OFFERING PUBLIC HEALTH COVERAGE ENROLLMENT IN HEALTH … Report.pdf · PUBLIC HEALTH COVERAGE ENROLLMENT ... Offering Public Health Coverage Enrollment in ... VIRGINIA COMMONWEALTH

OFFERING PUBLIC HEALTH

COVERAGE ENROLLMENT

IN HEALTH CARE SETTINGS

Covering Kids & Families is a national program supportedby the Robert Wood Johnson Foundation with directionprovided by the Southern Institute on Children and Families.

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Offering Public Health Coverage Enrollment in

Health Care Settings

Prepared for

May 2007

By Nicole Ravenell, MPP

LaCrystal Jackson, MPA

Covering Kids & Families National Program Office Southern Institute on Children and Families

500 Taylor Street, Suite 202 Columbia, SC 29201

(803) 779-2607

www.thesoutherninstitute.org

Southern Institute on Children and Families Covering Kids & Families May 2007 Out-stationing Eligibility Report

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ACKNOWLEDGEMENTS The Southern Institute on Children and Families extends appreciation to the Robert Wood Johnson Foundation for its generous support of the Covering Kids & Families (CKF) initiative. We thank all of the individuals and organizations, especially those who participated in the CKF Hospital-Based Eligibility Seminar I and Seminar II, for contributing information about onsite public health coverage eligibility determination processes. We also want to recognize the participants of the Children’s Hospitals Eligibility Process Improvement Collaborative. Listed below are the collaborative participants, hospitals and other organizations that provided information during the preparation of this report:

• City of Richmond Department of Social Services, Virginia • Columbus Regional Medical Center, Georgia • Connecticut Children’s Medical Center • Cuyahoga County Department of Employment and Family Services, Ohio • duPont Hospital for Children, Delaware • Hospital Association of San Diego and Imperial Counties, California • Medical College of Georgia Children’s Hospital • MetroHealth Medical Center, Ohio • Oklahoma Department of Human Services • Oklahoma Institute for Child Advocacy • Riley Hospital for Children, Indiana • SSM Cardinal Glennon Children's Medical Center, Missouri • San Diego County, California • State of Missouri Family Support Division • Virginia Commonwealth University Health System • Virginia Health Care Foundation • Virginia Hospital and Healthcare Association


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The views expressed in this report are those of the authors. No official endorsement by the Robert Wood Johnson Foundation is intended or should be inferred.


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TABLE OF CONTENTS

ACKNOWLEDGEMENTS............................................................................................................ ii TABLE OF CONTENTS............................................................................................................... iv LIST OF APPENDICES................................................................................................................ vi LIST OF TABLES AND FIGURES............................................................................................. vii INTRODUCTION ...........................................................................................................................1 BACKGROUND .............................................................................................................................1 Barriers to Public Health Coverage Enrollment ..................................................................1 Out-stationing ......................................................................................................................2 States’ Implementation of the Out-stationing Requirement ................................................3 COVERING KIDS & FAMILIES: INCREASING ENROLLMENT OF ELIGIBLE CHILDREN AND ADULTS IN PUBLIC HEALTH COVERAGE...............................................6 ESTABLISHING PUBLIC HEALTH COVERAGE ENROLLMENT SERVICES IN HEALTH CARE SETTINGS..........................................................................................................6 Opportunities and Challenges of Out-stationing..................................................................7 OUT-STATIONING IMPLEMENTATION.................................................................................11 Identification of Staff for the Out-station Site ...................................................................11 Attainment of Financial Resources....................................................................................13 Formation of the Out-station Team....................................................................................15 Location of the Out-station Eligibility Worker..................................................................16 Establishment of the Computer System.............................................................................17 Increasing Client Responsiveness and Continuity of Coverage ........................................17 OUT-STATIONING PROCESSES AND PROCEDURES ..........................................................18 Children’s Hospital at Oklahoma University Medical Center...........................................19


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Connecticut Children’s Medical Center.............................................................................21 Hospital Association of San Diego and Imperial Counties, California .............................23 MetroHealth Medical Center, Ohio ...................................................................................26 SSM Cardinal Glennon Children’s Medical Center, Missouri ..........................................30 Virginia Commonwealth University Health System .........................................................32 CONCLUSION..............................................................................................................................35 REFERENCES ..............................................................................................................................36 APPENDIX....................................................................................................................................38


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APPENDIX STATE MEDICAID DIRECTOR LETTER (SMDL# 01-008) ....................................................38


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LIST OF TABLES AND FIGURES

TABLE 1: STATE OUT-STATIONING COMPLIANCE IN FEDERALLY QUALIFIED

HEALTH CENTERS ..............................................................................................4 FIGURE 1: METROHEALTH MEDICAL CENTER OUT-STATION FLOWCHART ........29 FIGURE 2: VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM OUT-STATION FLOWCHART...........................................................................34


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Introduction In the United States, the number of uninsured has steadily increased for the past two decades. In 2005, 46.1 million Americans under the age of 65 were without health coverage, and nine million of those were children.1 The cost of health insurance has been cited as the main reason so many Americans are without health care coverage.2 For lower-income families, the risk of being uninsured is greater compared to those with higher household incomes. According to the Kaiser Family Foundation, “Nearly three-quarters of the nine million uninsured children live in families with household incomes below 200% of the federal poverty level ($39,942 for a family of four in 2005).” 3 Without health insurance, families may curtail needed health care services and lack the ability to pay for medical services they receive. Research shows individuals and families are affected in many ways when they are uninsured:

• Uninsured Americans are four times more likely to require avoidable hospitalizations and emergency hospital care.4

• Uninsured women receive fewer prenatal services.5 • Uninsured newborns are more likely to have low birthweights and to die prematurely.6 • Uninsured children are 30% less likely to receive medical attention for injuries.7

Congress recognized several years ago the importance of making public health care coverage more accessible, particularly for lower-income children and families who were eligible for public coverage but remained uninsured. In 1990, Congress mandated that states establish out-station Medicaid enrollment programs at Federally Qualified Health Centers and disproportionate share hospitals to provide an opportunity for the lower-income to apply for coverage at sites other than the traditional “welfare” offices.8

Background

Public health coverage has been shown to offer significant benefits to children and families. Public health coverage promotes access to care, increases use of necessary and appropriate care, improves families’ financial security and may promote employment among parents.9 In fact, an early study by the Southern Institute on Children and Families showed that welfare recipients and Transitional Medicaid recipients ranked Medicaid coverage for children as one of the most important benefits when making a decision to accept a full-time job.10 Families often face challenges in obtaining needed public health coverage. Enrollment and eligibility barriers are considered the primary factors that discourage eligible families from receiving public health coverage. Barriers to Public Health Coverage Enrollment

Several studies have been conducted and reports published highlighting the barriers to Medicaid and State Children’s Health Insurance Program (SCHIP) enrollment.11,12 Findings have identified both perceived problems and policy-related issues that affect people’s decisions to enroll in public health coverage programs. One nationwide study of in-person interviews of 1,400 lower-income families receiving health care at community centers found that respondents were significantly more likely to report a stigma associated with the Medicaid application


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process when applying for benefits at the welfare office versus at an alternative site such as a school, hospital or health clinic.13 Additional barriers and stigmas that negatively affect people’s enrollment decisions in Medicaid and SCHIP programs include:

• Misperception that a person must be on welfare in order to receive public health coverage;

• Applicants being made to answer unfair personal questions; • Long, complicated application forms; and • Unequal treatment by physicians.14

Recommended actions state governments can take to reduce barriers to public health coverage enrollment have included:

• Shortening and simplifying Medicaid applications; • Eliminating the assets test; • Eliminating face-to-face interviews; and • Utilizing community organizations to conduct outreach and enrollment activities.15,16

Based on the above information and other findings, health care policy leaders have recommended an increased use of and emphasis on out-stationing sites to enroll eligible children and families in Medicaid and SCHIP as a means to decrease the number of uninsured. Out-stationing It has long been possible for eligibility staff to perform outreach activities to inform families of available public health care coverage and assist them in the enrollment process. Federal matching dollars are available to support these activities. Prior to 1997, when SCHIP was created, the process for enrollment in public health coverage such as Medicaid was a cumbersome and, in most cases, demeaning process for families. The eligibility determination environment was one that was focused more on keeping ineligible children and families out of the system rather than getting those who were eligible for Medicaid enrolled. Since the implementation of SCHIP, the majority of outreach efforts have been focused on SCHIP and not on Medicaid. The screen and enroll requirement of SCHIP that requires states to determine children’s eligibility for Medicaid prior to enrollment in SCHIP has resulted in more children being enrolled in Medicaid.17 Outreach and application assistance have been found to be critical components of enrolling eligible children and families in public health coverage programs. Out-stationing is a form of outreach in which state or local Medicaid eligibility workers are placed at locations other than welfare offices in order to assist with the application and renewal processes. 18 In 1990, Congress mandated that states establish out-station Medicaid enrollment programs at disproportionate share hospitals (DSH) and Federally Qualified Health Centers (FQHCs) to accept Medicaid applications from children and pregnant women. The minimum requirements are that the out-stationed sites “provide for receipt and initial processing of applications of individuals for medical assistance . . . ” Amendments made to the statute make federal funding available to support states with the costs of out-stationing. Other locations where states and


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counties may out-station eligibility workers include, but are not limited to, schools, WIC offices, hospitals and health care centers.19 A 1992 report by the United States Government Accountability Office found that in addition to relieving families of the burden of going into a Medicaid office to apply for health insurance benefits, out-stationing is beneficial to health care providers because it reduces the level of uncompensated care.20 States’ Implementation of the Out-stationing Requirement Interpretation of the Congressional mandate to establish Medicaid enrollment programs at FQHCs and DSH hospitals differs across states. Not all states have fully complied with the mandate and the implementation of out-stationing processes has varied. A 2006 study by the National Association of Community Health Centers, Inc. (NACHC) found that only three states were fully compliant (out-stationed workers in every health center and every high-volume site and paid for by the state) with the Medicaid out-stationing requirements.21 Ten states were mostly compliant, 20 states were partially compliant and 17 states were described as non-compliant. NACHC surveyed Primary Care Associations in all 50 states plus the District of Columbia and Puerto Rico for the study. Survey results for 2003-2006 of states’ compliance with the out-stationing regulation in Federally Qualified Health Centers are provided in Table 1 on page four. 21,22,23,24


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Table 1

State Out-stationing Compliance in Federally Qualified Health Centers

State 2003 2004 2005 2006

Alabama Fully Mostly Mostly Mostly Alaska Partially N/C N/C N/C Arizona Partially Partially Partially Partially Arkansas Mostly Mostly Mostly Mostly California Partially Partially Partially Partially Colorado Partially Partially Partially Partially Connecticut Fully Fully Fully Fully Delaware N/C NR NR NR District of Columbia N/C Mostly Mostly Mostly Florida Mostly N/C N/C N/C Georgia Partially Mostly Mostly Mostly Hawaii N/C (yet)1 Partially Mostly Mostly Idaho Partially Partially Partially Partially Illinois N/C N/C N/C N/C Indiana Partially Mostly N/C N/C Iowa Partially Partially Partially Partially Kansas Partially Partially Partially Mostly Kentucky N/C N/C N/C N/C Louisiana N/C N/C N/C N/C Maine N/C N/C N/C N/C Maryland Partially NR NR NR Massachusetts N/C N/C N/C N/C Michigan Partially Partially Partially Partially Minnesota N/C N/C N/C N/C Mississippi Partially Mostly Partially N/C Missouri Partially Partially Partially Partially Montana N/C N/C N/C N/C Nebraska N/C N/C N/C N/C Nevada Partially Partially Partially Partially New Hampshire N/C Partially Partially Partially New Jersey Fully Mostly Mostly Mostly New Mexico N/C Partially Partially Partially New York NR Partially Partially Partially North Carolina Partially Partially Partially Partially North Dakota N/C Partially Partially Partially


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Table 1 (Continued)

State Out-stationing Compliance in Federally Qualified Health Centers

State

2003 2004 2005 2006

Ohio N/C Partially Partially Partially Oklahoma N/C N/C Partially Partially Oregon Fully Fully Fully Fully Pennsylvania N/C N/C N/C N/C Puerto Rico NR N/C N/C Mostly Rhode Island Fully Partially Partially Partially South Carolina Partially Partially Partially Partially South Dakota N/C Partially Partially Partially Tennessee N/C Partially Partially Partially Texas Partially Partially Partially Partially Utah Fully Fully Fully Fully Vermont N/C N/C N/C N/C Virginia N/C N/C N/C N/C Washington N/C NR NR Mostly West Virginia N/C N/C N/C N/C Wisconsin Fully Mostly Mostly Mostly Wyoming Partially N/C N/C N/C Fully Compliant: Out-stationed workers in every health center and high volume site, paid for by the state. Mostly Compliant: Out-stationed workers in some health centers and some sites, paid for by the state. Partially Compliant: Out-stationed workers in some health centers and some sites; some paid by the health center and some paid by the state. Non-Compliant (N/C): No out-stationed workers in any health centers or sites that are paid for by the state. If there are workers at centers, they are paid for entirely with health center dollars. NR: No response. 1. Hawaii had recently transferred $200K to the Health Department to try to draw down

Federal match under the de-linking fund to establish Out-stationed Eligibility Workers at FQHCs.

Source: Data based on surveys conducted by the National Association of Community Health Centers, Inc. (NACHC), 2003, 2004, 2005 and 2006. 21,22,23,24 NACHC surveyed Primary Care Associations in the 50 states, the District of Columbia and Puerto Rico.


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Covering Kids & Families: Increasing Enrollment of Eligible Children and Adults in

Public Health Coverage

Covering Kids & Families (CKF) is a national program funded by the Robert Wood Johnson Foundation and directed by the Southern Institute on Children and Families that promotes a strategy to involve health care providers in performing outreach and assisting with the application and renewal processes for Medicaid and the State Children’s Health Insurance Program (SCHIP).∗ In an effort to fully understand why the strategy of out-stationing eligibility was not being utilized extensively across the United States (US) or why the implementation was not comprehensive in many of the sites that did offer some form of out-stationing, Southern Institute on Children and Families staff studied existing out-station eligibility processes. Some of those who had not fully implemented an out-stationing eligibility process also were interviewed. The interview findings showed that there were two major reasons why out-stationing is not well implemented across the US. First, many health care providers are unaware of the potential of Medicaid and SCHIP to help alleviate the impact of their financial burdens of caring for uninsured patients. Second, health care providers who wanted to set up out-stationing at their sites did not know how to go about developing a system. This report highlights the barriers and opportunities related to out-stationing public health coverage eligibility such as Medicaid and SCHIP. Issues to consider prior to implementing out-stationing in a health care provider setting also are identified. The goal of this report is to share an effective strategy, out-stationing, for reducing the number of uninsured in the broader community.

Establishing Public Health Coverage Enrollment Services in Health Care Settings

Whether the choice is to rent or own a home or add a new wing to a health care site, a review of the pros and cons associated with those decisions is made. When looking at whether to provide public health coverage enrollment services at a health care site, there are several choices to consider:

A. Contract for an eligibility worker’s time that is accessed in one or two ways: 1) housed at the health care site to process applications and make eligibility determinations onsite or 2) housed at the local eligibility office to process applications generated and sent for processing by the health care site.

B. Contract with a vendor to assist patients in completing public health coverage applications.

C. Invest in strategies A and B. D. Do nothing.

∗ From 2001 - 2007, Covering Kids & Families statewide projects in all 50 states and the District of Columbia and more than 140 local projects worked to reduce the number of eligible, uninsured children and adults through enrollment in public health coverage.


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Prior to investing time and resources in developing and implementing a public health coverage eligibility process onsite, it is important to know the individuals who seek care at a facility. The answers to some key questions about the patients who seek care at a particular site are critical to whether onsite public health coverage enrollment services should be provided. Not investing in a process for providing or referring patients to public health coverage enrollment services can have a significant impact on the resources of a facility. Questions for consideration include, but are not limited to, the following:

• What segment of the population makes up your patient population – children, adults or the elderly?

• Who are your primary patients – fairly healthy individuals or seriously ill individuals? • What are the income levels of your patients – poor and lower-income or middle and

higher-income individuals? • What is the insurance status of your patients – insured, underinsured or uninsured? • What is the insurance status of your seriously ill, high-cost patients – insured,

underinsured or uninsured?

The answers to these questions should be studied in order to make a decision about whether or not a site should invest in the development of a process for providing public health coverage enrollment services. If many of a site’s patients are primarily children from families who are poor or lower-income and are underinsured or uninsured, they are more likely to be eligible for Medicaid, the State Children’s Health Insurance Program (SCHIP) or other public health coverage programs. Therefore, pursuing a public health coverage onsite enrollment process would be useful. On the other hand, if a site’s patients are primarily non-elderly, middle-income adults who are insured and seek specialty, elective procedures, they are unlikely to be eligible for public health coverage programs. In this case, an investment of resources to establish onsite public health coverage enrollment services is not as useful. A thorough review of patient profiles data, including utilization rates and expenditures over a period of time, should be performed prior to concluding that a site does or does not need a system for helping patients obtain public health coverage. More importantly, this initial data gathering will help determine the need for spending time developing a process for onsite eligibility determination services. Opportunities and Challenges of Out-stationing When a health care facility is considering whether to invest time, money and resources into establishing out-stationing, the benefits and drawbacks also should be taken into consideration. The opportunities as well as the challenges that exist from implementing public health coverage enrollment services in a health care setting cannot be overlooked. Prior research from others, as well as the work performed under the Covering Kids & Families initiative, has provided insight into the opportunities and challenges to implementing a public health coverage enrollment process within health care delivery sites.


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Opportunities Although not having health coverage is damaging to individuals personally, the consequence also is shared among others – the family, the community, health care providers and government. Individuals/families, the community, health care providers and government all can benefit from the out-stationing of public health coverage enrollment and eligibility. Individuals/Families For individuals and families, out-stationing means greater access to public health coverage. Out-stationing also reduces the time demands and hassles involved in going to the state/county social services office to apply for health care coverage. Community Providing out-stationing services in a health care setting can diminish some of the negative ripple effects of uninsurance on a community. For example, out-stationing can decrease the number of uninsured in the community, thereby decreasing the burden of disease and disability in the area. In addition, decreasing the number of uninsured helps to stabilize or increase access to population-based public health care services and personal health care services such as primary care, specialty care and hospital-based care due to higher revenues generated by providers and health care facilities. Reducing the level of uninsurance also can reduce tax burdens, the loss of providers and the loss of tax revenue in the community.26 Health Care Providers The greatest opportunities out-stationing offers health care providers are financial benefits such as reduced uncompensated care and bad debt, increased Medicaid reimbursement and increased revenue. The availability of eligibility workers in health care settings provides greater access and opportunities for uninsured and underinsured patients to enroll in public health coverage programs for which they may be eligible. When patients who lack or have insufficient health coverage become insured, the amount and frequency of charitable care offered by the medical site is reduced. When uninsured patients are enrolled onsite in public health coverage plans, the amount of lapse time between medical services rendered and payment received can be reduced. Health care providers can receive retroactive Medicaid reimbursements for up to 90 days for medical services provided to Medicaid clients. The quicker outstanding bills are paid, the sooner those resources can be used to funnel dollars back into the medical site to make improvements to the quality and delivery of medical services. Additionally, out-stationing is cost efficient. The return on investment can be greater than the cost of the investment. After implementing out-stationing, one health care provider reported recovering more than $200,000 in a six-month period. This amount was based on charges that would have been written off as bad debt had out-stationing not been in place.


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Government Out-stationing offers government the opportunity to maximize its resources. Placing workers outside of government agencies enables government to utilize and extend available resources to the community. In turn, out-stationing allows for greater points of contact for potential recipients. Out-stationing also can serve as a cost savings strategy for some states and counties. A study conducted by the South Carolina Legislative Audit Council on cost savings strategies for the state’s Medicaid program recommended that the South Carolina Department of Social Services (DSS) make greater efforts to place more eligibility staff in locations where recipients go to get health care. Having eligibility workers out-stationed costs the state less than having county DSS office-based eligibility workers. In the state, half of the funding for out-stationed workers comes from the health care providers and the other half comes from the federal government. Minimal costs associated with training and supervising the out-station staff are incurred by the state. The South Carolina Legislative Audit Council concluded in the report that not only could out-stationing more eligibility workers provide greater access to Medicaid and better services for recipients, “but the cost in state dollars could be greatly reduced if healthcare providers supported eligibility staff.”27 Challenges Out-stationing offers a variety of benefits to several different stakeholders, yet there also are challenges associated with implementing public health coverage enrollment services in a health care setting. Challenges to the implementation of onsite eligibility services in health care facilities can arise due to lack of leadership, a complicated eligibility process, a hard-to-reach patient population and other issues that must be addressed prior to implementation. Obtaining Leadership Buy-in When making the decision to out-station and/or maintain public health coverage enrollment and eligibility processes outside of a social services setting, it is important to have buy-in from both government administrators and health care site leadership. Without the support of leadership, out-stationing will not receive the attention or the resources needed to be successful. For instance, one medical facility recognized the value of having a caseworker onsite to offer application assistance and process applications but had been unsuccessful in pleading its case until state legislators were asked to complete the public health coverage application. After realizing the difficulty in completing the application, actions were taken to implement out-stationing not only in that medical facility but in other health care facilities throughout the state. Identifying Resources to Support Out-stationing Allocating financial and staff resources for out-stationing may pose a challenge for both the government agency and the health care provider. For the government agency, having an eligibility worker located offsite may cause the agency to have to trade-off and lose having an in-office full-time employee (FTE). Although this may occur, the benefits can outweigh the costs


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and the sacrifices associated with losing an FTE in the office. For instance, one social services agency’s philosophy is that it is more beneficial to have an eligibility worker(s) out-stationed to see clients than to have 150 clients come into the local agency to be seen. Some states, on the other hand, are allowed to increase their total FTE count when they out-station an eligibility worker at a health care facility. For example, the social services agency in one state does not lose the FTE allocation if half of the worker’s salary and benefits are being paid by the out-stationed site where the worker is located. For the health care provider, the departments within the health care site that may have a direct connection and most likely benefit from having an eligibility worker onsite are usually not the departments that have discretionary funds available with which to purchase the staff time. The financial or admittance departments are usually more inclined to identify the need for out-stationing eligibility, but do not have the budget to pay for the expense. Staffing Out-station Sites When eligibility workers are placed outside of a traditional office setting, issues and concerns related to staffing and the human resources aspect of out-stationing arise. Concerns can include identifying the “right person” to be housed in a health care site, worker isolation, turnover, supervision of the out-stationed eligibility worker and staff hours. An important challenge out-stationing sites encounter is related to the work hours of the eligibility worker or the coverage hour periods. State/county eligibility workers generally work traditional hours (Monday – Friday, 8:00 am – 5:00 pm). In a health care setting, traditional work hours may not be the best time or the prime time when most uninsured or underinsured patients seek or need medical attention. Health care providers may find that an eligibility worker is needed more after 5:00 pm and on the weekends. The opportunity to enroll eligible patients into a public health coverage program may be lost if an application is not completed at the time medical services are rendered. One solution to this is to enable the out-stationed eligibility worker to work non-traditional hours or set-up a process that will enable patients to complete applications in the absence of the eligibility worker. Team Building Hospitals and other health care sites may face resistance from key stakeholders when building a team to support out-stationing efforts. When establishing and maintaining out-stationing, having the support of particular staff and departments such as Administration, Patient Accounts and Social Work, to name a few, will help better facilitate the process. Developing Processes and Systems Establishing effective and efficient processes and systems can be problematic for the health care providers and the government agency involved in out-stationing if a detailed plan has not been developed. Out-stationing processes and systems that may present barriers for the state, county and/or health care site include consistent implementation of policies and procedures across out-stationing sites, tracking and monitoring referrals and applications and the computer system.


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In a state or county where there is more than one out-stationing site, it may be challenging to ensure that all of the sites are operating in the same manner and consistently applying policies and procedures. These concerns can be escalated, particularly if the out-stationing program is not centrally managed and supervised within the government agency. The ability to track and monitor the referrals and applications processed by the eligibility worker also can be an issue in out-stationing and can hinder establishing productivity standards for the worker. The computer systems of the hospital/health center and/or the government agency are critical to the ability to monitor public health coverage eligibility decisions and volume. The health care provider’s inpatient and outpatient systems’ inability to interface and communicate is another example of a computer deficiency that can create a barrier to effective and efficient out-stationing. An additional issue with the computer system of the health care provider may be the inability to document or tag patient cases that have a pending public health coverage application.

Out-stationing Implementation

Although states, counties and health care providers vary in their demographic, economic and political structures, there are particular areas that should be reviewed when designing out-stationing systems. Each area should be addressed to meet specific facility needs and to achieve the ultimate goal of reducing the number of eligible, uninsured and underinsured children and families through enrollment in public health coverage programs. The following areas have been identified to address a number of the out-stationing challenges and barriers previously discussed:

• Staffing • Attainment of Financial Resources • Out-station Team • Location of the Out-stationed Eligibility Worker • Computer System • Client Responsiveness and Out-stationed Eligibility Worker Productivity • Case Maintenance and Renewals

Identification of Staff for the Out-station Site When seeking to fill an out-stationed eligibility worker position, someone with experience in public health coverage eligibility processing and determinations is not always sufficient. Having an eligibility worker who can adapt to working in a health care setting also is an important factor. State/county representatives and health care provider representatives interviewed for this report have shared specific qualities and characteristics that an eligibility worker needs to have to be successful in an out-stationed setting. Qualities and Characteristics of the “Right” Out-stationed Eligibility Worker Team Player: The eligibility worker needs to be willing to work in collaboration with the health care site staff. The relationship between the eligibility worker and the site staff should be interrelated – functioning as a team. Team efforts should facilitate achieving the goal of reducing the number of uninsured by enrolling eligible children and families in public health


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coverage programs. Communication between the eligibility worker and the hospital/health center staff can be open yet not in violation of federal, state and/or county rules and regulations related to confidentially. Self-Directed and Independent Worker: The out-stationed eligibility worker is expected to be self-sufficient and properly manage his/her time and responsibilities. The worker is required to meet his/her goals and expectations with limited supervision from the government agency supervisor. He/she should be willing to accept supervision and direction from health care site staff and understand the best way to implement health care site requests within the policy and procedural boundaries of the public health coverage program. The out-stationed staff will have to work independently, and therefore will need to be able to properly analyze and respond to situations. Responsive to Multiple Stakeholders (the Client, the Health Care Provider and the Government Agency): Being in an out-stationed site requires the eligibility worker to respond to multiple stakeholders – the client, the out-stationed site and the government agency. The eligibility worker has to be willing to walk and track the client through the enrollment process. Unlike in a traditional office setting, an unenrolled, eligible client translates into financial losses for the out-station site. The eligibility worker will have to find ways to be responsive to the needs of the health care provider and adapt to its philosophies, management styles, polices and procedures and performance goals which may be parallel but different from the government agency. While meeting the goals of the out-station site, the eligibility worker also will be expected to respond to and meet the goals of the government agency. Committed and Supportive of the Mission and Role of the Health Care Site: The out-stationed eligibility worker needs to feel comfortable working in a health care setting. The nature of health care and health care facilities is not always viewed as an ideal workplace and may be uncomfortable for some to work. The eligibility worker should understand that part of his/her responsibility is to make the public health coverage enrollment process simple and convenient for clients who may be facing traumatic circumstances. The out-stationed eligibility worker should be positive and supportive of the clients. Having a good bedside manner and the ability to deal with ill patients and/or their families also is helpful. More importantly, the worker should constantly seek out improvement strategies in the enrollment process in ways that support the mission and goals of the health care site. Experience in Processing and/or Making Eligibility Decisions for Public Health Coverage Programs: The out-stationed eligibility worker will be viewed as the expert by clients and health care site staff. Placing a senior, experienced eligibility worker in an out-station site to carry out the enrollment and/or eligibility determination duties will be extremely conducive to an efficient and effective out-stationing system. The out-stationed eligibility person should have extensive knowledge and experience in processing a wide range of public health coverage applications including Medicaid, the State Children’s Health Insurance Program (SCHIP) and any state/county health coverage programs, if applicable. Other Qualities and Characteristics: Other qualities and characteristics include being customer-focused and compassionate, as well as having advanced computer skills and excellent


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verbal and written skills. Depending on the demographic make-up of the area, the person also may need to be fluent in other languages. Attainment of Financial Resources Funding may be the greatest barrier to out-stationing. Government and health care providers may be unable or unwilling to provide resources needed for out-stationing. The federal government makes funding available to states to implement out-stationing. The State Medicaid Director Letter (SMDL# 01-008) issued January 18, 2001, reviews the requirements and flexibility offered to states to ensure implementation of out-stationing in Federally Qualified Health Centers and disproportionate share hospitals sites.28 (See Appendix A.) Staffing and resource limitations do not relieve states of the obligation to comply with and pay for the out-stationing requirements. Federal financial participation is available for expenditures incurred by the state associated with out-station locations, regardless of whether the function is provided by a state or county employee or other person authorized to perform initial application processing activities. Funding is available for state expenditures for incurred out-stationing costs at regular out-stationing locations and at infrequently used and optional locations. The administrative functions of taking and processing applications are reimbursed at the 50 percent rate. Subject to the limitations noted below, this rate includes costs incurred by the state to implement and provide out-stationing of intake workers who are state employees, provider employees, volunteers or contractor employees. The rate covers such necessary administrative costs as salaries, fringe benefits, travel, training, equipment and space directly attributable to out-stationing activities. To the extent that out-stationing activities are directed at both Medicaid and SCHIP eligible children, enhanced matching funds are available for the SCHIP related activities subject to the cap on SCHIP non-coverage expenditures.29 Use of Provider Donations Provider-related donations made to a state by a hospital, clinic or similar entity for the direct costs of state or local agency personnel who are stationed at the facility to determine eligibility or

SSM Cardinal Glennon Children’s Medical Center’s Out-station Worker

SSM Cardinal Glennon Children’s Medical Center in St. Louis has an agreement with the state to have a Missouri Medicaid (MOMED) caseworker onsite to take and process public health coverage applications and make eligibility decisions. Sauda Carr has been the MOMED caseworker at Cardinal Glennon for a number of years and is the “right fit” for the children’s hospital. She is an intimate member of the Financial Services team at the Medical Center and is well-respected by the hospital staff. Cardinal Glennon also has an agreement with the State of Missouri that enables Ms. Carr to be a part-time employee of the hospital independent of being a MOMED caseworker. As a part-time employee, Ms. Carr works on the weekends in the Emergency Room’s Registration Department.


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to provide outreach services may be used as the state share of such state costs within a statutorily prescribed limit. Specifically, the provider-related donations for out-stationed eligibility workers i.e., state or local agency workers, are limited to 10 percent of a state’s medical assistance administrative costs, excluding the costs of family planning activities. Direct costs of out-stationed eligibility workers refers to the costs of training, salaries and fringe benefits associated with each out-stationed worker and a prorated cost of outreach activities applicable to the out-stationed worker. The Medicaid statute permits this arrangement as an exception to the general prohibition on provider-related donations. The exception does not apply to donations made by a hospital, clinic, or similar entity for the direct costs of non-state personnel.30 States and health care providers have used different funding arrangements to implement out-stationing in their communities. The following financial structures have been used by states and health care providers to make out-stationing possible. State/County Pays 100% of the State’s Portion of Out-stationing Costs: The state/county takes responsibility for all costs associated with out-stationing an eligibility worker(s). For example, a county may pay for all out-stationing costs at a county-based medical facility. This funding would then secure the federal portion for the personnel costs. Health Care Provider Pays 100% of the State’s Portion of Out-stationing Costs: The health care provider may agree to be responsible for all costs associated with placing an eligibility worker in its facility. This funding from the medical site can be used to draw down the federal portion to cover the full personnel costs. Equal Cost Sharing Between State/County and Health Care Provider (50/50) of the State’s Portion of Out-stationing Costs: The State may require the out-stationed site to provide partial funding for the state’s portion of out-stationing costs. Health Care Provider Shares State’s Portion of Out-stationing Costs with Outpatient Services/Physician Practices: If the health care provider is responsible for providing full or partial funding for out-stationed eligibility worker costs, the provider can use other resources to cover the costs. For example, the hospital may ask onsite physician practices to contribute to the cost of out-stationing considering they too will be utilizing and reaping the benefits of the out-stationed services. Health Care Provider Shares State’s Portion of Out-stationing Costs with Other Stakeholders: The health care provider with out-stationing or an interest in implementing out-stationing may be a member of a Hospital or Health Care Association. The association may establish a contractual agreement with the state/county to fund out-stationed eligibility workers at member health care provider sites. The association could pool financial resources of its member health care providers to share in the costs of out-stationing.


15

Formation of the Out-station Team A team approach should be a top priority when establishing and maintaining out-stationing. At the health care provider site, administrators and staff are needed to offer support for out-stationing and to give input and guidance on out-stationing processes and systems. The hospital/health care center may need to establish several teams around out-stationing issues. For instance, a pre-team should be developed to assess the feasibility of having an eligibility worker onsite and to design the out-stationing structure. Another team also may be useful for addressing ongoing issues related to out-stationing. The out-stationed eligibility worker should be viewed as a resource to the hospital staff and vice versa. One hospital with onsite eligibility workers credits obtaining a greater amount of reimbursable Medicaid charges to a successful out-stationing team approach. Within the first six months of the implementation of out-stationing, Medicaid reimbursements increased by $4 million. The out-station team at the health care provider site should include, but not be limited to representatives from the following areas and departments:

• Finance • Management • Information Technology/Support • Administration • Care Coordination • Discharge • Patient Accounts • Physician Practices • Registration • Social Work • Utilization Management

Additional representatives to include as a part of the out-station site team that are not a part of the health care provider site include:

• State/County Medicaid/SCHIP Administrators and/or Staff

Hospital Association of San Diego and Imperial Counties Supports Out-Stationing at Member Hospitals

The Hospital Association of San Diego and Imperial Counties has partnered with the County of San Diego to reduce the number of uninsured residents in the region by increasing health enrollment activities and improving access to health care through the Hospital Out-stationing Services (HOS) Program. Under the HOS Program, the Hospital Association has a contractual agreement with the County on behalf of the participating member hospitals to out-station eligibility workers. Twenty-eight staff members are located at 14 hospitals and 15 staff members are located at 11 clinics throughout San Diego County.


16

• Public Health Coverage Application Assistance Vendor • Public Health Coverage Managed Care Enrollment Vendor • Appropriate Professional Associations (e.g., Hospital/Health Care Associations, etc.) • Union (if eligibility workers are a part of a bargaining union)

The Location of the Out-station Eligibility Worker Although out-stationed eligibility workers can be placed anywhere in a health care provider site, placing the eligibility worker in the right location within the health care site is critical to a successful program. Locating eligibility workers near financial counselors is the most appropriate place considering that the duties and responsibilities of both are significantly interrelated. Assessments of all patients’ financial situations are conducted within the financial services area. After the financial counselors have screened the patients, patient information can be easily provided to the onsite eligibility worker for follow-up and processing for public health coverage eligibility.

Out-stationed eligibility workers also can best be utilized in areas where there is a high volume of uninsured and underinsured patients flowing through; in most cases, this is the Emergency Department (ED). A study conducted to assess the effectiveness of placing eligibility workers in the ED of hospitals found that ED-based Medicaid/SCHIP enrollment was an effective way to reduce the number of uninsured children and contributed to increased hospital revenue. In addition, sufficient revenue can be generated to pay for expenses associated with running the program.31

Another benefit of having out-stationing in the ED is that patients can obtain coverage for additional and/or ongoing health care services if needed. Moreover, in the future, these patients who have obtained a source of payment for health care will be more likely to seek medical care through a primary care physician, thereby assisting in decreasing overcrowding in the ED. There are other alternatives to having an eligibility worker located in the ED. These options include:

• Cross-train the ED Registration Staff: ED registration staff can provide application assistance and/or gather as much accurate information as possible to facilitate continued

Virginia Commonwealth University Health System Team Approach to Out-stationing

Virginia Commonwealth University Health System (VCUHS) considers a team approach a top priority in achieving its goal of assisting patients in receiving public health insurance benefits. VCUHS has out-stationed eligibility workers available to take regular public health coverage applications and uses a vendor to assist with disability cases. The out-stationing team approach at VCUHS involves key stakeholders such as the out-stationed eligibility worker supervisor, a vendor representative and representatives from Financial Counseling, Social Work and Care Coordination.


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movement of the public health coverage application process. This information can then be passed on to the out-stationed eligibility worker for follow-up and processing.

• Referral Forms: Referral forms can be used to refer patients for eligibility determination who are seen in the ED when an eligibility worker is not available. The forms can be developed to gather basic eligibility information needed to begin the application process. The form can be faxed to the local eligibility office or to the out-station eligibility worker for processing.

• Phone Applications: Uninsured and underinsured patients who enter through the ED can complete public health coverage applications by phone in some states.

Establishment of the Computer System The efficiency and effectiveness of the out-stationing process will be impacted by the set-up and functionality of the computer system at the out-stationed site. The computer system can affect the ability to track and monitor public health coverage applications and the productivity of the out-stationed eligibility worker. It also can effect how inpatients and outpatients are referred to the eligibility worker. For efficient and effective out-stationing, the out-stationed eligibility worker will need to have access to the state/county eligibility system. Having access to the eligibility system will enable the worker to check the status of public health coverage applications, make updates in the client case file and process application decisions immediately onsite. Additionally, the out-stationed eligibility worker also will need access to the health care provider’s computer systems. If the eligibility worker has access to these systems, then the worker can place notifications of the status of public health coverage applications that can be viewed by health care provider staff including appointment, registration and satellite office staff. As a result, hospital/health center staff will be aware of the application status and duplicative requests for public health coverage applications will be minimized. Moreover, health care provider staff can help facilitate the application process by simply reminding patients of any outstanding documentation that is needed to complete the application. Increasing Client Responsiveness and Continuity of Coverage Out-stationed sites can be an environment conducive for achieving high client responsiveness and public health coverage eligibility approvals. Health care provider staff can assist government eligibility workers in following up with patients. One out-stationed site has dedicated 1.5 full-time hospital employees for the purpose of making phone calls, sending letters and other duties that can increase client responsiveness. Collaboration across hospital departments and services can be instrumental as well. For example, when appointments are made for outpatient services, hospital staff can remind the patient to bring in documentation during the doctor visit. Renewals are not always conducted by out-stationed eligibility staff. To make out-stationing even more efficient and effective, it may be beneficial for out-stationed eligibility workers to be responsible for renewals. Doing so can assist in reducing churning. Churning occurs when


18

patients cycle on and off of public health coverage. Churning creates disruptions in receiving appropriate primary and preventive care.

Out-stationing Processes and Procedures

The processes, procedures and systems used to implement and maintain out-stationing in health care provider sites vary from one state to another and from one out-stationed location to another within a state. How the out-stationing processes and systems are constructed depends upon the needs and desires of the health care provider and the government agency. A variety of out-stationing models are provided on the following pages. Flowcharts of the public health coverage eligibility processes are shown for the out-stationing sites where they were available.


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Children’s Hospital at Oklahoma University Medical Center Oklahoma City, OK

Type of Site: Public

Hospital

Number of Beds: 194

Year Out-stationing Began:

1966

Number of Out-stationed Staff:

5

Primary Target for Out-stationing

Services:

All Departments

The Children's Hospital at Oklahoma University Medical Center (OU Medical Center) is Oklahoma's only full-service pediatric care facility. This Level 1 Trauma Center provides a full range of subspecialty children’s services. Bed capacity for the Children's Hospital is 194, with six operating suites. OU Medical Center has 848 licensed beds with an estimated 14.2 percent inpatient market share and a 6.5 percent outpatient market share.

Number of

Applications Processed Monthly:

162

Administrative Structure of the Out-stationing Office Background and Governance Out-stationing at OU Medical Center dates back to the early 1960s. Through the Crippled Children’s Program, eligibility workers were available onsite to assist families with children under the age of 21 who had congenital or acquired physically handicapping conditions in completing applications for public financial assistance. In 1966, onsite application assistance was extended to Medicaid-eligible recipients. In 1994, the Out-stationed Worker Program, a partnership between the Oklahoma Department of Human Services (OKDHS) and a hospital, clinic or other medical facility, was implemented in the Tulsa area. As of October 2005, there are 32 employees out-stationed in 30 facilities across Oklahoma. In the last few years there has been increased coordination of out-stationed programs with Indian Health Services and tribal clinics. These facilities serve many families who are eligible for Medicaid, but may be resistant or fail to go to an OKDHS local office to apply for benefits. Financial/Funding Structure The Out-stationed Worker Program requires that the partnering medical facility reimburse the state for 50 percent of the worker’s salary plus benefits. The approximate cost to the facility is $24,000 per year. The Oklahoma Department of Human Services Office of Finance bills the medical facility quarterly for the actual costs. The facility typically provides a work area, network access and office support and supplies at its expense. OKDHS provides a personal computer for the out-stationed worker. The out-stationed worker receives the same benefits as other state employees,


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including insurance, retirement and holidays. OKDHS and the facility sign a yearly agreement that outlines their mutual responsibilities. Since the facility pays the state’s share of the payroll costs, these positions are considered cost neutral for the Oklahoma Department of Human Services. Out-stationing Office Operations An out-stationed worker is a Social Service Specialist who is stationed onsite at a hospital or medical facility, but remains an employee of OKDHS. The primary responsibility of the out-stationed worker is to accept and process adult and children’s Medicaid applications. This benefits both the client and medical facility through accessing Medicaid funds that might not otherwise have been accessed. The Medicaid eligibility determination is made onsite and is often immediate. At OU Medical Center, there is a staff of five out-stationed employees: three eligibility workers, one clerical support worker and one supervisor. The staff members are OKDHS employees who would normally be in a county office. The out-stationed site at OU Medical Center has been in operation for more than 45 years. Unlike other medical facilities that are a part of the Out-stationed Worker Program, there is no contractual agreement between OU Medical Center and OKDHS. OU Medical Center is not required to pay any expenses for out-stationing, with the exception of office space. Office hours of the out-stationed office at OU Medical Center are Monday – Friday, 7:30 am – 5:00 pm. Return on Investment Within the first year, most medical facilities in Oklahoma with out-stationing see a 200% increase in the amount collected from Medicaid. One hospital's Medicaid collections were approximately $1,800,000 prior to contracting an out-stationed worker. With an out-stationed worker onsite, the hospital’s Medicaid reimbursements increased to $5,001,520 two years later.


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Connecticut Children’s Medical Center Hartford, CT

Type of Site: Private

Hospital

Number of Beds: 120


2004


1


Eligibility Services:

Emergency Room

Connecticut Children’s Medical Center (CCMC) is a full-service children’s hospital and a teaching hospital for the University of Connecticut School of Medicine Department of Pediatrics and its residency program in pediatrics. Annually, CCMC serves approximately 30,000 patients in the Emergency Department, admits more than 5,000 patients to medical/surgical units, performs nearly 6,000 surgeries and cares for about 500 critically ill or premature newborn babies. CCMC also is the Primary Care Center for the Hartford region serving nearly 15,000 children a year, making it the largest pediatric primary care service for children between Boston and New York. At the Primary Care Center, pediatricians provide primary care services such as well-child checkups and immunizations and care for minor illnesses.

Number of Applications Processed

Monthly:

50

Administrative Structure of Out-stationing Office Background and Governance CCMC implemented out-stationing at its medical facility in 2004. Financial/Funding Structure CCMC has an agreement with the Connecticut Department of Social Services. CCMC is responsible for 100% of the out-stationing costs, which include the caseworker’s salary, computer equipment, office space, etc. CCMC shares the out-stationing costs equally (50/50) with the CCMC Faculty Practice Plan, Inc. (FPP), a non-profit, multi-specialty pediatric practice. FPP is made up of 24 different health care providers specializing in Urology, Pediatric Surgery, Gastroenterology, Cardiology, Hematology and other specialty areas. Out-stationing Office CCMC has one onsite eligibility worker who works closely with the financial counselors to enroll clients in public health coverage programs and to update client files. The out-stationed worker also has the ability to make renewal decisions onsite. CCMC’s onsite eligibility worker has established a relationship with the nearby women’s clinic to ensure eligible newborns are enrolled in public health coverage programs in a timely manner. Office hours of the onsite eligibility worker are Monday – Friday, 7:30 am – 4:00 pm.


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Return on Investment There are numerous non-financial benefits associated with the onsite eligibility worker at CCMC. The return on investment is consistent with CCMC’s mission of providing the best in family-centered care. The out-stationed eligibility worker communicates in a caring manner that is vital at a time when parents have concerns about the health and well-being of their child. The eligibility worker is compassionate and understanding while educating families on the state plan eligibility process. Other benefits include improved utilization of CCMC staff time since the onsite eligibility worker reduces the numbers of inquiries employees make regarding the status of a patient’s application. The productivity of CCMC financial counselors is improved as well. The onsite eligibility worker also streamlines communications between the provider and the Connecticut Department of Social Services as he/she is now the single point of contact for both incoming and outgoing inquires.


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Hospital Association of San Diego and Imperial Counties San Diego, CA

Type of Site: Public and

Private

Number of Beds: 14 hospitals with 5,802 (total)


1989


28 (at hospitals)

15 ( at clinics)


Services:

Inpatient, Outpatient, Emergency Departments and Clinics

The Hospital Association of San Diego and Imperial Counties is a non-profit organization providing strong leadership, representation and advocacy on behalf of more than 35 hospitals and integrated health systems in the two-county region. The Hospital Association has 14 member hospitals in San Diego County that participate in the Hospital Out-stationing Services (HOS) Program, most of which are non-profit hospitals. The Hospital Association of San Diego and Imperial Counties and the County of San Diego Health and Human Services Agency (HHSA) have partnered to reduce the number of uninsured residents in the region by increasing health enrollment activities and improving access to health care. The HOS Program was established with the purpose of increasing timely patient access to Medicaid (Medi-Cal) and County Medical Services (CMS) at local hospitals. To operate the Hospital Out-stationing Services Program, the County of San Diego and the Hospital Association entered into a contractual agreement on behalf of participating hospitals. Number of

Applications Processed Monthly:

1,120 (at hospitals)

1,603 (at clinics)

Administrative Structure of the Out-stationing Office Background and Governance The partnership between HHSA and hospitals began in 1972. Initially, county staff were centralized and deployed daily to interview inpatients. Hospitals phoned in a list of potentially eligible patients to the centralized office. Discharged patients also were assisted by this centralized unit. At that time, only Medi-Cal applications were processed. In 1984, HHSA began out-stationing staff at hospitals. In 1989, a HOS agreement was established between the Hospital Association of San Diego and Imperial Counties and the County of San Diego. Under the HOS agreement, San Diego County and the Hospital Association collaborate to operate a program with the following shared goals: 1) to provide for the timely and accurate determination of eligibility for hospitalized Medi-Cal and CMS applicants; 2) to improve access to care for eligible Medi-Cal and CMS applicants; and 3) to support and preserve the indigent care safety net. CMS is a county-funded, safety net program that provides physical health services to eligible, medically indigent adults. Medi-Cal is California’s Medicaid program that provides health care


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coverage for low-income children and families as well as elderly, blind or disabled individuals. The CMS and HOS Program operate under the County of San Diego’s Health Coverage Access Program. Both CMS and HOS programs serve some of the most difficult clients who have been hospitalized due to serious and/or emergent needs and/or require immediate medical attention. Hospitals in San Diego County with out-stationing process Medi-Cal and CMS applications, whereas clinics only process CMS applications. Financial/Funding Structure The County of San Diego does not have a direct contract with individual hospitals; instead, it has a contractual agreement with the Hospital Association of San Diego and Imperial Counties. The hospitals pay up to a maximum of $688,000 annually (FY 06-07) for out-station costs, which represent the costs of out-stationing that will not be reimbursed from the state or federal government. The methods of calculating HOS costs are as follows: direct salary and benefit expense for out-stationed workers plus the indirect costs for countywide administration, Department of Social Services Administration and Department Support, less cost reimbursement for HOS costs claimed from the State of California pursuant to San Diego County’s claim for such reimbursement. Since the contract for services is not a direct relationship with the hospitals and the county, payments are processed through the Hospital Association. The CMS Program reimburses specialty and ancillary providers at interim Medi-Cal rates. CMS is not an entitlement program and applicants must have an immediate medical need. The scope of service is limited to the Program Medical criteria and no co-payments are required. Out-stationed Office Operations The HOS Program is governed by a contract between the County of San Diego Health and Human Services Agency and the Hospital Association of San Diego and Imperial Counties. Policies and procedures are in place to provide direction for the day-to-day operations. Staff in this program must be able to work independently and be highly knowledgeable about Medi-Cal and CMS programs in order to make accurate and timely eligibility determinations. Twenty-eight staff members are located at 14 hospitals throughout the County of San Diego. Five additional staff members are available as floaters and four supervisors provide additional support in this effort. All staff are employed, supervised and managed by the County of San Diego. Staff members are offered flexible work schedules between the hours of 7:00 am and 7:00 pm, Monday – Friday. Ten-hour, four-day work weeks are accommodated to maximize coverage on a daily basis. The number of workers designated per hospital varies by the patient volume at that hospital. This ranges from a part-time worker up to four workers per site. Hospitals and clinics are required to provide office space for out-stationed workers. The HOS Program Policy and Procedure Manual outlines the specifications of office space, storage and security. Patients receiving care through the CMS program must schedule an appointment for services through AmeriChoice, a county contractor. Appointments are made for the CMS population who suffer an acute illness or a chronic condition, which would result in death or significant disability


25

if left untreated. Additionally, CMS clients who were treated in the emergency department also receive appointments allowing them to receive follow-up services. County staff in the CMS program must have prior Medi-Cal experience in order to work in the clinic setting. Fifteen staff members are located at 11 clinics throughout the County of San Diego. Five floaters and four supervisors provide additional support in this effort. All staff are supervised and managed by the County of San Diego. Staff members work five days a week, Monday – Friday, 8:00 am – 4:30 pm. Hospital Support and Outreach Hospital and county staff are responsible for conducting outreach activities that support completion of the application and follow-through by patients. Some hospitals utilize contractors to conduct these activities in addition to hospital employees. The contracted hospital staff members assist in referring patients to the county staff and gathering documentation for patients. Return on Investment The HOS Program benefits both hospitals and the county as it provides increased access for patients to eligibility workers, and improves the customer services that both organizations are able to offer to patients. This program is an outstanding example of a public-private partnership and enables hospitals to be reimbursed for care provided to the uninsured population.


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MetroHealth Medical Center Cleveland, OH


Hospital

Number of Beds: 731


1989


2


Services:

Inpatient, Oncology, Burn, ED

MetroHealth Medical Center is a medical research center located on the near-west side of Cleveland and is a part of the MetroHealth System. It is the region’s leader in public and community health and uniquely qualified in the provision of critical care, emergency medicine and trauma surgery, rehabilitation and comprehensive stroke care, geriatrics and neonatal care. MetroHealth Medical Center provides care to nearly 28,000 inpatients, including more than 3,400 newborns a year. More than 700,000 visits are recorded annually in the medical center’s outpatient centers and more than 84,000 patient visits are made to the emergency department annually. The MetroHealth System is affiliated with Case Western Reserve University School of Medicine.


Monthly:

120

Administrative Structure of the Out-stationing Office Background and Governance Out-stationing began in Cuyahoga County, Ohio about 10 years ago. Out-stationed staff members are mostly responsible for cases where disability must be established. They also assist with existing Medicaid spend-down cases, billing problems and generally work as a liaison for the county agency and the hospital. Cuyahoga County Employment & Family Services implemented out-stationing in MetroHealth Medical Center, a county hospital, several years ago due to the direct benefits out-stationing offers of assisting and reducing the number of uninsured and underinsured in the county and the community. Eligibility Specialists (ES) out-stationed at MetroHealth work in tandem with the Patient Assistance Program (PAP) Unit at the hospital. Only Aged, Blind and Disabled (ABD) cases are processed by out-stationed staff because of the gap that exists in processing these types of cases. In addition to out-stationing eligibility staff, Cuyahoga County has a unique case processing system for children’s health care that was put into place in 1996. Healthy Start/Healthy Families Hotline, an application hotline located in MetroHealth Medical Center, is staffed to answer calls, assist in the completion of applications and send completed application packets to families who may sign the application and return it to the county. Once received, applications are cleared, registered in a statewide system, reviewed and approved, pended or denied. A unit of staff works via phone, fax and mail to review and follow-up with the eligibility process.


27

Financial/Funding Structure Salaries of the two Cuyahoga County ESs in the Medicaid Onsite Unit are fully funded by the Cuyahoga County Employment & Family Services Agency. There is a Memorandum of Understanding between the county and MetroHealth Medical Center. All costs for forms and the computer, as well as connectivity are the responsibility of the county for the out-stationed staff. In addition, the county is responsible for staffing, supervising, training and managing the out-stationed staff. Cuyahoga County has bargaining unit staff, thus there are limitations on what the hospital can ask of the eligibility staff and on what can be done by the staff. MetroHealth bills the county for expense items such as postage. The hospital makes three parking spaces available to county employees at the hospital’s expense. Out-stationing Office Operations There are two ESs in the out-stationed office at MetroHealth Medical Center. Cuyahoga County sets two workers per out-stationed site as the standard as this provides support and coverage for vacations and absences due to illness. The out-stationed office at MetroHealth works in tandem with the PAP Unit which is located in Financial Services. All ESs are employees of Cuyahoga County and are a part of a bargaining unit. They are supervised by a county supervisor who reports to the Team Coordinator from the local Neighborhood Family Service Center. Neighborhood Centers offer clients an opportunity to apply for public benefits at sites located throughout the county. Four hospital staff members are dedicated to assisting the out-stationed caseworkers by reviewing accounts and sorting and preparing ABD paperwork. Hospital staff members also determine if patient cases can be forwarded to the onsite caseworker team, handled internally or assigned to an eligibility vendor for follow-up based on internal hospital protocol. Self-pay and indigent care cases are processed by PAP unit staff who then forward the Medicaid application to a Neighborhood Family Service Center or a contracted eligibility vendor. However, if there seems to be some potential public health coverage eligibility opportunities for self-pay and indigent care cases, a decision is made onsite as to the best possible course for the patient. All other cases not fitting existing Medicaid eligibility criteria have the option of applying for the Ohio Hospital Care Assurance Program (HCAP) or the MetroHealth Discount Plan, if ineligible for HCAP. Office hours of the PAP Unit are Monday – Friday, 7:30 am – 4:45 pm. The onsite Medicaid eligibility unit hours are Monday – Friday, 7:00 am – 4:30 pm. Figure 1 is a visual depiction of the eligibility processing flow. Return on Investment In 2004, 4,207 admissions were Medicaid-approved at a Medicaid reimbursement amount of $30,062,376.37 in technical payments to MetroHealth Medical Center. In 2005, 3,715 individual admissions were approved at a Medicaid reimbursement rate of $33,437,111.00 in technical services. In 2006, 3,153 individual admissions were approved at a Medicaid reimbursement rate of $34,208,066.00 for technical services. Other benefits of out-stationing have included increased


28

access to Medicaid for patients, faster completion of determinations for disability cases due to greater access to medical records by the county staff and faster approval and release of Medicaid spend-down cards and coverage in general. An intangible benefit gained through out-stationing has been an improved relationship between the county and the hospital, which facilitates problem-solving and collaboration.


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FIGURE 1 MetroHealth Medical Center Out-station Flowchart


30

SSM Cardinal Glennon Children’s Medical Center St. Louis, MO

Type of Site: Private

Hospital

Number of Beds: 190


1996


1


Services:

Registration Services

SSM Cardinal Glennon Children's Medical Center, a Level 1 Trauma Center, is one of eight hospitals in the St. Louis area sponsored by the Franciscan Sisters of Mary. This 190-bed inpatient and outpatient pediatric medical center specializes in neonatology, cardiology and cardiovascular surgery, hematology (bleeding disorders) and oncology (cancer services). Cardinal Glennon is home to the Bob Costas Cancer Center, the St. Louis Cord Blood Bank, the Pediatric Research Institute and the Missouri Regional Poison Center, which provides free statewide service 24 hours a day, seven days a week. A 2004 Missouri Quality Award winner, Cardinal Glennon cares for children of all ages, primarily from Missouri and Illinois, but also from around the world. Annually, 34,467 patients are seen in the emergency department, 5,430 patients are admitted and 2,649 patients are seen for observations.


Monthly:

100

Administrative Structure of the Out-stationing Office Background and Governance Out-stationing has been in place at SSM Cardinal Glennon Children's Medical Center for more than 10 years. There is one onsite eligibility worker at the facility in the Financial Services division. The number of State of Missouri Medicaid (MOMED) caseworkers out-stationed at Cardinal Glennon is based on the number of households in the zip codes that the medical center serves. Considering that Cardinal Glennon serves children in Missouri, as well as Illinois, efforts were made to secure someone to process Illinois related cases. Recently, SSM Cardinal Glennon Children's Medical Center formed a Medicaid Eligibility Service Unit and hired a hospital employee to be responsible for Illinois cases. Financial/Funding Structure SSM Cardinal Glennon Children's Medical Center pays 50 percent of the MOMED caseworker’s salary. Cardinal Glennon also is responsible for providing office space for the out-stationed caseworker, in addition to computer equipment, which amounts to approximately $3,950 including upgrades and wiring. Out-stationing Office Operations The onsite MOMED caseworker is a part of the Financial Services department and is managed by the director of Registration Services at SSM Cardinal Glennon Children's Medical Center. The


31

eligibility worker, a full-time employee of the state, works in the Financial Services office in conjunction with two financial counselors. Office hours of the out-stationed eligibility worker are Monday – Friday, 8:30 am – 5:00 pm. Return on Investment SSM Cardinal Glennon Children’s Medical Center has received positive feedback from patients as well as hospital staff about having a MOMED caseworker onsite. The intangible benefits of having an out-stationed eligibility worker are often immeasurable, particularly for a hospital that cares for terminally and critically ill patients. In the future, SSM Cardinal Glennon Children’s Medical Center hopes to place a second MOMED caseworker onsite for a total of two caseworkers dedicated to Missouri cases and a third worker dedicated to Illinois cases.


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Virginia Commonwealth University Health System Richmond, VA


Hospital

Number of Beds: 779


1989


12


Services:

Inpatient and high dollar outpatient

Virginia Commonwealth University Health System (VCUHS) is the only academic medical center in Central Virginia and is a regional referral center for the state. It serves as the clinical delivery component of Virginia Commonwealth University Medical Center. VCUHS is comprised of the Medical College of Virginia Hospitals (MCVH), a number of outpatient clinics and the Medical College of Virginia Physicians, a 600-physician, faculty group practice. MCVH has 779 licensed beds and approximately a 20% share of the Richmond inpatient market. VCUHS comprises more than 200 specialty areas. VCUHS records 30,000 admissions and more than 500,000 outpatient visits each year. More than 80,000 patients are treated annually in the hospital’s emergency department, which is the region's only Level I Trauma Center.


Monthly:

220

Administrative Structure of the Out-stationing Office Background and Governance VCUHS became the first hospital-based out-station site in Virginia in 1989. Implementation of out-stationing began after several Virginia legislators were asked to complete a Medicaid application during a tour of the hospital. Seeing the difficulty in completing the application, representatives of the public hospitals formed a committee with the purpose of designing out-stationing programs in hospitals. Today there are 15 out-stationed sites statewide. Financial/Funding Structure The cost of out-stationing eligibility workers at VCUHS is shared between the hospital system and the state. This financial structure is unique in that VCUHS contracts with the City of Richmond for the out-stationed eligibility workers. The hospital system provides half of the funding for the eligibility workers, while the state funds the other half. The City of Richmond does not provide funding support, however the out-stationed workers at VCUHS report to the City of Richmond. This allows the workers the capability to approve cases onsite. In localities other than the City of Richmond, Chesterfield and Henrico counties, VCUHS out-stationed workers approve/deny the cases and forward the cases to the appropriate locality for enrollment. For the City of Richmond and Chesterfield and Henrico counties, the VCUHS out-stationed workers can approve the cases and are responsible for enrollment. An enhancement is being reviewed to allow VCUHS out-stationed workers to process all Medicaid application regardless of the locality.


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Out-stationing Office Operations There are 12 staff members in the out-stationed Medicaid Unit at VCUHS. Three caseworkers are located within the hospital, and two caseworkers are in the outpatient clinics. There also are two support staff members and four staff members dedicated to processing cases. There is one supervisor responsible for managing the Medicaid Unit at VCUHS. Workers in the outpatient office are able to perform all caseworker functions including interviewing and making eligibility decisions. Out-stationed eligibility workers can handle all types of Medicaid eligible cases. Self-pay and indigent care patients who do not meet a Medicaid category are referred for a medical review for disability determination. Office hours of the Medicaid Unit located within the hospital are Monday – Friday, 6:00 am – 5:30 pm and Saturdays, 8:00 am – 5:00 pm. For outpatient clients, walk-ins and appointments are accepted. VCUHS implemented its current team approach to Medicaid eligibility in June 2004. This team approach brought together all the departments/agencies involved in the process. These areas included VCUHS’ Financial Counselors and Social Workers, City of Richmond out-stationed workers and the disability vendor (Chamberlin Edmonds). These areas worked to develop processes and continued to meet on a monthly basis to ensure cases were processed in a timely and efficient manner. See Figure 2 for a visual depiction of the flow of the eligibility process. Return on Investment Within the first six months of implementation of out-stationing at VCUHS, Medicaid reimbursements increased by $4 million. Throughout the years, the volume of Medicaid enrollment has continued to increase.


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FIGURE 2 Virginia Commonwealth University Health System Out-station Flowchart


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Conclusion

America is in a health care crisis. Health care insurance options that remain available for many are employer-sponsored and government-sponsored health care, both of which are quickly eroding because of the increased costs of health care. There is a national push for government and the health care industry to do more to decrease the number of uninsured and provide relief from rising health care costs for those who have insurance. There are a number of proposals to cover the uninsured and continue affordable coverage for the insured. Government has taken the lead in creating health care coverage opportunities for lower-income children and for poor families. However, more needs to be done to get solutions for America’s health coverage problem, particularly for lower-income children and families who more often lack access to affordable, accessible health care. Outreach efforts such as out-stationing are important to ensuring eligible but uninsured children and families receive public health coverage benefits. For all stakeholders – government, health care providers, families and the community – to receive the full benefits of out-stationing, several improvements are needed. For example, greater enforcement and compliance with the out-stationing requirement should be the focus for federal, state and local governments. While there is a lot of attention to keeping ineligible individuals out of Medicaid and SCHIP, less attention is paid to ensuring that children, adults and families eligible for Medicaid and SCHIP are enrolled. Additionally, sufficient funding for Medicaid and SCHIP outreach activities, including out-stationing should be allocated. There has been a great deal of investment in raising the awareness of public health coverage. Many families, however, are still not aware of the availability of public health coverage for themselves or their children. Further, they are unaware that there are alternative sites in the community other than the welfare office to apply for coverage. Many health care providers are not aware of out-stationing or the opportunities that out-stationing can provide their facilities. An effectively administered out-stationing process can generate significant resources for the community with minimal costs to the health care provider or state and local governments and can increase the likelihood that more children and families can access preventive and primary health care.


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REFERENCES

1 Kaiser Family Foundation. The Uninsured: A Primer. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2006. Accessible online at http://www.kff.org/uninsured/upload/7451-021.pdf. 2 Galambos, C. “The Uninsured: A Forgotten Population” [Editorial]. Health & Social Work, 30(1), February 2005: 1-6. 3 Kaiser Family Foundation. Health Coverage for Low-Income Children. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 2007. Accessible online at http://www.kff.org/uninsured/upload/2144-05.pdf. 4 American College of Physicians-American Society of Internal Medicine. No Health Insurance? It's Enough to Make You Sick - Scientific Research Linking the Lack of Health Coverage to Poor Health. Philadelphia, PA: American College of Physicians-American Society of Internal Medicine, November 30, 1999. Accessible online at http://www.acponline.org/uninsured/lack-contents.htm. 5 Institute of Medicine. Health Insurance Is a Family Matter. Washington, DC: National Academies Press, 2002. 6 See note 5 above. 7 Overpeck, Mary D. and Jonathan B. Kotch. “The Effect of US Children’s Access to Care on Medical Attention for Injuries” American Journal of Public Health: 85:3, March 1995. 8 Centers for Medicare and Medicaid Services. State Medicaid Directors Letter (SMDL# 01-008): Outstationing - Pregnant Women and Children Applying for Medicaid at Locations Other than Welfare Offices. Washington, DC: United States Department of Health and Human Services, January 18, 2001. Accessible online at http://www.cms.hhs.gov/smdl/downloads/smd011801b.pdf. 9 O’Brien, Ellen and Cindy Mann. Maintaining the Gains: The Importance of Preserving Coverage in Medicaid and SCHIP. Columbia, SC: Covering Kids & Families National Program Office, Southern Institute on Children and Families, June 2003. 10 Shuptrine, Sarah C., Vicki C. Grant, and Genny G. McKenzie. A Study of the Relationship of Health Coverage to Welfare Dependency. Columbia, SC: Southern Institute on Children and Families, March 1994. 11 Stuber, Jennifer and Elizabeth Bradley. “Barriers to Medicaid Enrollment: Who Is At Risk?” American Journal of Public Health, 95(2), February 2005: 292-298. 12 Grant, Vicki C., and Nicole Ravenell. CKF Primer: Understanding Policy and Improving Eligibility Systems. Columbia, SC: Covering Kids & Families National Program Office, Southern Institute on Children and Families, December 2002. 13 Rosenbaum, Sara, Jennifer P. Stuber, Kathleen A. Maloy, and Karen C. Jones. Beyond Stigma: What Barriers Actually Affect the Decisions of Low-Income Families to Enroll in Medicaid? Washington, DC: Center for Health Services Research and Policy, School of Public Health and Health Services, The George Washington University, July 2000. 14 See note 13 above. 15 Center on Budget and Policy Priorities. Facilitating Enrollment of Children in Medicaid. Washington, DC: Center on Budget and Policy Priorities, August 5, 1997. Accessible online at http://www.cbpp.org/fmo.htm 16 See note 12 above. 17 Health Management Associates. Opportunities to Use Medicaid in Support of Maternal and Child Health Services. Washington, DC: United States Department of Health and Human Services, Health Resources and Services Administration, December 2000. 18 Kaiser Family Foundation. Medicaid Glossary. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 2003. 19 Centers for Medicare and Medicaid Services. State Medicaid Directors Letter (SMDL# 01-008): Outstationing - Pregnant Women and Children Applying for Medicaid at Locations Other than Welfare Offices. Washington, DC: United States Department of Health and Human Services, January 18, 2001. Accessible online at http://www.cms.hhs.gov/smdl/downloads/smd011801b.pdf. 20 United States General Accounting Office. District of Columbia: Barriers to Medicaid Enrollment Contribute to Hospital Uncompensated Care. Report to the Committee on the District of Columbia, House of Representatives, December 1992. 21McKinney, Dawn, Rob Kidney, Kelsey Mishkin and Mandla Moyo. Gaining Ground? State Funding, Medicaid Cuts, and Health Centers. Washington, DC: National Association of Community Health Centers, Inc., October 2006. 22 Mizeur, Heather. State Medicaid Outstationing Compliance at FQHCs. Washington, DC: National Association of Community Health Centers, Inc., March 2003.

http://www.kff.org/uninsured/upload/7451-021.pdf

http://www.kff.org/uninsured/upload/2144-05.pdf

http://www.cms.hhs.gov/smdl/downloads/smd011801b.pdf


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23 McKinney, Dawn and Roger Schwartz. Fighting Back: Health Centers Work to Restore State Funding and Medicaid/SCHIP Cuts. Washington, DC: National Association of Community Health Centers, Inc., August 2004. 24 McKinney, Dawn. Shifting Sands: State Funding, Medicaid Cuts, and Health Centers. Washington, DC: National Association of Community Health Centers, Inc., August 2005. 25 See note 20 above. 26 Institute of Medicine. A Shared Destiny: Community Effects of Uninsurance. Washington, DC: National Academies Press, 2003. 27 South Carolina Legislative Audit Council. Cost Savings Strategies for the South Carolina Medicaid Program. Columbia, SC: South Carolina Legislative Audit Council, October 2001. 28 See note 8 above. 29 See note 8 above. 30 See note 8 above. 31 Mahajan, Prashant, Rachel Stanley, Kevin W. Ross, Linda Clark, Keisha Sandberg and Richard Lichtenstein. “Evaluation of an Emergency Department-Based Enrollment Program for Uninsured Children” Annals of Emergency Medicine, 45 (2005): 245-250.


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APPENDIX STATE MEDICAID DIRECTOR LETTER (SMDL# 01-008)


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500 Taylor Street, Suite 202 Columbia, South Carolina 29201 Phone: 803.779.2607 Fax: 803.254.6301

www.thesoutherninstitute.org

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