LINDA LINGLE LILLIAN B. KOLLER, ESQ.

GOVERNOR DIRECTOR

HENRY OLIVA
DEPUTY DIRECTOR

STATE OF HAWAII
DEPARTMENT OF HUMAN SERVICES
Med-QUEST Division
Administration In reply, please refer to:
In reply, please refer to: P. O. Box 700190
Kapolei, Hawaii 96709-0190 Governor’s Referral No.:

June 24, 2010

MEMORANDUM

TO: Lillian B. Koller, Director

FROM: Kenneth S. Fink, M.D., M.G.A., M.P.H., Administrator

SUBJECT: REQUEST TO FILL ESSENTIAL VACANT POSITIONS AT THE MED-QUEST

DIVISION IN RESPONSE TO THE AMERICAN RECOVERY AND
REINVESTMENT ACT (ARRA) OF 2009

I am requesting expedited approval to fill positions in my Division for us to be able to effectively

implement the American Recovery and Reinvestment Act (ARRA) of 2009 and the Children’s Health
Insurance Program Reauthorization Act (CHIPRA), and serve the unprecedented demand for our
services.

As you know, we had placed a self-imposed hiring freeze as we began our reorganization. When we
ready to begin filling those positions, a State government wide hiring freeze was placed. We did make a
request for approval to fill a set of critical positions, that was approved. Currently, we still have a large
vacancy rate (62 positions plus 4 imminent retirements), and we are unable to adequately meet the
current demands of increased applications and enrollment with determinations within the required
timeframe, the requirements of the ARRA, and the implementation of the CHIPRA. These programs can
generate in excess of $327 million in new Federal funds for the State if we meet all of the requirements.
The following 41positions are necessary:

• 20 positions in the Eligibility Branch

• 17 positions in the Customer Services Branch (8 are vacant and 9 are converting from exempt to
civil service
• 2 positions in the Policy and Program Development Office
• 1 position in the Health Care Services Branch
• 1 position in the Training Office

Although I have provided a justification for each position on the individual B-1 and B-2 forms, I will
summarize the needs of each Branch or Office in general terms here.

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Eligibility:
The Eligibility Branch needs to fill its vacancies not primarily as a result of the ARRA, but as a result
of the factors that led to passage of the ARRA. We have seen an unprecendented increase in
applications and enrollment, with the most recent data showing a 12% increase. The average
Medicaid Eligibility Worker (EW) has approximately 800 cases, and staff are experiencing backlogs
in processing applications. We are required to make determinations within certain time frames, and
we are not meeting those requirements.

Not filling these vacancies will impede our ability to fulfill our full safety-net role because we could
not be able to make to make timely eligibility determinations. The Eligibility worker is responsible
for determining initial and on-going eligibility for medical assistance. If application processing is
delayed beyond 45 days, the department will be out of compliance with federal regulations. This
leads to presumptive eligibility which increases work because this eligibility needs to be entered in
the system and then updated once a formal determination is made. If an applicant is found ineligible,
the coverage would be ineligible for Federal match and would be entirely State funded.

With the ARRA provisions that affect BESSD, we expect increased work to roll over in addition to
that agreed upon in the SOPs. We also plan to revamp the funeral payments to avoid the need for
contracting and will instead keep with the EWs to decrease expenditures. We continue to streamline
processes, use a one-year expansion of the eligibility pilot, and pursue uses of information
techonology, but we still need the bodies for the extraordinary volume of work.

Customer Services Branch:

The Customer Service Center currently has a 56% vacancy rate in this unit. Staff are struggling to
meet the current volume and will be unable to effectively address the increased volume without
filling these vacancies. If we do not fill this vacancy; we will need to continue and expand a
temporary contractual relationship with an outside call center. We would expect to receive union
challenges to this action and obstruction all the while incurring an increase of medical expenditures
of QUEST eligible’s before enrolling.

The average number of monthly calls has dramatically increased due to QUEST Expanded Access,
and is expected to only further increase as a result of the ARRA as people call to inquire about
whether they should apply, the status of their application and to make their selection of a health plan.
If we experience a delay in responding to client and provider requests and concerns, this will result in
negative community feedback and accusation of State’s obstruction to clients obtaining medical
services. Without getting reinforcements, we have a very high risk or burn-out, as we already see a
high incidence of sick leave and emotional break-downs.

A few contributors that lead the Division to anticipate an increase of 12% new clients over the next
12 months include 1) extension of the Transitional Medicaid Assistance (TMA) which allows the
State to provide coverage to families for an additional 12 month period, 2) extension of the Qualified
Individual (QI) Program for the State to continue paying Medicare premiums for qualified
individuals not eligible for Medicaid, and 3) the economic downturn in employment. The
unemployment rate for January 2009 (6.1) doubled from January 2008 (3.0). If this trend continues
the State will find more individuals and families seeking the State’s assistance for medical coverage.

The Member File Integrity Section is supposed to perform timely actions to respond to customer and
provider concerns related to needed corrections in the automated data systems that generate
eligibility, assignment to health plans, recovery of incorrect payments, and timely payment of
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Medicare premiums for qualified individuals not eligible for Medicaid. Not filling the vacancies will
result in increased time that clients are enrolled with Fee-For-Service coverage, which is more costly
and less effective due to the non-integration of medical services. Additionally, increased time to
correct eligibility discrepancies will increase the number of people who are presumptively eligible
for Medicaid and thus paid for with 100% State funds. An increased Medicaid population brought on
by the ARRA will only exacerbate this concern.

Failure to fill this position with an increased Medicaid population will increase the time to identify
and validate correct capitation rates used to pay and recovers over/incorrect payments to health plan,
resulting in cash-flow complications. It also decreases staff’s ability to monitor eligible Medicaid
recipients who may be eligible to receive a portion of their medical care through Medicare benefits.

There is currently a 22% vacancy rate in this unit. Staff struggles to meet the current volume and
will be unable to effectively address the increased volume without filling the vacancies. There are no
internal efficiencies or staff transfer options within the Division to support increased output of this
Unit. Failure to fill this position could result in increase costs to the State.

Policy and Program Development Office:

Depending on guidance from CMS on FMAP eligibility under the ARRA, we may be needing
to expedite State Plan Amendments and Hawaii Administrative Rules. We are already needing
to do this to comply with CHIPRA. Both of these bills generate millions of Federal dollars for
Hawaii, but we need to be able to do the work in order to be able to access these funds. Due to
two vacancies, staff will not be able to execute the provisions of both ARRA and CHIPRA
without filling these vacant positions.

Additionally, we will need to implment a number of policy changes related to the extension or
reprocurement of QUEST. And in efforts to reduce State expenditures, we intend to integrate
mental health and developmentally disabled DOH services into the QUEST and QExA health
plans that will require substantial policy work.

Health Care Services Branch:

As more clients become eligible for Medicaid due to the ARRA stimulas bill, there will be an
increase in complaints and grievances for the Member and Providers Relations Section to
process. The public impact of not filling this position is that client and provider complaints and
grievances will not be processed in a timely manner leaving the public to assume that the State
is unable to address their needs. In addition, the impact of not processing appeals in a timely
manner is continuation of services, which the Department does not believe should be provided,
increasing the costs to the Med-QUEST Divison programs.

In addition, due to the cut backs that are occurring in the Department of Health that are
reimbursed by the MQD (i.e., 15% reduction in DD/MR waiver and decrease in case
management for AMHD), clients are appealing the DOH’s decisions. These appeals have
doubled the number of appeals that Member and Provider Relations is processing.

Training Office:
Federal regulation, 42 C.F.R., Part 432, Subpart B, Sec. 432.20, mandates that the State Plan
provides a training program for Medicaid agency personnel, which “(1) include initial in service
training for newly appointed staff, and continuing training opportunities to improve the operation of
the program; (2) be related to the job duties performed or to be performed by the persons trained; and
(3) be consistent with the program objectives.” Hawaii’s State Plan under Title XIX of the Social
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Security Act for Medical Assistance Programs specifies that this requirement is being met; therefore,
federal financial participation (FFP) is being claimed for training costs at 50%. This Office currently
has a 43% vacancy rate. One employee is new and the Supervisor is retiring on May 1. If the funding
for this position is not approved, the State will not be able to provide the required level of training for
existing and new employees and will not be able to claim the federal funds for its training costs.

The ARRA impacts Hawaii’s Medicaid Program, resulting in an increased need for additional staff
who will need the full battery of training and additional training for existing staff.

SUMMARY:
The Med-QUEST Division requests permission to fill 41 positions which are essential workers for
the implementation of the ARRA, CHIPRA, and to otherwise fulfill our safety-net role. Your
expedited review and recommendation to the Budget and Finance Office is most appreciated.

If there are any questions regarding this recommendation, please contact either myself at 692-8050 or
Patty Johnson, the MQD Assistant Administrator at 692-8052.

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