8/20/13 QC SNAP TAG Meeting - Notes provided by Christine Hurschman (DE)

8/20/13 – FNS SNAP QC TAG Meeting – Patrick Lucrezio and Dave Young CAPER error rate - people didn't know the error causal breakdown. FNS surprised that unclear notices 2% of error but alarmed at other items like no notice going out at all, or verifications were in the record and not acted on. There is no legislation for Negatives to be sanctioned, so State IT want to wait until after ARA is in place to be able to make any changes to comply with notice requirements. Participants indicate this is a resource issue for States. Policy FNS has asked regional staff for good and bad notices - think they would need to go through notices and give a policy memo on good notices and what they expect to be in notices. Would be suggestion of the Memo. Hope would be to get to DSS (local State agency) policy units engaged. FNS wants field workers to really work on their processing of information - such as enter information right away. Collins Greer comment - feels that QC is now dictating policy to field. FNS - feel that processing is addressed in CFR regulations and it isn't something that QC just came up with. Certain elements of the regulations were not looked at in previous QC review methodologies. Carolyn (MD) comment – Some regional offices are looking at cases differently than other regions. FNS – Doesn’t feel this is true as regression across the country was fairly consistent. Some regions had higher regressions and those cases went to arbitration and lost. Most region within 3-4% in regression - they are not looking at the reasons behind the regression or that the same notice is either called valid or invalid between regions. Don't believe the differences are so broad to throw off statistics. John (VA) comment - most States lose in arbitration (except Delaware). FNS - feel that the regional offices are coding things correctly and that you don't always win Arbitrations. Patricia (NC) comment - questions from States FNS - will not comment on an arbitrator decision How specific do you have to be on a notice - subjectivity should be easily understandable and shouldn't have things that are conflicting information. You can give more than one reason on notice as long as all are correct. Example: the household provides some but not all of the verifications requested and case is denied for non-cooperation. Notice should say what specific verifications that they haven’t given you to make it understandable. If all verifications are missing, then you would be ok to say "you did not return verifications". If some of the verifications were provided then the notice should specify which verification(s) were missing. Every State is telling the client up front of all the verifications, but should be saying specifically what is still missing. FNS Dave Young - Say that their certification people are put in the position that the reason the adequacy is not important because QC isn't looking at it. Now QC has changed and we are all adapting. FNS Patrick Lucrezio - pick the big problems first then the other things later. Use the breakdown of causal factors to assist you. Notice issues are just a little bit higher than Eligibility problems. Maybe not get so upset about it when you have other problems to work on. Recommends use of the 10-day waiver to deny early as a tool to use to get the work out. Collins Greer (AK) comment - thinks there is a FNS change in philosophy over the last year and is a different than what was explained in the beginning of FY12. Q+A's that were released - some regions were told to hold on different questions FNS - question number 8 about the client moving out of State. Notice would acceptable to say that no member eligible. But should say that moved out of state. That is the one that should change in the Q+A. That is the only one that is going to change. Clarification on Q+A - question 7 living with mom - household eligible for expedited. No have to have an interview before determining expedited. Policy memo feb 6-06 with regard to expedite the interview is a requirement and cannot determine eligible for expedite. ex - living w mom and has income, cannot expedite without finding out if mom has income; cannot just consider him separate household. (IS UNDER 22?) FNS Patrick Lucrezio - feels guidance is hard to be broad and all are specific to the situation. Maybe in future, summit specific questions with layers. 310 is not certification policy. it belongs with policy not QC. Won’t put in certification policy in the 310-manual FNS Patrick Lucrezio - Identify the element that had the most impact on the case so field can do corrective action. The predominant causal factors are the egregious problems. Question: may mean more if got hold harmless. FNS Patrick Lucrezio - no hold harmless periods available but States can submit questions to region and get an answer in writing. FNS Patrick Lucrezio – States can submit question from region - now is not sent to all regions, FNS will consider disseminating informal opinion. Question: if income listed on notice is slightly off by $1, then invalid negative occurs FNS Patrick Lucrezio - If you are being specific enough to list the income, why wouldn't it be accurate? FNS Patrick Lucrezio - completion rate study – some site visits to get an idea of how States are improving their completion rates. Surveys will be conducted in every state by phone. You don't know what you don’t know. It is something to help. They are taking into consideration State busy and want to get good information. For corrective action on negatives; if have negative error should do corrective action plan over 1%. The responses should be from policy on the errors but be realistic. FNS Dave Young - There are no QC errors. There are errors in the certification that are discovered by QC. Somebody screwed up and it wasn't us. Will give breakout of the CAPER rate. When they broke out four categories based on State reported data, and it was problematic. The instructions do say that you use the one that was the most likely the major cause of the error. Consider is important for corrective action. The data should still give you accurate data as to where the error is coming from, and can break them down into smaller percentages and can double check what the errors are from. FNS Dave Young - said that the evaluation of negatives was not thought through. He thinks eligibility is first then timeliness. But other States have other opinions. Will be drafting changes to coding which will better show multi errors.

Building a Flexible House - El Paso CO

8-20-13 Building a Flexible House - Building a Flexible Business Process Model

Arturo Serrano, Economic Assistance Manager, El Paso County Colorado

(Building a Flexible House PowerPoint)

Building a Committed Leadership Team

flexible house = the need to be efficient

flexibility is critic in human services agencies right now.  

El Paso county has 31,000 SNAP cases 

360 degree leadership model committed to change

start with small things - make small changes

worked with consultant on business process improvements

you have to commit to the task - like climbing a mountain.  at some point you commit to make it to the top.

And someone has to commit to the task professionally.  Someone has to see the vision, encourage others and lead the team.

Connect the vision with  your staff.

Start the vision with a small group.  Pilot it.  Fix it.  Then expand it to other units/offices.

Plan. (Decide where you're going-create the vision-obtain buy-in and commitment)  Do. (put plan into place on small scale) Study. (Analyze what you're doing.  Tweak processes/resources.  Update plan.)   Act. (Put updated plan into play in another small area.  Repeat as necessary.)

**Building Your House**

Know what type of house you want to build.  Evaluate your strengths, your resources, your people, your needs.  Decide what is the foundation (core) needs/wants/desires.  Match staff strengths to tasks.  

Transition from appointment scheduling to same day processing is example.

capacity was 119 interviews per day with daily application average of 85.  This started the ball rolling.  moved to same day processing.  All work is held in a common area.  Workers do not keep any applications at their desk.  On worker controls all pending applications.  Processes were re-aligned to new demands.  Cultural change for the staff but they will embrace it.   

El Paso County identified all EW tasks and grouped some tasks to replace individual caseloads.  Honed in on processing timeframes and eliminated unnecessary steps/tasks.  Constantly putting goals in front of staff to keep momentum.  Tasks are assigned fluidly and staff are flexible.      

Keep statistics and data.  Display numbers.  Data will calm emotional responses to issues.

** Remodeling the Home **

Making adjustments in your process.  Constant adjustments toward improvements. 

**The House is Built**

The final product should produce the desired outcomes.  Hold people accountable to expectations.

Federal Panel - Part 2

8-20-13 Federal  Panel - ACA Updates - Part 2

Bob Garcia (ACF) - Correction of website location -  www.acf.hhs.gov

Child Care program - ACF monitors how money is spent and how successful the program is - Quality Performance Report has been introduced as a mandatory report and States must report how they spend their quality money. Federal reviews for eligibility are conducted every 3 years and presently entering into the 3rd cycle set.  Error rates are calculated for the benefit of the individual States.  Self-Assessment tool has been developed to assist States in the identification and assessment of their implementation of the CCDF program.  It shows what they do well along with what they can improve upon.  

Gale Harris (GAO) - Improving Efficient and Effectiveness presentation (PowerPoint)  recent issued work demonstrates:  data sharing (GAO-13-106)  Looked at Michigan, New York, Utah and Allegheny County PA. Focused on eligibility and enrollment and case management.  Showed reduced chance of improper payments and time savings.  Challenges to data sharing - confusion about what can be shared, agencies overly cautious in interpreting requirements, requirements are inconsistent across programs, and organizational challenges (outdated systems, etc)  Assistance is needed in providing guidance, models which comply with federal requirements, funds for pilots and demonstration projects.  Existing federal efforts OMB Partnership fund and toolkit.  GAO is working on data sharing issue. Privacy Act computer matching provisions (coming Dec 2013)  GAO-13-680SP

Options to Improve TANF Performance and Oversight - Examples of options - eliminate or limit the caseload reduction credit, develop additional measure such as job placement or retention.  This would shift focus on work.

GAO-13-570 Strategies to facilitate agencies' use of program evaluation results.  GAO on-going work - Duplication, overlap and fragmentation; Effects of Sequestration; and Improper Payments (SNAP trafficking and the role of participant fraud in the SNAP error rate.)

Gloria Nagle (CMS) - PERM and MEQC reviews - there will be substantial changes in the review process as a result of ACA.  There have been substantial changes to eligibility under ACA such as Switch to MAGI (this is a calculation process); single streamlined application (Medical only and Integrated); multiple access points; seamless account transfers; and hub to provide real-time data.  The show letter provided last week basically said that due to the big changes, there will be an interim review process established.  Looking for States to develop pilots which can be tested and implemented.  

Mary Ellen Wiggins (OMB) - PowerPoint Presentation-  Inspiring to see focus on customers and outcomes.  But how can programs be delivered in a more efficient and accountable manner?  Apply existing evidence that works, generate new knowledge and test new approaches of program delivery.  Partnership Fund -established direct communication between States and OMB.  Launched 11 pilot projects to improve program integrity, efficiency and effectiveness.  Laid foundation for innovative initiatives to improve outcomes for clients.  FY2014 $6 million Evidence-based Innovations built on Partnership Fund defining principles.  Increase cost-effectiveness and return on investment across programs.  Sign-up on Collaborative Forum website to stay current.

Jessica Shahin (FNS) - moving into 21st century has been a focus for SNAP for several years.  States have done great work in this area.  SNAP has a passion on program integrity.  Face of SNAP - 47 million participants, reason is that the program is operating as intended and responding to the national economy.   87% are at or below poverty line, 15% had 0 income, only 3.5% had income over 133%.  41% SNAP households have income.  SNAP's major impacts - lifts people out of poverty and SNAP reduces food insecurity. SNAP needs public support to do it;s job and it needs accountability to gain this support. 

Reducing improper payments - QC program is strong - over 99% of people determined eligible are in fact eligible.  96.58% payment accuracy.  (3.42% error rate)

Retailer Fraud - have taken significant actions to identify high-risk retailers.  When reauthorizing, high-risk are completed annually.  New rules increase retail sanctions.  

Recipient fraud - FY12, there were 730,000 investigations.  Final rule has been published on EBT card replacements which will provide States more opportunities to assist States.  Can look at all transactions and identify those deemed suspicious.  Florida has obtained a waiver to determine identity for on-line applications.

Q:  Medical guidance on MEQC seems late for implementation, will there be any flexibility?  A: The call Thursday may help and should ask the question there.  

SNAP Award Presentations

Completion rate awards - 

Oklahoma - 98.12%

North Carolina - 98.13%

Rhode Island - 98.39%

North Dakota - 98.65%

Vermont - 98.67%

Arkansas - 98.69%

Kentucky - 99.35%

South Dakota - 99.37%

Wyoming - 99.82%

Virgin Islands - 100%

8/20/13 - General Session - Federal Panel - ACA Updates - Part 1

8-20-13 Federal Panel - ACA Updates - Part 1

ACF - Robert Garcia, Acting Regional Administrator, Region IX (San Francisco)

GAO - Carolyn Yocom, Director on the Health Care Team at the U.S. Government Accountability Office

FNS - Jessica Shahin, Associate Administrator SNAP

CMS - Gloria Nagle, Associate Regional Administrator for the Division of Medicaid and Children's Health Organization, San Francisco Office

OMB - Mary Ellen Wiggins, OMB Analyst

APHSA - Larry Goolsby

Medicaid and the Patient Protection and Affordable Care Act (PPACA)

Bob Garcia (ACF) - Asked what is their role in ACA when it was first released.  Concerns about confidentiality.  MIDA development as a result.  Check websites for more details.  Presently working with States on implementation of their system.  National Information Exchange model.  Data exchange program.   Has 1 yr grants available to assist in these implementations.  Confidentiality toolkit will be published in the Fall '13.  Integrated services between agencies/programs.  Developing program fact sheets which can be used to explain various programs available to clients.

Carolyn Yocom (GAO) - Completes investigative work for Congress.  Recent GAO work and the impact to the ACA.  Conducted a study to determine if the State covered parents would it improve the children in the home.  Found there was a strong association with insurance within family.  Looked at Express Lane Eligibility in 13 States.  Found it can save costs, can be beneficial to families, States want to continue in some form, and there were concerns about accuracy.   Studied access to programs.  Challenges are to expand adult provider networks.  Studied Exchanges.  34 States will have exchanges.  Federal Funded Exchanges (FFE) will be critical in program success.

Jessica Shahin (FNS) - Encouraged States to use the waivers and funding opportunities currently available.  Agencies are truly working together on ACA roll-out.  There are regular meetings being held in DC on this.  Encouraged NAPIPM members to get issues and concerns to Larry Goolsby so they can be brought forward.  Consider what are opportunities for policy harmony.  Believes there is a lot of data available in SNAP eligibility files.  Considers ACA to be an outreach opportunity.  The multi-benefit application and integration across programs will be an tremendous advance in customer service.  Will be conducting quarterly wage pilots in 4 States - Texas, Utah, Arizona and Florida.

Gloria Nagle (CMS) - 42 days away from 10/1.  Individuals and families will be able to apply for commercial health insurance or premium tax credits.  Applications will be submitted and information will be available from federal data sources, MAGI applied and customers will be notified of available options.   

Have regional coordinating outreach staff who will work with other federal agencies, stakeholders and customers.  Educate, encourage and enroll.  Presently training navigators and certified application assistants who will be helping individuals apply and enroll.  Marketing and education is current focus. Exciting as transition is occurring from paper system into electronic one.  

Mary Ellen Wiggins (OMB) - Resources available under Partnership Funds.  2 pilots - State System Interoperability and Integration (S12) and Trusted On-Line Credentials for State Agencies.  More information available at website -

www.collaborativeforumonline.com 

Do Not Pay Update - Stops payments when death, excluded parties list, debt check database, List of Excluded Individuals/Entities and Central Contractor Registration.  Summer of 2014 goal is to move from monthly to real-time matching government wide, as appropriate.  

If interested in participating in a pilot, contact Ms. Wiggins. 

Larry Goolsby - From APHSA perspective, sharing information is a challenge with multiple opportunities.   Excited about Federal Data hub and concentration in gathering information and sharing it in real-time is extremely exciting and will tremendously improve program delivery.  90% matching rate is a great asset to States.  

Q:  Address for standard data act A: www.hhs.acf.gov

Q: QC is curious about CMS direction A: Waiting for guidance but know that old MEQC and PERM will require to be updated.  August 15th announcement that there will be an interim review pilot for States.  There is a call this morning regarding this and there is more to come.  (Call has been rescheduled for Thursday 8/22)

Q:  Funding available for computer upgrades for States  A: 210 funding for new systems relating to ACA.  Upgrades to existing systems are 50/50 match.  On APHSA website, there are resources posted to help with funding issues.

Strategies to Reduce Improper Payments in CCDF Program

8-19-13 Strategies to Reduce Improper Payments to the CCDF Program:  Changes to the Error Rate Methodology

Jim Bates (Senior Research Associate) with McDonald and Associates

PowerPoint:  Strategies to reduce Improper Payments in the CCDF Program

Joined McDonald about a year ago.  Previously involved in child care in Wisconsin.

Presentation Agenda:

Data Collection Instructions (DCI)

Error measurement findings'

DCI Modifications'

Technical Assistance strategies

Goals of CCDF Program: 

serve higher proportion of low-income children in high-quality care

increase the continuity

increase the supply of high-quality providers

enhance strong program integrity

Error rate process background

final rule published in September 2007

2002 IPIA (Improper Payments Act) and 2010 IPERA (Improper Payment Error Reduction Act)

renewal methodology October 2010

revision methodology September 2012

Reporting Cycles

1/3 of 50 States, DC and Puerto Rico report each year

First review cycle and second review cycles have been completed.

ACF-402 report is being replaced by ACF-404 report effective 2013

Error rate consists of percentage of IAP (Improper Authorizations for Payments)

percentage of overauthorizations

percentage of underauthorizations

Error rate is calculated on improper authorizations

For 2012 the percentage of IAP was 9.43%

8.68% Overissuances

0.75% Underissuances

2008 - 11.50%

2009 - 11.90%

2010 - 13.30%

2011 - 11.20%

2012 - 9.43%

Under new law, CCDF has to be under 10% or be under a corrective action plan.  This is at OCC level and goes to OIC.  There was not a corrective action plan for FFY12.

For 2012, 14,347 cases were reviewed.  14.14% had IAP errors.  51.61% were due to missing or insufficient documentation.

Missing or insufficient documentation - 34% involved income, 33% involved hours of care, 15% involved eligibility forms, 12% involved residency and 7% involved the provider.

"Other" Error Causes

45% involved income, 23% involved hours of care, 10% involved parental fee, 9% involved the eligibility begin date, 9% involved data entry and 4% involved income changes.

Number of States by Error Rates - 35 states were under 10%, 8 states were between 10-20%

Revised Review Details

Reasons for change - authorizations not accurate proxy for payments

authorizations 20% higher than actual payments

changes allow states to access amount if eligibility error based on actual authorizations

sampled cases - old - any child authorized for a sample month / new - a child for whom a payment was made for the sample month

review focus - subsidy amount / payment amount

sampling decisions, assurances, and field work preparation plan - field work preparation plan / mandatory portions of the fieldwork

record review worksheet - states may modify the RRW / states will modify the RRW (needs customization to meet individual states needs)

Fieldwork Preparation Plan

Mandatory Items -

project and review team leadership

review team composition

methods to ensure inter-reviewer consistency

error definition  (Re: Threshold - if State defines as an error through their policy, it is an error.  Example: If income changes by more than $200, it was not required to be reported under State policy.  Therefore, these income variances could be accepted under these reviews.)

record retention measures

Comment:  The focus is looking at what the worker had in front of them at the time they processed the case.  If the client failed to report, the worker wouldn't have known. If the client reported and the worker should have acted then there is an error. If they didn't or couldn't have known at the time of their eligibility decision, it would not be considered an error for this process although you would pursue any overpayments.

Also, if policy requires workers to look at interfaces and electronic matches and they don't then it is an error.  However, if that is not required under state policy, then it may not be an error.

Optional Items -

designee(s) for submission of final report

process

Key Definitions -

Subsidy amount - maximum amount the State will pay

sample month payment amount - the amount paid for services in the sample month.

Record Review Worksheet - Federal requirement - can use your own techniques/systems to populate the form

underpayments and overpayments are added together to determine the actual amount of total amount of improper payment (they are not netted) 

Technical assistance to support review process and error measurement include:

State training workshops

Fieldwork plans, sampling plans and review worksheets

Case review scenarios

Final report submission and review

OCC National Error Measures Report

Comment: Partial payment months can be dropped if included and defined in your fieldwork plan.  Delayed payments can also be dropped if your State fieldwork plan and sampling plan allow for it.

If payments reflect multi-month service, the State must define how they want to review those payments.  Some States prorate the payments and others assign it to the month of payment.  Either is ok as long as it is consistent and there is logic behind it.

Error Definition

core eligibility vs. business process items

define which errors affect core eligibility as opposed to business processes

all errors are important

determine what constitutes a reasonable/flexible review approach

all-state calls

IT guide

self assessment site visits

error definition workgroup

subsidy TA requests (e.g., fraud prevention and detection, policy reviews)

Goals of Self-assessment

assess internal controls

identify strengths and weaknesses

address areas at greatest risk of fraud, waste, abuse and mismanagement

formulate mitigation strategies

Grantee Internal Controls Self-Assessment Tool

50 + page document to look at CCDF regulations and walk through what State does, what works, what doesn't and how to improve

5 sections - Program Operations and Integrity; Eligibility Determinations and Reviews; Fraud Detection, Reporting and Recovery; Audit and Fiscal Monitoring and Information Systems

Self-Assessment process usually takes 2 full days.  Focused on States with higher error rates and some States for their Best Practices.