Building Human-Centered Benefits Renewal Processes with Client Equity in Mind

Safety net benefits are critical for many people in this country, and especially so for those who are elderly or living with disabilities. Many rely on benefits to pay for daily needs—like prescription medication or in-home care—so it’s crucial that these benefits are available continuously and don’t hit snags during annual renewal periods. 

But renewal processes can be burdensome. Often, clients are unaware of renewal requirements, or are overwhelmed by long paper forms and confused about deadlines. Clients who don’t make it through the process are cut off from benefits for which they’re still eligible; then, they reappear a short time later at the program’s front door as new applicants. Processing new applications and re-enrolling longtime clients is more time consuming and expensive than a regular renewal—leaving state administrators, caseworkers, and clients with more work to do.

It would be great if there were some way to automatically renew people whose circumstances haven’t changed—and the good news is, there is! Ex parte renewals are a process by which government renews benefits using data that’s already available. Federal regulations require state agencies to attempt ex parte renewals for Medicaid coverage and check existing data sources before requiring clients to submit any paperwork. But ex parte renewals are underutilized, and there’s no time this process has been more necessary. Most people have been kept on Medicaid since 2020 through continuous enrollment provisions that were included in federal legislation early in the pandemic, which was intended to ensure people kept benefits without hassle during the pandemic. But with the Public Health Emergency (PHE) unwinding, hundreds of thousands of people have lost Medicaid coverage and states across the country are facing a massive number of expected renewals; it’s a huge challenge for caseworkers—many of whom were hired during the pandemic and have never had to process Medicaid renewals—and clients alike.

Using an equity-centered lens to meet this challenge

The state of Minnesota has been a nationwide leader in improving the benefits experience for clients by focusing on accessibility, equity, and efficiency. The state already uses ex parte renewals for Modified Adjusted Gross Income (MAGI) Medicaid (which serves people who are parents, children, or pregnant, for example). But the non-MAGI program (which serves people who are age 65 or older, blind, or disabled) has been using an older system that requires clients to submit annual paper renewal forms to keep their health care, despite having persistent need and unchanging financial circumstances. Minnesota isn’t alone: In a 2022 analysis of 40 states, 40% reported they don’t have an ex parte process for their aged, blind, or disabled populations. 

Streamlining renewals for people who are aged, blind, and/or disabled is a huge opportunity to increase equity for a population where people have ongoing medical needs and whose Medicaid eligibility status is unlikely to change. 

My caseload is entirely elderly and disabled … it can be difficult for them to navigate these forms anyway. And they'll either throw them away or they'll send it back to me blank, or unsigned, I have to send it back to them and then request verifications … There's this back and forth that ends up taking a great deal of time. And if they don't get these verifications to me as the system was by a certain date, their case auto closes. 

For the past 10 months, we’ve been working with the state of Minnesota to build out and pilot a process for expanded ex parte renewals—especially for those who need it most. Of the 200,000 people who make up the aged, blind, and disabled Medicaid population across Minnesota, the state will now consider 140,000 of them—roughly 70% of all cases—for ex parte renewal (versus none before). We anticipate that 90% of all those cases will have a successful ex parte renewal—roughly 126,000 of the full 200,000 aged, blind, and disabled population—and that the rest may need further information before renewal can be complete.

Before partnering with Code for America to improve ex parte renewal processing, it took Minnesota workers about 70 minutes across a three-week period of back and forth with a client to complete one renewal. As a result of process improvements across these pilots, we were able to shave 55 minutes from that process, bringing it down to about 15 minutes per case, with no input needed from the clients. We further anticipate this number to go down to approximately 11 minutes per case during the state expansion. 

This change is a big deal—here’s how we got there and what we learned along the way.

Interested in improving ex parte renewal rates in your state? Fill out our partnership form.

Lessons from piloting expanded ex parte renewals

Policy and dated legacy systems do not have to be blockers. We started with a two-county pilot, and then later a four-county-pilot. At each stage of the process, we worked closely with county and state workers in policy, operations, and tech to understand how to roll out a process change in MAXIS, their legacy  benefits management system from 1989. In both pilots, we held working sessions, giving county eligibility workers the opportunity to troubleshoot through live cases with Minnesota Department of Human Services (DHS) policy and operations experts in the room.

We can say that it’s absolutely possible to build and pilot human-centered processes in legacy benefits management systems—if the right people are on board for the change. We regularly met with policy and operations experts at the state level to align on creative ways to interpret policy during the development of the ex parte process. Building side-by-side with caseworkers who understood the intricacies and complexities of the process allowed us to turn their feedback into process improvements and ensured we stayed aligned with requirements and constraints. We were surprised to find that the state’s legacy system, although dated, was adaptable. This made it easier to develop automated notices and other efficiencies to streamline processes and save worker time. 

We can say that it’s absolutely possible to build and pilot human-centered processes in legacy benefits management systems—if the right people are on board for the change.

Pre-determining and identifying the ex parte eligibility pool speeds the process. During the pilot, county leads identified and pulled cases for the renewal month and had to manually check each case to see that it fit certain criteria. It took a lot of time and energy to evaluate whether each case would be eligible for an ex parte renewal based on certain state issued criteria.

To make this process simpler, we worked with Minnesota IT Services (MNIT) and DHS policy and operations experts to develop policy guidelines for identifying cases likely to be successfully renewed ex parte. From there we supported the creation of an automated list of eligible cases per renewal month, removing that time-consuming burden from the county. Now, the state delivers a monthly report to counties ahead of the renewal timeline that indicates which cases the counties should try to renew ex parte.

It’s necessary to write clear policy and operational documentation to support caseworkers in processing renewals for people with complex cases. The hardest moment for a caseworker is when they come across a case where the details don’t align with any instructions or policy they’ve been given. During the pilot, we worked side-by-side with counties and the state to develop clear process guidance with edge cases in mind—for example, what to do if a client moves out of state between phases of the enrollment process. Code for America shared process guidance in multiple formats including a worker-facing website, a training deck with step-by-step guidance and screen shots, and a recording of a case walkthrough that met rigorous Medicaid privacy standards. Looking ahead to the statewide rollout, DHS is using these learnings to provide training and materials that will support caseworkers in processing renewals for complex cases.

Strategically leveraging automation eases administrative burden while increasing accuracy for clients and caseworkers alike. During the pilot working sessions, Code for America staff noticed that the majority of caseworker time was spent manually producing a notice that would be sent to a client alerting them of their ex parte renewal. In a legacy system where word processing has not matured since 1989, this was a long and tedious process. It also introduced the possibility of human error—for example, a caseworker manually inputting a client’s name into a notice could accidentally share another’s personal identifiable information.

Automation is ideal for workers, because it makes for an efficient process and ultimately gives them more time to work on their caseload or other work while eliminating risk of manual errors. We worked with MNIT, as well as DHS policy and operations experts, to create state- and federally-compliant approval notices that clearly inform clients their Medicaid had been renewed, and to develop an approach that generates a notice when a worker identifies the case as ex parte eligible. 

The impacts of these changes:

• Clients are successfully renewed and relieved of the burden of navigating the confusing renewal process. These people are no longer susceptible to benefits churn—meaning they won’t experience a lag in critical access to medications, doctors, or other medical needs.
• Caseworkers now have more time to dedicate to more complex cases and are spending less time on cases that have churned through the system. 
• Office support staff are no longer spending time supporting the intake and tracking of renewal paperwork—and can instead spend that time on new enrollments. 

Here’s what that means by the numbers: 

• This reduction in caseworker and office support staff time needed to process a renewal case translates to $4.6 million in annual savings.
• We expect that Minnesota seniors and people who are blind or have a disability will get an extra $636 million in Medicaid benefits each year thanks to ex parte renewals coming from both state and federal funds

The right moment for scaling renewal work

With the looming end of the public health emergency, it’s estimated that 15 million people across the country could be disenrolled from healthcare coverage as terminations that were suspended during the pandemic resume—despite about 45% of those 15 million people still being eligible for Medicaid.

So Minnesota isn’t the only state facing an impending mountain of benefits renewal work—but we hope that our collaboration in this arena can serve as a beacon for states facing similar challenges. We know this work can happen in states with both legacy and modern benefits management systems, as long as the right stakeholders come together at the  table to build an ex parte process with equity at the center of it. Dedication like that can help build an improved benefits renewal process for state administrators, caseworkers, and clients alike.