Moving Forward with the ACAPart I: Enrollment Challenges

Health Care for the Homeless Regional Training

August 14, 2014Kiwon Yoo, MPH – Insure the Uninsured Project

ITUP is a non-partisan, non-profit health policy “think tank” based in Santa Monica, CA.

We are funded by generous grants from The California Wellness Foundation, The California Endowment, Blue Shield of California Foundation, California Community Foundation, Kaiser Permanente, and The California HealthCare Foundation.

About ITUP

A Really Brief ACA Overview

Coverage Expansions

The ACA expands healthcare coverage through two major systems:

• Medicaid(Medi-Cal): public coverage program for low-income Californians

• Covered California: Virtual “shopping mall” where individuals, families, and employers can purchase affordable health insurance

Medi-Cal

On January 1, 2014

Medi-Cal extended coverage to all citizens and legal permanent residents ages 19 - 64 with incomes up to

138% of the federal poverty level ($16,105 for an individual and $32,913 for a family of four).

Increased income standard for parents from 100% to 138% FPL

Extended coverage to adults without dependent children to 138% FPL

Expanded Benefits

Mental health services are now more accessible.

• Mental health services for the severely and chronically mentally ill are available through the county Mental Health Departments.

• Psychological services for those with less severe mental illness are provided through the Medi-Cal Managed Care plans and their provider networks.

• Expanded Substance Use Disorder treatment services are available to all Medi-Cal members.

Medi-Cal

Expanded Benefits

Dental services are now more accessible.

On May 1, dental benefits for adults were restored.

•Office visits•Cleanings•X-rays •Fillings •Crowns•Complete dentures •Root canals

Medi-Cal

EnrollmentThe ACA helps to streamline and modernize the enrollment process for Medi-Cal applicants.

• Central application and enrollment system for both Medi-Cal and Covered California – CalHEERS

• Electronically processed applications with income and residency information verified electronically

• Eliminated asset tests

• Except for seniors, Medi-Medis, and individuals in long-term care

• Improves renewal process with pre-populated forms

Medi-Cal

Medi-Cal for Former Foster Youth

Young people who were in the foster care system on their 18th birthday qualify for Medi-Cal up to age 26.

Regardless of income

Regardless of state residency while in foster care

Simplified one-page application

No recertification until age 26

Exempt from managed care

Apply via county social services offices

Foster Care Ombudsman available for assistance – fosteryouthhelp@dss.ca.gov or 1-877-846-1602

ImmigrationU.S. Citizens and Lawful Permanent Residents (LPRs) have full access to coverage and financial assistance based on income.

There is no waiting period or 5-year ban for legal immigrants newly in the U.S.

Undocumented Immigrantso Not eligible for full scope Medi-Cal or Covered Californiao Eligible for Emergency Medi-Cal (limited scope)

Deferred Action for Childhood Arrivals (DACA)o Not eligible for Covered Californiao Eligible for Medi-Cal

Temporary Immigrants and Non-immigrantso May or may not be approved for Medi-Calo Eligible for Covered California

Year 1: Results & Lessons Learned

1,395,929 individuals enrolled in plans through Covered

California

1,930,000 individuals newly

enrolled in Medi-Cal

Enrollment (Covered California: April 15, 2014)

Enrollment(Covered California: April 15, 2014)

Covered California Enrollment

(Covered California: April 15, 2014)

Vulnerable Populations

We have to improve Medi-Cal enrollment, period

• ACA promised streamlined applications, but due to technical problems, a 400,000+ backlog persists

• Continued education of outreach, education and enrollment staff is still needed

• Misinformation about asset tests, immigration statuses, etc.

• Streamlined, express enrollment opportunities should be taken advantage of

• CalFresh, re-entry/parolee populations

Enrollment Challenges

We need additional resources for enrollers

• Financial compensation for successful applications have been promised, but payments have been delayed

• Many clients have been auto-enrolled through LIHP transitions, but are unaware of it

• Resources needed to correct primary care providers, medical home assignments, and plan choices

• Redeterminations may lead to confusion

• Renewal packages being sent to incorrect addresses

• New renewal forms request tax information

Enrollment Challenges

We don’t have enough data

• Homeless population requires additional outreach/education and special services, but we need to be able to identify them at the plan/provider level

• Unreliable means of communications complicates matters, making follow ups difficult

• Mailings (plan choice, medical home placement)

Enrollment Challenges

We need to break bad habits

• Coverage is effectively meaningless if care isn’t sought

• Need to encourage health care utilization at appropriate sites of care, instead of relying on ERs

• Instill importance of preventive and primary care

• Mental health and substance use disorder services are now a benefit for all Medi-Cal enrollees. If needed, these services should be taken advantage of

Enrollment Challenges

We must improve coordination of services

• With the majority of homeless individuals requiring behavioral health/substance use disorders, coordinating medical and behavioral health is critical

• The state and local entities need to make case management a priority

• Such services are currently not funded by Medi-Cal, so we need to identify other funding sources

Enrollment Challenges

We need more permanent supportive housing

• Health coverage alone is like putting a bandaid on a broken leg

• Coverage is only meaningful if clients become healthier

• Housing and intensive case management are critical components of health

• Must identify and maximize funding for PSH and case management

• Fragmented funding for housing and health a significant hurdle

Enrollment Challenges

What Kind of Work is

Underway?

• Established in November 2012, Housing for Health (HFH) is a new division within the Los Angeles County Department of Health Services (DHS)

• Focused on creating housing opportunities for clients who are homeless and have complex physical and behavioral health conditions

• Provide permanent housing, recuperative care and stabilization housing linked to intensive case management services

Housing for Health

• DHS provides services to almost 14,000 annually who are homeless, including 2,300 who have inpatient stays

• ALOS overall is 6.4 days; homeless patients’ ALOS is 10.6 days (at $2-3k per day per bed)

• A comparison of hospital utilization by homeless patients 12 months before and after being housed found a 77% reduction in ER visits, 77% in inpatient admissions, and an 85% reduction in inpatient days

• Housed clients used an average of $32,000 per year less in DHS services in the year following housing compared to the year prior to housing

Housing for Health

• Emphasis on intensive case management services (ICMS), which are provided to every client, and includes:

• Outreach and engagement• Case management with ongoing monitoring and follow-

up• Linkage to health, mental health, and SUD services• Assistance with benefits establishment• Assistance with life skills, job skills and

educational/volunteer opportunities• Crisis intervention

• Provided on-site at supportive housing locations by staff who have offices on-site, or by mobile teams

• Provided by experienced homeless services providers who have contracts or provider agreements with DHS

Housing for Health

• Housing is county-wide and based on the needs of the client. Uses a wide range of community-based housing options including:• Non-profit owned supportive housing, affordable housing,

and private market housing

• Single units, blocks of units, and master leases

• Scattered site and project-based

• Rental subsidies a combination of tenant-based Section 8, Project Based Vouchers, Shelter Plus Care, LAHSA subsidy, Flexible Housing Subsidy Pool (DHS subsidy) and tenant rent

• Tenants are asked to contribute 30% of income, with an average contribution of $168/month

Housing for Health

• Flexible Housing Subsidy Pool (FHSP) established in January 2014, and is funded by the LA County DHS, the Conrad N. Hilton Foundation, and the Office of Supervisor Mark Ridley-Thomas

• Provides 300 rental subsidies in year one (2014), 600 in year two, 1200 in year three, and 2400 in year four

• Operated by West Bay Housing Corporation

• Set up so that other public and private entities can participate, with discussions underway with other county departments and with health plans

Flexible Housing Subsidy Pool

• Funded largely by DHS

• System savings are put towards housing

• Funding to be ongoing indefinitely

• In 2013, had 280 new permanent housing units, and 68 interim housing beds

• DHS plans to add 390 more permanent housing units in 2014, for a total of 670

• Also plans to add 146 interim housing beds in 2014, for a total of 214

• Retention rate of 96%

Housing for Health

FAQs & Resources

For questions about coverage, call your insurance company.

If you have a complaint, file a grievance or appeal with the insurance plan.

For Medi-Cal eligibility issues, contact your county DPSS office. For benefits issues, contact the managed care plan.

Persistence is key.

Troubleshooting

To become a certified enrollment counselor:

Call 888-402-0737

Or email assisterinfo@ccgrantsandassisters.org

Training is free and can be online or in person

Counselors must be connected to a Certified Enrollment Entity

Enrollment Systems

Resources

1.Get informed. Know the details of your plan and the benefits you are eligible for.

2.Everyone is learning together, and there will be a steep learning curve. Persistence is key.

3.Use your coverage (and wean off of any over-reliance on emergency departments).

4.Need help? Ask! Call your Medi-Cal plan, your provider, and additional resources.

5.Collaborate with non-traditional partners.

Final Thoughts

For resources and additional information:

kiwon@itup.org(310) 828-0338

http://www.itup.org