Healthcare Reform Readiness - Patient Enrollment & Navigator Strategies

“Patient Enrollment & Navigator Strategies”

Educate | Navigate | Connect

Disclosure/Disclaimer Statement
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 CANAV-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.”
What will we cover today…
• Understanding Reform & Expansion
• How do we get ready and reduce the risk of caring for the uninsured

© 2013 Advanced Patient Advocacy

3

Accountability
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)


Knowledge of Medicaid Expansion
Posted on Monday, 10.28.13

Miami Herald | EDITORIAL

Florida should follow Ohio’s lead
By Miami Herald Editorial
HeraldEd@MiamiHerald.com
•

“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/floridashould-follow-ohios-lead.html#storylink=cpy


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
Categorical
group

U.S. minimum
threshold preACA, 2009*

Children 0-5

133% FPL

Children 6-19

100% FPL

State
thresholds,
2009: medians ,
(ranges)
235% FPL
(133-300% FPL)
235% FPL
(100-300% FPL)
185% FPL

Pregnant
women

133% FPL

Working
parents

State's July
1996 AFDC
eligibility level^

64% FPL

Non-working
parents

State's July
1996 AFDC
eligibility level^

38% FPL

Childless
adults

Eligibility not
mandated.
State must
apply for waiver
to cover this

0% FPL
(0% FPL in 46
states; 100160% FPL in 5
states)

Elderly, blind,
disabled

Receipt of SSI^

(133-300% FPL)

(17-200% FPL)

(11-200% FPL)

75% FPL
(65-133% FPL)

Sources: Kaiser Family Foundation


U.S. minimum
thresholds
under ACA,
2014**
133% FPL
133% FPL
(note traditional
vs new)
133% FPL
133% FPL
(note traditional
vs new)

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."

133% FPL
(note traditional
vs new)
133% FPL
(note traditional
vs new)

Receipt of SSI

Because Florida did not expand your
need to Mind the Gap
2013 Poverty Guidelines
Family
Size
1
2
3
4
5
6
7
8

100%
957.5
1,292.50
1,627.50
1,962.50
2,297.50
2,632.50
2,967.50
3,302.50

110%
1,053.25
1,421.75
1,790.25
2,158.75
2,527.25
2,895.75
3,264.25
3,632.75

120%
1,149.00
1,551.00
1,953.00
2,355.00
2,757.00
3,159.00
3,561.00
3,963.00

133%
1,273.48
1,719.03
2,164.58
2,610.13
3,055.68
3,501.23
3,946.78
4,392.33

135%
1,292.63
1,744.88
2,197.13
2,649.38
3,101.63
3,553.88
4,006.13
4,458.38

150%
1,436.25
1,938.75
2,441.25
2,943.75
3,446.25
3,948.75
4,451.25
4,953.75

175%
1,675.63
2,261.88
2,848.13
3,434.38
4,020.63
4,606.88
5,193.13
5,779.38

185%
1,771.38
2,391.13
3,010.88
3,630.63
4,250.38
4,870.13
5,489.88
6,109.63

200%
1,915.00
2,585.00
3,255.00
3,925.00
4,595.00
5,265.00
5,935.00
6,605.00

250%
2,393.75
3,231.25
4,068.75
4,906.25
5,743.75
6,581.25
7,418.75
8,256.25

300%
350%
2,872.50 3,351.25
3,877.50 4,523.75
4,882.50 5,696.25
5,887.50 6,868.75
6,892.50 8,041.25
7,897.50 9,213.75
8,902.50 10,386.25
9,907.50 11,558.75

Case Study
• 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


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)
One key to getting people to buy will be
Premium and Cost Sharing for Individuals
up to 400% FPL
Health
Insurance
Marketplace

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.


QHP Enrollment Opportunity
Counties Within PUMA
uninsured total % uninsured < 138% FPL 139 to 400%
Suwannee County, Levy County,
Gilchrist County, Dixie County,
34,618
31%
20,007
12,149
Hamilton County, Lafayette County
Columbia County, Bradford County,
Baker County, Union County
Alachua County (part)
Alachua County (part)
Duval County (part)
Duval County (part)
Duval County (part)
Duval County (part)
Duval County (part)
Duval County (part)
Duval County (part)
St. Johns County
Clay County
Putnam County, Flagler County
Marion County (part)
Marion County (part)
total
data.cms.gov


> 400% FPL
2,461

35,790

31%

25,285

8,914

1,591

17,619
17,134
22,580
25,170
21,060
21,342
19,718
14,751
30,154
23,253
24,983
31,044
26,531
36,838
402,585

17%
15%
18%
24%
21%
18%
16%
19%
18%
14%
15%
24%
28%
25%

12,450
7,773
12,228
18,116
11,408
11,165
8,038
7,094
17,116
8,385
12,184
20,067
15,875
21,621
228,812

4,313
7,568
8,720
6,638
8,110
8,158
9,905
6,357
11,217
11,583
10,010
7,347
8,271
12,740
142,000

856
1,794
1,632
416
1,542
2,020
1,775
1,300
1,821
3,286
2,789
3,630
2,385
2,477
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.


Enrollment Assistance
Toll-free Call
Center

Marketplace
Website

Navigators

Certified Application
Counselors
Agents/Brokers


Florida Navigator Resources
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


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
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


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

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


Update Policies & Procedures
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?


Segment & Target
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
Categorical Patient Mix

Inpatient


Outpatient/ED

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

• Veterans Benefits

• Supplemental Security Income

• Indian Health

• COBRA

• SCHIP

• Pre-existing condition coverage

• Immigrant programs

• New Minor & Adult groups for Medicaid • Liability (MVA & WC)
• Insurance Exchange Opportunities
Disability
20%
NonMedicaid
30%


Medicaid
50%

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.


Disabled Patients
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

•

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
mwilmoth@apallc.com

(410) 268-1577
www.aparesults.com

Healthcare Reform Readiness - Patient Enrollment & Navigator Strategies

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