HealthWave, the state’s health insurance program for children in working, low-income families, is supposed to be easy to get, easy to hold on to.

But it’s not, say many parents, social workers, doctors and pharmacists.

Their complaints may explain why each year thousands of struggling families give up or lose their HealthWave coverage, even though premiums are only $10-$15 a month.

“They’ve dropped me three times. Once in February, once in March and again in May,” said Susan Hastings, a 21-year-old mother, who lives in Ottawa with her husband and their three children. She’s eight months pregnant.

“The last time they dropped me, they said it was because they couldn’t read the results of a pregnancy test my doctor faxed them like four times,” she said. “They didn’t send me a letter or call me, they just dropped me.”

Hastings called HealthWave’s toll-free number several times.

“They have someone take down your information, and they say someone will call you back, but they never do  you have to call them. It’s a giant hassle.”

It’s like that in Douglas County, too, said Nancy Jorn, director of maternal child health field services at the Lawrence/Douglas County Health Department.

“Our nurses are spending an awful lot of time helping families sort through HealthWave,” she said.

“It’s difficult to get through to them on the phone  we just put them on ‘speaker phone’ so we can do other things while we’re waiting,” Jorn said. “When you do get through, you’re transferred to somebody who isn’t there. You leave a message, but nobody calls you back.”

The same thing is happening in Garden City, said Penney Schwab, executive director at United Methodist Western Kansas Mexican-American Ministries Care Centers and Clinics.

“The idea behind HealthWave was to make things simpler for consumers and providers, but that’s not proven to be the case,” she said.

Not perfect

At the Kansas Department of Social and Rehabilitation Services, Bob Day is in charge of medical services. HealthWave, he readily admits, is loaded with problems.

“Is the system perfect? No, it’s not,” he said. “Are we aware that it’s not? Yes, we are.”

Launching HealthWave, he said, has not been easy. For starters, SRS’ computer system had trouble sorting through the complexities of who was and was not eligible.

Overhauling the department’s massive computer program was neither practical nor affordable, Day said.

At the same time, SRS found itself grappling with how, in the wake of welfare reform, to move families off of public assistance while, at the same time, encouraging them to sign up for HealthWave.

“That’s not as easy as it sounds,” Day said. “Those are two very different philosophies  get off, stay on.”

It didn’t help matters, Day said, that families leaving public assistance often wanted nothing more to do with SRS.

Then in 2000, lawmakers directed SRS to combine HealthWave with Medicaid in hopes of creating a gap-free system.

In Kansas, Medicaid underwrites health care for pregnant women and children in households with incomes between 100 and 150 percent of the federal poverty guideline, roughly $1,400-$2,200 a month for a four-person family. Eligibility varies with the children’s ages.

Families are eligible for HealthWave at up to 200 percent of the poverty guideline, $2,942 a month for a four-person family.

Medicaid and HealthWave are each financed with blends of state and federal funds.

To run HealthWave-Medicaid, SRS hired two contractors: FirstGuard, a Kansas City, Mo.-based HMO, to handle claims and payments; Maximus, a Virginia-based company, to handle eligibility determination and enrollment. Both are for-profit companies.

In hopes of maximizing efficiency, legislators later decided to channel all HealthWave-Medicaid applications through a single Maximus-run clearinghouse in Topeka, accessible only by mail or by calling a toll-free number.

Throughout the state, SRS workers are still available to help families fill out application forms and electronically forward the information to Maximus.

SRS switched to the clearinghouse in October 2001. Though Maximus thought it was ready, it wasn’t.

“The volume of calls was much greater than anyone anticipated,” Day said. “There were times, early on in the process, that (Maximus) was getting between 35,000 and 40,000 phone calls a month. They were swamped.”

Other problems soon followed:

 Calls didn’t go through or went unanswered.

 Workers hired to take on the calls lacked the training needed to answer callers’ questions. Those who could were soon overwhelmed.

 Applications sat unopened for two to three months.

 Requests for information needed to confirm a family’s eligibility weren’t mailed. Without the information, hundreds of families that assumed they were covered were dropped without notice.

 HealthWave eligibility lasts a year. After ten months, families are supposed to be sent notices, letting them know they need to re-apply. But many of these notices either weren’t mailed or were sent to a former address. Again, families were dropped without notice.

 Figuring out eligibility proved more difficult than anticipated.

 Spanish-speaking families were often sent requests for more information that were written in English, creating confusion and, in some cases, denial.

Day admits that mistakes were made, but that’s to be expected, he said, when a program the size and complexity of HealthWave-Medicaid switches from one system to another.

Most of the problems, he said, have been or are being resolved.

“Things are much, much better today than they were back in January or March,” Day said. “But there’s still a lot to do. We know that, we’re working on it.”

Maximus officials declined comment on its performance, referring the Journal-World’s questions to SRS.

SRS expects to pay Maximus about $13 million this year.

Ailing system

Dr. Doren Fredrickson, a pediatrician at the Kansas University School of Medicine-Wichita, has spent the past two years overseeing focus-group discussions with families on HealthWave.

“The data collected over the last two years suggest the system has not worked very well,” Fredrickson said.

“This is one of those situations where the Legislature tells SRS to invent a whole new system, and then doesn’t give it anywhere near the money it takes to make it happen,” Fredrickson said. “So a private company, Maximus, comes in and designs a system with no input from consumers, which, of course, opens up all kinds of holes that people end up falling through left and right.”

To fix the system, Fredrickson said, legislators and SRS will have to give low-income families a voice in how it’s run.

“Let’s get something straight here,” he said. “We’re not talking about ‘welfare cheats.’ These are salt-of-the-earth, working people who happen to need help in understanding how the product works, which is really not much different from what middle-class workers get from Blue Cross/Blue Shield.”

HealthWave’s troubles surprised Sen. Sandy Praeger, R-Lawrence, a key player on health care issues.

“I knew that we’d been having trouble with Maximus, but I thought most of the problems had been worked out,” Praeger said. “If that’s not the case, then I guess we’ll have to take a closer look at it over the summer.”

Praeger is chairwoman of the joint Committee on Children’s issues. She also is running for state insurance commissioner.