Appendix A (Part 1)
HEALTH AND HUMAN SERVICES COMMISSION
PROGRAM: Children's Health Insurance Program (CHIP)
MEETING DATE: Friday, June 30, 2000
1. ServicesCHIP is a state sponsored insurance program designed for families who earn too much money to qualify for Medicaid health care, yet cannot afford to buy private insurance. Families pay premiums that vary depending on family income, regardless of the number of children in the family. These costs could be as little as a $15 annual premium, or as much as $18 paid each month ($216 a year). Most families also have co-payments that vary on a sliding scale, depending on family income. Children enrolled in CHIP are guaranteed 12 months of coverage. Children must be re-enrolled annually.
The program just started accepting applications in April, 2000. Health care started 5-1-00. Enrollment is expected to reach 100,000 by this fall. The original projection was for 400,000 after two years, but Texas is currently ahead of the pace of other states' startup experiences.
2. Current Delivery SystemA third-party administrator, Birch and Davis, determines eligibility and they are responsible for premium payments collection. Applications are currently taken over the phone and by mail.
The state contracts with private HMO's to provide the coverage. The HMOs issue a member card to enrollees - just like any HMO card. The provider dials in on the phone to check eligibility, cost-sharing and co-payment information; or they can call the health plan to check services. The system is comparable to commercial market coverage. Members can change plans once a year or more frequently with good cause.
Although the program is supported with state funds, members see it as private insurance, and it has a non-governmental profile.
3. Identify Current or Planned EBT/ESD InitiativesMr. Jason Cooke, director of CHIP, thinks that ESD applications could improve this program, eliminating, for example, some of the current telephone processes relating to confirmation of cost sharing and co-payments liability. A card system could streamline that process. Others suggest that it could also carry basic health information, immunizations, etc.
Another possible program enhancement would be to allow for CHIP premiums to be paid at various cash payment sites, like HEB, similar to the way utility bills are currently handled. Issues around such an initiative would need to be explored.
Texas Healthy Kids Corporation is a private, non-profit program similar to CHIP, but it was started before CHIP. It is expected that CHIP-eligible kids enrolled in that program will eventually migrate into CHIP.
4. Issues to Consider Related to an EBT/ESD System:
- There may be concerns about a central repository of health data; however that would be minimized if the data were input by the health provider instead of accessed from a large database.
- Because of the program's profile, any card used would have to avoid the image of a 'welfare' card. Also, since the program is open to legal immigrants, any image of connection to a government sponsored program (especially one perceived to relate to INS) is an emotionally charged area.
- The HMO's currently view their client member cards as a marketing tool, so that is another issue to consider in designing the face of any card used.
5. General Comments:The CHIP program is very busy now with startup. They want to avoid a major change, such as ESD, in the immediate future, but they will be interested in exploring its possibilities within the next couple of years.
Mr. Cooke would like for a draft, high level description to be discussed with the third-party administrators so that any additional issues associated with an ESD plan can be identified.
TEXAS DEPARTMENT OF HUMAN SERVICES
MEETING DATE: June 8, 2000
- Goal: The primary goal of EBT2 is to provide seamless, low-risk transition, ensuring no disruption to delivery of Food Stamp and TANF benefits.
- Target Population: TANF (Temporary Assistance to Needy Families) provides financial and medical assistance to needy dependent children and the parents or relatives with whom they are living. Eligible TANF households receive monthly cash and Medicaid benefits.Food Stamps permit low income households to purchase a nutritionally adequate diet through normal channels of trade.
Legal Citation: Texas Human Resource Code Annotated, Section 21.001
2. Current Delivery System:Texas operates the nation's largest EBT system, delivering TANF (Temporary Assistance to Needy Families) and food stamp benefits to over 1.4 million recipients (528,000 households) via a magnetic stripe debit card that can be used at over 13,000 Texas retail outlets. EBT was implemented statewide in November 1995.
3. Identify Current or Planned EBT/ESD Initiatives:Transactive Corporation informed DHS that it was exiting the EBT business upon the expiration of its contract in February 2001. EBT2 will replace the current system operated by Transactive. The transition to EBT2 will be completed in January 2001.
A key objective in the EBT2 transition is to replace the approximately 15,000 point-of-sale devices currently being managed by Transactive, i.e., the state. The new devices, the Hypercom ICE 5500, will be deployed by Affiliated Computer Services (ACS). ACS's contract with TDHS calls for the transition of retailers who currently process transactions through state-supplied (Transactive) equipment to retailers who process transactions through ACS/Card Systems as a third-party processor. As part of its agreement with TDHS, during the transition period ACS must execute new retailer agreements (contracts) with these retailers and provide them with new point-of-sale (POS) terminals and training.
GTECH has been selected to provide call center services for Texas' EBT2 system. The contract was executed on May 15, 2000 and has been approved by the U.S. Department of Agriculture Food and Nutrition Services (USDA/FNS). Under this contract, GTECH will provide multi-lingual hotline services for Texas Department of Human Services' Lone Star cardholders and manual voucher
processing for retailers participating in the Lone Star EBT program. The call center handles over 1.8 million client and retailer calls per month. GTECH will be compensated on a per call basis.
Northrop Grumman Technical Services, Inc. (NGTSI), in partnership with Transaction Processing Services, has been selected as the data center for the Texas EBT2 system. The letter formally announcing the selection was released March 17, 2000. The contract was approved by the U.S. Department of Agriculture Food and Nutrition Services (USDA/FNS) and was executed on April 27, 2000. The five-year contract is valued at $19 million and includes a five-year option valued at $20 million. Under this contract, NGTSI will provide all EBT transaction processing and EBT software maintenance services.
4. Issues to consider related to an EBT/ESD System:
- All stakeholders are important, especially retailers.
- The use of ATMs for cash transactions - who pays the fees.
- Retailers cannot afford to keep too much money on hand for large cash transactions
- How would one card, one platform, multiple services be administered - an option suggested is to model the administration of an ESD system on the process used to administer the Health and Human Services Communication Network (HHSCN).
5. General Comments
- EBT2 group is about 15 people
- The cost of the new system should be less than a 30% increase over the old system
- DHS is happy with Transactive
- In the new arrangement the state will have a perpetual license from Transactive for the software and can make modifications - TDHS has the source code required to allow modification to the software.
- Other agency programs and services that require code modifications can be added to the EBT2 system, however the licensing agreement requires a payment of $1million for each agency added up to a total of $2.5 million. Once the $2.5 million maximum is reached other agencies can be added at no additional cost.
- The WIC program will not be using this software to process their transactions
- The system will have three mirrored systems running at the same time to provide backup in case of system failure.
- The EBT2 contract is for five years beginning in January 01.
- EBT2 offers a more open infrastructure - allowing more retailers, ATMs and programs with cash benefits to be added.
TEXAS REHABILITATION COMMISSION
PROGRAM: Vocational Rehabilitation and Disability Determination Services
MEETING DATE: June 12, 2000
- Goals: To provide services to people with physical and mental disabilities, by adjudicating disability determinations for those individuals as appropriate and providing rehabilitation services where appropriate.
- Target population: People with physical and/or mental disabilities
- Legislative authorization:Vocational Rehabilitation Act of 1973, as amended and Social Security Act of 1935, as amended.
2. Current Delivery System:
- Describe: The commission has two major programs, Vocational Rehabilitation and Disability Determination Services.
- Disability Determination Services
- Claims for disability are first filed at SSA and then sent to TRC for investigation and determination. Then the claim goes back to SSA after a determination is made by TRC.
SSA then either authorizes payment of the claim or not based on the information provided by TRC;
- TRC in most cases does not see the claimant. Information is usually obtained by a phone contact with the client and from medical records;
- Disability determination is just a 'paper view' of the claimant. A paper file containing all the medical evidence is sent to SSA. TRC does has a face to face hearing with some beneficiaries, but only about 10,000 per year;
- Vendors used in the claims process are mainly medical providers to obtain medical evidence;
- Payment for transportation is sometimes provided to get claimants to medical examinations;
- SSA still issues a lot of paper checks but most are electronic deposit; and
- TRC processed 241,637 Title II and Title XVI cases in Federal fiscal year 1999.
- Vocational Rehabilitation:
- Vocational Rehab is centrally administered from Austin;
- Vocational Rehab eligibility is determined not by income but by a combination of factors, including ability/restrictions of client and level of need;
- The client is seen in 140 offices around the state for application, eligibility determination service counseling. There are 491 counselors for vocation rehab services in these field offices;
- Together the counselor and the client chose the vendor for treatment/service, as appropriate;
- TRC provides services for approximately 114,000 persons a year. Generally the active time frame for a VR case is about 18 months;
- Payment for transportation is sometimes provided for client to get to school/training or services, but transportation orders are usually very short-term;
- SSA will reimburse the VR program for VR services provided to SSI/SSDI recipients that are employed as a result of the services;
- No information could be provided on clients being banked or unbanked;
- A purchase order is sometimes mailed to the vendor but usually given to the client who delivers it to the provider. Vendors send an invoice when the service is delivered. Payment is made only after the agency is assured the services have been provided; usually by invoice or report (paper). Prepayment is made on occasion for such costs as rent or dormitory fees;
- An amendment to the 1993 Vocational Rehabilitation Act regarding post closure services allows services to be provided after the client is closed and employed. There is only a small percentage of return clients. When a case is closed, it can be re-opened after 2 years as a new case; and
- An enterprise database is used for vendors. That informs counselors what vendors are certified to deliver a specific service in their geographical area.
- There is no consistency in reporting format from vendor to vendor; and
- Verification of service delivery by providers is sometimes difficult; e.g. did clients actually attend classes at a university?
Direct and indirect costs:
- For Vocational Rehabilitation there is federal matching; 78.7% federal and 21.3% state funds; and
- For Disability Determination Services; 100% federal funds from Social Security Administration.
3. Identify Current or Planned EBT/ESD Initiatives:Is EBT/ESD currently used by the agency?
- In June, 1997, an electronic case file system was implemented for VR, which is used by the counselor. It is purely informational with some options to guide the counselors in treating the client. The counselor still makes individual eligibility and plan decisions then enters that information into the electronic file. There is no program cross match in the system to inform the VR and DDS staff if the applicant/claimant is already active in the system.
Has the agency evaluated the financial and programmatic impact of EBT/ESD on the agency programs?
- Yes; in the late 1980's early 1990's, some research with laser card technology was considered but it did not seem to work for the applications needed at that time. Also, equipment cost was prohibitive. At that time there was not a fit; and
- One area looked at in the past was E-commerce but it was not quite right to fit the TRC functions.
If yes, is the report published and available?
- A report was developed in the early 1990's; however, the report is no longer available.
Can EBT/ESD improve the delivery system? How or why not?
- Discussion at an SSA conference in Baltimore suggested the Internet as the vehicle for medical reporting in the next 10 years. TRC agrees this is the way to proceed; and
- A possible enhancement would be an electronic system that could validate actual service delivery from a university (or other vendor) and provide an audit trail that assures the service has been provided. This could also certify the payment for a provider service.
4. Issues to consider related to an EBT/ESD System:
- Difficulty of separate agency budgets for capital outlay expenses in acquiring equipment for ESD.
- Physical and mental disabilities of clients tend to limit use of technology that requires use of hands or full mental capacity.
- Client permission issues with mentally disabled client - are they competent to give permission?
- Confidentiality of medical records.
- Individual providers may not be able to participate in a 'standard' vendor system.
- The agency may not be able to support the spending of money on a 'card-type' methodology.
- Interfacing with other agencies is very difficult; Internet would be the best method.
5. General Comments:
- An oversight of providers is necessary to assure authorized services are delivered.
- Should consider moving to a process that would allow moving to a centralized Internet system instead of spending money for a card system.
TEXAS DEPARTMENT OF MENTAL HEALTH/MENTAL RETARDATION
PROGRAM: Facility Residential Services
MEETING DATE: June 6, 2000
1. Services:Mental health and mental retardation services delivered in state hospitals and state schools are provided by medical and nursing professionals and attendants. Twenty-four hour monitoring, supervision, and assistance is provided in an environment designed to provide treatment, habilitation, rehabilitation, safety and security. Mental health patients are treated in state hospitals during acute psychiatric crises, and the length of stay is relatively short-term. State Schools operate as long-term homes for persons with more severe mental retardation who often have significant medical complications and behavior disorders and are unable to live in a less restrictive environment.
- Goal:The goal of treatment in state hospitals is to relieve acute psychiatric symptomatology and restore the patient's ability to function in a less restrictive setting. The goal of residential services in state schools is to provide active treatment and habilitation in a safe and secure home for persons with more severe retardation who require more assistance than can be provided in their own home or in a community residential setting.
- Target population: Mentally ill citizens and citizens with mental retardation. These services are delivered only to those clients in MHMR's defined priority population.
- Legislative authorization: State Agency.
2. Current Delivery System:
Clients in need of state facility services must be recommended or authorized by the local MH or MR authority having geographic jurisdiction, before admission to a state hospital or state school. The local MH or MR authority (usually the local MHMR Community Center) certifies that the client's needs can not be met appropriately in a community setting, either because of the person's level of need or because of a lack of available community resource. The client is registered on the centralized and automated case management (CARE) system. Discharge planning is also done in partnership with the local authority, and the case is transferred to them upon discharge.
During residential treatment the medical record is a hard copy file, which is maintained in the unit's nursing station. Entries in the record are made by hand or typed following dictation by the attending staff. Closed records are stored on microfiche after a certain period of inactivity.
Records can physically reside in the same location as patients, and are readily available to appropriate treatment professionals without expensive automation infrastructure.
- The current manual medical record system is cumbersome. Hand written charts are time consuming and duplication of records, when necessary, costs time and paper.
- When sharing copied or transferred records they must be mailed or transported in a manner that insures confidentiality is maintained. The necessary security could be better controlled with an electronic file.
- Authorizations for release of medical information is never a blanket release - each instance of information sharing is treated as a separate 'event' and must be separately authorized.
- Technical infrastructure:
- Central agency mainframe maintains client records, which document client; registration, types of services and service locations. Details of service events are not collected;
- Case files are manual and kept locally by the Centers;
- Centers may operate Local Area Networks; and
- There is a statewide email system among state facilities. Community MHMR Centers do not participate in this network.
3. Identify Current or Planned EBT/ESD Initiatives:
- MHMR is currently implementing an electronic client record system for state facilities. (Community MHMR Centers are not included.) A master electronic record is maintained that clinicians access through work stations for reading and for direct data entry to the charts. Data will also continue to be entered through traditional voice dictation, which will then be keyed into the automated system. Staff are exploring a possible voice response system that can interface with the electronic client record to eliminate this manual keying requirement. As MHMR is exploring options for electronic intra-agency sharing of the medical records, existing laws relating to privacy of information will govern these activities.
The system is currently implemented in eight facilities: four state schools and four state hospitals. It is not necessarily cost effective in the short run, but has potential for significant savings with full implementation. Completion of Phase I and Phase II rollout are planned for the end of FY2002 for all facilities. However, lack of funding for capital outlay may slow statewide implementation.
Several states across the country are currently implementing this type electronic client record system, and Scott and White Clinic in Temple is working on a similar pilot.
Another area for possible exploration is patient trust fund accounts. Facilities are often trustees for clients' personal funds and expenditures from those funds must be carefully monitored. Debit cards or similar technology might be considered; however, audit trails with verifiable receipts must be assured for SSI and other funding sources. There is a high volume of these transactions and they are often complex. TDMHMR currently has an automated client trust fund system, but it has traditional data entry interface.
4. Issues to consider related to an EBT/ESD System:
- Confidentiality of client information is a major concern. Clients of MHMR are particularly concerned about privacy issues because of potential stigmatization. MHMR is currently working on confidentiality issues for the electronic medical record. MHMR is collaborating with Carolyn Purcell at the Department of Information Resources (DIR) who is coordinating state efforts toward security assessment rules. Beliefs and behaviors need to be firm in this area before proceeding. MHMR is ready with the necessary encryption code and is now working on a list of secure access criteria (who should be allowed the information).
DIR and the Health and Human Services Commission are also incorporating an assessment of the impact of the federal Health Information Portability and Accountability Act (HIPAA) on state agencies. Rules are currently being promulgated by the federal government that will dictate how confidentiality of automated health information is handled. This is significant legislation, but may not have major impact in Texas, since this state's existing privacy laws are so stringent.
- MHMR strongly supports and encourages development of systems with multiple interface features. This is partially an ADA issue - being able to accommodate access needs of a variety of levels of client and professional capabilities. The core systems must have multiple access options. An example of this is the exploration of voice response entry into the client record system in addition to direct keyed entry.
- MHMR has concerns regarding the client population's abilities to responsibly manage a card system (such as in Trust Fund accounts.
- When sharing copied or transferred records they must be mailed or transported in a manner that insures confidentiality is maintained.
- Authorization for release of medical information is never a blanket release - each instance of information sharing is treated as a separate 'event' and must be separately authorized.
- In a practical sense, expedience sometimes wins out over care regarding confidentiality: situations have been discovered where staff have e-mailed patient information. In at least one instance, the e-mail was misrouted, resulting in a major breach of confidentiality.