National Academy for State Health Policy
20th Annual State Health Policy Conference
Reach Out and Keep Someone: States Get Creative on
Enrollment and Retention
MaryAnne Lindeblad, Director
Division of Healthcare Services
Health and Recovery Services Administration
Department of Social and Health Services
State of Washington
626 8th Avenue S.E.
P.O. Box 45502
Olympia, Washington 98504-5502
(360) 725-1786
Email: lindem@dshs.wa.gov
Washington State
Department of Social
1
& Health Services

Reach Out and Keep Someone
Topics To Be Covered
•
Citizenship verification both transitioning
•
existing clients and new enrollment
Auto enrollment for expanded population
•
Retention pilots
•
Coverage for Foster Children
•
Washington State
Department of Social
2
& Health Services

Reach Out and Keep Someone
Problem
How to verify citizenship in over one
3.
million existing Medicaid and Family
Planning waiver clients
How to verify citizenship for new
5.
enrollees
Washington State
Department of Social
3
& Health Services

Reach Out and Keep Someone
Existing Medicaid Clients
Approach: Batch-style, automated match of

historical Medicaid caseload, with manual
verification of imperfect or ambiguous matches
Results: 496,035 birth certificates found for

1,079,933 clients from birth to age 65
Product: Flag posted in automated client

eligibility database so that field staff could
immediately determine whether a BC had been
found for a given client
Washington State
Department of Social
4
& Health Services

Reach Out and Keep Someone
17-year history of matching Medicaid deliveries

to birth certificates for program evaluation and
research
Technical expertise in matching, and knowledge

of data elements in Medicaid databases and in
vital records
Long-standing collaborative relationship with

State vital records agency (Dept. of Health)
Washington State
Department of Social
5
& Health Services

Determinants of Success (1)
Percentage of low-income, U.S.-born persons who
live in the state which they were born
Children <18 Years Old Adults 18-64 Years Old
California 95% Louisiana 83%
Texas 92% New York 82%
Washington 53%
Washington 80%
New Hampshire 65%
Idaho 43%
Nevada 21%
Nevada 59%
Source: Ku L, Ross DC, and Broaddus M. Documenting Citizenship and Identity Using Data
Matches: A Promising Strategy for State Medicaid Programs. Center on Budget and Policy
Priorities, 2006.
Washington State
Department of Social
6
& Health Services

Determinants of Success (2)
Age distribution of Medicaid
caseload
100%
90%
80%
70%
Match Rate
60%
50%
40%
30%
20%
10%
0%
1
5
5
0
5
0
0
5
0
65
70
85
00
05
4
4
5
5
6
7
8
9
9
19
19
19
19
19
19
19
19
19
19
19
19
20
20
Birth Year
Match rate computed for estimated Washington-born clients (excludes out of state births)
Washington State
Department of Social
7
& Health Services

Reach Out and Keep Someone
Vital statistics’ requirement that Medicaid

agency not retain permanent electronic birth
certificate data: we returned all birth certificate
data to them and they will return to us in the
event of an audit
Changing format of birth certificates: fewer data

elements are available for births in earlier years
than in more recent years. Matching algorithms
changed to use available data
Transition to production work in research

environment
Washington State
Department of Social
8
& Health Services

Reach Out and Keep Someone
Challenges we could not solve
SSNs on birth certificates were not available for

matching (due to Privacy Act of 1974, PL 93-
579)
Limited electronic access to out-of-state birth

certificates (different formats and different
laws)
Imperfect data in existing records

Washington State
Department of Social
9
& Health Services

Reach Out and Keep Someone
Feasibility Issues
Size of caseloads and numbers of births  volume of

workload
Age distribution of Medicaid caseload

Migration patterns

Availability of electronic birth records

Data elements common to birth records and Medicaid

clients
Washington State
Department of Social
10
& Health Services

Reach Out and Keep Someone
Benefits
Cost savings (avoided direct cost of obtaining

birth certificates)
Reduced workload for state staff and burden on

clients
Timelines: State staff had immediate access to

results
Washington State
Department of Social
11
& Health Services

Reach Out and Keep Someone
Newly Eligible and Unable to Match:

If the required verification is not available

applicant completes the “Citizenship
Documentation and Identity Form”
Monthly reports pulled from eligibility system to

determine which clients have been put on with the
declaration form
The Centralized Citizenship Unit (CCU) follows up

with the family to obtain the needed verification
Requesting and paying for out of state birth

certificates (10,500 birth certificates to date)
Working with families to obtain Tier 3 or Tier 4

verifications
Washington State
Department of Social
12
& Health Services

Reach Out and Keep Someone
Failure to cooperate:
Two letters sent for needed information

Attempt to contact the recipient by

telephone
Terminated if above efforts not successful

 Of the 8,949 individuals terminated
8,026 of these individuals are
children
Washington State
Department of Social
13
& Health Services

Reach Out and Keep Someone
July 22, 2007 Washington State implemented

legislation covering all children at or below
250% of the FPL
7,500 children known to Department auto

enrolled
Children with US citizen siblings

Synced certification with Medicaid/SCHIP family

members
Washington State
Department of Social
14
& Health Services

Reach Out and Keep Someone
Targeted Outreach to Families and Children
Known to Department
•Families receiving food benefits
•Families receiving child care subsidizes
•Parents providing support enforcement for children
•Children losing eligibility because family does not complete
citizenship documentation requirements
•Children not eligible because family did not complete
application
Washington State
Department of Social
15
& Health Services

Reach Out and Keep Someone
Pilots to Reduce “Churn Rate “ – Children
losing eligibility because family did not complete
renewal
•Notice to families in specially designed envelopes
•Telephone reminders when renewal forms sent
•Out-stationed eligibility workers follow-up with families whose
children lost eligibility
•Investigate use of managed care plans to assist families in
renewal process
Washington State
Department of Social
16
& Health Services

Reach Out and Keep Someone
Future Options
•Evaluate “express lane” eligibility
•Evaluate “passive re-enrollment”
Washington State
Department of Social
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& Health Services

Reach Out and Keep Someone
2007, Legislature expanded eligibility for foster

care medical
Youth in foster care, if 18th birthday is on or

after July 22, 2007, eligible to remain on
medical benefits until 21 as long as they remain
Washington residents
Estimated 900 children eligible

Washington State
Department of Social
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& Health Services