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community education. Unless and until judicial relief is obtained, legal services programs continue to serve hundreds of SSI applicants each year whose need for a speedy determination of Medicaid eligibility remains unmet. It therefore behooves legal services staff members to make sure that those clients are made aware of their right to file a separate application, directly with the state Medicaid agency, under the medically needy program. By definition, disabled clients have little, if any, present earnings. Their incomes therefore usually fall under the MNIL, without having to satisfy a spend-down requirement. And for those whose higher incomes do require spend-down, their disabilities typically are associated with a history of large medical expenses that will enable them to immediately satisfy the spend-down requirement.
Work on the development of spend-down education materials helped staff members to understand these relationships between the different programs, and disability applicants are now routinely advised to promptly file separate applications for Medicaid with the state agency if, as is usual, they are likely to have a need for medical care pending SSA's disposition of their claim.
purpose of such a project is to ensure that eligible individuals actually receive the benefits of the program. But one's strategy in achieving this objective can be the subject of some tough decisionmaking.
For example, one approach might be to tout the benefits of the program and to encourage as many people as possible to apply, trusting to the state's eligibility determination process to winnow out the ineligible. However, this approach may create unrealistic hopes and pointless hassles for ineligible applicants and harried caseworkers. It also places great trust in the accuracy of the eligibility determination process. Such trust can only be sustained by ignoring the complexity of the program, the high potential for worker error, and our collective experience with such government programs.
The alternative strategy is to give priority to informing potential beneficiaries of the rules of the program as fully as possible. This approach makes applicants more self-sufficient and less dependent upon the knowledge, interviewing skill, and empathy of the eligibility worker to accurately determine eligibility. It also is calculated to screen out those who are clearly ineligible and for whom the filing of an application would be a useless and disappointing inconvenience. However, this approach can have the unintended effect of discouraging applications from those who would in fact be eligible if a full application were taken and they were given the benefit of various exceptions, earnings disregards, and other technical rules that cannot possibly be included, as a practical matter, in the kind of general audience materials you are attempting to develop.
In our case, we decided upon a mixed approach. We decided our objectives would be:
C. Step-by-Step Recommendations
Based on our own experiences, we would make the following recommendations to others interested in developing community education materials on the spend-down program.
Step 1: Read the relevant materials. Start with An Advocate's Guide to the Medically Needy Program, discussed above, which can be covered in two or three hours. Then read all materials relating to spend-down eligibility determinations contained in your state's Medicaid policy and procedures manual, memoranda or bulletins to eligibility workers, published regulations, etc. Be sure that you do not limit yourself only to published regulations. Typically, these materials, published under a state's administrative procedure act, are general in nature, are completely unknown to the state workers who actually determine eligibility, and may therefore be of only limited relevance. Make sure that you review the actual applications and worksheets used by eligibility workers, since these materials may produce eligibility decisions that are inconsistent not only with published state rules, but also with the informal memoranda or instructions they purport to implement.
(1) to give our readers a very general understanding of the purposes and nature of the spend-down program, in positive tones that would encourage applications from any who might conceivably qualify;
(2) to inform patients of those eligibility rules in their favor that we thought were most likely to be overlooked by state eligibility workers; and
(3) to identify those personal circumstances that clients should consider in deciding when to apply, in order that they might derive maximum benefit from the program's limited benefits. In other words, we sought simultaneously to encourage applications and to address those factors that the state agency was most likely to overlook.
Step 2: Decide what the primary objective of the materials you are about to draft should be. It may sound strange to suggest that you make a significant investment of time in the project before settling upon your objectives, but it is probably necessary to have at least a basic understanding of the program before you try to settle on your priorities for the project. This is not as simple as one might assume. Of course, the ultimate
Step 3: Write a preliminary draft or outline of the substantive points you want to make in the materials. Then decide on the best format for communicating this information. Possible alternatives are a single pamphlet, a series of different leaflets focused on different topics or directed at different audiences, or a “game board” format.
13. If a state has an administrative procedure act, this provides an
additional reason to compare formally promulgated rules with informal manuals, bulletins, or policies. Under the Uniform Administrative Procedure Act (UAPA), agency policies that affect the rights of members of the public are invalid unless promulgated in accordance with statutorily prescribed procedures. If informal rules restrict client eligibility, they may be subject to challenge under the state's version of the UAPA if they are in conflict with formal rules, or if they should have been officially promulgated themselves, but were not.
Step 4: “Translate" the outline of substantive points into readable English in the format selected. The skills and training that are useful in synthesizing and analyzing the various sources of Medicaid law are quite different from the separate sets of skills, knowledge, and creativity required to translate such technical information into readable educational materials. That is why we found a team approach involving an attorney and a community education specialist to be most helpful.
Regardless of whether you adopt a team approach, you will find it useful to refer to a standardized “readability scale" of the type available from any of a number of different published sources. 14 Such scales require no training to use and involve a simple analysis based upon sentence syntax and numbers of syllables used in your vocabulary. The use of such an instrument will allow you to gauge the level of reading skills required of your audience for readers to be able to read and comprehend your draft. You will find that your creativity is taxed to its maximum in trying to come up with simple ways of communicating such complex subject matter.
Step 5: Have the draft reviewed by state Medicaid eligibility determination staff and by clients. Field testing helped us to identify a number of points where, despite our best efforts, the text remained unclear or misleading. Review of a series of drafts by Medicaid officials helped us to identify technical mistakes and, on a couple of occasions, helped Medicaid staff to identify policies that were inconsistent with federal law and required revision.
ence and the pregnant women/children-linked audience in the same material. Eligibility rules and practical concerns of these different audiences are simply too different, and we decided to develop materials for the second group when time and resources permit.
We strongly recommend that the effectiveness of your final product will be greatly enhanced by professional-quality layout and graphic design. This, of course, is more expensive than typewriter-produced pamphlets. An alternative, economical only if a program is planning on producing a number of publications, is in-house “desktop publishing." A personal computer with two disk drives, page layout software, and a laser printer's gave us the flexibility to field test several finishedlooking versions of the text and to produce camera-ready copy without the cost and hassle of trips to a typesetter or graphic artist.
Page layout software enables you to "flow" previously typed text into columns and around illustrations. You see on the screen the page design and the type size and style you have selected. The laser printer then prints near-typeset quality pages. " It is easy to produce for review by clients several finished versions of the material with different page designs, type styles and sizes, column widths, graphic and paper sizes, and folds. You can then take the most satisfactory laser-printed version to the printer and eliminate typesetting altogether. A more costly but equally convenient approach is to take the floppy disk itself to a printer who has the equipment to produce actual typeset pages directly from your floppy disk.
If you do not have desktop publishing capacity in-house, but you frequently produce printed community education materials, you might want to check on the availability of self-service desktop publishing equipment at local “quick print" businesses. Such firms allow customers to use desktop publishing computers and printers for an hourly fee. They may or may not provide the instruction and technical assistance you need during the learning phase.
If you have to pay someone outside your office to design the layout, you may not be able to afford to have each of several drafts professionally laid out. At a minimum, however, your investment of time and energy deserves professional design of the final draft. It is pointless to invest significant resources in the development of materials that remain unread, and the design of a well-illustrated, attractive layout will have a great deal to do with whether your final product is actually used by clients.
Review of a series of drafts by Medicaid officials helped us to identify technical mistakes and... helped Medicaid staff to identify policies that were inconsistent with federal law and required revision.
Although we were fortunate enough to be able to work with highly competent, empathetic administrators who supported our work, we would strongly recommend consultation with state officials even in less favorable circumstances. Even if such officials are hostile, they will still have a stake in seeing to it that your material is accurate. And, when drafting material on such a complex subject, you will find it essential to obtain criticism of your work from other knowledgeable readers, since meanings and implications will occur to them in reading the draft that you would never be able to recognize in your own writing. From that standpoint, the more critical the reader, the better. Engaging Medicaid officials in the review process also offers opportunities for educating and sensitizing officials whose policy decisions have great impact upon our clients' lives.
Step 6: Finalize your draft. You will almost certainly find yourself having to make some difficult choices. The research, drafting, field testing, and review process—a cycle that may have to be repeated several times as you continue to revise the material—will highlight difficult problems of length, complexity, substantive content, and cost. Trade-offs will have to be made, and you may end up concluding that you simply cannot accomplish everything that you originally hoped to do. For example, we concluded on about the seventh draft that we could not feasibly target both the elderly/disabled reading audi
Step 7: Distribute your materials, not only to your program's clients, but to other agencies that deal on a regular basis with low-income people who are chronically or acutely ill. This would include hospitals and their state trade associations, nursing homes, home health agencies, state medical societies, and clinics. Depending on the age group targeted, do
15. Ease of learning and software availability compelled us to buy an
Apple McIntosh Plus with an internal disk drive and an Apple Laserwriter for desktop publishing, even though the rest of our computer equipment is IBM-compatible. Tops software by Centram Systems West enables us to transfer the data between the two types of computers. Pagemaker by Aldus Corporation is the page layout
program we use. 16. Our laser printer prints 300 dots per inch, compared to 1,200 dots
per inch with true typesetting. The layperson will see the difference only with a magnifying glass.
14. There are a number of such scales printed in educators' profession
al literature. The instrument we used was distributed by the Alabama Consortium of Legal Services Programs and is available from the authors.
not overlook such agencies as the Heart Fund, the Diabetes Association, etc., that serve clients with chronic diseases. You may find, as we did, that such outreach efforts produce welcome public relations benefits for your program. This is a selling point worth noting to project administrators hesitant to invest in the small printing costs associated with this community education effort.
SEE Computer and Research News Section for results of computer research based on this article, pages 150-151.
Distribution of Pamphlet Is Part of Notice Relief
in Class Action
The availability of the pamphlet described in the article above made it possible to enhance the practical value of notice relief obtained in the case of Edington v. Harwell, No. 3-87-0135 (M.D. Tenn. filed Feb. 13, 1987) (Clearinghouse No. 42,168). That case, filed by attorneys from Rural Legal Services of Tennessee and Legal Services of Upper East Tennessee, challenged procedural irregularities in the state's determination of disabilities of Medicaid applicants. Several thousand plaintiff class members who were denied disability-linked Medicaid after October 1984 will receive mailed notice of their rights under a negotiated settlement. Enclosed with each notice will be a copy of the spend-down pamphlet, printed and mailed at state expense. By negotiating for this type of notice, plaintiffs counsel helped to target distribution of the pamphlet to the population that is perhaps most in need of the benefits described in the pamphlet. The Edington case is more fully described in the Case Development section of the May 1987 issue of Clearinghouse Review.