When any new public benefit becomes available, it takes time for people to understand what it offers and how its provisions apply to them. All potential beneficiaries of new or expanded programs have this problem, which they often share with case managers and others who have the responsibility of helping newly eligible people to access all of the benefits for which they qualify. Medicaid eligibility expansion is no exception.
States that have expanded Medicaid eligibility through early implementation of the Affordable Care Act or provided Medicaid-financed coverage through waivers have developed many useful strategies to disseminate information about eligibility and stimulate interest among newly eligible people in the opportunities that have become available to them.
Early outreach and enrollment efforts have generally started with people who are already receiving health care services from hospitals and clinics that have been using state or local funding, grants, or other resources to pay for services.
The six communities studied intensively for this report were pursuing various enrollment strategies, described below. These include finding and engaging the newly eligible people and helping them through the Medicaid enrollment processes, helping people qualify for SSI, and helping people avoid being dropped from Medicaid.
2.5.1. Strategies for Enrolling Newly Eligible Members
Whether expanded eligibility occurred through early implementation or 1115 waivers, jurisdictions faced the challenge of enrolling thousands of people as quickly as possible. Some of the strategies used in this process include the following:
Starting with people already enrolled in state-only health insurance programs.
Starting with people using health services and engaging them at the time of treatment at clinics and hospitals.
Hiring and training specialized staff to handle the volume and the potential complexities of enrollment, and to help people obtain documents needed to complete the enrollment process.
Going to streets, shelters, and other locations to engage and enroll people who were likely to be eligible but not already connected to care.
Using new technologies to enable completion of an application in one encounter.
Automatically enrolling people based on information and documentation previously submitted to the county or state to establish eligibility for other benefits.
Starting With Existing Enrollees and Those Using Health Services
All five of the case study sites that pursued either early implementation of income-based eligibility or expansion through 1115 waivers began recruiting new enrollees from among people already enrolled in state-only health insurance programs or people already using safety net providers. Recognizing that enrollment would depend on the full understanding and cooperation of personnel in the agencies in contact with patients, these states clearly articulated the new eligibility criteria, pursued major informational and training strategies for people serving the target population, established enrollment procedures and forms, clarified the differences between old eligibility criteria (in jurisdictions with stateonly programs) and the new, and updated websites and other access points.
These jurisdictions assumed from the start that one of the best ways to reach people was to tell them about the new program when they came in for treatment. New procedures were established at safety net provider clinics and hospitals, including Health Centers. In outpatient settings, patients were notified as they signed in for appointments or during walk-in times. In hospitals, they were contacted in the emergency department or, if admitted, once they were established in a bed.
Hospital staff was encouraged to identify the people they saw most often and whose use of health care could become more rational and effective if they received proper case management. Special attention was focused on bringing these frequent users not only into Medicaid or the waiver plan, but also into case management and, if appropriate, housing. In Los Angeles, hospital staff reported almost immediate declines in hospital use after people in this group were connected with care and housing, which made them increasingly enthusiastic participants in strategies to engage this population.
Hiring Additional Staff and Focusing Them Solely on Enrollment
Health Centers in case study sites described the lengths they went to help their patients get enrolled into newly available coverage. Many hired staff for the sole purpose of processing applications and helping people get identification cards and other documents needed to establish eligibility. They then set up intake procedures at their appointment desk to refer all people coming in for care to the enrollment specialists first, before going to their medical appointment. The enrollment staff received specialized training in eligibility requirements and enrollment procedures. Many other safety net providers took similar steps to get people enrolled and connected to a primary care provider.
Going to the Streets and Using New Technologies
An important strategy for finding people who did not make frequent use of health care facilities was outreach to the streets. This strategy is important for addressing two barriers that often keep people experiencing chronic homelessness from enrolling in programs to which they are entitled--trust and difficulty navigating application processes. People experiencing chronic homelessness often have had negative interactions with public and safety net agencies, including health care providers, and have chosen largely to avoid them. Street outreach teams often include people who have had extensive contact with the people they want to enroll and have established a level of trust that makes it possible to start a conversation about enrollment.
Mobile technology can help turn those conversations into completed applications. The most successful outreach teams use mobile devices that allow them to connect to application websites wirelessly. They visit meal sites, shelters, and street locations, "going where they are" to work with people to establish eligibility "on the spot," preferably within the same single encounter as finding people again can be a challenge. Team members can complete an application on-line while talking to the applicant, photograph and convey documents (e.g., Social Security card, birth certificate) and an image of the applicant, get needed signatures on their mobile devices, and so on. These strategies have proved to be successful in enrolling some of the hardest-to-find eligible people.
Los Angeles County pursued an auto-enrollment strategy for newly eligible people to be covered through Healthy Way LA, basing eligibility on information and documentation that had been submitted when applying for other benefits. This information, which included documentation of residency, citizenship, age, and income, could be used to verify eligibility for coverage through the waiver program. The County also auto-enrolled people who were on the General Relief rolls into Healthy Way LA. Through autoenrollment, many people who were experiencing homelessness obtained coverage. However, enrollment alone did not connect people to health care, because many people did not know they had been enrolled into Healthy Way LA and did not know they had been assigned to a primary care provider or clinic. Their care-seeking behavior did not change until they connected in person with an outreach worker or with someone at a clinic or hospital. Funding from local foundations allowed the County Department of Health Services and several Health Centers to add outreach workers and case managers who actively worked to enroll people experiencing homelessness into coverage through Healthy Way LA and Medicaid, and to get those who were enrolled connected to a primary care provider or clinic that would best meet their needs.
After January 1, 2014, both case study sites that used 1115 authority to expand coverage automatically transitioned eligible beneficiaries from their waiver programs (Healthy Way LA and CountyCare) into enrollment in the state's traditional Medicaid program with full access to the entire Medicaid state plan. In the transition, most participants were assigned to a primary care provider and Medicaid managed care plan based on information about each person's primary care assignment and service use through the waiver program.
In 2014, California also implemented "Express Lane" enrollment into Medicaid for people receiving benefits through the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps). This process uses the information provided by applicants for SNAP benefits to determine eligibility for Medicaid enrollment, without the need to complete a new application or submit additional documents.21
2.5.2. SSI Eligibility
Even in states that implement the expansion of Medicaid eligibility permitted under the Affordable Care Act, enrolling people who are chronically homeless in Supplemental Security Income will continue to be important. The categorical eligibility for Medicaid that comes with enrollment in SSI may provide access to a broader array of services available in a Medicaid state plan than in the benefit package available under an Alternative Benefit Plan. Access to full Medicaid state plan benefits can help cover more of the costs that PSH providers incur for the care they offer clients who are currently or formerly homeless. In addition, SSI provides these clients with a reliable income source to help pay for rent and other essential items.
There are, however, many barriers to qualifying for SSI, so it is very important for people experiencing chronic homelessness or those already living in PSH who are not yet enrolled in SSI to work with knowledgeable people who can guide them through the process. Applicants must document that their disability meets requirements of the Social Security Administration's (SSA's) requirements for diagnosis type, duration, and severity or functional impairment. As the process can be long and complicated, very few applicants experiencing chronic homelessness are approved on their first application attempt unless they have support from well-trained case managers, legal assistance, or help from other advocates.22
The case study sites examined in this study used a number of strategies to support SSI outreach and enrollment in SSI.
In Louisiana, persons displaced by Hurricanes Katrina and Rita in 2005 and other more recent hurricanes could gain access to federally funded PSH services. The source of these funds was timelimited disaster-related Community Development Block Grant funding. Beginning in 2008, the state's Permanent Supportive Housing Program (PSHP) used its homeless outreach teams to facilitate SSI enrollment for its clients. In PSHP, clients are assigned to the community support teams, so the issue of finding clients has not been as acute as in some other communities. PSHP caseworkers did have to work on engaging those clients, helping them understand the importance of obtaining SSI, and assisting them in obtaining documentation, completing the application, and continuing to pursue enrollment when an initial application was denied, which happened frequently. In cases where clients once had been SSI beneficiaries but enrollment had lapsed, sometimes for many years, PSHP staff helped with reinstatement. By 2011, at least 80 percent of current PSHP clients were SSI recipients and thus qualified for Medicaid, up from no more than 25 percent at the time the program was initiated.
In Los Angeles, the county-funded B.E.S.T. program, housed at JWCH's Center for Community Health (a Health Center), has achieved excellent results in helping people establish eligibility for SSI. On average, B.E.S.T. clients are approved for SSI within four months of enrollment in B.E.S.T., and more than 90 percent are approved with their first application. B.E.S.T. attributes its success to experienced staff who have support from upper management, do whatever it takes for clients, have excellent relationships with local SSA offices, and have highly developed and efficient records retrieval and standardized forms and procedures. In addition, the program focuses on clients who are likely to be approved; the program takes fewer than 20 percent of the people it screens, but is able to help almost all of its participants obtain SSI. Such screening is fairly common among agencies that work with clients to establish SSI eligibility since this is the most efficient way to deploy their specialized knowledge.
In the District of Columbia, the Medicaid enrollment process (both before and after expansion) includes a screen for homelessness and disability. Enrollment staff are expected to refer someone who is experiencing homelessness or is highly likely to be found disabled to Interim Disability Assistance (IDA), a special section within the department that assesses them for likely SSI eligibility. If SSI eligibility is likely, the person is enrolled in IDA while applying independently for SSI. IDA staff help the applicant to assemble the documentation needed for IDA eligibility. IDA pays a monthly stipend as well as qualifying the applicant for full fee-for-service Medicaid. IDA stops as soon as SSI receipt is approved. With SSI, full fee-for-service Medicaid continues.
If a person experiencing homelessness already has a caseworker from any of several agencies, that caseworker will assist with this process. The contracts for case management in its PSHP (see below) include the requirement that caseworkers assist with IDA/SSI applications. All of these caseworkers are trained in the HHS Substance Abuse and mental health Services Administration's (SAMHSA's) SSI/SSDI Outreach, Access and Recovery (SOAR) techniques, which staff say has helped facilitate access to IDA/SSI.23 In previous years, the Los Angeles County Department of Health Services (DHS) recovered between $2.3 and $2.4 million in health care costs from Medicaid; since the SOAR training, that amount increased to $3.5 million in 2011 and was expected to go up even further for 2012.
For more information on these and other examples of strategies for improving access to SSI for homeless and formerly homeless people, see Burt and Wilkins 2012b.
2.5.3. Maintaining Medicaid Enrollment Over Time
Organizations intending to provide comprehensive and coordinated care for populations with complex health conditions usually make financial calculations based on a set of assumptions. One essential assumption is that once someone is enrolled in Medicaid, that individual will remain enrolled and the provider can count on receiving a given amount of money from Medicaid every month to cover the cost of care.
Provider experiences during the first year or two of operating in the new mode has shown that this assumption is not borne out by reality. An important but not initially fully appreciated reason is the attitudes and care-seeking habits of the newly eligible population. Many newly enrolled beneficiaries have never had health insurance, and have difficulty understanding the need to maintain coverage when they do not need care. They are accustomed to going to the doctor, emergency room, or hospital when they are sick, usually very sick as they wait too long to seek care, and do not see why they should worry about maintaining insurance coverage when they can always get re-enrolled on the spot when they need care again.
Thus enrolling people in Medicaid is only the first challenge; keeping them enrolled can be equally challenging. Some providers reported that almost as many patients drop off their rolls every month, due to loss of Medicaid eligibility attributable to difficulties with recertification, as they are able to enroll. Before full implementation of the Affordable Care Act, states often required their beneficiaries to re-establish eligibility every six months, and sometimes more often.24 Beneficiaries had to submit paperwork to document their continued eligibility. In recent years, state policymakers in several of the case study sites enacted requirements for frequent eligibility redetermination as a strategy for achieving budget savings. If beneficiaries did not submit the paperwork on time they were dropped from Medicaid and had to go through a full reapplication process to get reinstated. These requirements are quite difficult for people experiencing homelessness to comply with, putting them at great risk of losing eligibility not only because they have more difficulty assembling the documentation required, but also because their unstable housing situations mean they may not receive reminders of pending deadlines.
For example, people experiencing homelessness often face gaps in eligibility for California's Medicaid program because they do not receive notifications or are unable to complete the paperwork required to maintain their enrollment. Service providers find it difficult to communicate with the county and the state to verify that the people they serve are currently enrolled in Medicaid, and county and state records have been known to differ.
Because Medicaid providers may experience disallowances if they bill for services delivered while a client is off the rolls, they invest considerable staff time in verifying enrollment and documenting eligibility.
Hennepin County, Minnesota, is one case study site finding that its assumptions about stable enrollment have not been borne out. Hennepin County is developing an Accountable Care Organization called Hennepin Health, which began enrolling people who were newly eligible for Medicaid shortly after Minnesota implemented its early expansion of income-based Medicaid eligibility in March 2011.
Hennepin Health has faced challenges maintaining and increasing the number of people enrolled in the plan because many people lose coverage when they fail to submit their eligibility paperwork every six months. In December 2012, enrollment stood at 6,000 people. Although the plan enrolls about 1,000 members every month, it also loses 800 members whose coverage is dropped because they have not submitted the required documentation.
The State of Minnesota recently approved a process for sharing eligibility redetermination dates with Hennepin County, but in December 2012, Hennepin Health was still working with paper lists. Staff hope to integrate the information about eligibility redetermination dates into state data systems so that clinic workers can monitor upcoming deadlines and encourage clients to submit required documentation on time. This could include providing reminders when patients visit the clinic or contacting members whose eligibility ends.
Hennepin Health contracted with a vendor to track and facilitate eligibility redeterminations, but this did not have a significant impact on reducing the rate at which members lost coverage. Hennepin Health has found that many of the very low-income adults enrolled in the plan had not established strong connections to primary care providers in the past, instead relying on emergency rooms for care when needed. It is taking time and ongoing efforts to help previously uninsured adults build relationships with care providers and recognize the value of having year-round coverage with ongoing access to a primary care provider.
Minnesota's broader experience with enrollment churning in the Medicaid expansion population has been similar to the experience with plan enrollment at Hennepin Health. However, state agency staff expect that changes in 2014 will reduce churning. Factors such as simplifying eligibility and income verification and a change from 6 months to 12 months for redetermination should significantly reduce the number of people who lose eligibility or experience gaps in enrollment.
2.5.4. Shifts to Managed Care Enrollment
In some of the case study sites, the state Medicaid program is requiring that recipients be enrolled in a Medicaid managed care plan. This reflects a nationwide trend. In 2012, the Kaiser Family Foundation reported that more than half of all Medicaid beneficiaries were already enrolled in managed care plans.25 Until recently, seniors and people with disabilities were less likely to be enrolled in managed care arrangements than children and their parents, but an increasing number of states are expanding mandatory managed care enrollment to include people in this group. States are likely to use Medicaid managed care plans to provide coverage to people who are newly eligible for Medicaid. When the District of Columbia established income-based eligibility in April 2010, for example, it assigned all new Medicaid beneficiaries to a managed care plan. Those who had been enrolled in its self-financed health insurance program (Alliance Health Care) were assigned to one health plan (United), and all other enrollees were assigned to either United or another health plan (Chartered).
Enrolling people with histories of homelessness and complex needs has posed challenges for managed care plans. For example, the enrollment process often requires that Medicaid beneficiaries select a managed care plan from among two or more choices and designate a primary care provider, or get assigned by default if they do not make a choice. The selection of (or assignment to) a plan and provider usually limits where people can receive Medicaid-reimbursed health care services, or which providers can get reimbursed if they deliver care. These issues are discussed in more detail in Chapter 6.