healthcare reform readiness - patient enrollment & navigator strategies

“Patient Enrollment & Navigator Strategies”

Educate | Navigate | Connect

What will we cover today…

• Understanding Reform & Expansion

• How do we get ready and reduce the risk of caring for the uninsured

During this presentation the presenter may discuss information provided by

and gained as a result of this organizations having received federal funding to

act as a Navigator as part the of the Federal Health Insurance Exchange. The

following are required disclosure statements:

• “The project described was supported by Funding Opportunity Number CA-

NAV-13-001 from the U.S Department of Health and Human Services,

Centers for Medicare & Medicaid Services.”

• “The contents provided herein are solely the responsibility of the authors

and do not necessarily represent the official views of HHS or any of its

agencies.”

© 2013 Advanced Patient Advocacy

Disclosure/Disclaimer Statement

Who has the most to lose if consumers are not enrolled in the

healthcare coverage that best meets their needs?

• Federal Government

• State Government

• Insurance Carriers

• Providers (need not just coverage but the coverage that

delivers the best reimbursement)

3

Accountability


Knowledge of Medicaid Expansion

Posted on Monday, 10.28.13

Miami Herald | EDITORIAL

Florida should follow Ohio’s lead

By Miami Herald Editorial

[email protected]

• “Earlier this month, Ohio became the 25th state to

decide that it would accept federal funding to

expand Medicaid, giving more Americans health

insurance coverage that they could not otherwise

afford.”

• “Gov. Scott, though opposing Obamacare, did the

math and sided with Medicaid expansion here, a

sensible move that would have returned an

estimated $51 billion in federal funds to Florida

over the next 10 years and created an estimated

120,000 new jobs. As a businessman and former

hospital company CEO, Mr. Scott understood the

bottom-line value of this deal for the Sunshine

State.”

Read more here:

http://www.miamiherald.com/2013/10/28/3717311/florida-

should-follow-ohios-lead.html#storylink=cpy


mailto:[email protected]

http://www.miamiherald.com/2013/10/28/3717311/florida-should-follow-ohios-lead.html










Understanding Florida Is Not Enough!


What is happening in

other states? - Enrollment requirements

- Coverage & out of State

benefits

- How does presumptive

eligibility apply

- Some states have a

coverage gap

- Other states have

broader coverage and

thus reimbursement

opportunities

Knowledge of Medicaid Expansion

A New Eligible Group: All adults not already eligible.

The ACA expands the minimum income eligibility threshold to

133 percent FPL (effectively 138 percent FPL) for everyone

except the elderly and disabled. This is a floor, not a ceiling: if

states already had higher thresholds for certain populations, or

want to set higher thresholds, that's fine.

Under the ACA expansion, the categorical definitions shown in

the table to the right will be less relevant than the difference

between "traditionally eligible" and "newly eligible" persons.

• Those in any population who were already eligible in their

state (whether or not they were already enrolled) can be

thought of as "traditionally eligible." They will continue to

receive the services to which they are already entitled,

and states will continue to receive their standard federal

contribution for covering them, whether they enroll before

or after 2014.

• Those in any population who were not previously eligible

but become eligible under ACA (which will include

nearly all childless adults, plus many parents

and some children depending on states'

current thresholds) can be thought of

as "newly eligible."

Categorical

group

U.S. minimum

threshold pre-

ACA, 2009*

State

thresholds,

2009: medians ,

(ranges)

U.S. minimum

thresholds

under ACA,

2014**

235% FPL

(133-300% FPL)

235% FPL

(100-300% FPL)

185% FPL

(133-300% FPL)

64% FPL

(17-200% FPL)

38% FPL

(11-200% FPL)

0% FPL

(0% FPL in 46

states; 100-

160% FPL in 5

states)

75% FPL

(65-133% FPL)

Elderly, blind,

disabledReceipt of SSI Receipt of SSI

Non-working

parents

State's July

1996 AFDC

eligibility level

133% FPL

(note traditional

vs new)

Childless

adults

Eligibility not

mandated.

State must

apply for waiver

to cover this

133% FPL

(note traditional

vs new)

Pregnant

women133% FPL 133% FPL

Working

parents

State's July

1996 AFDC

eligibility level

133% FPL

(note traditional

vs new)

Children 0-5 133% FPL 133% FPL

Children 6-19 100% FPL

133% FPL

(note traditional

vs new)

Sources: Kaiser Family Foundation


Because Florida did not expand your

need to Mind the Gap

• 62 year old widowed female seeks coverage through the Exchange

• She worked in a textile mill for 24 years until the mill closed in 2009

• After being unemployed for almost 2 years, last year she secured a part-time job earning $8.50/hr. as a house

keeper at a hotel and works 30 hours per week. 110% FPL

• She completed QHP enrollment and selected the lowest cost coverage option

• Her monthly premium was $410 with a $6000 deductible


Case Study

Family Size 100% 110% 120% 133% 135% 150% 175% 185% 200% 250% 300% 350%

1 957.5 1,053.25 1,149.00 1,273.48 1,292.63 1,436.25 1,675.63 1,771.38 1,915.00 2,393.75 2,872.50 3,351.25

2 1,292.50 1,421.75 1,551.00 1,719.03 1,744.88 1,938.75 2,261.88 2,391.13 2,585.00 3,231.25 3,877.50 4,523.75

3 1,627.50 1,790.25 1,953.00 2,164.58 2,197.13 2,441.25 2,848.13 3,010.88 3,255.00 4,068.75 4,882.50 5,696.25

4 1,962.50 2,158.75 2,355.00 2,610.13 2,649.38 2,943.75 3,434.38 3,630.63 3,925.00 4,906.25 5,887.50 6,868.75

5 2,297.50 2,527.25 2,757.00 3,055.68 3,101.63 3,446.25 4,020.63 4,250.38 4,595.00 5,743.75 6,892.50 8,041.25

6 2,632.50 2,895.75 3,159.00 3,501.23 3,553.88 3,948.75 4,606.88 4,870.13 5,265.00 6,581.25 7,897.50 9,213.75

7 2,967.50 3,264.25 3,561.00 3,946.78 4,006.13 4,451.25 5,193.13 5,489.88 5,935.00 7,418.75 8,902.50 10,386.25

8 3,302.50 3,632.75 3,963.00 4,392.33 4,458.38 4,953.75 5,779.38 6,109.63 6,605.00 8,256.25 9,907.50 11,558.75

2013 Poverty Guidelines

Presumptive Eligibility How will Presumptive Eligibility Work?

• The patient provides basic information—to an intake worker at

the hospital who then assesses "on the spot" whether the person

has an income at or below Medicaid income eligibility guidelines

for the state. If so, the intake worker determines the individual to

be presumptively eligible for Medicaid for a temporary period

• An individual's temporary eligibility period lasts until the end of

the month following the month in which the presumptive eligibility

determination was made. During this time, hospitals will be

paid—at regular Medicaid rates—for the services they provide,

regardless of a person's ultimate Medicaid eligibility

determination.

• During the temporary eligibility period, the patient will also be

able to receive treatment from other Medicaid providers after he

or she leaves the hospital


Household Income & Same-Sex Couples

United States v. Windsor

CMS issued state on September 27, 2013

…as a general matter, for purposes of the Medicaid and CHIP programs,

• We believe that it is appropriate to recognize same-sex marriages that (1) are recognized

by the state or territory in which the applicant or beneficiary resides, or (2) were celebrated

in accordance with the laws of any state, territory, or foreign jurisdiction.

• However, in view of the unique federal-state relationship that characterizes the Medicaid

and CHIP programs, we interpret section 1902(e)(14)(G), which incorporates section

36B(d)(2), to permit states and territories to apply their own choice-of-law rules in deciding

what law governs the determination of whether a couple is lawfully married; that is, we are

permitting states and territories to adopt a different same-sex marriage recognition policy if

they do not recognize same-sex marriages consistent with their laws.

• Under this approach, with respect to Medicaid and CHIP, a state is permitted and

encouraged, but not required, to recognize same-sex couples who are legally married

under the laws of the jurisdiction in which the marriage was celebrated as spouses for

purposes of Medicaid and CHIP.


Knowledge of Insurance Exchange(s)

Income (% FPL) Coverage Premium & Cost Sharing

< 138% FPL Medicaid No Premium

Cost sharing limited to nominal amounts for most services

139% - 250% FPL Exchange Sliding scale tax credits limit premium costs to 3 – 8.05% of income

Sliding scale cost-sharing credits

251% - 400% FPL Exchange Sliding scale tax credits limit premium costs to 8.05 - 9.5% of income

No Cost sharing credits

Notes: Exchange coverage and tax credits are limited to lawfully residing individuals who do not

have access to employer‐sponsored insurance. Lawfully residing individuals who are barred from enrolling in Medicaid during their first five years in the U.S. may receive Exchange coverage and tax credits. Premium credits will adjust annually. Source: “Summary of New Health Reform Law”, Focus on Health Reform, the Kaiser Family Foundation, June 18, 2010.

One key to getting people to buy will be

Premium and Cost Sharing for Individuals

up to 400% FPL


Health Insurance

Marketplace

QHP Enrollment Opportunity

data.cms.gov


Counties Within PUMA uninsured total % uninsured < 138% FPL 139 to 400% > 400% FPL

Suwannee County, Levy County,

Gilchrist County, Dixie County,

Hamilton County, Lafayette County

34,618 31% 20,007 12,149 2,461

Columbia County, Bradford County,

Baker County, Union County35,790 31% 25,285 8,914 1,591

Alachua County (part) 17,619 17% 12,450 4,313 856

Alachua County (part) 17,134 15% 7,773 7,568 1,794

Duval County (part) 22,580 18% 12,228 8,720 1,632

Duval County (part) 25,170 24% 18,116 6,638 416






St. Johns County 23,253 14% 8,385 11,583 3,286

Clay County 24,983 15% 12,184 10,010 2,789

Putnam County, Flagler County 31,044 24% 20,067 7,347 3,630

Marion County (part) 26,531 28% 15,875 8,271 2,385

Marion County (part) 36,838 25% 21,621 12,740 2,477

total 402,585 228,812 142,000 31,775

Getting people to enroll in the exchange?


Where are the lines?



Some

groups are

taking the

Girl Scout

Cookie

Approach

We think Lucy had the

right idea



• Schedule appointments

• One-on-one

• Communicate in the

patients language of

choice

• Be available at the time

the patient is most

motivated to make the

decision

Can Hospitals

Pay QHP Premiums?

45 CFR §155.240 Payment of Premiums

(a) Payment by individuals. The Exchange must allow a qualified individual to pay any

applicable premium owed by such individual directly to the QHP issuer.

(b) Payment by tribes, tribal organizations, and urban Indian organizations. The

Exchange may permit Indian tribes, tribal organizations and urban Indian organizations to pay

aggregated QHP premiums on behalf of qualified individuals, including aggregated payment,

subject to terms and conditions determined by the Exchange.

(c) Payment facilitation. The Exchange may establish a process to facilitate through

electronic means the collection and payment of premiums to QHP issuers.

(d) Required standards. In conducting an electronic transaction with a QHP issuer that

involves the payment of premiums or an electronic funds transfer, the Exchange must

comply with the privacy and security standards adopted in accordance with §

155.260 and use the standards and operating rules referenced in § 155.270.


http://www.law.cornell.edu/cfr/text/45/155.260

http://www.law.cornell.edu/cfr/text/45/155.270

Enrollment Assistance


Toll-free Call Center Marketplace

Website

Navigators

Certified Application Counselors

Agents/Brokers

The eight Navigator entities that were awarded a grant by the federal

government are:

• University of South Florida, College of Public Health

• Epilepsy Foundation of Florida

• Advanced Patient Advocacy, LLC

• Legal Aid Society of Palm Beach County, Inc.

• Pinellas County Board of County Commissioners

• National Hispanic Council on Aging

• Mental Health America

• Public Health Trust of Miami Dade County dba Jackson Health System

www.myfloridacfo.com/Division/Agents/Industry/News/Navigators

HealthCare.gov

EnrollAPA.com

Florida Navigator Resources


APA Navigator Strategy

Patients are most motivated to enroll in

coverage at the time they need acute care.

By building on the enrollment processes

providers have already established more

patients will have access to QHP

enrollment services:

• Catch the applicant at the point in

time where they are receptive to

considering healthcare coverage

• Provide access outside the “normal”

business hours

• Provide services in an environment

where the applicant is comfortable

• Speak to the individual in their

language of choice


Enrollment Decision Tree


Navigator Strategy

Limited Funding and Limited Scope

• Focus on accessing the uninsured at

the time and place they receive

medical care

• Community outreach centered around

the host provider organization and

limited to 10 hours per month

APA Navigator Partnerships

HCA

Plantation General Hospital

Plantation, FL

University Hospital & Medical Center

Tamarac, FL

Bethesda

Bethesda Memorial Hospital

Boynton Beach, FL

Catholic Health East

Holy Cross Hospital

Ft. Lauderdale, FL

What are the possibilities of expansion?

• Not at this time

• Maybe next funding cycle?


Navigator Challenges

Getting Started

Notified 8/15 & first meeting with

Grantee officer 8/22 leaving 45

days to: • Find 20+ capable staff

• Hire 20+ people

• On-board 20+ people TRAIN 20+

people

Hospital partners were GREAT but

we all know that it takes time to

find offices, get phones, execute

hospital on-boarding

The Healthcare.gov “debacle” has planted or

surfaced a lot of negative feelings • Disinterest (this is all screwed up….I will wait until they

get it figured out)

• Confusion

• Mistrust (website broken…security is vulnerable)

• Procrastination

Lack of CMS material • Difficulty just getting CMS produced material to our

people on the front lines

• Material not available, out of stock

• Hospital partners have been GREAT helping with

printing, etc…

When we DO schedule an appointment and

talk to participants • “What do you mean it is not free?”

• “I did not know my actual cost was impacted by my

income”

• “What is a premium”

• “I don’t understand a deductible is”

• Sessions are taking 50-60 minutes


Build a NEW Enrollment Strategy

• Streamline & Partner

• Update Policies & Procedures

• Segment & Target

• Maximize Reimbursement & Broaden

• Disability


Streamline

Processes - Eliminate redundancies

• Within in your enrollment process

• Between the facility and the state/county

• With the patient and your process

Communication

• Make sure everyone who needs to know has access to the information

• Create system-wide communication strategies

Partnerships - Look beyond the hospital walls

• Leverage the resources others in the community have available

for patients


Understand your State’s decisions

• And the position of other States

Charity policy updates

• How will exchanges affect current

charity write-offs?

• Adjust policies to be in line with NEW Medicaid guidelines.

What changes are needed in the registration process?

• New verification procedures (New Technologies)

• Are you asking THE RIGHT questions?

• Assistance strategies for those uninsured or

with life changes?

Update Policies & Procedures


Segment & Target

Categorical Patient Mix

Inpatient Outpatient/ED

Do you know the categorical breakdown of your patient population?

• Understand your patient mix then you can target the populations most

likely to qualify for assistance programs

• Focus resources and customize the enrollment strategy

• Develop an outpatient strategy that delivers enrollment assistance at the

time and place eligible patients access services


Are You Getting the Maximum Return on Your

Enrollment Solution Investment?

A Broad Enrollment Solution will reduce your level of Uncompensated Care

An effective enrollment program must be more than just Medicaid!

• Social Security Disability Insurance

• Supplemental Security Income

• COBRA

• Pre-existing condition coverage

• New Minor & Adult groups for Medicaid

Medicaid 50%

Non-Medicaid

30%

Disability 20%

• Veterans Benefits

• Indian Health

• SCHIP

• Immigrant programs

• Liability (MVA & WC)

• Insurance Exchange Opportunities


How far will you go?

STRATEGY: Initial contact during inpatient visit or at the time of care is not

enough, a strong follow-up program is essential.

• Over-reliance on the patients word and diligence (no contact with patients attorney, etc.)

• Set standard abbreviations and ensure all team members consistently document

activity

• Establish a post discharge follow-up program that includes outreach and

ensures filing deadlines are met

• Incorporate HIE enrollment into your existing process

Recommend using an account management process, software or tool.

This would ensure patients are not falling into gaps, increase

conversions and help with performance measurement.


Why offer patients assistance?

• They are frequent utilizers of healthcare

services

• Their medical care typically results more

expensive levels of care

• They frequently max out benefits for private

insurance coverage

• Long-term access to Medicare and if

Medicaid eligible SNF services

• There is a Disproportionate Share

opportunity as 65% of disabled patients are

dual eligible

Disabled Patients

• One out of every ten

(12.6%) working age

Americans(ages 21-64)

has a DISABILITY


Go Deeper

Strategy: Focus on disabling diagnosis and consider patients entire situation.

Do not rely on the patient to achieve success.

• Be proactive

– Patients are high utilizers of hospital services

– Compassionate allowance cases

– Data scrubbing and trending

• Accelerate disability process

• Maximize Disproportionate Share reimbursement


Action Items

Make Decisions • Decide what role your organization is able/willing to play

• Review and update policies

Segment • Customized enrollment programs for different patient groups

• Use technology to expand opportunities and leverage the registration

process to expedite decision making

Partner & Expand • Build community relationships to improve access & eliminate

redundancies

• Take a broad approach beyond traditional Medicaid & SSI

• Expand communication and share information system wide

Educate, Navigate & Connect • Be the resource and ensure your patients are knowledgeable of all

options

• Mitigate financial risk by connecting patients to programs with better

reimbursement


Thank You

Michael Wilmoth [email protected]

(410) 268-1577

www.aparesults.com

healthcare reform readiness - patient enrollment & navigator strategies

Health & Medicine