1. Vermont Section 1115 Demonstration Grant PROJECT UNIMED 2005-2008 A Unified Approach to Medical Support Through Intra-Agency Collaboration/Data Exchange Prepared by Sean Brown of the Vermont Office of Child Support Presented and Co-Prepared by Christin L. Semprebon, Esq. ERICSA Conference 2011, Atlantic City, New Jersey

2. Project Goals  Improve collaboration with key partners  Collect and analyze medical support data  Report lessons learned and best practices

3. Goal 1- Improve Collaboration  Prior to applying for grant OCS identified the key partners and secured their participation in the grant via a written agreement.  The key partners included: Office of Vermont Health Access (OVHA) Economic Services Division (ESD) Health Access Eligibility Unit (HEAU)

4. Goal 1- Improve Collaboration  OVHA is responsible for administering the Medicaid program in Vermont. It operates essentially as a managed care organization.  ESD is responsible for making eligibility determinations and enrollment for applicant’s applying for Medicaid and other benefits such as TANF.  HAEU is responsible for making eligibility determinations and enrollment for applicant’s applying solely for Medicaid.

5. Goal 1- Improve Collaboration  A workgroup was created with staff from OVHA, ESD, HAEU and OCS to develop new policies, procedures and forms to increase Medicaid referrals to OCS. The workgroup: Created new assignment of rights for medical support for Medicaid-only cases and new process for referring cases to OCS. In 2006 about 2,864 and in 2007 about 2832 of the new forms were processed by OCS. Created new assignment of rights for medical support for Medicaid-only cases and new process for referring cases to OCS. In 2006 about 2,864 and in 2007 about 2832 of the new forms were processed by OCS. Developed and implemented Medicaid sanctions for custodial parents who did not cooperate with OCS. Developed and implemented Medicaid sanctions for custodial parents who did not cooperate with OCS. Developed and implemented Medicaid waivers of cooperation for custodial parents with domestic violence concerns. Developed and implemented Medicaid waivers of cooperation for custodial parents with domestic violence concerns. Agreed not to pursue child-only Medicaid cases due to lack of cooperation from custodial parents and lack of sanctions. Agreed not to pursue child-only Medicaid cases due to lack of cooperation from custodial parents and lack of sanctions.

6. Goal 2- Collect & Analyze Data  Many changes were made to ACCESS, the shared mainframe computer system, to collect and share data among the IV-D, IV-A and Medicaid agencies. Key changes allowed for: Improved communication between staff. Improved communication between staff. Improved collection and exchange of employment/wage data. Improved collection and exchange of employment/wage data. Improved collection and exchange of health insurance data. Improved collection and exchange of health insurance data. Improved collection and exchange of court hearing/order data. Improved collection and exchange of court hearing/order data.  The new data elements in ACCESS were uploaded into the OCS data warehouse (PEAKS) for reporting and analysis.

7. Goal 2- Collect & Analyze Data

8. Other examples include NCP’s employer does not offer, NCP works part-time, NCP is Medicaid active, and NCP has a waiting period before insurance is available. Other examples include NCP’s employer does not offer, NCP works part-time, NCP is Medicaid active, and NCP has a waiting period before insurance is available.

9. Goal 2- Collect & Analyze Data

12. Other examples include CP’s employer does not offer, CP works part-time, CP is Medicaid active, and CP is full-time student.

13. Goal 2- Collect & Analyze Data

18. Data Mining Model Summary  8.56% of IV-D cases used in the data mining model have confirmed health insurance in place.  Almost 89% of the cases with current monthly wages greater than $5,900 have insurance coverage.  Cases with the lowest obligation to arrears ratio range (0 to 2.5) had the highest percentage of health insurance coverage at 10.4%.  Of all case types, Medicaid-only cases are the least likely to have health insurance coverage.

19. Data Mining Model Summary  95% of the cases with nominal child support orders, $100 or less per month, do not have insurance.  NCP earnings above $5000 per quarter are indicative of health insurance coverage.  Cases under 2 years of age had the highest percentage of coverage (10.25%) than all other case age groups.

20. Data Mining Model Summary  The difference in health insurance coverage for interstate (8.71%) and non- interstate (7.41%) cases is not significant.  There is a higher likelihood of insurance if the NCP changes jobs.  The more phone contacts logged on a case, the higher the likelihood of insurance enrollment.

21. Goal 3- Lessons & Best Practices Exclude “inappropriate” cases from the referral process. OVHA, ESD, HAEU and OCS have agreed to exclude the following cases from the referral process: The SSN for the NCP is unknown to custodial parent, the Access system and ESD/HAEU not able to find it. The SSN for the NCP is unknown to custodial parent, the Access system and ESD/HAEU not able to find it. The NCP is currently or has been on a IV-A program (TANF, General Assistance or Food Stamps) or Medicaid in the past 12 months. The NCP is currently or has been on a IV-A program (TANF, General Assistance or Food Stamps) or Medicaid in the past 12 months. The NCP is currently incarcerated or has been in the past. The NCP is currently incarcerated or has been in the past. The NCP is currently unemployed. The NCP is currently unemployed. The NCP is not able to work due to a disability (SSI, SSDI). The NCP is not able to work due to a disability (SSI, SSDI). Note: ESD/HEAU staff are currently manually reviewing and excluding the above cases pending programming to automate the process.

22. Goal 3- Lessons & Best Practices A National Medical Support Notice (NMSN) should be sent on a periodic basis when insurance is not being provided. A National Medical Support Notice (NMSN) should be sent on a periodic basis when insurance is not being provided.  The data mining model identified a high correlation between a case having health insurance and the number of employment changes.  A NCP with recent job changes is more likely to have private health insurance than a non-custodial parent who has maintained the same employment for a long period of time.  OCS has requested new ACCESS programming to automatically send a NMSN to employers on a periodic basis (once a year).

23. Goal 3- Lessons & Best Practices Implement a collaborative workgroup that consists of partners from the IV-D, IV-A and Medicaid agencies. It can and does work.  The workgroup increased the number of Medicaid case referrals to OCS which increased the number of insured children for Medicaid cost avoidance and recovery.  The workgroup continues to share data on an ongoing basis.  The workgroup continues to meet twice a year to review data and processes to ensure that progress continues.

24. Goal 3- Lessons & Best Practices Pursue cash medical support in cases where health insurance is not available.  Health insurance was ordered and obtained in only 13% of these cases mainly due to cost.  Pursuing cash medical contributions in the remaining 87% of the cases could result in more cost recovery for the Medicaid agency.  Vermont law currently limits the ability of OCS to pursue cash medical contributions in Medicaid-only cases.

25. Goal 4 – Look to the Future  Vermont law formerly limited cash medical contribution in lieu of insurance coverage to 5% of the child’s actual premium cost under a Medicaid program (i.e., = $-0-).  A new Vermont law (15 V.S.A. sec. 658(f) has eliminated the 5% limit language of a child’s premium cost under a Medicaid program when ordering a parent to pay a cash medical contribution. This will further contribute to cost avoidance and recovery in the administration of the Medicaid program.

26. Goal 4 – Look to the Future  The Patient Protection and Affordable Care Act (H.R.3590) makes quality, affordable health care coverage available to 95% of all Americans.  Acceptable health care coverage is private, public or publicly subsidized (this includes Medicaid).  The IRS Code is amended effective 2014 to require that the parent who claims the child as a dependent on their tax return is responsible for demonstrating that the child has acceptable health care coverage.

27. Questions??

28. Contact Information Christin L. Semprebon, Esq. Office of Child Support 100 Mineral Street, Suite 202 Springfield, Vermont 05156 (802)-885-6293 (802)-885-6213 (fax) christin.semprebon@ahs.state.vt.us