By Rose Hoban
In 2013 and 2014, headlines proclaimed months-long delays in processing applications for Medicaid and food stamps for low-income families.
At the time, former Department of Health and Human Services Sec. Aldona Wos blamed the backlogs and the expense to clear them on a confluence of events: The deadline for rolling out the new state IT system for processing benefits, called NC FAST, and new federal requirements for Medicaid applications both went into effect in the summer of 2013.
Others placed the blame on county social service departments, noting some counties did a worse job than others at keeping up. Some counties – in particular, several urban counties – had greater backlogs.
In turn, officials from those county departments of social services said they were overwhelmed.
Lawmakers wanted to be sure. Last year, they ordered the nonpartisan legislative Program Evaluation Division to examine “the effectiveness and efficiency of Medicaid eligibility determinations.”
A report presented to the Joint Legislative Program Evaluation Oversight Committee last week showed that, indeed, those county workers were being slammed by changes to their processes; multiple, competing demands; tight deadlines; and software systems that were temperamental and slow.
From their findings, PED analysts are recommending state lawmakers create legislation to facilitate the Department of Health and Human Services taking over a county DSS office if that office has fallen too far behind and is unable to make the changes that would allow it to catch up.
“It was not easy,” said Carol Shaw, who led the study for the PED. “It was hard. Workers were having to learn a whole new way of doing business with a system that they had never used before.”
Confluence
North Carolina is one of only eight states where county workers determine Medicaid eligibility for applicants. Those county workers now use the North Carolina Families Accessing Services through Technology, or NC FAST, system to do much of their work.
NC FAST was created to consolidate many of county DSS tasks – everything from processing Medicaid applications to tracking home-heating program subsidies – into one computer program. But each part of the system needs to be introduced one “module” at a time.
The Medicaid registration module was originally scheduled to roll out some time in 2014. But as the Affordable Care Act was being implemented, initiation of the Medicaid portion of NC FAST was pushed up by a year so it could work in conjunction with the launch of ACA exchanges in October 2013.
Both systems ended up having trouble. Healthcare.gov, the website for the ACA exchanges, was famously problematic at launch. And federal officials kept sending Medicaid policy changes to the states, which workers had to learn and programmers had to work into the NC FAST software.
“In fact, the department [of Health and Human Services] was unable to send out [Medicaid] policy information until late August because it did keep changing,” Shaw told lawmakers. “In fact, they had to make several changes even after it was effective. So county workers had a lot to learn in a short period of time.”
County workers were also trying to manage the simultaneous rollout of the part of NC FAST that manages Supplemental Nutrition Assistance Program benefits, more commonly known as food stamps. The rollout of that module was also a glitch-filled mess, crippling the system, causing delays and denials of benefits for many eligible families.
“We believed we were current until the meltdown in mid-July,” Mecklenburg County DSS director Peggy Egan told N.C. Health News at the time, referring to implementation problems that hobbled the SNAP system during the summer of 2013. “When NC FAST was down in mid-July, we had staff coming in at 5 a.m. and staying until 7 p.m. It took us to mid-to-late-August to catch back up.”
Shaw reported that county workers, already inundated with all the work and the bugs in the system, also had to contend with Internet-access issues, particularly in smaller counties. And all of the county workers in the state were hampered by outages in the system that permits access to state records.
“Workers had two months – two months to learn how to use the NC FAST system,” Shaw reported to the committee. “So they had to learn a complicated software system to use and they also had to learn new Medicaid eligibility policy that was sent down from the federal government.”
Finally, the help desk set up to assist county workers with problems was also swamped.
“We reviewed help desk tickets for a six-month period in 2015 and found that average resolution time for help desk tickets during that time was 23 days,” Shaw said. “There were some help tickets that had wait times ranging from 64 to 189 days.”
Federal rules require Medicaid applications be processed within a maximum of 45 days.
Medicaid applications from the buggy Healthcare.gov system poured in. More than 160,000 extra applications came in during a two-year time period; fewer than 13 percent were eventually approved.
“The approval rate was so low because Healthcare.gov applications were either duplicated, so there might be several from the same person; [were] from individuals that already were on Medicaid who perhaps didn’t know they didn’t need to apply again; from people who were just not eligible, probably based on income; or the applicant withdrew their application after they were contacted by the DSS office for more information,” Shaw said.
“Medicaid eligibility workers still had to spend time on every one of these applications, regardless of the outcome.”
Down to zero
In 2012, all 100 of North Carolina’s county social service offices met their benchmarks for timeliness set by the state and federal government. By 2014, no counties met those benchmarks.
“PED concluded there is a relationship between the increased Medicaid application workload and the decline in the statewide timeliness percentage,” Shaw said.
When she and her team interviewed county DSS directors, they learned the extent of county woes: increased use of sick time and family leave, and many workers simply quit.
County agencies had to hire close to 1,500 new workers over the two-year time period, with the federal government picking up 75 percent of the tab.
“We were doing our best,” said Susan McCracken, director of the Lincoln County DSS.
“It was very frustrating and hurtful for our staff and for these families who had trusted us for so long to do what we were expected to do,” McCracken said, recalling how line workers were on the receiving end of applicants’ frustration.
She said it was also “agonizing” for workers to know that “someone might not get the surgery or the medication or the things that they needed the next day.”
The good news, she said, is that the system has improved significantly, something Shaw also reported.
Takeover
Shaw and her team suggested to lawmakers that they draft legislation to allow the state to take over a troubled county DSS agency in the event of similar meltdowns in the future.
“DHHS has limited authority for holding counties accountable for meeting state standards,” she said, noting that there’s a similar law that allows for takeover of a child-welfare agency that’s underperforming.
Under state management, county DSS offices would be divested of Medicaid administrative authority and the state would withhold federal funds to the county.
The state association of county DSS directors has supported the proposed bill and there’s thus far been no objection from county commissioners.
McCracken noted that having the PED report also means something for county managers and county commissioners who felt the pressure from constituents and had to approve money to hire new workers.
“We needed resources; we asked for resources,” McCracken said. “Now they can really see why.”
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