Summary

Pennsylvania has had important success in providing health insurance coverage: according to a 2005 state report only 8 percent of Pennsylvanians, and only 4 percent of the state’s children, are uninsured. A core component of this success has been strong public programs. About one in three children are covered by Medicaid or CHIP (its State Children’s Health Insurance Program), and in March 2007 the state expanded eligibility for CHIP in an effort to cover the remaining 133,500 uninsured children.

Pennsylvania has also been successful in implementing innovative technology to create enrollment and renewal practices that are easy to navigate for families and program staff. In particular, the state developed an online application called COMPASS (Commonwealth of Pennsylvania Access to Social Services) and then worked to link this system to the state’s toll-free Healthy Kids Helpline. The work in Pennsylvania demonstrates how technology can be utilized to make sure children and families get the health insurance coverage they need.

This state example focuses on COMPASS. For information on the 2007 state eligibility expansion, Cover All Kids, see the Summary and Pennsylvania: At a Glance. You can also read the full brief Streamlined Enrollment & Renewal through Technology.

Background/History

In the early 1990’s, a lawsuit on EPSDT¹ service delivery in Pennsylvania brought advocacy groups and government staff together to develop strategies for improving access to health care. Because Medicaid and the then-state-funded Children’s Health Insurance Program (CHIP) were housed in different agencies (the former in the Department of Public Welfare and the latter in the Insurance Department), the need for joint efforts and strategic alignment of policies and practices was pronounced.

Following the launch of the federal State Children’s Health Insurance Program (SCHIP) in 1998, these working sessions resulted in development of a key product: a joint Medicaid and CHIP application that was literacy tested and more user friendly. Additional Medicaid and CHIP enrollment and renewal policies and practices used in Pennsylvania include:

• 12 months continuous eligibility for CHIP (although Medicaid has a 6-month renewal period);
• No face-to-face interview required to apply for, or renew, coverage;
• No asset tests for children; and
• Presumptive eligibility for pregnant women.

Building on this simplified system, in 2001, the Pennsylvania Department of Public Welfare launched COMPASS, an online program that allows families to apply for, and renew, coverage for social service programs directly from their homes or communities.

COMPASS’s first offering was the state’s joint application for Medicaid and CHIP, but since that time, it has expanded to enable applications and renewal for a wide range of social service programs. COMPASS links with a database of existing client information to further streamline the eligibility determination process.

Over the years, the Departments of Public Welfare and Insurance have regularly reviewed how the system is being used and made improvements as needed.

• Providing clearer instructions. In the early days of COMPASS it was discovered that thousands of users who filled out applications were failing to hit the “transmit” button—the system detected these “incomplete” applications sitting in cyberspace. In addition to person-by-person outreach to make sure those applications were submitted, the Department of Public Welfare changed the final COMPASS screen to ensure completion of the process.

• Targeting other government service users. In 2007, in an effort to reach more users of government services, “post-eligibility screening” was added to COMPASS. This means people completing applications for non-health programs get an on-screen message indicating they may, based on the information they provided, be eligible for Medicaid or CHIP. If desired, they can add health care coverage to the application prior to submitting it.

• Reducing the paperwork burden. Under a current US Department of Agriculture grant, the Department of Public Welfare is testing the ability of the Food Stamp program to scan client documents and attach them to COMPASS applications. When the pilot is completed, these scanned documents may be available to all programs using the online system to assist with verification for the non-Food Stamp programs.

• Undertaking deliberate marketing strategies. In a 2006 survey, the Insurance Department found that 70 percent of Pennsylvanians had Internet access. It was also learned that COMPASS did not have the same brand recognition as CHIP. In response, a number of steps were taken to enhance the user-friendliness of the COMPASS website, increase its prominence in advertisements and other outreach vehicles, and more explicitly link it to the CHIP program. For example, the state now does web advertising for CHIP (with a direct link to COMPASS) through search engines like Google and Yahoo.

Linking the Online Application to the Toll-Free Helpline
In 2003, to further improve the Medicaid/CHIP application process, the state, in partnership with the Pennsylvania Covering Kids & Families coalition and the state’s Helpline contractor, Deloitte Consulting, decided to develop a direct link between COMPASS and the state’s toll-free Healthy Kids Helpline. The proposed solution was that Helpline callers, instead of being sent a paper application in the mail, would be able, if they chose, to receive over-the-phone application assistance in the moment. Helpline staff would then submit the information through COMPASS on the caller’s behalf (the paper application option remained available to callers).

Beginning in December 2003, the idea was tested and when compared to outcomes for callers who were sent an application by mail, those who had been directly linked to COMPASS had significantly higher rates of completion. Training the operators was unnecessary: they were already skilled in coaching callers on eligibility, and because the paper application had been literacy-tested, if the operator read it verbatim, it was found that the caller knew what to do. Deemed a success, in November 2004 the Helpline-COMPASS link was adopted statewide. Currently, all Helpline callers can immediately apply for, or renew, coverage for Medicaid or CHIP over the phone.

Primary Support

The political climate in Pennsylvania has been consistently supportive of innovations that facilitate Medicaid and CHIP enrollment. The creation of COMPASS also benefited from early inclusion of non-government partners as Beta-testers and advisors. As the Web site has evolved over the years, the Departments of Public Welfare and Insurance have continued to bring a diverse group of stakeholders to the table to provide feedback.
The Helpline link itself was established through a team-based approach that included a number of critical roles:

• Medicaid officials provided leadership and decision-making as policy and systems issues arose.
• The Outreach Director at the Insurance Department provided data on COMPASS and Helpline utilization.
• The Helpline Director trained and monitored staff and oversaw the pilot tests.
• COMPASS system technology staff tracked applications.

Also helpful, many state legislators were familiar with the Helpline and COMPASS since their constituent services staff regularly referred people to these services. Some legislative offices have even been designated as “COMPASS Community Partners,” meaning they can take and submit applications for CHIP, Medicaid and all other social services programs offered through COMPASS.

Program Elements

The COMPASS website allows individuals to apply for, and renew participation in, a broad range of social service programs, including: Medicaid, CHIP, adultBasic, cash assistance, food stamps, home and community-based programs for individuals with mental retardation, long term care, the Low-Income Home Energy Assistance Program (LIHEAP), and school lunch and breakfast programs.

COMPASS allows applications to be completed in English and Spanish, with a direct link to assistance in Russian, Chinese, Vietnamese and Cambodian. The site only asks questions relevant to the eligibility criteria associated with the programs selected. The system does not determine program eligibility, but for health care applications COMPASS does perform a high-level eligibility review and routes the application to the proper program. Documentation of income must be submitted separately.

Renewals completed through COMPASS are faster and simpler than the paper renewal process, since key information is automatically imported from the eligibility system. At the conclusion of the renewal, COMPASS provides a list of any items requiring verification and provides instructions for submitting them.

COMPASS has a number of other key features:

• Pre-screening. COMPASS administrators discovered that many people do not want to complete and submit a full application without knowing whether or not they are likely to be eligible in the end. As a result, a confidential screening mechanism is available for every program: no name or identifying information is necessary to determine if a user “appears eligible” and what his or her grant or allotment may be. Information from the screening can be imported into an application if the user decides to apply, eliminating the need to re-enter the data elements. Concerns about users printing their screening results and then demanding” benefits were unfounded.

• Personalized Accounts. COMPASS allows current public benefits recipients to create secure, personal accounts through which they can get quick information about their health care, food stamps, or cash assistance benefits, check on the status of an application or temporarily suspend an application or renewal in order to gather additional information.

• The “Power User” Version: Facilitating Community-Based Application Assistance. COMPASS was initially developed for use by citizens. As a result it features user-friendly “bells and whistles,” numerous help screens, etc. However, community organizations seeking to help many applicants did not want to be slowed down by these features. In response, the Department of Public Welfare created a streamlined “Power User” version of the application, which can be used by organizations registering with COMPASS as a “Community Partner.” In addition to helping people complete applications, COMPASS Community Partners can also track applications (individually and in groups) and develop reports with aggregate data.

• E-Signature. Individual applicants using COMPASS can “e-sign” by submitting identifying information and an e-mail address in place of a signature. The applicant is then e-mailed a password, which is used to verify identity. While this is a common process for credit card applications, it is not widely used for public program applications. This e-sign process has federal approval for use by Medicaid, CHIP and nutrition programs such as food stamps. (See: Office of Management and Budget, Memorandum for the Heads of Departments and Agencies, M-00-10, “OMB Procedures and Guidance on Implementing the Government Paperwork Elimination Act,” April 25, 2000.) Applications completed by COMPASS Community Partners or via the Helpline require that a signature page be printed and sent. Troubleshooting on this step of the process resulted in use of an overnight “batch mail” procedure through which signature pages are automatically sent out to those who need them.

• Linking to the state’s toll-free Helpline. As of November 2004, all callers to the state’s “Healthy Babies Healthy Kids” Helpline are offered the opportunity to apply for, or renew, coverage over the telephone if they prefer to do so, rather than wait for a paper application in the mail. Helpline staff take the needed information and submit it through COMPASS. Helpline staff also make reminder calls to families who have less than 30 days to renew their children’s CHIP coverage.

Funding

The initial investment for development of COMPASS was approximately $3.5 million. High-level support for the initiative—and leveraging it with another automation effort ongoing at the time—made it possible. Annual maintenance is split by four departments (Education, Health, Public Welfare and Insurance).

The addition of various features has ranged in cost: post-eligibility screening capacity, for example, required a $50,000 investment. Ongoing web improvements also range in cost, depending on how much is needed. In 2007, a $50,000 “facelift” was undertaken to simplify the main page; a more substantial upgrade currently underway to further simplify the application process through COMPASS will cost approximately $200,000.

Results

In 2003, COMPASS earned first place in the Center for Digital Government’s Best of Web competition for innovations in State General Government. On the ground, online application assistance in Pennsylvania has yielded a number of concrete results. While the state does not yet track coverage by application mechanism (i.e. via mail-in, COMPASS, Community Partners, or the Helpline), and retention rates are currently under study:

• Over the last two years, electronic applications for CHIP have doubled from about 10% to about 20% of all applications received.

• Approximately 700 Medicaid/CHIP applications per month are the result of post-eligibility screening available through COMPASS.

The Helpline completes approximately 400 Medicaid/CHIP applications through COMPASS each month. An unexpected result of this innovation has been a morale boost for staff, who are pleased to now be able to connect people to health care coverage in real time. In some instances, a child can receive coverage within five days of a Helpline call.

In 2002, West Virginia became the first state to replicate the COMPASS system. An independent organization executed the code transfer into inROADS, West Virginia’s version of the application. The design and development was completed in six months. In addition, the following states have leveraged the COMPASS concepts, approach and best practices in developing their own “Self Service” products: Wisconsin, Delaware, Massachusetts, New Hampshire, Florida, Indiana and Nausau County, New York. In February, 2008, Georgia and New York began moving forward with Self Service applications using the COMPASS concepts.

Lessons Learned

Officials and advocates in Pennsylvania have learned:

• No matter how simple a particular enrollment or renewal strategy may seem, it will never work for everyone. There must be a range of mechanisms and choices available.

• Flexibility to make mid-course process corrections is key.

• Small-scale testing of new practices enabled development of workable structures for moving forward.

• Community and consumer advocates play a critical role in securing on-going improvements. The recommendation for the “Power User” version of COMPASS, for example, came from a local Covering Kids and Families pilot site.

Contacts

George L. Hoover
Deputy Commissioner
Office of CHIP and adultBasic Programs
Pennsylvania Insurance Department
717-705-0542
gehoover@state.pa.us

Kristen Wolf
Division Chief for Marketing and Outreach
Office of CHIP and adultBasic Programs
Pennsylvania Insurance Department
717-705-4197
kwolf@state.pa.us

Ann Bacharach
Special Projects Director
Pennsylvania Health Law Project
215-625-3596
ABacharach@phlp.org

David Callahan
Executive Vice President
PA Partnerships for Children
717-236-5680
dcallahan@papartnerships.org

1. EPSDT, the Early Periodic Screening, Diagnosis and Treatment program, is the child health component of Medicaid. EPSDT provides a structure for, and guidance to, states on providing health care services for children in Medicaid and requires states to cover all medically necessary services.