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The Role of Safety Net HealthCare Providers in Outreach and Enrollment (Enroll America)
1. 1
The Role of Safety Net Providers in
Outreach & Enrollment
Community Connections Pre-Application Workshop
Jenny Sullivan April 26, 2013
2. Delivering on the promise of
affordable health coverage for
millions of Americans . . .
2
3. . . . starts now.
only 158 days
until October 1, 2013.
3
4. Enroll America
Two-fold Strategy
Our Mission
Maximize the number of uninsured Americans who
enroll in health coverage made available by the
Affordable Care Act
Promoting Enrollment Best Practices
National Enrollment Campaign Using Cutting
Edge Engagement Strategies
1
2
4
5. The 2014 Enrollment Opportunity
0
5
10
15
Source: February 2013 CBO estimates
Millions
Enroll at least 15 million people in new coverage options
} 7 million in Exchange coverage
8 million in Medicaid or CHIP
}
5
6. Health Coverage in 2014
6
Medicaid
Exchange
(“Marketplace”) with
Tax Credits
Exchange or
Private Plan
Income as a percent of the federal poverty level
0 133 400+
Coverage Options for Adults without Medicare
or Employer-Based Coverage
An Opportunity for a Complete Continuum of Coverage
7. The Coverage Continuum in Ohio
Children Pregnant
Women
Parents Non-parent
adults
Exchange without tax
credits
Exchange with tax
credits
Medicaid expansion?
Medicaid
400%
300%
200%
100%
Percentageofthefederalpovertylevel
?
?
8. The Enrollment Opportunity in Ohio
Source: March 2011 and 2012 Current Population Survey
790,000
611,100
126,400
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
Non-elderly uninsured
Thousands
Likely exchange
eligible, w/out
financial help
Likely exchange
eligibile w/financial
help
Likely Medicaid-
eligible
8
Connect more than 1.5 million people to coverage
9. Enrollment isn’t a snap
Program
Percent of Eligible People
Enrolled
Children’s Medicaid/CHIP, national average, 2009 84.8%
Medicare low-income subsidy, 2009* 40%
Unemployment benefits 72-83%
Earned income tax credit 80-86%
SNAP (food stamps) 54-71%
* Does not include populations automatically enrolled in the low-income subsidy.
Take-up in optional public benefit programs
10. Limited Public Awareness
The majority of uninsured Americans
don’t know the health reform law will
help them.
75%
Three out of four of the newly eligible
want in-person assistance to learn
about and enroll in coverage.
10
Enroll America Research, November 2012
78%
11. CA
TX
FL
NY
GA
ILNCOHPA
NJ
MI
AZ
VA
TN
WA
IN
MO
SC
LA
MD
AL
CO
Rest of the US
Where are
the
Uninsured?
11
Two-thirds of
the uninsured live
in 13 states
• California
• Texas
• Florida
• New York
• Georgia
• Illinois
• North Carolina
• Ohio
• Pennsylvania
• New Jersey
• Michigan
• Arizona
• Virginia
12. Demographic Profile of the Uninsured
(Nonelderly Adults, Ages 18-64)
12
53%47%
Race/Ethnicity
Percent of
Uninsured
Uninsured
Rate
White (non-Hispanic) 45% 13%
Black (non-Hispanic) 15% 21%
Hispanic 32% 32%
Asian/Pacific Islander 5% 18%
American Indian/Alaska Native 1% 27%
Two or More Races 2% 15%
62%
Live in Families
with at least One
Full Time Worker
38%
13%
25%
13%
10%
Federal Poverty Level
Source: Kaiser Commission on Medicaid and the Uninsured, October 2012
13. Why Safety Net
Providers?
13
Relationships with the uninsured
Community Benefit
DSH decreasing
Medicaid Primary Care Rates Increasing
PartofCoreMission People trust
providers
Enroll the
Whole Family
15. Requirements for ALL states
A Single, Streamlined Application
• One application for all health coverage programs
• Available in online, phone, and paper
Use Modified Adjusted Gross Income/No Income Disregards
Eliminate Asset Tests
Eliminate In-Person Interview Requirements
Use Electronic Verification to the Greatest Extent Possible
Regardless
of Medicaid
expansion!
16. A New Way to Enroll in Coverage
Consumers can connect to whichever program they are eligible
for, no matter where they start.
16
Complete single
application
Determine eligibility
Enrolled in correct
program!
Medicaid
CHIP
In-Person
Assistance
Exchange
Single
Application
17. Public Perceptions
75%
Three out of four of the newly eligible
want in-person assistance to learn about
and enroll in coverage.
17
Help gets them
from here… …to here.
Source: Enroll America, November 2012
18. Uninsured, but Online and Connected
63
57
20
57
67
63
39
62
74
49
38
77
81
71
48
7573
67
31
68
0
20
40
60
80
100
Frequent
internet user
Facebook
user
Smart phone
user
Uses text
messaging
Uninsured <139% FPL
Uninsured Latinos
Uninsured African
Americans
Uninsured Young Adults
Uninsured Women
18
Percent
Source: Enroll America, Forthcoming March 2013
19. Too Important to Do Online?
29
43
30
49
36
49
31
42
35
53
0
20
40
60
80
100
Uncomfortable using a
website to find a plan
Getting health insurance is
too important to do online
All Uninsured
Uninsured Latinos
Latinos <139% FPL
African Americans*
Uninsured Women
19
Percent
Source: Enroll America, Forthcoming March 2013
*Data provided are for all African Americans; subset for uninsured African
Americans not available.
20. Preferences for Help: The Uninsured
20
7%
24%
30%
77%
Online Chat
Email
Telephone
In-person
21%
22%
27%
29%
Medicaid office
Clinic/doctor's office
Family/friend's home
Agent/broker's office
What Kind?
From Whom?
How?
Where?
52%
56%
Finding the best
plan
Qualify for
financial help?
31%
32%
32%
34%
48%
Health insurance
company
Medicaid office
Doctor or nurse
Family member
State employee whose
job it is to help
Source: Enroll America, November 2012
21. Value of In Person Assistance
21
• What is and isn’t covered
• Out of pocket costsKnowledge
• In-person beats online/self-service
experienceSecurity
• Have provided all necessary
paperwork
• Have completed application correctly
Confidence
• Know when their insurance will start
• Know what to do if they need health
services before they get their card
Reassurance
Source: Enroll America, Forthcoming March 2013
22. Understanding State Assistance Options
22
Certified
Application
Counselors
In-Person
Assistance
Programs*
Navigators
*IPA programs not available in federally facilitated exchange states.
Consumer
Assistance
Programs
Medicaid
eligibility
workers
Insurance
Agents, Bro
kers
Other
Community
Based
Groups
24. All insurance plans will have
to cover doctor
visits, hospitalizations, mater
nity care, emergency room
care, and prescriptions.
You might be able to get
financial help to pay for a
health insurance plan.
If you have a pre-existing
condition, insurance plans
cannot deny you coverage.
All insurance plans will have
to show the costs and what is
covered in simple language
with no fine print.
Four Key Messages to Reach Most Uninsured
One of these =
top message
for 89% of
population
25. An Action Plan for Safety Net Providers
25
1. Invest in staff/identify
partners
2. Make your data work for
you
3. Develop a plan
4. Utilize technology
5. Hold on to what you’ve got
6. Recognize everyone’s role
in outreach
26. Outreach and Enrollment Resources
• In-Person Assistance
Resource Center
• Public Education
Resource Center
26
Enroll America will execute a national enrollment campaign using cutting-edge engagement strategies and will continue to build coalitions + share best practices
Health Insurance ExchangesA marketplace to purchase and enroll in health insuranceCan be State or federally run“No Wrong Door” entry point for all forms of coverageDetermine eligibility for different plans and subsidies.Seamless enrollment for all program (public and commercial). Provides consumers with easy way to review all optionsExchange certifies qualified health plans which must offer “essential health benefits”The Mental Health Parity and Addiction Equity Act appliesInsurance Affordability ProgramsPremium tax subsidies for moderate income non-Medicaid eligible population up to 400% FPLCost-sharing subsidies to eligible enrollees up to 250% FPLPremium tax credits are refundable and payable in advanceMedicaid ExpansionLow-income Americans can enroll in the program regardless of whether or not they have dependent children or a disabilityA uniform nationwide Medicaid eligibility floor of 138% of Federal Poverty Level (FPL) New Medicaid eligibility group for low-income individuals not otherwise eligible under an existing mandatory category in MedicaidEligibility will be based on income only – no asset or resource testModified Adjusted Gross Income (MAGI): Total income, interest income, and foreign earned income.
Children’s coverage remains the sameUp to 200% of povertyCoverage for pregnant women remains the sameUp to 200% of povertyExisting Medicaid coverage for adults remains the sameParents up to 90% of povertyOption to cover adults without dependent children in MedicaidUp to 138% of povertyExchange coverage Adults and children ineligible for other coverageTax credits to help with premiums between 138% and 400%
These are # of eligible, NOT likely the number likely to enrollThese figures will likely change with the September release of the new census figures1.5 million nonelderly uninsured% Medicaid% exchange% exchange w/out APTC790,000 <138% FPL611,100 Between 138-400% FPL126,400 400% FPL and upTake-up Rate in Children’s Medicaid in Ohio = %
Sources:Medicare low-income subsidy, 2009* - http://www.kff.org/medicare/upload/8094.pdfUnemployment benefits - http://aspe.hhs.gov/health/reports/2012/MedicaidTakeup/ib.shtml#_ftn21 Earned income tax creditSNAP (food stamps)Just because it’s accessible, doesn’t mean people will automatically apply. Other programs have taught us this. In places where enrollment in programs has increased, it has been combined with significant marketing and outreach. But where are they? Where do they live?Next slide
Consumers trust safety net providerswith their health care, so trusting them to provide assistance getting health coverage is a natural fit. In fact, research suggests that health care settings are one of the most popular places people would like to go for enrollment help.
Half of uninsured in only 115 counties (of 3,300+ counties nationwide)Franklin county = county w/39th highest number of uninsuredCuyahoga county = 42ndHamilton county = 83rd
17% of adults between 18-64 less then 400% FPL have a college degree30% of uninsured adults and 49% of the uninsured expansion population have less then a high school education76% are below 250 FPLEA LOOKS AT THESE NUMBERS TO IDENTIFY TARGET AUDIENCES. MORE THAN HALF OF THE UNINSURED WILL BE MEDICAID ELIGIBLE, AND LATINOS OVERWHELMING REPRESENTED¼ SPEAKS A LANGUAGE OTHER THAN ENGLISH IN THE HOMEWHAT ELSE DO THEY ALL HAVE IN COMMON?
FOR SOME THIS MAY BE OLD INFORMATION, FOR OTHERS THIS MAY BE TOO COMPLEX- REMEMBER THE END GOAL: HAVING SOMEONE AVAILABLE TO HELP PEOPLE APPLY.FOR THOSE THAT HAVE HAD SOME EXPERIENCE WITH MEDICAID IN THE PAST- IT’S BEEN COMPLEX AND FOR MANY, TRYING TO NAVIGATE THE SYSTEM HAS FELT LIKE THE PICTURE ON THE LEFT
NOT necessarily a single point of entry!The goal of no wrong door is to create a system where services wrap themselves around the individual and provides seamless access to all available optionsIt is philosophy that can support many different models for helping people get the information they need to get services and supports. Some states are applying the “no wrong door” policy through an integrated/centralized systems – significant cost-savings Others apply the “no wrong door” philosophy through an intricate information and referral system that creates a virtual door in multiple locations, the coordinated/decentralized approach. In this model, consumers have seamless, real-time access to relevant and necessary information about services, but the full array of services may not be offered in one location.In-person assistance: will return to later but that could be through navigators, OEWs, person to person assistance, etcCoordination Notes:Agencies must work together and exchange data electronicallyOnce information has been collected once, cannot be requested againExchanges must make Medicaid eligibility determinations for MAGI-populations; may refer non-MAGI determinations to Medicaid agencyIndividuals receiving a disability-related Medicaid determination can enroll in Medicaid/exchange while awaiting final determination
78% of the public doesn’t know about the changes in coverage that are coming83% of potentially Medicaid eligible populations don’t know changes are coming*BUT* when people are given more information about QHPs/health insurance exchanges/premium tax credits and the possible Medicaid expansion, they are interested. However, most expect they will need help figuring out this new system.This makes sense, because when we ask people about their experience trying to get affordable coverage in the past, most have very negative feelings associated with this experience. Having reliable, knowledgeable, accessible sources of enrollment assistance is one of the best ways to reverse these feelings and get people to a more confident, secure place when it comes to their feelings about coverage.
Often tempted to think that this population does not have access to the Internet; their access is more limited that the general population, and most limited for those with income <139% FPL, but our research found that they are nonetheless relatively “wired”.63% of uninsured adults say would be very (31%) or somewhat likely to go to the exchange website to find and compare plans if they did not have insurance in 2014.44% of the uninsured have made a website purchase in last 3 months.BUT, while electronic communications may be an important medium for outreach and peer-to-peer sharing of information about health coverage, our survey found that people prefer to get help in person.
Our findings bear this out; on average about a third said they would be uncomfortable using a website to find a plan, and almost half said getting health insurance is too important to do online. Especially true of Medicaid expansion population (to the extent we have data on them).40% of women in expansion population are uncomfortable using a website to find a plan.53% of uninsured women think getting health insurance is too important to do online.Going back to those initial feelings about purchasing coverage and past experiences, people perceive health coverage as complex, important, and at times anxiety-inducing; it’s not the same as other online purchases.
So, how *do* people want to get help?--important to keep in mind here that respondents were answering questions based on their current experiences of the world; don’t necessarily know about all the changes coming in 2014 with Navigators, IPAs, new application process, etc.—What kind: other things include where to go for help, fillingout the application, and how to use the websiteHow: in person is hands-down most preferred (even more so among uninsured than general population: 77% vs. 75%)From Whom: someone whose job it is = most important for uninsured, followed closely by other options; all should be able to refer, or should consider housing trained assisters (if not serving in that role themselves); also important to think about these individuals as outreach messengers = mom, partner/spouse are trusted messengersWhere: Universe for these data = uninsured, except for “Where?” that is among all survey respondents Which family member? Spouse (42%) or mom (20%)People also need information about how help is available, where they can go for help.Among the <139% FPL uninsured population, #1 preferred source of help is “state/fed govt. worker whose job it is to help” followed by family member or doctor/provider (tied), then lastly Medicaid office. As go up income scale, growing preference for help directly from health insurance company, but state/fed worker is still always #1.
Knowledge is most important factor in who is providing assistance – why we see agents/brokers and insurance companies as leaders among who respondents wanted to get assistance from.Despite long waits and sometimes cumbersome administrative process, people value seeing an enrollment worker who can work with them one-on-one. Know that their paperwork was submitted correctly and completely, know what to expect for next steps, know how to use their coverage.Will be important to include information about help being available and how to get that help in outreach and education messages.
STATES HAVE OUTSIDE BUBBLES CURRENLTY TO HELP PEOPLE GET COVERAGE (TO VARYING DEGREES)IN THE FUTURE- THE BUBBLES IN THE CENTERS WILL ALSO EXIST.OUTER BUBBLE= CACSCENTER= FOR STATEBASED AND PARTNERSHIP EXCHANGESNAVIGATORS ARE GRANTS AND IN EVERY STATE
A message with all four facts reaches 89% of the population and 87% of the uninsured population. This means for 89% of the population, the most important fact is one of the top four facts above. Common key findingsUniversal value of insurance Cost and affordability are biggest barriersUniversal messages surrounding exchanges Deep skepticism among consumersPrevious bad experienceToo good to be true Insurance is confusingLatinos vastly overrepresented among uninsuredEveryonewants help enrolling in coverageA message with all four facts reached 89% of the population and 87% of the uninsured population. This means for 89% of the population, the most important fact they need to hear is one of these four.NEW WAY TO BUY COVERAGE, HELP WITH THE COST WITH THEM. KNOWING THERE IS HELP WITH THE COST OF COVERAGE IS ESSENTIAL. KNOWING THAT THE COVERAGE THEY ARE GOING TO BUY IS ACTUALLY GOING TO GET THEM THE HELP THAT THEY NEED ARE THE THE TWO THINGS THAT GETS THEM TO FEELING SAFE SECURE.We are putting together in-depth looks at target populations such as the clusters mentioned and also by race and income. There are minor differences- for example: amongst Latinos- in california and florida- the top motivators are financial security, your plan will be there for you, and you will be able to find a plan that fits your budget. In Texas the motivators are the same but in a different order- financial security, you will be able to find a plan that fits your budget and your plan will be there for you.
What role will your hospital play?What is your hospital currently doing?What tools exist?What tools does your hospital need?
Exchange branding researchPublic opinion pollingStatewide marketing and outreach plans