recent years, many workers and customers said the combined application—and to a lesser extent, the Medicaid-only application—remain difficult to understand and can be discouraging to applicants. This is especially true if customers only apply for a subset of services; in these cases, it is often unclear which parts of the application are required and which pieces of verification information are needed for which programs. The state may wish to consider further revisions to the combined application to make it easier to read and more clearly define which sections must be filled out for which services.

e. Ensure That Customers Denied FEP Are Not Inadvertently Denied Medicaid

Workers said some customers denied FEP also have been denied Medicaid, when in fact they were Medicaid-eligible. A primary reason for this is PACMIS’ inability to run more than six authorization sequences concurrently. Additionally, because Utah has a two-tiered Medicaid system in which FEP eligibility creates an automatic eligibility for 1931 Medicaid, workers sometimes fail to independently determine the Medicaid eligibility if FEP is initially denied. The state could eliminate this issue a number of ways: by emphasizing Medicaid eligibility determination procedures during initial worker training, by reviewing denied FEP cases to ensure they were not inadvertently denied Medicaid, and by modifying PACMIS to automatically screen denied FEP cases for Medicaid eligibility.

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D. ONGOING ELIGIBILITY PROCESS

1. Promising Practices

a. Use of ESCs for Ongoing Case Support

ESCs facilitate customers’ ongoing participation in FSP and Medicaid in many ways. Once initially authorized for benefits at ECs, customers’ cases are transferred to ESCs, where all ongoing casework is conducted. Other than a yearly face-to-face review for food stamps and FEP, customers are not required to return to an employment center. They can fulfill all ongoing participation requirements by mail or by calling a toll- free number and speaking with an ESC worker to complete simple tasks, such as obtaining information on their cases, identifying additional benefits or programs for which they may be eligible, or ensuring that their review forms were received.

In addition to being a central point where customers can obtain answers to most of their

case-related inquiries, ESCs have consistently improved on a number of performance metrics, including increased satisfactory resolution of calls and decreased wait times for callers. Answering calls quickly and providing proper answers help ensure that customers continue to fulfill participation requirements. PACMIS also has been integrated with ESCs’ phone answering system, so that when customers call and enter their case number, PACMIS automatically pulls up their cases and makes the information immediately available to the worker.

DWS recognizes that the ESC is an evolving model and diligently works on quality control

issues. For example, many customers criticized the ESC because they typically had to speak with a different worker each time they called ESC. Many said they preferred to have a single caseworker handle their ongoing concerns. This gave customers the chance to develop a familiarity and rapport with their assigned caseworkers and avoided the need for customers to repeatedly explain their situations to different workers. Responding to this ongoing concern, ESCs recently changed their organizational structure. Workers were assigned specific caseloads and assumed overall responsibility for managing those cases. Many participants in the customer focus group had not heard of this relatively new change but welcomed it.

b. Pre-Printed, One-Page Review Forms

Another positive feature of the ongoing eligibility process is DWS’ use of pre-printed review forms. When a customer is due for a review, PACMIS automatically generates a letter informing the customer of the requirement for the review and the review due date. The letter consists of a pre-printed form containing the most current data regarding income, household composition, and other information relevant to the customer’s ongoing eligibility. The customer merely indicates what information has changed, signs the form, and submits it with whatever verification is required, such as pay stubs. PACMIS automatically generates a reminder letter to customers who have not returned their review forms within a specified period of time.

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c. Document Imaging System

Utah recently implemented a document imaging system that maintains a digital image of customers’ verification information and documentation. Verification information is scanned, and the digital images are stored with customers’ case records in PACMIS. These images are available to any EC or ESC worker with access to case records. (DWS plans to extend this capability to other sites and agencies, including outstationed DOH sites.) Workers were excited about its implementation, and they predicted it would reduce the burden on customers to repeatedly furnish the same documentation (e.g., birth certificate, social security card).

d. Stop the “Bleeding” Training

As part of its Medicaid reinstatement program, Utah developed “Stop the Bleeding” to improve Medicaid retention among families leaving FEP. The key messages of the training were: that workers should not automatically close Medicaid when a household loses FEP eligibility; that they should not deny or close Medicaid when the household does not provide information or comply with requirements not applicable to Medicaid; that workers should complete an ex-parte review; that they should consider 1931 FM-O or TMA first for a household leaving FEP; and that workers should remember that FEP participation requirements do not apply to Medicaid. The training went somewhat beyond FEP case closures and eligibility for 1931 FM-O. It also addressed other program closures and the operational logistics of ex-parte reviews and determining eligibility. The training also dealt with emphasizing the need to look at eligibility under all Medicaid categories before closing a case, using existing verification of information before asking the customer, and only asking for verification required for eligibility.


a. Implement Procedures to Ensure Continued Medicaid Receipt

Managers and workers discussed a risk point where a Medicaid case may be inappropriately closed when a customer’s situation changes and other assistance programs are affected. Because Utah has different 1931 Medicaid eligibility standards for FEP and non-FEP recipients, leaving FEP requires the customer to re-qualify for Medicaid under a different category, usually non-FEP-based 1931 Medicaid. (Other states do not face this issue, with a few exceptions, because leaving TANF does not require a re-qualification, since Medicaid eligibility is independent of TANF eligibility). PACMIS does not perform the calculation automatically, so workers must initiate the eligibility process and then open a new Medicaid case, if the customer qualifies. This creates a burden for the worker, leaves room for error, and runs counter to CMS’ guidance, which says a manual fix for an automatic Medicaid case closure is unacceptable.

An added complication is PACMIS’ inability to determine eligibility for more than six

programs concurrently. After a customer’s FEP case closes and the customer fails to requalify for Medicaid on the first screen of six programs, a worker must proactively select additional Medicaid categories to test. This opens up the chance for some appropriate categories to go “untested” and could result in an eligible customer not being enrolled in a Medicaid category. In instances where a change is reported and customer does not provide additional information, workers said the ex-parte review is inconsistently performed, resulting in some customers not being assessed for ongoing Medicaid eligibility.

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To help ensure that eligible FEP-leavers retain Medicaid and food stamp eligibility, the state may wish to consider ensuring that all FEP-leavers are properly assessed for eligibility. Remedies could include requiring a DOH supervisor to review all FEP case closures in which Medicaid eligibility was not retained. The supervisor could generate a daily, weekly, or monthly case closure report for customers whose FEP and Medicaid programs were closed. New caseworkers could be asked to take “Stop the Bleeding” training again. Another option is to make programming changes to PACMIS so it does not automatically close a Medicaid case when an FEP case closes.

b. Modifications to Review Periods

Workers had conflicting responses about how they manage review periods across programs with different certification periods. Some said when they review eligibility for one program, they review eligibility for all programs and extend eligibility for other programs, even if it was not scheduled for a review. While this may be a promising practice, it was unclear whether some of these workers were inappropriately shortening certification periods and closing cases during a non-review period if the cases appeared ineligible. For example, there may be instances in which customers were determined ineligible for food stamps at three-month reviews and their Medicaid cases also were closed, even though Medicaid benefits were certified for six months.

Another area of uncertainty was the use of the maximum certification periods for Medicaid.

There was a range of responses from workers about how long they certified customers for Medicaid within basic categories (e.g. earned income, stable income, without earned income, etc.) as well as the maximum period they could certify cases. It was unclear how consistently certification periods were being applied and if maximum certifications were being used at all.

The state may wish to review policy and guidelines with workers to ensure they are looking

at other programs at any review, but only to extend these certifications. If, in the example above, customers had their food stamp certification approved for an additional three months, then Medicaid certification also could be extended based on information gained from the food stamp review. Other states have used this practice effectively to extend benefits (typically for Medicaid) and reduce the burden on ongoing caseworkers.

The state may also wish to review the standards for Medicaid certification periods (for those

with earned income, unstable income, etc.) and review a representative set of cases to determine whether there is currently any deviation from the standards. If there is significant deviation from the standards, or it does not appear that the state is taking advantage of maximum periods, we suggest reviewing the recommendations for certification periods with workers and making sure that criteria for authorizing a benefit period are clear on their “cheat sheets.”

c. Facilitate Customer Movement Between Programs

Individuals we interviewed discussed situations in which existing customers wish to apply for different or additional benefits. In these instances, customers sometimes are unable to do this with their current workers. For instance, if a customer receiving only Medicaid (and whose case is managed by a DOH eligibility worker) wants to apply for FEP or food stamps, he or she must reapply through an EC front desk and see a DWS eligibility worker. The DOH Medicaid worker

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and DWS eligibility worker must then coordinate transition of the case. Similarly, if a customer enrolled in multiple programs decides she only wants Medicaid, the case must be transferred to a DOH caseworker. These situations are inherently risky because of complex coordination for verification and certification and increased burden on customers and workers.

Other potential areas for improvement include enhanced review of case documentation,

creating better standards and documentation for procedure and timing or transfers, and working within PACMIS to automate the process and/or make it easy to track cases.

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III. CONCLUSIONS AND FUTURE CONSIDERATIONS

With DWS’ creation, Utah refocused its vision by helping customers attain lasting self-sufficiency through meaningful employment. DWS’ efforts have proven successful in this regard, and it has created a model for helping customers re-enter the labor market with the assistance of supportive services such as food stamps and Medicaid. However, eligibility services are now a secondary focus of the service delivery process, and are used to support customers’ transition to work. This has created a unique set of access and retention issues for those seeking benefits from FSP and Medicaid.

A. INITIAL ENROLLMENT IN FOOD STAMPS AND MEDICAID

1. Use of ECs creates a strong focus on work but may inhibit initial access to and enrollment in food stamps and Medicaid

The primary focus of the employment centers is to help customers re-enter the labor market, through the provision of employment and training services. It was clear from interviews with customers and workers that the centers are noted for providing employment-related services and that anyone can access these services, regardless socioeconomic status. There was little stigma attached to using the centers’ services.

The state believes that framing supportive programs—such as food stamps and Medicaid—

in terms of employment helps minimize the stigma of using these services. By co-locating the application sites for food stamps and Medicaid with employment services, ECs offer customers one-stop centers and provide information to employment-seekers who may be eligible for food stamps and/or Medicaid but who otherwise may not have learned about the programs.

However, there are some features of ECs that may inhibit initial access to food stamps and

Medicaid, making it difficult to assess the extent to which ECs have supported access to these programs. These include a general lack of program information in the centers. The information that is available is not prominently displayed and focuses primarily on program requirements, availability, or the degree to which they can assist families in need. Front desk workers emphasize work and employment services, and the universal customer registration form focuses on work skills and employment history. All this leads some customers to conclude incorrectly that work or work-search activities are a prerequisite for receiving food stamps and Medicaid. Our observations showed that customers interested in or potentially eligible for food stamps and/or Medicaid might never make it past the front desk. That is due because front desk workers often discuss food stamps and Medicaid only when customers specifically inquire about these programs. Individuals who are unaware of these programs or assume they are ineligible may not receive information or be encouraged to schedule an eligibility interview.

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2. Eligibility services are provided in a supportive manner that promotes access to food stamps and Medicaid

For customers who do meet with an eligibility worker, the eligibility staff appears to provide services in a supportive and non-threatening environment. Workers we observed during initial eligibility interviews seemed committed to fully assessing customers for food stamps and Medicaid eligibility and enrolling them whenever possible. They did not discourage participation in food stamps and Medicaid, although they did counsel FEP applicants about using their 36 case months of assistance wisely. In instances when applicants decided not to pursue FEP to save the benefits for times of greater need, eligibility workers took necessary steps to ensure that all eligible customers were enrolled in food stamps and Medicaid.

3. FEP application process may discourage enrollment in food stamps and Medicaid

The application process for FEP is significantly more complex than for food stamps and Medicaid. It requires FEP customers to meet several times with various workers. An applicant must meet with an employment counselor on the first visit to the center for a quick screening, then with an eligibility worker for the eligibility interview, and again with an employment counselor to undergo a more comprehensive assessment and to complete the self-sufficiency plan. These meetings often occur on separate days, requiring multiple trips to the EC. Due to the number of required meetings and the ongoing focus on work and FEP program requirements, some customers may be discouraged from continuing the FEP application, which also may result in a customer abandoning Medicaid and food stamps applications. However, one promising practice in Utah, is that once an eligibility interview is completed and a customer is determined eligible for food stamps and Medicaid, benefits are authorized and initiated, regardless of the customer’s FEP application status. (In some states, the authorization of food stamps and Medicaid benefits is delayed until the TANF benefits are either approved or denied). Because the eligibility interview typically occurs after the initial meeting with the employment counselor, it still is possible that some customers who drop their FEP applications also may not complete the application process for food stamps and Medicaid. It should be noted that most employment counselors we observed thoroughly discussed food stamps and Medicaid options, regardless of applicants’ FEP status.

B. RETENTION IN FOOD STAMPS AND MEDICAID

1. ESC both facilitates and inhibits retention in food stamps and Medicaid

Utah created the ESC to streamline the ongoing eligibility process for customers and workers. The ESC promotes ongoing participation in FEP, Food Stamp, and Medicaid programs by making the ongoing eligibility process more user- friendly. It provides customers with a toll-free number and serves as a single point of contact for customer issues, questions, concerns, and case changes. Extended hours of operation make it easier for working families to reach the ESC. While this has made the logistics of maintaining eligibility in food stamps and Medicaid more straightforward, we heard from many customers that they prefer working with an assigned eligibility worker, as opposed to a team of workers, any of who may get involved with their cases. Customers said relying on one worker usually results in stronger working relations, which gives workers and customers the chance to work harder together to achieve compliance with program requirements and ongoing eligibility requirements. ESC managers indicated there are

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benefits to having a single worker assigned to a case, and they said they are moving in this direction. In the future, workers will be assigned a caseload, so a single worker will have responsibility for specific cases. Customers in the focus group said this would facilitate ongoing program retention.

2. DOH outstationed workers facilitate ongoing program retention

DOH’s outstationed eligibility workers have helped to increase enrollment in Medicaid. In general, this has held true in most states. But Utah is unique in that outstationed Medicaid workers also provide full case management services, and they conduct redeterminations for ongoing Medicaid eligibility. We found that this facilitates ongoing enrollment in Medicaid, as customers who are receiving only Medicaid are able to receive all Medicaid services at a community location that often is the same health clinic where they receive their primary health care services.

The only potential drawback regarding the Medicaid workers outstationed at community

locations is that many customers also are potentially eligible for food stamps or other benefits, but applications for these services are not provided nor accepted by outstationed Medicaid workers. Customers interested in food stamps are instructed to visit ECs, where can get more information and file applications. It is unclear whether all of these customers subsequently apply. There may be others who are unaware of FSP but would benefit from having food stamp information and applications at outstationed Medicaid sites.

3. Medicaid issues result from two-tiered 1931 Medicaid program

In some respects, the two–tiered family 1931 Medicaid program treats income more generously for families receiving FEP. For example, after four months (because of the time-limited income disregard) the income standard drops to $703 (58 percent of FPL) for families on FM-O compared to $1002 (82 percent of FPL) for FEP families. This results in different income triggers for TMA. The lower income standards potentially create a shorter period of Medicaid eligibility for non-FEP families, since they move more quickly into TMA. There also may be some implications for families who reach the FEP time limit—it is unclear what happens to families’ Medicaid coverage when they reach the FEP time limit but their income is too high to qualify for FM-O, but low enough to qualify for FM while on FEP.

The different standards and treatment of the two tiers of Family Medicaid adds a level of

complexity for workers that could affect ongoing access. For example, under the current system, when an FEP case closes, PACMIS automatically closes the Medicaid case. The caseworker must complete a manual work-around to redetermine a customer’s Medicaid eligibility and then manually reopen a Medicaid case. In a truly delinked system, an FEP case closure would be a non-event for Medicaid, reducing the chance that Medicaid participation would be negatively affected.

C. OUTREACH

In the past several years, Utah has aggressively marketed SCHIP and, for the past two years, has surpassed enrollment targets. Part of the state’s success may be attributable to its decision to

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position SCHIP as health insurance, as opposed to a welfare program. While SCHIP marketing and outreach has been successful, the state has not yet launched a food stamp and Medicaid outreach campaign, and overall enrollment in these programs continues to decline. A food stamps outreach committee recently was formed, and the state may wish to consider how to transfer the tactics and strategies of SCHIP’s outreach effort to the food stamp campaign. The state may also wish to consider refocusing public opinion of food stamps and Medicaid so it no longer views them as welfare programs, but as nutritional assistance and health insurance programs.

D. AUTOMATED SYSTEMS

Utah has several effective practices regarding the use of automated systems to support enrollment and retention in food stamps and Medicaid. The state’s automated eligibility system, PACMIS, helps determine eligibility for FEP, food stamps, and Medicaid. This is notable because many other states rely on multiple systems, and, in some cases, still rely on manual processes to determine eligibility for some programs, usually Medicaid. The document imaging system allows workers to make and store digital records of static documentation, such as birth certificates and social security cards, and relieves customers of the burden of providing this information every time they apply for services. The proposed eligibility-screening module that integrates with PACMIS can provide customers with enhanced program information.

There are some remaining challenges, however. While PACMIS supports initial eligibility

determination, it is not fully automated. Workers must manually input codes for program categories. This process is somewhat prone to error, in that only a limited number of program codes can be tested concurrently, and workers must continually retest customers’ eligibility in other program categories. Although there were mixed opinions, workers we interviewed generally said they thought there were cases in which individuals were improperly denied Medicaid because of workers’ failure to properly test customers for eligibility against all Medicaid codes. In addition, improvements can be made to ensure that PACMIS fully supports ongoing participation in food stamps and Medicaid. Specifically, the transfer of cases between DWS and DOH could be supported more fully in PACMIS, and PACMIS should not automatically close customers’ Medicaid cases when FEP closes.

E. COORDINATION BETWEEN DWS AND DOH

Workers from DWS and DOH are co-located in the ECs. This is helpful during initial eligibility determination. Customers who wish to apply for all available services (FEP, Medicaid, food stamps) can see DWS workers, whereas those who wish to apply only for Medicaid services can be seen by DOH workers. This eliminates the need for referrals to other locations for applicants seeking specific types of services. For customers deemed ineligible for cash assistance or food stamps but eligible for Medicaid, their cases can be immediately transferred from DWS workers to DOH workers.

There is room for improvement in terms of coordination between DWS and DOH, however.

DOH workers said they sometimes receive cases from DWS in which Medicaid eligibility was not determined correctly or was improperly discontinued. This may be due in part to program complexity resulting from the state’s decision to continue its two-tiered 1931 Medicaid program,

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in which varying Medicaid eligibility standards exist depending on whether customers are receiving FEP. Improved training of DWS workers on these varying standards may help correct instances of improperly determined Medicaid cases, and it would improve communication between DWS and DOH on policies and procedures for conducting eligibility determination on all categories of Medicaid. Several workers said that while case transfers typically happen quickly, there are often varying qualities in the notes attached to the cases, making it difficult sometimes to understand histories of cases transferred between DWS and DOH. Again, improved communication may alleviate this issue.

F. POLICY CONSIDERATIONS

Throughout this report, we focused primarily on operational issues related to providing families with access to Medicaid and food stamps. There are broader policy changes that could substantially improve access for eligible families while simplifying program administration. The following are three promising policy changes for Utah’s consideration.

1. Simplify Eligibility and Reporting for the FSP

The U.S. Department of Agriculture is offering states new opportunities to adopt food stamp procedures structured more appropriately for working families. The new semi-annual and quarterly reporting options (authorized by November 2000 regulation) help working families maintain food stamp benefits by reducing reporting burdens while protecting state exposure to quality control errors. Under the semi-annual option, customers’ benefits are frozen for six months and do not change based on income fluctuations. Recipients are required to report income changes above 130 percent of poverty, which would result in their ineligibility, and they may report losses in income that would result in an increase in benefits. Recipients’ six-month reviews are limited to questions about the previous month (rather than the entire previous six-month period). State do not get penalized for payment “errors” if income changes go unreported.

At the time of our visit, Utah was assessing adoption of the 6-month option and weighing

various waiver modifications. The 12-month certification with 6-month reporting would enhance access and support participation in food stamps because the typical certification is currently for 3 months. While some states have pursued waivers to the 6-month option, straightforward implementation is most desirable (as long as the states’ information systems can accommodate it). Utah may want to consider coordinating review periods for TANF and Medicaid to conform to the 6-month food stamp review period. Many states are doing this because it greatly simplifies the reporting and review procedures, not only for customers but for workers, too.

2. Consider and Address Consequences of Two-Tiered Family Medicaid

In the findings section, we highlighted some of the implications of maintaining two-tiered Family Medicaid:

• Potentially shorter periods of Medicaid eligibility for non-FEP families because of

different income triggers for TMA

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• Administrative complexity and confusion that could affect access, including information system requirements for manual work-arounds for FEP case closures.

For Utah to continue with the program set out by its AFDC demonstration waiver, which allows two-tier family Medicaid, the state must continue to meet conditions of the waiver. This restricts any changes to TANF, giving the state little flexibility to shape the program to address emerging needs. Given these issues, we suggest the state take a closer look at the two-tier system and the advantages of having one Family Medicaid program: simplification of the ongoing eligibility process, reduction of administrative burden, and greater flexibility in setting program policy.

3. Eliminate Asset Test for Medicaid

A recent research study (Smith, Ellis and Chang 2001) found that eliminating the asset test for adults in families in 10 states enabled them to streamline the eligibility determination process—adopt automated eligibility determination systems; improve productivity of eligibility workers; establish Medicaid’s identity as a health insurance program distinct from welfare; make the enrollment process for families friendlier and more accessible; and achieve Medicaid administrative cost savings. These states said the asset test was “cumbersome” to administer, “onerous” for applicants (perhaps deterring them from completing the application process), and in the end, kept few families from meeting Medicaid eligibility requirements.

We think that most, if not all, benefits that these 10 states accrued by eliminating the asset test also could accrue in Utah. Most notably, the burden on customers to provide verification—and workers to check it and determine eligibility—would be significantly reduced, especially because family Medicaid, family Medicaid other, and children ages 6 to 18 have different asset tests. Eliminating the asset test would render moot the need for a separate SCHIP addendum for families who appear eligible for SCHIP, because there would be no difference in the information needed to determine eligibility for SCHIP or Medicaid. The eligibility process for these programs would become even more streamlined.

G. FINAL CONCLUSIONS

When DWS was created in 1997, Utah implemented a new model for delivering employment and social services to its residents. The institution of ECs has created an overarching focus on providing customers with a package of short-term assistance and benefits they need to re-enter the labor force and attain long-term self-sufficiency. While co- locating employment services with social services, such as food stamps and Medicaid, has made it easier for clients to apply, challenges remain in ensuring that all customers are informed of the programs for which they may be eligible and that the availability of food stamps and Medicaid is not overshadowed by overarching emphasis on work.

33

REFERENCES

American HealthLine (AHL). “CHIP: States Cease Expanding Enrollment, Cutbacks.” February 25, 2002.

Bureau of Eligibility Services (BES), Department of Health. “Transitional Medicaid Benefits.”

Salt Lake City, UT: BES, August 2000. . “1931 Family Medicaid: FM-O.” Salt Lake City, UT: BES, January 2001. Jones, Charisse. “Cuts Threaten Kids’ Medical Care.” USA TODAY, March 31, 2002. Pavetti, LaDonna. “Welfare Policy in Transition: Redefining the Social Contract for Poor Citizen

Families with Children and Immigrants.” Prepared for “Understanding Poverty in America: Progress and Problems,” conference convened by the Institute for Research on Poverty, Madison, WI, May 22-24, 2000. Washington, DC: Mathematica Policy Research, 2000.

Ross, Donna Cohen, and Laura Cox. “Making it Simple: Medicaid for Children and CHIP

Income Eligibility Guidelines and Enrollment Procedures.” Washington, DC: Kaiser Family Foundation, October 2000.

Department of Workforce Services (DWS). “Sanction Periods (Volume IV, Sec. 305-5 #1).” In

Food Stamp Overview, Training Materials, Modules ES-200 to 275. Salt Lake City, UT: DWS, May 2001.

Schott, Liz, Dean Stacey, and Jocelyn Guyer. “Coordinating Medicaid and Food Stamps: How

New Food Stamp Policies Can Reduce Barriers to Health Care Coverage for Low-Income Working Families.” Washington, DC: Center on Budget and Policy Priorities, 2001.

Smith, Vernon, Eileen Ellis, and Christina Chang. “Eliminating the Medicaid Asset Test for

Families: A Review of State Experiences.” Washington, DC: Kaiser Family Foundation, April 2001. Available at [www.kff.org].

State Policy Documentation Project (SPDP). “Time Limit Extension Criteria As of October

1999.” (Part 1 of 2). Washington, DC: SPDP, June 2000a. Available at [www.spdp.org/ tanf/timelimit.htm].

. “Time Limit Extension Criteria As of October 1999.” (Part 2 of 2).

Washington, DC: February 2000b. Available at [www.spdp.org/tanf/timelimit.htm].


35

APPENDIX A: RESEARCH METHODS

The information for this report was primarily collected on a three-day visit to Utah July 9-11, 2001. The objective of the site visit was to gather information on a wide variety of perspectives about policies and practices that may affect initial enrollment and ongoing participation in FSP, Medicaid, and SCHIP. We met with managers and staffs of state agencies administering these programs, managers and staffs in the South County EC and ESC, as well customers and community-based organizations. We conducted a focus group of 14 individuals who were receiving or had received some combination of benefits. Our research team analyzed the general approach and identified specific strategies being used to improve program enrollment and retention. We documented our experiences and lessons learned in the implementation of these practices.

Our research team paid special attention to barriers that may have arisen or become

magnified because of welfare reform policies, such as diversion, sanctions, and time limits. Specific practices we looked out include those pertaining to outreach, enrollment simplification, and use of automated systems to determine or continue eligibility. We paid a great deal of attention to the application and retention process for Medicaid and FSP for both TANF and non-TANF customers, and we examined how procedures were followed to ensure that food stamp and Medicaid/SCHIP benefits continue when families leave TANF. We conducted interviews at South County EC and the Central Region ESC to explore staff procedures and client interactions, work flow, supervisory structure, and office environment. Our methods included:

• Group interviews with supervisors and the county office director

• Individual and group interviews with eligibility counselors and employment counselors handling TANF, food stamps, and Medicaid

• Case reviews with employment counselors and DOH caseworkers handling various combinations of TANF, food stamps, and Medicaid

• Job shadowing

• Targeted shadowing with front desk staff, eligibility workers, and employment counselors at South County EC and the ESC while they interviewed customers

• Observation of South County reception/front desk area and activities

• Interviews with DWS training coordinator and automated systems expert

• Interview at community health center in South County with an outstationed DOH caseworker handling Medicaid/SCHIP-only cases

36

We also gathered information from a variety of other sources: • Group and individual interviews with state agency staff and leadership responsible for

policies and procedures in TANF, food stamps, and Medicaid/SCHIP

• Interviews in Salt Lake City with representatives of community-based organizations serving customers

• Interviews with outstationed DOH eligibility workers who handle Medicaid/SCHIP in South County

• Focus group with customers in Salt Lake City; detailed description of the focus group discussion is provided in Appendix C

37

APPENDIX B:

WORK FLOW DIAGRAMS

38

Meet with front

desk staff

Initial determination

of needs/provide

appropriate

application forms

Customer returnscompleted

applications to

Business Desk

Customerwants support

services

Assist with

employment

services

Applying in

correct EC?

Refer to

appropriate EC

Eligible

for expedited

FSP?

No

Refer to eligibilityworker for same

day or next day

appointment

Eligibility worker

receives &

reviews case file/

application

Meet with

customer for

eligibility interview

Eligible for

any programs?

Authorize

Medicaid & retain

case/refer to DOH

for ongoingcasework

Authorize FSP &

transfer case to

ESC

Authorize FSP /

Medicaid &transfer case to

ESC

No

Deny application

YesVerification

sufficient?

No

Inform client of

verification

requirements,

review procedures,

rights &

responsibilities

Client returns

verification?

Inform client of

review

procedures, rights

& responsibilities

No

No

Yes

No

Yes

Yes

Applying

for FEP?

See FEP Intake

process (page 2)

Schedule eligibilityinterview; transfer

case folder to

eligibility worker

Business Express

Desk Processes

Front Desk Processes

Eligibility Specialist Process

- DWS worker for FSP & Medicaid

- DOH worker for Medicaid/SCHIP only

Instruct client to

completeapplications &

return to Business

Express Desk

If the application is forMedicaid/SCHIP only, the

case will transferred to a

DOH/BES worker

Yes

No

Deny application

Figure B.1: Utah Department of Workforce Services, Intake for Food Stamps & Medicaid-only Customers

39

Figure B.2: Utah Department of Workforce Services, Intake for FEP Customers

Eligibility worker

receives &

reviews case file/

application

Meet with

customer for


Eligible for

any programs?

No

Deny application

YesVerification

sufficient?

No

Inform client of

verification

requirements,

review procedures,

rights &

responsibilities

Client returns

verification?

Inform client of

review

procedures, rights

& responsibilities

Applying

for FEP?Business Express

Desk Processes

On-call Employment

Counselor

Schedule eligibility

interview; transfer

case folder to

employment

counselor

Receive case file/

application from

Business Express

Desk

Review customer

history in PACMIS

& UWORKS

Meet customer;

quick screening

for cash

assistance

eligibility

Customer

potentially

cash eligibile?

Page on call

Employment

counselor to meet

with customer

Yes

Encourage

customer to attend

scheduled


Discuss other

available options

and assistance

Customer

still interested

in FEP?

No Yes

Assign customer

to ongoing

employment

counselor/

Schedule appt

Meet with ongoing

EmploymentCounselor (usually

next day)

Complete Family

EmploymentAgreement & Self-

sufficieny Plan

Inform eligibility

worker whenAgreement is

signed

Family EmpAgreement

signed?

Ongoing Employment

Counselor

(intake process

for FEP is the

same as for FSP/

Medicaid only until

this point)

Eligibility

Specialist

Authorize

Medicaid/FSP;Pend FEP

application until

Agreement signed

No

Discuss rights &

responsibilities

with customer

Maintain ongoing

contact with

customer/provide

ongoing case

mgmt

Deny application

No

Authorize FEPtransfer case to

ESCYes

Agreementsigned within

30 days?

Yes

No

Deny FEP

application and

transfer case to

ESC


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APPENDIX C: CUSTOMER FOCUS GROUP SUMMARY

A. BACKGROUND

During our Utah site visit, we conducted a customer focus group to gather feedback on experiences in applying for, enrolling in, and retaining benefits through FEP, FSP, Medicaid, and SCHIP. Participants were asked to discuss their overall impressions and interactions with ECs, where they had applied for services (both labor-exchange as well as work-supportive services), and the ESC.

B. PARTICIPANTS

Fourteen individuals participated in the focus group. All were receiving some form of assistance or had received some type of assistance in the recent past. Twelve are female, two male. Of the male participants, one is a single man who had previously received food stamps and was in the process of re-applying. The other is a single father who is receiving cash, food stamps, and Medicaid for himself. Only a few of the female participants were receiving or had ever received cash benefits; two of them had exhausted the 36-month limit. All female participants had received Medicaid and/or food stamps. There were several women who were combining SSI and food stamps.

C. PARTICIPANT OBSERVATIONS

1. Value of the Benefits

a. General Comments

A good part of the time was spent discussing the relative value of food stamps, Medicaid, and cash assistance. While many said there were significant obstacles to applying and remaining eligible, all said the benefits were generally worth the time and effort it took to navigate the application and review processes. One woman said, “If it wasn’t for Medicaid, I would have pulled my hair out and screamed when my son was born. The food stamps have been very, very helpful. … They’ve been helping my boyfriend get a job, too.” Another said, “Food stamps and Medicaid are excellent.”

There was mixed reaction when participants discussed which benefits are the most

important. Many said food stamps, while others said Medicaid. Understandably, participants who said Medicaid was the most important benefit all had high health care expenditures, including one cancer survivor with $600 a month in prescription drug costs and another woman whose husband has $1,000 a month in medical expenses for diabetes treatment.

No one said cash was the most important benefit, although everyone agreed that it is critical,

particularly those who are employed or had some form of income but still had no way to meet

42

financial obligations. Some participants said the value of cash benefits depends on individual situations and whether it is worth “jumping through all the hoops” to get it.

While everyone agreed that benefits are important, most said the amount of cash assistance

is insufficient to meet basic needs. The woman whose husband has diabetes said when she was removed from FSP, her husband’s $96 benefit was the only money they had for food each month. She said, “It’s OK for me not to eat for three or four days but my husband is diabetic and needs the food to live.” Many others said they were receiving less than $10 in food stamps each month. One woman said, “What can I do with $10 a month?”

Few participants discontinued cash benefits even though amounts are small, although one

woman said she “got $9 a month once, and I was like … not worth it, not worth it.” Another said, “We went in once … my husband hurt his back … and I saw this huge form, and I was like ‘I’m just not even going to deal with this’… we ended up going into a little bit of debt instead of doing that. …” Everyone said they knew of others who had not applied for cash benefits (even though they were probably eligible for some type of assistance) because it was not worth the trouble of applying.

Many said cash benefits should be extended after customers start working until they get

“back on (their) feet”—at least a month or two—and food stamps should continue through this period, regardless of income. One woman said, “One of the problems with food stamps is that if you are working to better your situation, the second you better your situation, you are cut off.”

b. Work Versus Assistance

There was some disagreement as to whether it was better to work in a low-paying job or stay on assistance. Slightly more than half indicated they would rather work than stay on assistance. Others had these types of comments: “For $5.50 an hour with four kids, there’s no way.” “My rent’s going to go up, the cost of food, I’ve got to pay for child care.” “It’s better for me to stay home and receive food stamps and welfare.”

Many participants said the lack of affordable child care was a significant barrier to

employment.

c. Need for Temporary Support

Most participants said there should be more flexibility in providing customers with temporary support services, particularly cash support. The group said it was unfortunate that temporary help is usually unavailable. Everyone said more temporary assistance would keep people from losing their jobs and falling onto assistance. They said this would reduce the need for and cost of providing assistance over time.

2. Issues with Applications and Ongoing Participation

Most of the time, the focus group dealt with issues and problems that customers had experienced during the application and review processes. Verification issues came up often, as

43

did the initial application process, and problems with retaining eligibility (reviews, closures, and the ESC).

Please note: Comments below are from customers, most of who used the ExpoMart EC. We

recall only one customer who had been to South County EC, and she was enthusiastic about her experience there.

a. Initial Application

One of the main criticisms about the application process was the way customers are treated and made to feel when they applied. While focus group participants were not completely in agreement, there was a general consensus that customers were not treated as well as they would have wished, especially once they identified themselves as potential FEP, FSP, or Medicaid customers. The group thought that FEP, FSP, and Medicaid applicants were made to “feel pretty low.” In the words of one woman, “They really treat you rotten.” When asked whether they thought this was truly the case or whether the centers were more business- like than they had been in the past, one participant remarked there is a difference between “business-like and good, courteous, customer service.” A good portion of the group heartily agreed with this comment. Also, participants said workers did not treat customers politely during initial contact or eligibility interviews and did not truly take an interest in the customers or appreciate their situations. They said many customers are in crisis mode when they apply. One said the workers “remind you of cops—like they are interrogating you.”

Of secondary concern was the policy of processing applications according to customer zip

codes and matching them geographically to an appropriate EC. Two participants said they live very close to one center but had to go to one farther away because of the zip code policy. They said it would be a hardship if they did not have a car; one of them lives far away from a bus route.

Participants expressed concern about the time it took to get an appointment, particularly if

customers are not approved for expedited services. They told several stories about waiting more than two weeks for initial eligibility interviews. One woman was especially vocal—she had brought what she thought was all the verification she needed and believed the worker should have been able to “work” her case before the interview. A woman living in a distant rural community said the application process was especially problematic for her, because she needed an entire day to participate in her eligibility interview. She questioned what other residents of rural areas would do if they did not have a car or other means of transportation. Evidently, there are many rural areas within an hour of Salt Lake City where public transportation is not provided.

Most customers said it would be quite useful to receive a list of required verification

documents when they first visit an EC, so when they return for eligibility interviews, they could have everything that was required. Because they typically have two weeks between the initial visit and the interview, they said that is sufficient time to gather any verification documents.

44

b. Role of Workers in the Application Process

Participants voiced some resentment about workers. In some cases, this was because the customers had been denied and forced to reapply repeatedly for benefits. It was unclear whether a worker’s mistake forced a reapplication or whether a customer failed to comply with requirements. Although no one provided any evidence of workers’ mistakes, they talked about staff losing verification documents, verification documents mysteriously disappearing, or fax lines being busy 24/7. Some stories seemed more valid about workers not completing applications in time. One participant said, “I had all my paperwork in and did everything they said. It took them three months to approve me. … After the first month, they sent me a notification saying they turned me down and I called them up to find out why, and it was because they were backed up and it was their fault—they were backed up so they automatically turned me down.”

There were a number of comments about what customers said was a cavalier attitude toward

applicants. One customer said a worker told her when she was denied benefits, “Oh well, … we’ll get you next month.”

c. Ongoing Participation

A major complaint pertained to requirements for retaining eligibility. Many customers reported they felt “forced” to go to work, even though they said they were unable to do so, mainly because of disabilities. One woman said she was in a catch-22 situation, in that her doctor said that she could go to work if she were properly medicated, but because she was terminated from assistance, she had no money to purchase the medication.

One of the most common issues was that customers who were terminated did not really

understand why it had happened, how they had provoked the termination, and, in some cases, they did not even know about the termination because they were not notified. Some comments that highlight this:

“I’ve have had a lot of problems with them … off and on. … They cut me off for some reason or another, and they don’t even notify me. … Last time, it was nine months that I was totally off, and I didn’t have nothing.” “They come up with reasons that I overworked, and I hadn’t worked in two months.” “(My experience) has turned out to be a nightmare. … My case was closed every other month … turned out to be more of a pain in my butt—trying to work and be a single mom.” Many expressed concern about the amount of time needed to complete reviews. It was

evident that this group of individuals does not like the quarterly reviews, particularly those who are working and need to take time off from work. The participant from the rural area said that coming in for reviews was especially difficult because she usually had to take time off from work. She mentioned that although she lived 45 minutes north of Salt Lake, she was once required to attend a meeting in Provo (about an hour south of Salt Lake) to retain her benefits,

45

and she did not understand why. There was a lot of confusion over how often the reviews were required, and how often customers needed to come into the office for face-to-face interviews. Some thought they needed to come into the office every 30 days, and some had no idea—indicating that they should come into the office whenever DWS says to. One said that people are required to come into the office more often if they have earnings and that it was inconvenient because if people are working, they should not need to come into the office more often. On the other hand, many participants did have a good understanding of the change reporting requirements.

Another general concern is the feeling that notices are very difficult to understand. Often,

there is a lot of legal language (and references to state or federal laws) that is not understandable to customers.

d. Reapplication Process

Once terminated from benefits, many customers said reapplication requirements were more taxing than the initial application. They said they had to start the process over again, including the initial application to the ESC, and then the two-week wait for the eligibility interview. But one woman said her worker “fixed things” so all she needed to do was send in her check stubs. (It’s possible she was late submitting something for her review, but the 30 days had not expired, so she still got her verification in within the allotted time).

e. Eligibility Service Center

There was significant discussion about the ESC. Almost everyone in the focus group had used the center, and they all had a basic understanding of the types of services provided, including case reporting, updates, disputing case closures, and sending in verification and reviews that do not require a face-to-face interview.

Overall comments were mixed but tended toward the negative. Many laughed at the idea

that the center is supposed to provide an enhanced means of service. Many but not all reported having trouble getting through to a worker and said the automated voice response system was long and “really annoying.” There were some remarks that not all notices contain the center’s phone number, let alone when to call.

The most significant complaint was that customers were unable to talk to an assigned

worker who knew their case histories. This issue was a unifying theme that ran throughout the discussion. One comment that the entire group readily agreed with: “You never ever talk to the same individual—there is always a different individual.” Another person remarked that the center “makes it harder because you don’t talk to the same person.” Some said the lack of case managers results in a great deal of confusion among customers and is burdensome because customers are continually re-explaining what are often times very complex case histories. Participants said they often receive different information from different workers, depending on whom they speak to at any given time. One person said, “They don’t really tell you nothing … it’s so confusing.” Almost everyone agreed “it was easier when you could call personally and talk to the one person who was working on your case.”

46

Most agreed that service could improve once ongoing cases are assigned to a single worker who has the overall responsibility for those cases. However, they still said that having to talk to someone other than that worker (which will continue to occur with the new system) would cause the same problems. Several said they preferred to see a worker in person, because it makes them feel more comfortable and confident that their message was getting through to someone.

Some customers said they frequently call ESC with the same question, which we heard from

the workers. Workers referred to these customers as “shoppers”—meaning they keep calling until they find the answer they want. But customers told us they do this because they are sometimes searching for a particular worker they worked with before, believing that worker would be more like to understand their cases and their situations, and, therefore, would provide better service.

3. Misunderstanding About Programs and/or Application Processes

Woven throughout the discussions were misunderstandings about programs, benefits, and application processes. Many customers—typically those who did not understand why they had been denied—simply did not understand that their denials were beyond the control of the workers, the ECs, and sometimes the state. In many cases, denials and requests for voluminous verification documents are required by state or federal program regulations.

There were numerous comments about the complexity of applying for SSI benefits. One

customer called it a “painstaking process.” Many customers were either receiving SSI, were in the process of applying, or had been denied. It is well known that the SSI application process is long and arduous and can take well over a year. Customers were very frustrated about this, and those who had been denied did not understand why.

Benefits calculation also caused confusion. One woman said she “was making $6 an hour

and only got $10 in FSP a month” and later was “making $8 an hour and was getting $79 in food stamps … that was my biggest problem. I didn’t understand … was the more money I was making hourly, the more food stamps they would give me.” Everyone nodded in agreement with this and agreed that the calculation of benefits was confusing and often seemed to make little sense. What this means in terms of participation is unclear.

4. Stigma and Related External (Non-DWS) Issues

Many participants felt stigmatized when accessing and utilizing benefits. One customer said, “Any problems that I have had have not really been with the caseworkers or the government or the system. It’s been with the personal stigma of the doctors and the people that I have seen … like… ‘Oh, she’s on Medicaid.’ ” While everyone said the electronic benefit transfer card is simple to use and understand, many feel awkward and embarrassed to use it, because other customers in the stores know what the card is for.

Another woman said, “The social stigma is what gets me the most.” She explained that

when she went off Medicaid and went back to her doctor with her new (non-Medicaid) insurance card, a nurse said to her, “Well, I bet you feel like a real person now.” While many customers felt stigmatized, it appears that few chose not to participate because of it.

47

Several participants said they and their families may not be receiving the best medical care—or may be receiving substandard care or no care at all—because they are on a Medicaid. One woman said she has “heard about not getting the best shots for my daughter because of the Medicaid. ... One of my friend’s daughters’ doctors told her that Medicaid children didn’t get the same shots as other insured children.” There was another customer story about a dentist who said her daughter, whose teeth were evidently in poor condition, said she should not be concerned about the overbite, there was nothing he could about it because Medicaid did not cover services to repair an overbite.


49

APPENDIX D: APPLICATIONS


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