Expansion Exchange Outreach Enrollment Strategies

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Medicaid Expansion & Medicaid Expansion & Health Insurance Health Insurance

Exchanges Strategies for Exchanges Strategies for Successful Outreach Successful Outreach

& Enrollment& Enrollment

Michigan Primary Care AssociationAugust 29, 2012

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Agenda• Update on Michigan & Medicaid expansion -

Doug

• Update on Michigan & health insurance exchange - Doug

• Discuss impact on Health Centers - Harry

• Discuss outreach and enrollment strategies utilized in other states - Harry

• Discuss what opportunities Michigan health centers have to grab populations impacted by ACA – Harry/Natasha

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Michigan Primary Care AssociationWebinar

August 29, 2012

Doug Paterson M.P.A.Director of State PolicyMichigan Primary Care Association

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Affordable Care ActAffordable Care Act

Expansion of Community Health Centers• $11 billion up-front investment thru

Trust Fund

Medicaid Expansion• Tax Subsidies making health

insurance affordable for low and moderate income families and employers

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Supreme Court DecisionSupreme Court Decision

• Upheld constitutionality of individual mandate

• Upheld insurance reforms• Prohibits denial based on conditions• Lifetime caps• Kids to 26• New coverage standards• Establishes Exchanges

• Medicaid expansion is unconstitutional coercion

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Medicaid ExpansionMedicaid Expansion

Potential to reach 1.9 million more Health Center Patients

Ten states have indicated they will not expand:

Florida Iowa

Louisiana Mississippi

Missouri Nevada

New Jersey New York

South Carolina Texas

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Insurance ExchangesInsurance ExchangesPurpose

◦To provide individuals and small business employees with access to health insurance coverage beginning January 2014.

◦Creates competitive marketplaces for direct comparison based on price, quality and options. Facilitates the purchase of Qualified Health

Plans by individuals Establishes a Small Business Health

Options Program (SHOP)

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Types of ExchangesTypes of Exchanges

• State based exchange• State operates all activities

• Governance• Consumer and Stakeholder Engagement and Support• Eligibility and Enrollment• Plan Management• Risk Adjustment and Reinsurance• SHOP operation• Organization and Human Resources• Finance and Accounting• Technology• Privacy and Security• Oversight, Monitoring and Reporting• Contracting

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Types of ExchangesTypes of Exchanges

• State Partnership Exchange• State operates

• Plan Management• Consumer Assistance• Both

• Federally-facilitated Exchange• HHS operates all components but

state MAY elect to use federal services for Medicaid and CHIP eligibility assessment or determination

H Perlstadt <[email protected]> 10

Michigan Primary Care AssociationWebinar

August 29, 2012

Harry Perlstadt, PhD, MPHMedical Sociologist and Professor EmeritusMichigan State University

H Perlstadt <[email protected]>11

Passing the Affordable Care Passing the Affordable Care Act:Act:

Medicaid Expansion and Medicaid Expansion and Community Health CentersCommunity Health Centers

Special Deals to get the 60 votes in US Senate◦Sen. Ben Nelson (D-NB)

Feds to pay 100% of Nebraska's costs for expanding Medicaid indefinitely;

◦Sen. Bernard Sanders (I-VT) Extra funds to Vermont for Medicaid

expansion plus $10 billion for Community Health

Centers nationwide.



Affordable Care Act (ACA) expands Medicaid to nearly all individuals under age 65 with incomes up to 133-138 percent of the federal poverty line (FPL) which will extend coverage to large numbers of the nation’s uninsured population, especially adults.

However, the ultimate reach of the program will depend heavily on both federal and state actions to implement the new law.

Kaiser Commission Medicaid and the Uninsured



The federal government will pay a very high share of new Medicaid costs in all states

Increases in state spending are small compared to increases in coverage and federal revenues and relative to what states would have spent if reform had not been enacted.



Standard Standard Lower Participation ScenarioLower Participation Scenario

Assumes moderate levels of participation similar to current experience among those made newly eligible for coverage and little additional participation among those currently eligible.

Assumes 57 percent participation among the newly eligible uninsured and lower participation across other coverage groups.



Higher ParticipationHigher ParticipationOutreach ScenarioOutreach Scenario

Assumes more robust participation among those newly eligible (75 percent participation among the newly eligible that are currently uninsured and lower participation across other coverage groups)

Assumes higher participation among those currently eligible for coverage than in the standard scenario.



Medicaid Expansion: Medicaid Expansion: MichiganMichigan Medicaid Expansion to 133% of FPL,

Impact of Reform on Uninsured Populations: Increase in Enrollment in 2019 Relative to Baseline


T New Enrollees

Previously Uninsured

Newly Enrolled

% Decrease Uninsured

Adults <133%

Baseline Medicaid

Enrollment

% Change in

Enrollment

Lower Particip Rate

589,965

430,744

50.6%

1,952,376

30.2%

Higher Particip Rate

812,818

635,231

74.6%

1,952,376

41.6%


Medicaid Expansion: Medicaid Expansion: MichiganMichigan Medicaid Expansion to 133% of FPL

Changes in Total Spending 2014-2019


Percent Change in Spending Federal Matching Rates

State Federal Total Baseline Reform Lower Particip Rate

2.0%

21.5%

14.8%

65.8%

69.6%

Higher Particip Rate

3.2%

25.6%

17.9%

65.8%

70.1%


Medicaid Expansion: Medicaid Expansion: MichiganMichiganEstimated Impact of Medicaid Expansion Decisions

on Health Centers’ Growth Capacity by 2019

Estimates based on state proportion of uninsured children and adults (potentially) eligible for Medicaid by Urban Institute Hayes, Shin, and Rosenbaum

By 2014 between 106,000 and 110,000 currently uninsured adults patients served by Health Centers in Michigan will be eligible for Medicaid

Bergquist

Total Patients No

Medicaid Expansion

With Medicaid Expansion

Medicaid Expansion

Impact on New Patients

N New Patients Eligible

for Medicaid

% New Patients Eligible

for Medicaid

Total State

Population Eligible for Medicaid

972,900 1,129,500 156,600 76,300 49% 730,000


Building the Exchange: Building the Exchange: Massachusetts Tool KitsMassachusetts Tool Kits

Toolkit #1 – Building an Effective Health Insurance Exchange

Toolkit #2 – Implementing a Successful Public Outreach and Marketing Campaign

Toolkit #3 – Determining Health Benefit Designs

Toolkit #4 – Mitigating Risk in a State Health Insurance Exchange

Toolkit #5 – Effective Education, Outreach and Enrollment for Populations Newly Eligible for Health Coverage

MAHealthConnector


Building the Exchange: Building the Exchange: ProvidersProviders

States need to consider how providers will be invited to participate in the exchange.

States are required by the ACA to present provider information on their websites that allows easy comparison across insurance plans (Gold-Silver-Bronze).

States may require providers to have necessary information and to participate in any training concerning the website.

MAHealthConnector


Building the Exchange: Building the Exchange: ProvidersProviders

In Massachusetts first phase focused on enrolling low-income uninsured residents who had already been receiving uncompensated care at hospitals and community health centers.

Many became eligible for fully subsidized health insurance.

State used database of past uncompensated care to users to convert them automatically to public insurance.

MAHealthConnector


Building the Exchange:Building the Exchange: WebsiteWebsite

Informational materials on websites distributed to community health centers, community based organizations, school nurses, hospitals

Healthcare providers and patient advocate and community service agencies◦Use website to assist in signing up

residents for coverage.

MAHealthConnector


Outreach and Marketing:Outreach and Marketing: Community Events, Health Fairs etc.Partners Comcast, CVS, H&R BlockRegular Media—TV, Radio, Print Ads

◦Less effective as more are insuredDigital Marketing—Browsers Google AdWords

◦Aimed at uninsured individuals and small businesses

Digital Marketing—Social Media◦Use TweetDeck to track “followers”;

respond to them◦ MAHealthConnector


Outreach and Marketing: Outreach and Marketing: Federally Facilitated StatesFederally Facilitated States

Call Centers◦By Oct 2013, Center for Medicaid and Medicare

(CMS) will have a call center to answer questions about open enrollment, eligibility, and assist in plan comparisons.

Small Business Health Options Program (SHOP)◦Employer chooses plan and cost sharing level◦Employee enters info on self and dependents

and then chooses plan based on net price after employer contribution. CMS Consumer Support CMS Small Business


Churning: Medicaid & Churning: Medicaid & ExchangeExchange

Expanded eligibility for Medicaid to <133% FPL Subsidized health insurance 133% - 400% FPLPeople near the cut-off (133%-200%) will have to

shift enrollment as income goes up or down.Estimate churning for families <200% FPL

◦within first 6 months 35% will shift once◦within first year 50% will shift once; 24% twice

Disrupted coverage. May not even seek insurance since low income exempts them from mandate,

Increase administrative costs (new enrollments) Sommers and Rosenbaum Health Affairs


Managing the ChurnManaging the ChurnMinimum guaranteed eligibility period to avoid

churning due to short term income fluctuations.Plans dually certified to serve both Medicaid

and exchange enrolleesBetter ways to track/ report income changesAlign coverage between Medicaid and

exchangeCoordinated marketing between Medicaid,

exchanges and community health centers Raise Medicaid eligibility to <200% FPL

◦ Sommers and Rosenbaum / Hwang, Rosenbaum, Sommers


Partnering with CHCsPartnering with CHCs Neighborhood Health Plan (MA carrier) serving

Medicaid and other low-income populations partnered with Community Health Centers

Currently has 35 percent of market for unsubsidized individual and small business products offered through the health exchange.

* * * * * * * * * *

In Michigan County Health Plans ◦not insurance but provides limited health

care services [doctor visits, lab tests, x-rays and prescriptions] to Adult Benefits Waiver (ABW) recipients


AccessAccessAssist low-income people to enter and

navigate through the health care system.Help them determine

◦Which plan is most appropriate for them ◦How the health plan works, ◦Costs– premiums, co-pays and

deductibles◦The role of primary care◦Which providers are available, ◦Finding and selecting providers, ◦Scheduling appointments.

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Tips from OregonTips from OregonOregon will expand Medicaid and is establishing an exchangeConsiderations include:Patient navigator piece – The Exchange Corporation is determining the criteria now for what defines a patient navigator. FQHCs are monitoring to ensure eligibility workers fulfill that role. FQHCs are essential access point - Get training on how exchanges are set up and how to navigate the portal. Oregon Primary Care Association is weighing in on the essential benefits package required by exchange; Workgroup established to make sure FQHC model is protected in the exchange.If the federal government does the exchange, how involved can we be at this level? Who do they consult with?Information based on conversation with Mary Falls-Staley, Provider Outreach Coordinator, Office of Client and Community Services - Office of Healthy Kids, Oregon

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Tips from MassachusettsTips from Massachusetts Network of more than 50 CBOs in Massachusetts trained to

provide outreach & enrollment assistance to consumers through rollout, implementation, and post implementation.

Without outreach efforts, enrollment wouldn’t have been as successful.

CBOs were given grants for outreach & enrollment, so it would help to seek funding. (MCO, state Medicaid agency, private foundations).

State Medicaid staff didn’t do any enrollments themselves, they would mail a blank application or advise you to go to an outreach grantee.

Health Centers & CBOs set up financial counseling office. Do follow up with patients. Assisting organizations get copies of notices sent to clients, which is pivotal to make sure folks are informed on enrolling in the appropriate coverage.

Information based on conversation with Kate L. Bicego, Consumer Education & Enrollment Manager, Health Care For All, Massachusetts

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Tips from MassachusettsTips from Massachusetts Health Care For All is community based advocacy

organization - operates a toll-free helpline that people can use statewide. Operators are trained in exchange technical assistance, website navigation, and explaining terminology; offers multiple languages)

Outreach methods: health fairs were effective way to enroll people (take help line staff w/laptops to complete applications in real time), make sure that outreach materials were consumer friendly and in multiple languages, use faith-based community (people trust them), ethnic media channels (radio, papers, etc.), outreach and enrollment in small businesses, local neighborhood stores, barbershops, auto repair shops, hospital emergency rooms and CHCs

Information based on conversation with Kate L. Bicego, Consumer Education & Enrollment Manager, Health Care For All, Massachusetts


ReferencesReferences Bergquist, P. (2012) Currently Uninsured Health Center Patients

That will become Medicaid Eligible in 2014. Michigan Primary Care Association.

Hayes, KJ, Shin, P and Rosenbaum, S, (2012) How the Supreme Court’s Medicaid Decision May Affect Health Centers: An Early Estimate. Policy Research Brief #30. Geiger Gibson/ RCHN Community Health Foundation Research Collaborative. George Washington University. Available at: http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub _uploads/dhpPublication_9BB1853A-5056-9D20-3D3DCBB99318306E.pdf

Hwang, A, Rosenbaum, S and Sommers, BD (2012) Creation Of State Basic Health Programs Would Lead To 4 Percent Fewer People Churning Between Medicaid And Exchanges Health Affairs June 2012 31:61314-1320


ReferencesReferences Kaiser Commission on Medicaid and the Uninsured (2011) Medicaid

Coverage and Spending in Health Reform: National and State-by-State Results for Adults at or Below 133% of FPL Available at:

http://www.kff.org/healthreform/upload/Medicaid-Coverage-and-Spending-in-Health-Reform-National-and-State-By-State- Results-for-Adults-at-or-Below-133-FPL.pdf

MAHealth Connector Health Reform Toolkit Series: Resources from the Massachusetts Experience. Available at:

https://www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=default

CMS Consumer Support: Web and Call Centers Available at: http://cciio.cms.gov/resources/files/hie-consumer-support-web-call-

center.pdf CMS Small Business Health Options Program. Available at:

http://cciio.cms.gov/resources/files/Files2/15_shop.pdf.pdf Sommers, BD and Sara Rosenbaum S (2011). Issues In Health Reform: How

Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges Health Affairs February 2011 30:228-236;

Questions?Questions?For further information, please contact: Harry Perlstadt, PhD, MPH

Medical Sociologist and Professor EmeritusMichigan State University517.316.5658 [email protected]

Doug Paterson, MPADirector of Public Policy, [email protected]

Natasha RobinsonCHIPRA Program Specialist, [email protected]

Expansion Exchange Outreach Enrollment Strategies

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