1. Modernization of Client Service Delivery (MCSD) at The Connecticut Department of Social Services

2. The Changing Landscape We have significant challenges in staffing, technology, and physical plant. We are helping more and more people every day. Programs are increasingly complex. Our challenges create barriers to efficient and effective service to Connecticut residents.

3. Applications On The Rise Over 23% 2009 gain over 2007 Over 12% 2009 gain over 2008 Application Activity 2007 - 2009

4. Need In CT Is Increasing Average Annual Recipients 2007 - 2009

5. Comparing Staffing Levels to Activity Monthly Comparison of Active ‘Assistance Units’ and Application Activity to Eligibility Staff

6. Call Volume Is Tremendous

7. Technology is Our BIGGEST Challenge The technology infrastructure is non-existent. Phone systems cannot manage the volume of calls. Each phone system is different in our 13 offices. There is limited storage for voicemails.

8. Technology is Our BIGGEST Challenge Virtually no capability to electronically manage documents. Reporting capabilities are severely limited and restrict the production of reports for analysis. The Eligibility Management System (EMS) is obsolete EMS is the primary tool for the determination and maintenance of ongoing eligibility.

9. EMS Has Challenges EMS Has Challenges The Eligibility Management System Mainframe system initially developed in the 1980s consisting of 217 data bases, 3,419 programs, 428 screens and over 9.1 million lines of COBOL program code; and Requires production staff on duty 24-hours a day to support the on-line system and the extensive batch processing conducted nights and on weekends.

10. EMS Has Challenges The system determines eligibility and issues notices and benefits to approximately 389,000 assistance units and 653,000 clients each month; Receives information entered on-line from over 1,500 terminals in 12 DSS regional offices across the state; and Exchanges and matches data through interfaces with other state and federal agencies, as well as with towns, banks, insurance companies, and other entities to ensure the accuracy of information contained in the client and assistance unit database.

11. EMS Has Challenges Each programmatic change requires an extraordinary amount of ITS staff resources to implement modifications, create notices and support new eligibility processes.

12. EMS Has Challenges - Example Program policy was modified that required a wording change and inclusion of a variable data element on one of the EMS notices. Modify the eligibility module with the new data element to be passed to the nightly notice process. Modify the notice linkage area layout (data passing area) to include the new element. Rebuild all eligibility programs that access the notice linkage area.

13. EMS Has Challenges – Example (cont.) Modify the nightly notice process to extract the new element from the notice linkage section. Rebuild all notice programs that use the notice linkage area. Modify the notice to include the new data element and to display the new text.

14. EMS Has Challenges – Example (cont.) The notice text needed to be re-formatted (re- built) from the point of the first change to the end of the notice. This is required due to the notice module does not have automatic formatting similar to MS- Word. All notices are built character by character using a COBOL program. The change would have been more time consuming if a different font or bolding was requested. This would be a simple change using current development tools however it took over a month to implement in EMS.

15. EMS Has Challenges New programs or expanded eligibility has been contracted out because EMS cannot be programmed to manage the complexity of the eligibility criteria. HUSKY B, Charter Oak, Care4Kids There are 500 change requests in the queue for EMS.

16. EMS Has Challenges Utilize workarounds in EMS to implement program changes. Work-arounds are processes designed to circumvent the computer system allowing for manual work procedures. Requires reprogramming of EMS for implementation of any program policy or procedural changes.

17. EMS Has Challenges Work-arounds are labor intensive for the eligibility determination process, create complexity and inefficiency. Jeopardizes program integrity which may lead to significant federal penalties. Case in point in the Supplemental Nutrition Assistance Program (SNAP) – SNAP has undergone significant changes in the last 5 years.

18. EMS Has Challenges DSS has been unable to make changes in EMS to make eligibility management of the SNAP program less demanding. As a result, SNAP eligibility is labor intensive and cumbersome. The Food and Nutrition Service (FNS) tracks error rates for the states and monetarily penalizes those that are out of compliance with federally set targets for program administration.

19. EMS Has Challenges CT is currently ranked 52 of 53 states and territories for its error rate. We are in danger of receiving a significant federal penalty of up to $10 million dollars per year. A more flexible eligibility management system that could be programmed more easily would allow for the implementation of system supports to simplify eligibility processing and subsequently reduce the error rate.

20. EMS Has Challenges Eligibility processing is cumbersome and EMS has been called “rigid” (LPRIC, 2004). The system negatively affects the efficiency of business operations daily. The greatest impact is to the residents of Connecticut that need access to the services DSS provides.

21. EMS Has Challenges In the Malloy/Wyman Transition Team - Final Report of The Policy Committee there is reference to the Social Safety Net and access to the very services DSS provides, it states “Access to services that respond to basic human needs must remain available to Connecticut's most vulnerable residents, even during difficult economic times” (Kelly and McGee, 2011). One of the greatest tests of DSS’s ability to provide that access has been EMS.

22. Why Modernize The mounting demands and increased expectations could not be addressed with our current systems. There Was Little Choice

23. Why Modernize? Currently, DSS does not have the staffing and sophisticated technology to best serve the residents of Connecticut. Our systems and programs are complex and made more difficult by the patchwork of technology and a dated business model. Legislators, advocates, providers, federal partners, other human service partners and, most of all, the people in the communities we serve, share our belief that we can do better with new technology.

24. Why Modernize? The Raymond Settlement In 2007 DSS settled a class action lawsuit. Class action law suit filed by CT Legal Services organizations on behalf of persons with physical and mental disabilities. Brought about as result of 2003 layoffs and office closings. Advocates claimed inadequate accommodations available for persons with disabilities to access DSS programs.. The eligibility processes were specifically named.

25. Why Modernize? The Raymond vs. Rowland settlement agreement created groundwork for a new infrastructure supported by cutting-edge technology that will revolutionize our client service delivery system through Universal Design. Universal Design includes a broad-spectrum of solutions that create environments that are usable and effective for everyone, including people with disabilities. Universal Design Impacts the Physical, Communication, and Information environments of DSS. To insure that the people we serve and in particular people with disabilities (cognitive and physical) are able to successfully interact with our systems.

26. Why Modernize? In Order To Successfully Implement Universal Design For Improved Client Access Better Quality Outcomes Enhanced Customer Service Cost Reduction Create a Technological Framework for the Future Modernization Is Critical

27. We Have To Do Better We recognize and acknowledge Limited access/entry points Outdated facilities…costly facility storage Inadequate phone systems Dated business model In need of technology Limited staffing Lack of ease for community partners to assist in client services

28. We Have To Do Better We looked at what was working successfully in other states Visited FL facilities and reviewed the operations Spoke in depth with officials from other states that have implemented PA, MA, WI, CA Held and continue to hold focus groups across CT Staff at all levels of DSS are involved in workgroups for implementation Modernization is a comprehensive response to the issues we face and provides a framework for expansion

29. It’s Time For Modernization It’s time to make changes to our business model and utilize the technology available to support positive change. Modernization will streamline our business processes and as it does, your agencies and clients will gain Quicker response time Ability to self-serve Access

30. Modernization of Client Service Delivery (MCSD ) Initiated in September of 2008. Capitalizes on new technology, Raymond Settlement funding and best practices from other states. Does not replace EMS but creates the framework to do so eventually.

31. Modernization of Client Service Delivery Currently in the design phase. Negotiating terms and conditions with vendor. 21 month implementation timeline (once contract is finalized). What exactly will MCSD do?

32. DSS Services Web Front-End Benefits Center Service Center IVR Process Center Doc Imaging Dedicated Units Community Partners Modernization of Client Service Delivery

33. Modernization – Meeting the Challenge Paper, Paper, Paper Document Management

34. Meeting the Challenge – Document Management Document Management will simplify access to documents through the use of scanning and indexing. Paper documents and other files will be sent to a central repository for scanning and DSS staff will be able to access documents almost immediately from their desktop computer.

35. Meeting the Challenge – Document Management Document management will also allow for the implementation of workflow. Documents will be scanned and indexed to a person’s case. Once a document is received, an electronic work order is created, the work is assigned to a DSS staff person through the use of technology, the DSS staff process the application, redetermination, or change.

36. Meeting the Challenge – Document Management A Document Management System will process the approximately 3.7 million pages per month (44 million pages per year) – our current volume. Document management will eliminate wasted time for workers searching for paper and clients replacing lost documents. We will be able to access information the moment we need it, wherever we need it. WITHOUT TOUCHING PAPER !!!!

37. Meeting the Challenge – Document Management This will improve timeliness, customer satisfaction and quality assurance. Massachusetts reports that health assistance application processing time was reduced by 50% with the implementation of a document management system. Community partners no longer have to assist clients with the task of locating paperwork to resubmit to DSS because it has been lost. No more frustrated clients who can’t get their cases processed because of misplaced forms or documentation.

38. Modernization – Meeting the Challenge Physical Plant Inadequate to address high volume and movement of people Processing Centers Service Centers

39. Meeting the Challenge – Processing Centers Processing Centers will be a part of the current regional offices. The DSS staff will be providing the case maintenance functions such as processing redeterminations and applications, TANF activities for time limited program participants, processing computer matches, and managing Long-Term Care Cases.

40. Meeting the Challenge – Service Centers The regional offices will also be Service Centers. Service Centers will provide access to self-service tools, as well as the opportunity for one-on-one assistance. Service Centers will be redesigned to accommodate people with a variety of disabilities, including: cognitive, physical, auditory and visual. As more and more people take advantage of DSS services via the phone or internet, the volume of people who come to a DSS service center will diminish.

41. Regional offices will be redesigned to facilitate self- service activities. Computers to apply or complete a redetermination online. Phones to be connected directly to Benefits Centers in 3 CT locations. Fax machines to send documents to the document management center for indexing. Self service areas will be supported with DSS staff to assist people who prefer to use these systems. DSS staff will be available to see people who want to or need to be seen as a result of the program they are on or applying for. Meeting the Challenge – Service Centers

42. Some people will still need to be seen by DSS staff. Certain types of programs such as SAGA cash and time-limited TFA require people to see an eligibility worker. People may need extra support to be able to apply for or stay on our programs. People with physical or cognitive disabilities may need or prefer a face-to-face contact. Some may simply prefer to see a DSS staff person.

43. Modernization – Meeting the Challenge Phone Systems Differ from office to office Differ from office to office Cannot direct callers to appropriate staff Cannot direct callers to appropriate staff Voicemail not able to manage volume of calls Voicemail not able to manage volume of calls Interactive Voice Response (IVR)

44. Meeting the Challenge – IVR When a client calls, they have the option of speaking to a worker, or using the new “IVR” (available in English and Spanish). Organizations, public and private, are increasingly turning to IVR to reduce the cost of common questions, service, inquiry and support calls to and from their organization. IVR allows the use of pre-recorded voice prompts and menus to present information and options to callers, and touch-tone telephone keypad entry to gather responses without the intervention of staff. Enables a caller to access specific case information, general program information, or connect to a DSS worker.

45. Meeting the Challenge – IVR People can call and request to have forms mailed to them, for example, applications, redeterminations, change reports and budget verifications; check the status of their case; verify that their mail was received by us and other steps. With these types of calls, that do not require an interaction between the caller and a DSS staff person, IVR will save time for both the caller and DSS. Callers who need more specific information will be directed to a DSS staff person at a virtual Benefits Center.

46. Meeting the Challenge – IVR Successful Child Support IVR system within DSS for approximately 8 years. IVR provides real-time access to child support information for custodial parties, noncustodial parents, employers, other state child support agencies, and the general public. Approximately 185,000 calls per month are currently processed by the IVR with only 4% of callers opting out to a customer service representative. Since implementation, the number of individuals utilizing the IVR has increased. Enhancements to available information and IVR script has substantially reduced the need for customer service assistance.

47. Meeting the Challenge – IVR If a caller wants or needs to speak with a DSS staff person, there will be a seamless transfer. The call will be handled in most instances by an eligibility worker, who can respond to the concern of the caller and process any change on his/her case. In most instances, the calls are eligibility related. In the case of medical providers or other types of calls, the caller will be transferred to the appropriate area of DSS. Benefits centers will be a part of our current regional offices. Three locations across the state to provide necessary system redundancy. People call in to one toll-free number and call can be responded to from anywhere. Does not require new offices.

48. Modernization – Business Model Changes A refined business model supported with new technology provides additional supports to insure access and efficiency. Service Centers – the regional offices will be available for clients and our partners. Processing Centers – located in the regional offices staff will be dedicated to the case maintenance functions that are needed to maintain eligibility. Benefits Centers – located in three regional offices and manages eligibility functions via telephone for the entire state. Dedicated units – specialized work like that of the current Regional Processing Units, will be administered with dedicated DSS staff to account for the complexities of TFA, LTC, and the RPU.

49. Modernization – Meeting the Challenge Web Front End Limited Hours Limited Entry Points Limited Access Paper, Paper, Paper

50. Meeting the Challenge - Web Front End Our response is a web-based application similar to online banking. A web-based front-end will interface with our eligibility management system. Creates “anywhere” access for applications, redeterminations, and case information via the internet. Through the use of Web Front-End, an individual: Can apply or conduct his/her redetermination online Can report changes online. Can find out the status of his/her benefits Literally from anywhere where there is internet access.

51. Meeting the Challenge - Web Front End Allows people to submit an application or comply with program rules through the redetermination process without having to come to a DSS office. Other states like Pennsylvania, Florida and Wisconsin have had great success and residents report greater and easier access to services. Other states report community partners play a critical role in providing that access. Wisconsin reports 40% of its applications are submitted through the web front-end, ACCESS.

52. What About EMS? EMS Has Challenges!! Cost estimates to replace EMS run anywhere from $100 million to $150 million. DSS began the modernization effort to respond to the mounting challenges and to create a framework so that EMS can eventually be replaced. Fiscal costs prevented DSS from expanding the scope of modernization into replacement of EMS.

53. A New Opportunity In the later part of 2010, The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would expand the interpretation of existing regulations governing MMIS systems to allow for enhanced funding of automated eligibility systems for Medicaid (Covington, 2010). Enhanced Federal financial participation (FFP) would be available to include 90% for design, development and installation and 75% for operation and maintenance for Medicaid eligibility systems. (Covington, 2010). Design, development and installation need to be completed by December 31, 2015. Approximately $2.9 billion dollars is available for states who select to replace their eligibility systems.

54. A New Opportunity Along with the existing pressures on EMS, we have new expectations resulting from the Affordable Care Act. The Affordable Care Act (ACA) requires states to set up health care exchanges for the purchase and sale of health insurance in 2014. Included in the ACA is the condition that individuals are permitted to apply for Medicaid and CHIP (Children's Health Insurance Program – HUSKY in CT) through the exchange or the state Medicaid agency – any door (HealthCare.gov, 2010).

55. A New Opportunity The exchange and state Medicaid agency must facilitate electronic applications, minimize paper documentation and ensure continued enrollment of eligible individuals and families (Jost, 2010). There is an expectation of system integration, maintenance of ongoing eligibility, streamlining and simplification of eligibility processes for health insurance provision under the ACA (Covington, 2010).

56. A New Opportunity Recognizing the ITS restraints of most states to operationalize the conditions of the ACA, the federal government has initiated guidance and financial support to help states prepare for implementation. This is an UNPRECEDENTED financial opportunity in the world of eligibility management systems.

57. A New Opportunity In guidance issued jointly from Health and Human Services (HHS), Office of Consumer Information and Insurance Oversight (OCIIO) and the Centers for Medicare & Medicaid Services (CMS) in November 2010, the expectation is clear. We expect IT systems to support a first-class customer experience, as well as seamless coordination between the Medicaid and CHIP programs and the Exchanges and between the Exchanges and plans, employers, and navigators. We also expect these systems to generate robust data in support of program evaluation efforts and ongoing improvements in program delivery and outcomes. (p. 3)

58. EMS Cannot Meet The Challenge MCSD Will Bring Some Relief To Eligibility Determinations And Maintenance HOWEVER It Does Not Address The CORE Issue The Need To Replace EMS

59. Data Collection & Reporting Paper, Paper, Paper Staffing The Raymond Settlement Federal Penalties Increased Need Program Complexity Affordable Care Act Phone Systems EMS New Programs DSS Services

60. The Replacement of EMS DSS proposes a planning process to identify expectations and explore the costs and resources needed to determine the feasibility of replacing EMS. Budget option has been submitted to OPM for $2.5 million dollars for FY2012 to begin this planning process.

61. The Replacement of EMS There may be the opportunity to renegotiate the scope of the vendors for MCSD and reallocate monies into an initiative to replace EMS. What will be required in the planning phase? Maximization of federal financial participation through approvable Cost Allocation methodology. Cost Benefit Analysis. The creation of an Advanced Planning Document (APD) to obtain federal approval and federal financial participation. The creation of a RFP. Identification of business requirements. Utilize a contractor and DSS resources to support this process.

62. The Replacement of EMS The cost of the planning process is $2.5 million and assumes 50 – 90% federal reimbursement. Costs for the replacement of EMS will be estimated in time for the Governor’s budget adjustment for SFY 2013.

63. The Replacement of EMS There may be the opportunity to apply for federal reimbursement at the 90% level for parts of MCSD. The planning process will identify these opportunities.

64. The Cost of Replacing EMS? While we cannot estimate the total cost of replacement of EMS, the most current information from other states expenditures run from $100 million to $300 million dollars. Recent examples from other states are included below. Michigan - planning started in 2004 and implemented statewide in 2009. The original contract $70M plus. Tennessee - planning started in 2004 and implementation has been delayed until 2012. Original contract around $50M plus.

65. The Cost of Replacing EMS? New Jersey - planning started around 2005, the project is just getting started. Original contract $50M plus. Wyoming – planning started in the early 2000’s and was aborted around 2008. Original Contract around $20M plus. Los Angeles - estimating that it will cost $530M plus to replace its eligibility system. The estimated start date for system development is this month. New York - system cost nearly $330M.

66. The Cost of Replacing EMS? While it is important to consider other states examples, each eligibility management system is as unique as each Medicaid program. There is an adage that says – if you have seen one Medicaid program, you have seen one Medicaid program.

67. What Do The Costs Include? New eligibility management system for CT that can meet today’s and tomorrow's growing expectations. Proven eligibility management system – clear examples of performance in other states. Skilled and experienced support for development and implementation.

68. What Do The Costs Include? Integration of technologies available in the public domain and proprietary technologies. Meets criteria set by CMS under the proposed rule change “Ensure that States make appropriate use and reuse of components and technologies available off the shelf or with minimal customization to maximize return on investment and minimize project risk” “We intend to work with States to identify promising State systems that can be leveraged and used by other States”

69. What Do The Costs Include? Assurance that a new eligibility management system can easily and cost effectively integrate with other technologies. Securely Timely Accurately

70. What If We Don’t Replace EMS? It is unlikely we will be able to meet the demands of the ACA and the exchange. The current pressures on the regional offices will expand. Resulting in… Federal penalties Inefficient eligibility processing The system negatively affects the efficiency of business operations daily. That being said Greatest impact is to the residents of Connecticut that need access to the services DSS provides.

71. What If We Don’t Replace EMS? We are unable to manage the expanding complexity of programs in EMS now. Staying the course is no longer an option. Snapshot of the Western region comparing 2008 and 2010. Staffing. Growth in applications. Growth in caseload.

72. Staffing Staffing Snapshot of Western Regional Offices

73. Monthly Application Activity Per Worker Monthly Application Activity Per Worker Snapshot of Western Regional Offices

74. Monthly Application Activity by Office Monthly Application Activity by Office Snapshot of Western Regional Offices

75. Assistance Units Per Worker – Active Cases Assistance Units Per Worker – Active Cases Snapshot of Western Regional Offices

76. Assistance Units by Office Assistance Units by Office Snapshot of Western Regional Offices

77. Percentage Increase in Workload Percentage Increase in Workload Snapshot of Western Regional Offices

78. DSS Recommendation EMS is rigid and inefficient. EMS cannot meet today’s demands and will not be able to support the expectations of the Affordable Care Act. This is an unprecedented opportunity for enhanced federal funding. Modernization will still go forward while exploring EMS replacement.

79. DSS Recommendation In government there are few moments when there is leadership support, a political will and the ability to access new federal dollars to implement the change everybody wants. This is one of those moments. Replacing EMS and accessing enhanced federal funding to do so is an action item that will deliver efficiency, effectiveness and better service.

80. Changing The Face Of DSS

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