Providers and plans tar­get big push to boost Med­i­caid en­roll­ment

Modern Healthcare - - REFORM UPDATE - By Vir­gil Dick­son

One of Oba­macare’s big­gest suc­cess sto­ries this year was that mil­lions of pre­vi­ously unin­sured Americans got cov­er­age through the law’s ex­pan­sion of Med­i­caid to low-in­come adults.

Hos­pi­tals, in­sur­ers, com­mu­nity health cen­ters, nav­i­ga­tor or­ga­ni­za­tions and ad­vo­cacy groups now face the chal­lenge of re-en­rolling all those new ben­e­fi­cia­ries and sign­ing up mil­lions of ad­di­tional Americans who qual­ify for the pro­gram. They will make their big­gest push dur­ing the up­com­ing open en­roll­ment start­ing Nov. 15 and last­ing three months, though ben­e­fi­cia­ries can sign up at any time. It’s es­ti­mated that as many as 11 mil­lion more Americans will join Med­i­caid by the end of 2015, ac­cord­ing to the Con­gres­sional Bud­get Of­fice. This would sig­nif­i­cantly re­duce the bur­den of un­com­pen­sated care on health­care providers.

As part of the push, en­roll­ment work­ers hope to sign up low­in­come adults who qual­ify un­der the health­care re­form law’s Med­i­caid ex­pan­sion as well as poor chil­dren and adults who pre­vi­ously were el­i­gi­ble but have not yet signed up. The work­ers will set up at fes­ti­vals, street fairs, parks, after-school events, and church ser­vices with their name tags and clip­boards.

Hori­zon Blue Cross and Blue Shield of New Jersey is plan­ning to par­tic­i­pate in at least 800 com­mu­nity events in the next year. The strat­egy was suc­cess­ful this year, when the plan en­rolled 170,000 new Med­i­caid mem­bers. “There are all th­ese things peo­ple are hear­ing, and it helps to have face-to-face con­ver­sa­tion with peo­ple they know,” said Len Kudgis, di­rec­tor of mar­ket­ing for NJ Health, the plan’s Med­i­caid sub­sidiary.

New York-based Fidelis Care, which has signed up 100,000 mem­bers since last Oc­to­ber, will be plac­ing self­serve kiosks in shop­ping malls. “It’s about tak­ing any op­por­tu­nity we can to ed­u­cate peo­ple,” said Pamela Hassen, chief mar­ket­ing of­fi­cer at Fidelis. “Some­times

peo­ple are in a rush, and may not have time to sit through a pre­sen­ta­tion.”

But providers and en­roll­ment groups are wor­ried about the need to re-en­roll peo­ple who signed up for this year. “One of the con­cerns as we en­ter year two is, will we be able to re­tain all the peo­ple that came to our plan last year,” said Ge­off Bartsh, vice pres­i­dent of state pub­lic pro­grams at Min­nesota-based Medica, which has en­rolled 30,000 new Med­i­caid mem­bers as of Jan­uary. “We will need to be ex­tra dili­gent.”

The re-en­roll­ment is­sue was high­lighted as a ma­jor con­cern in re­search re­leased by the Med­i­caid and CHIP Pay­ment and Ac­cess Com­mis­sion, which found that there has been a lack of mes­sag­ing that ben­e­fi­cia­ries need to reen­roll in Med­i­caid each year. “Many do not know they need to re­new to keep their cov­er­age,” ac­cord­ing to the re­port. “This is par­tic­u­larly true of first-time en­rollees in Med­i­caid.”

As of Oc­to­ber, 27 states and the Dis­trict of Columbia had ex­panded Med­i­caid to low-in­come adults with in­comes up to 138% of the fed­eral poverty level, as al­lowed by the Pa­tient Pro­tec­tion and Af­ford­able Care Act. Pre­vi­ously, most states had limited Med­i­caid to preg­nant women and chil­dren, dis­abled peo­ple and adults with almost no in­come. Count­ing both ex­pan­sion and non-ex­pan­sion states, nearly 8.7 mil­lion peo­ple en­rolled in Med­i­caid or the Chil­dren’s Health In­surance Pro­gram be­tween Oct. 1, 2013, and Aug. 31, 2014, in­creas­ing to­tal en­roll­ment in the pro­grams by nearly 15%, ac­cord­ing to the CMS. En­roll­ment in states that ex­panded Med­i­caid grew by 22%, com­pared to only 5% in states that did not.

This year’s Med­i­caid en­roll­ment sur­passed the Con­gres­sional Bud­get Of­fice’s ear­lier es­ti­mate that 7 mil­lion would sign up in all of 2014. De­spite the suc­cesses, much more needs to be done to ex­pand en­roll­ment, in­clud­ing more ag­gres­sive com­mu­ni­ca­tions strate­gies by states and in­surance ex­changes about the avail­abil­ity of Med­i­caid cov­er­age, said Michael Perry, a part­ner at Perry Un­dem Re­search/Com­mu­ni­ca­tion.

While peo­ple can sign up for Med­i­caid at any time of the year, providers, plans and en­roll­ment groups will take ad­van­tage of the pub­lic­ity sur­round­ing the three­month open en­roll­ment to reach Med­i­caid-el­i­gi­ble peo­ple. The still-un­en­rolled pop­u­la­tion in­cludes peo­ple who speak limited English, lack health lit­er­acy, are home­less, have be­hav­ioral and/or sub­stance-abuse is­sues, or are skep­ti­cal about Oba­macare, ac­cord­ing to En­roll for Amer­ica data.

At the same time, en­roll­ment work­ers need to make sure cur­rent ben­e­fi­cia­ries un­der­stand they need to re-en­roll in the pro­gram to con­tinue cov­er­age. Med­i­caid en­rollees who sign up re­ceive 12 months of cov­er­age and then have to reen­roll. Un­der the ACA, states are ex­pected to move to­ward au­to­matic re­newals based on use of in­for­ma­tion about ben­e­fi­cia­ries’ in­come, said Tri­cia Brooks, a re­searcher at the Ge­orge­town Univer­sity Cen­ter for Chil­dren and Fam­i­lies. Ben­e­fi­cia­ries must be no­ti­fied to re­port any in­come changes that would af­fect their el­i­gi­bil­ity.

Mean­while, ad­vo­cates ex­pect tough out­reach chal­lenges in the 23 non-ex­pan­sion states, mostly Repub­li­can-led states. They also worry that cer­tain racial, eth­nic and so­cio-eco­nomic groups such as Asian-Americans— who come from many coun­tries and speak many dif­fer­ent lan­guages—will be over­looked by state and fed­eral agen­cies.

Much of the gov­ern­ment out­reach and com­mu­ni­ca­tions so far have been only in English and Span­ish. That left com­mu­nity groups and Med­i­caid plans scram­bling to get the word out to Asian-Amer­i­can com­mu­ni­ties, in which an es­ti­mated 1 out of 10 peo­ple qual­ify for Med­i­caid, said Priscilla Huang, se­nior di­rec­tor for im­pact at the Asian & Pa­cific Is­lan­der Amer­i­can Health Fo­rum, an ad­vo­cacy group based in San Francisco. Huang said there is no in­di­ca­tion that the CMS in­tends to boost out­reach or pro­vide ad­di­tional trans­lated ma­te­ri­als to the Asian-Amer­i­can com­mu­nity this time around.

The CMS de­clined to com­ment on up­com­ing out­reach strat­egy re­lated to the ACA and Med­i­caid.

Pri­vate Med­i­caid man­aged-care plans have a strong in­cen­tive to get the word out, since in many states they pro­vide the cov­er­age for the newly en­rolled pop­u­la­tion. En­roll­ment of Med­i­caid and Chil­dren’s Health In­surance Pro­gram ben­e­fi­cia­ries in man­aged care will in­crease by 13.5 mil­lion in­di­vid­u­als from 2013 to 2016, ac­cord­ing to con­sult­ing firm Avalere. States that ex­panded Med­i­caid will see the big­gest jump in the per­cent­age of en­rollees in man­aged care, from 73% in 2013 to 79%, or 10.2 mil­lion ad­di­tional mem­bers in 2016.

Var­i­ous states have dif­fer­ent rules gov­ern­ing Med­i­caid plans’ out­reach to con­sumers. Some, such as Florida, pro­hibit any com­mu­ni­ca­tion to non-mem­bers to pre­vent abu­sive mar­ket­ing prac­tices. In other states that al­low Med­i­caid plans to en­gage in mar­ket­ing, the plans will use print and TV ad­ver­tise­ments and em­ploy one-onone coun­sel­ing.

Hori­zon Blue Cross and Blue Shield of New Jersey has five mo­bile health vans roam­ing the state, staffed with nurses of­fer­ing health screen­ings. This helps build a trust that can per­suade peo­ple to sign up for Med­i­caid cov­er­age, Hori­zon’s Kudgis said.

Hos­pi­tals and health sys­tems also are heav­ily en­gaged in ef­forts to en­roll and re-en­roll peo­ple in Med­i­caid. The Med­i­caid ex­pan­sion has been cred­ited as a ma­jor rea­son hos­pi­tals can ex­pect to see as much as a $5.7 bil­lion de­crease in un­com­pen­sated-care costs in 2014, ac­cord­ing to HHS.

Some providers say they have de­cided not to work in tan­dem with Med­i­caid plans around en­roll­ment. “One thing that frankly didn’t prove to be pro­duc­tive last year was work­ing with ex­ter­nal agents like health plans,” said Marvin Pem­ber, pres­i­dent of the acute-care di­vi­sion at Univer­sal Health Ser­vices. “They had their own ap­proach and spe­cific rea­sons rel­a­tive to how they were ap­proach­ing en­roll­ment that did not sync with what we were try­ing to do.”

The ten­sion arises from the fact that hos­pi­tals em­ploy­ing cer­ti­fied ap­pli­ca­tion coun­selors must be im­par­tial and are not al­lowed to rec­om­mend spe­cific plans.

LifePoint Hos­pi­tals also re­fused to work with Med­i­caid plans last year, said John Kerndl, se­nior vice pres­i­dent and op­er­a­tions chief fi­nan­cial of­fi­cer for the hos­pi­tal chain. LifePoint said al­low­ing mul­ti­ple in­sur­ers to set up booths in the sys­tem’s fa­cil­i­ties did not fit with its twin ob­jec­tives of help­ing peo­ple en­roll while re­spect­ing pa­tients and their con­fi­den­tial­ity. “We de­cided the right ap­proach for our pa­tients was to have hos­pi­tal-cer­ti­fied ap­pli­ca­tion coun­selors work di­rectly with them on an in­di­vid­ual ba­sis,” he said.

The Detroit Med­i­cal Cen­ter has found it is bet­ter to keep en­roll­ment events smaller be­cause some peo­ple feel a stigma about sign­ing up for a gov­ern­ment pro­gram that ben­e­fits the poor. “Do­ing a smaller event at a church, com­mu­nity cen­ter or po­lice sta­tion is more in­ti­mate and per­sonal,” said Con­rad Mal­lett, the hos­pi­tal’s chief ad­min­is­tra­tive of­fi­cer. For at­ten­dees, “it seems like you’re ex­pos­ing your­self less.”

En­roll­ment groups say more ef­forts are needed to sign up low-wage work­ers in ser­vice in­dus­tries who don’t have job-based cov­er­age. Re­cent an­nounce­ments by Wal-Mart, Tar­get, Home De­pot and Trader Joe’s that they will no longer of­fer cov­er­age to part-time em­ploy­ees opens up new venues for out­reach op­por­tu­ni­ties. Many em­ploy­ees at th­ese com­pa­nies are el­i­gi­ble for Med­i­caid based on their in­comes.

“The (re­tail) in­dus­try may now be an op­por­tu­nity to raise aware­ness on the na­tional level,” said Jen­nifer Tol­bert, di­rec­tor of state health re­form at the Kaiser Fam­ily Foun­da­tion.

A chal­lenge even in states that did ex­pand Med­i­caid is that con­sumers may have a neg­a­tive im­age of Med­i­caid be­cause of po­lit­i­cal rhetoric vil­i­fy­ing the pro­gram as part of Oba­macare. So nav­i­ga­tors and other en­roll­ment groups have de­vel­oped cre­ative ways to pro­mote en­roll­ment. Com­mu­nity health cen­ters in Ken­tucky have fo­cused on get­ting peo­ple to go to the state’s popular Kynect ex­change web­site, know­ing that many would qual­ify for Med­i­caid, said Lind­say Nel­son, co­or­di­na­tor of com­mu­nity de­vel­op­ment and out­reach at the Ken­tucky Pri­mary Care As­so­ci­a­tion.

Com­mu­nity health cen­ters in West Vir­ginia have used a sim­i­lar ap­proach. The state sig­nif­i­cantly ex­ceeded the pro­jected num­ber of Med­i­caid en­rollees. “Peo­ple want health in­surance, and en­roll­ment was pro­moted as just that—in­surance—and not stereo­typed as ‘Oba­macare,’ ” said Louise Reese, CEO of the West Vir­ginia Pri­mary Care As­so­ci­a­tion.

Hori­zon Blue Cross and Blue Shield of New Jersey reaches out to com­mu­ni­ties in hopes of sign­ing up peo­ple for Med­i­caid cov­er­age.

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