UCLA CENTER FOR HEALTH POLICY RESEARCH POLICY NOTE SEPTEMBER 2012 Successful Strategies for Increasing Enrollment in California’s Low Income Health Program (LIHP) Ying-Ying Meng, DrPH Livier Cabezas, MPAff Dylan H. Roby, PhD Nadereh Pourat, PhD Gerald F. Kominski, PhD This policy note was funded by Blue Shield of California Foundation and the Department of Health Care Services, with support from the California Medicaid Research Institute. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 2 Table of Contents Executive Summary 4 Innovative Outreach Strategies 4 Effective Enrollment Strategies 4 Successful Retention and Redetermination Methods 4 Background5 Moving Individuals from Eligible to Enrolled 6 Number of Individuals Enrolled Has Nearly Doubled Since Program Began 7 Sociodemographic Status of LIHP Enrollees 8 LIHP Enrollment Demonstrates Progress Toward Enrolling 9 the Estimated ACA-Eligible Population In-reach and Outreach Strategies 11 Challenges for Outreach 11 Partnerships: Pivotal in Reaching Eligible Populations 11 Service Providers 11 Advocacy Groups 12 Information Technology: Facilitating Distribution of Information 13 and Identifying Eligible Populations Enrollment Strategies 13 Challenges in Enrolling Eligible Adults 15 Revamping Enrollment Systems to Streamline Processes 15 Decreased Time in Determining Eligibility 15 Retention and Redetermination Strategies 16 Challenges in Retention and Redetermination 17 Effective Approaches to Retaining and Redetermining LIHP Enrollees 17 Patient-Centered Care 17 Conclusions: Looking Forward to 2014 18 UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 3 List of Exhibits Exhibit 1: LIHP Implementation Timeline by County or Consortium 6 Exhibit 2: Outreach, Enrollment, and Redetermination Process for LIHPs 6 Exhibit 3: Total Monthly Unduplicated Enrollment in LIHPs, July 1, 2011, to March 31, 2012 7 Exhibit 4: Demographics of LIHP Enrollees 8 Exhibit 5: LIHP Enrollment as of March 31, 2012, and Estimated ACA-Eligible Population 10 Exhibit 6: Outreach Methods by LIHP 12 Exhibit 7: Enrollment Sites by LIHP 14 Exhibit 8: Retention and Redetermination Strategies by LIHP 16 Appendix Appendix 1: Local LIHP Federal Poverty Levels, Enrollment as of March 31, 2012, and Estimated ACA-Eligible Population 20 UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 4 Executive Summary More than 400,000 Californians had ever enrolled in Effective Enrollment Strategies California’s Low Income Health Program (LIHP) as of • LIHPs take applications and process enrollment at an March 2012. These LIHP enrollees, who would otherwise array of sites; however, the most commonly used type be underinsured or uninsured, now have access to services of site was health and social service agencies. Another through their county’s safety net facilities and contracted effective method was to streamline screening and providers. This policy note highlights innovative and enrollment processes: for instance, facilitating data successful strategies for outreach, enrollment, and entry of applicants’ information using kiosk systems. redetermination and retention, as well as the challenges • Placing outreach and eligibility workers in high- faced by LIHPs. volume service provider locations. Innovative Outreach Strategies • Verifying documentation using available information systems. • Partnering with service providers, county-based organizations, and advocacy groups. – Service providers are the most commonly used Successful Retention and Redetermination Methods channel for in-reach and outreach, as reported by • Mailing of notifications and prepopulated applications 14 LIHPs. to redetermine and renew enrollees. – Advocacy groups play a key role in reaching • Web-based renewal options that allow clients to renew the targeted population due to their established via the Internet. relationships with users who might not otherwise be exposed to the program, as reported by 7 LIHPs. This policy note documents how LIHPs have identified and implemented innovative strategies to mitigate the • Utilizing information technology (IT) systems to train challenges they have encountered. LIHPs have developed workers for outreach and to help identify eligible customized approaches to dealing with problems reported individuals in other public programs. by clinics, public agencies, and enrollees, with the goal of improving the enrollment and redetermination processes. While LIHPs continue to face challenges, efforts to improve outreach, enrollment, and retention and redetermination continue. The efforts made by LIHPs can better prepare counties for the full implementation of the Affordable Care Act (ACA) in 2014. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 5 Background Definitions California’s Low Income Health Program (LIHP), known as California’s “Bridge to Reform” §1115 Medicaid CMSP: The County Medical Services Program (CMSP) Waiver, is an optional program established at the local is a consortium of 35 rural counties: Alpine, Amador, level that offers health care coverage to low-income adults. Butte, Calaveras, Colusa, Del Norte, El Dorado, LIHPs receive 50 percent federal financial participation Glenn, Humboldt, Imperial, Inyo, Kings, Lake, (FFP) funds due to the waiver administered by California’s Lassen, Madera, Marin, Mariposa, Mendocino, Department of Health Care Services (DHCS). To be Modoc, Mono, Napa, Nevada, Plumas, San Benito, eligible for LIHP, individuals must be U.S. citizens or Shasta, Sierra, Siskiyou, Solano, Sonoma, Sutter, have satisfactory immigration status, be between the ages Tehama, Trinity, Tuolumne, Yolo (joined on of 19 and 64, have incomes less than 200% of the federal July 1, 2012), and Yuba. poverty level (FPL), and not be eligible for Medicaid programs. LIHP includes two components, distinguished Legacy County: Counties that participated in by family income eligibility levels: Medicaid Coverage the previous Health Care Coverage Initiative Expansion (MCE) for those living at or below 133% demonstration waiver program (2007-2010): FPL, and Health Care Coverage Initiative (HCCI) for Alameda, Contra Costa, Kern, Los Angeles, those living above 133% through 200% FPL. LIHP Orange, San Diego, San Francisco, San Mateo, builds upon the previous Health Care Coverage Initiative Santa Clara, and Ventura. demonstration waiver program operated by the 10 legacy counties to provide a statewide expansion of health care New LIHPs: For the purposes of this policy note, coverage in the counties that opt to participate. the newly implemented programs discussed are the CMSP consortium, Riverside, San Bernardino, and Counties and other governmental entities are implementing Santa Cruz counties. LIHP through a staggered process that began in the 10 legacy counties in July 2011. “Governmental entities” MCE: Medicaid Coverage Expansion is the refers to the County Medical Services Program (CMSP), component of LIHP that covers adults ages which is a consortium of 35 counties. In addition, health 19-64 with family incomes at or below authorities like the California Rural Indian Health Board 133% of FPL. are eligible to create a program. In January 2012, CMSP and three counties began operating LIHPs, and seven HCCI: Health Care Coverage Initiative is additional counties plan to launch during 2012 and 2013. the component of LIHP that covers adults Two counties’ launch dates are currently pending. The ages 19-64 with family incomes above 133% program will end on December 31, 2013, at which time through 200% FPL. enrollees will be transitioned into the Medi-Cal program (MCE enrollees) or the California Health Benefit Exchange (HCCI enrollees), which will launch on January 1, 2014. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 6 Exhibit 1. LIHP Implementation Timeline by County or Consortium July 2011 Jun 2012 Demonstration Begins San Joaquin December 2013 Alameda, Contra Costa, Kern, Los Angeles, Jul 2012 Demonstration Orange, San Diego, Yolo Ends San Francisco, San Mateo, (into Santa Clara, and Ventura Jan 2012 CMSP) CMSP Riverside Aug 2012 San Bernardino Placer Oct 2012 Jan 2013 Santa Cruz Monterey Merced Sacramento Stanislaus (Tentative) Tulare (Tentative) January 2012 January 2013 July 2011 December 2013 Notes: (1) CMSP refers to the County Medical Services Program, which is a Source: Low Income Health Program contracts with Department of consortium of 35 counties. Yolo joined CMSP on July 1, 2012. Health Care Services. (2) Implementation dates are current as of August 2012, yet are subject to change for pending counties. One governmental entity and one county (California Rural Indian Health Board and Santa Barbara) are planning to participate in the program but have not determined launch dates. Due to the time of survey administration, data on outreach, and enroll an eligible individual within its existing enrollment, retention, and redetermination efforts were system. Outreach refers to those same activities but is collected among the 14 LIHPs that were operating as of aimed at individuals outside the county’s system. Each March 31, 2012 (Exhibit 1). This survey was administered LIHP first identifies its eligible population and then during February 2012, and follow-up questions or calls formulates an in-reach or outreach strategy. The LIHP with key informants were administered if needed. receives applications from a portion of those who were contacted through in-reach/outreach, as well as from Moving Individuals from Eligible to Enrolled individuals who have learned of the program through Exhibit 2 displays the processes that lead eligible other avenues. The application process culminates in populations to LIHP enrollment. There are two overall eligibility determination. For those who are determined methods: in-reach and outreach. In-reach refers to to be eligible, an enrollment period of up to 12 months activities administered by the county to identify, engage, is granted (with the exception of CMSP and Contra Costa County, which only grant an enrollment period of up to six Exhibit 2. Outreach, Enrollment, and Redetermination Process for LIHPs In-reach and/or Eligibility Redetermination Application Enrollment Outreach Determination and Renewal Source: Data from UCLA’s survey of LIHPs on outreach, enrollment, retention, and redetermination. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 7 Exhibit 3. Total Monthly Unduplicated Enrollment in LIHPs, July 1, 2011, to March 31, 2012 512,000 413,295 387,615 353,667 278,638 261,723 246,012 225,444 206,305 188,552 July 2011 September 2011 November 2011 January 2012 March 2012 Projected Enrollment by Dec. 31, 2013 Note: Project enrollment (512,000) is the total projected enrollment target as Source: Individual-level enrollment data submitted to UCLA Center for Health submitted to CMS in the DHCS waiver concept paper. Policy Research by operating LIHPs as of March 31, 2012. months). Several months before each enrollee’s enrollment number of 512,000 enrollees (Exhibit 3). While this goal term ends, the LIHPs notify and assist the enrollee with is the projected target for December 2013, LIHPs were redetermination of eligibility, as required by program rules close to reaching it after just nine months of program for renewal. implementation. Number of Individuals Enrolled Has Nearly Though the data demonstrate growth in enrollment, Doubled Since Program Began approximately 11.9 percent of LIHP enrollees have The data show that enrollment has increased steadily disenrolled at some point in the program. Eleven LIHPs since the beginning of the program. As of March 31, provided data on disenrollment reasons, with enrollees 2012, a total number of 413,295 adults were ever found to have left the program for one of the following enrolled, which includes all individuals who remained reasons: they were determined eligible for another public or who disenrolled from the program during the nine- program or private coverage; they became ineligible for month program operation period (Exhibit 3). This is an the program due to either increased income or relocation; increase of 54.4 percent statewide since the first month or they failed to respond to redetermination requests or to of the program. During the first six months of operation, submit a renewal during redetermination.1 The last reason enrollment grew by an average of 8 percent. In January is a challenge that many counties face. 2012, enrollment grew by 21 percent, due mainly to the 1 Disenrollment data are unavailable for Alameda County, CMSP, and Los new LIHPs launched on January 1, 2012. Overall, LIHPs Angeles County. Disenrollment data represent roughly 6 percent of all individuals ever served in the program, for any break in coverage, whether reached 80.7 percent of the program’s target enrollment or not they reenrolled in LIHP. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 8 Exhibit 4. Demographics of LIHP Enrollees Grandfathered Unavailable Unavailable Enrollees (HCCI) 1% 1% 3% Unavailable 10% New Unavailable Enrollees (HCCI) 18% Other 5% 2% Ages Asian/PI Grandfathered 55 and Above Other Languages Enrollees (MCE) 35% 5% 6% 23% Female Asian/ Spanish 51% Pacific Islander 19% 10% Ages Hispanic/Latino 45-54 31% 27% New Enrollees (MCE) 69% Ages Black/ English 35-44 African American 64% 13% 11% Male 48% Ages 25-34 White 16% 25% Ages 24 and Under 8% Gender Age Race/Ethnicity Language Enrollee Type Total Cumulative Unduplicated Enrollees: 413,295 Note: Numbers may not add up due to rounding. Source: Individual-level enrollment data submitted to UCLA Center for Health Policy Research by operating LIHPs as of March 31, 2012. Sociodemographic Status of LIHP Enrollees White, 11 percent are African American, and 10 percent Given that California’s demographics are rich in variety, are Asian/Pacific Islander. About 27 percent of LIHP it is no surprise that the demographics of LIHP enrollees enrollees are non-English speakers. Close to three-fourths mirror that diversity. Gender is evenly distributed, with a (74 percent) are new enrollees. Of the total LIHP population, little more than half of enrollees being female (51 percent). 92 percent have incomes at or below 133% FPL LIHP enrollees are predominantly older adults, with three (Exhibit 4). in five of all enrolled adults over the age of 45. Almost one-third (31 percent) are Latino, while 25 percent are UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 9 LIHP Enrollment Demonstrates Progress Toward the Medi-Cal Expansion (the Expansion) or the Health Enrolling the Estimated ACA-Eligible Population Benefits Exchange (the Exchange). LIHP is jointly funded by local and federal dollars, and each program can therefore limit enrollment by Exhibit 5 not only demonstrates the number of adults establishing a lower income level for eligibility. Of the 22 enrolled in the various LIHPs across the state, but it LIHPs, only 4 will expand enrollment to the maximum also shows the progress the program has made toward allowable level of 200% FPL. The remaining 18 programs absorbing the estimated number of ACA eligibles. The will operate only the MCE component of LIHP, with majority of LIHPs, whether they are legacy counties or restricted eligibility of 133% FPL or less. A list of the new LIHPs, have enrolled at least one-fourth and as many various FPLs across the LIHPs can be found in Appendix as almost half of UCLA’s estimated eligible populations, 1: Local LIHP Federal Poverty Levels, Enrollment as of if their income thresholds for eligibility were set at the March 31, 2012, and Estimated ACA-Eligible Population. maximum allowable FPL of 200% (Exhibit 5). Having lower local income thresholds to determine eligibility To assess the impact of the LIHPs providing coverage effectively reduces the eligible population pool and those to uninsured Californians, we estimated the number who would seamlessly transition from LIHP to ACA, of uninsured who meet legal residency and citizenship increasing the need for ACA take-up for those not enrolled requirements and do not exceed the maximum income in LIHP. This policy note, however, highlights best threshold approved by CMS for LIHP enrollees (200% practices for outreach and enrollment that are currently in FPL) in each county (Exhibit 5). Specifically, estimates place across the LIHPs, which can be applied to outreach of the potentially eligible population include adults ages ACA-eligible individuals who are not LIHP enrollees. 19-64 whose income is less than or equal to 200% FPL, who are U.S. citizens or have satisfactory immigration status, are currently uninsured, are residents of the county/ region, are not currently eligible for Medi-Cal, and are not currently pregnant. Estimates do not account for potential uptake by currently insured individuals who may use LIHP-MCE as secondary coverage if they meet other program eligibility requirements. This population is also the group that will be eligible for coverage once ACA is implemented in 2014, when they could go into either UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 10 Exhibit 5. LIHP Enrollment as of March 31, 2012, and Estimated ACA-Eligible Population 38,731 Alameda 52,000 12,711 Contra Costa 34,000 47,131 CMSP 153,000 5,478 Kern 62,000 137,557 Los Angeles 637,000 Merced 19,000 Monterey 23,000 33,406 Orange 147,000 Placer 9,000 16,140 Riverside 157,000 Sacramento 61,000 7,830 San Bernardino 127,000 25,740 San Diego 133,000 10,676 San Francisco 30,000 San Joaquin 40,000 8,219 San Mateo 21,000 Santa Barbara 15,000 9,284 Santa Clara 47,000 1,307 Santa Cruz 15,000 Stanislaus 31,000 Tulare 33,000 Ventura 9,877 32,000 Currently Enrolled Estimated ACA-Eligible Sources: The estimated number of eligible ACA individuals is based on small area estimation using 2007 and 2009 California Health Interview Survey (CHIS) data, with the exception of CMSP, which used the CHIS 2009 direct estimate. The methodology for these estimates can be found in Data Sources and Methods. Current enrollment estimates are based on enrollment data submitted to UCLA by operating LIHPs as of March 31, 2012. Please see Appendix 1: Local LIHP Federal Poverty Levels, Enrollment as of March 31, 2012, and Estimated ACA-Eligible Population for more information on the various FPLs across the LIHPs and 95% confidence intervals of the estimates. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 11 In-reach and Partnerships: Pivotal in Reaching Eligible Populations Outreach Strategies LIHPs often partnered with community-based organizations, network providers, and county staff of health and social service agencies for in-reach and outreach In developing in-reach and outreach strategies, certain efforts to reach their target populations. Training clinical LIHPs began by first targeting specific populations to staff was effective in reaching and enrolling frequent enroll in their program. Ten of the fourteen implemented emergency room users or other medical service users. LIHPs have strategic outreach and in-reach plans targeting Capitalizing on the resources of partnering organizations existing low-income populations that already use services alleviated the burden of outreach activities for county in the county system. Seven LIHPs reported outreach eligibility workers. to potentially eligible “nonusers,” who may be unaware of available programs, are healthy and not proactively Service Providers seeking care, or have experienced barriers to accessing Service providers are the most commonly used channel care. Several LIHPs also reported targeted outreach to for in-reach and outreach (Exhibit 6). Thirteen LIHPs special populations, such as the general release population reported that collaborating with their own network (individuals released from jail or prison), those who are providers was the most successful mechanism for reaching chronically ill, high utilizers of health services (e.g., eligible adults. San Francisco and San Mateo counties frequent emergency room visitors), and college/university noted that outreach to potential applicants through their students. existing network providers was successful due to the high level of interest among individuals while seeking Challenges for Outreach care. Roughly an equal number of LIHPs reached eligible The central challenge reported for outreach was the small populations at hospitals or emergency departments number of staff dedicated solely to LIHP enrollment (ED) by utilizing financial counselors at EDs or training activities. Counties may have staff either perform outreach frontline staff to educate and enroll LIHP eligible adults activities or process enrollment for any of their public (Contra Costa, Kern, Santa Cruz, and Ventura counties). programs, depending on what the demand might be. Training clinical staff was also identified as an effective Eligibility staff are at times pulled from the office to strategy. San Bernardino County trained staff at all conduct outreach and vice versa. This leads to delays or licensed emergency hospitals through quarterly meetings limited outreach activities. In any case, LIHPs found about program eligibility requirements and the emergency ways to overcome these obstacles to continue ramping up reimbursement process. enrollment. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 12 Advocacy Groups informing eligible adults about LIHP and assisting Advocacy groups played a key role in reaching the targeted them with the application process. Kern County population due to their established relationships with users partnered with its local initiative health plan to develop who might not otherwise be exposed to the program, as an aggressive outreach strategy targeting the county’s reported by seven LIHPs. These advocacy groups represent eligible population. Lastly, the Santa Cruz County Health patients, foster youth, low-income populations, laborers’ Department partnered with local nonprofit community rights, housing, and Latino health, as well as homeless health clinics, the County Organized Health System, local service agencies, legal aid, and faith-based groups. Santa hospitals, and the County Social Services Department Clara County partnered with a local consortium of to facilitate LIHP implementation, including outreach, community health clinics to hold educational sessions training, and enrollment activities. Exhibit 6. Outreach Methods by LIHP San Bernardino San Francisco Contra Costa Los Angeles Santa Clara Santa Cruz San Mateo San Diego Riverside Alameda Ventura Orange CMSP Total Kern Outreach Methods Community-Based Advocacy Groups – – – 3 3 3 3 3 – – – 3 3 3 8 Community Events – – 3 3 3 – – 3 3 3 – – – 3 7 Health Fairs – – 3 3 3 3 – 3 – – – 3 – 3 7 Service Providers Clinics/FQHCs 3 – 3 3 3 3 3 3 3 3 3 3 3 3 13 Emergency Rooms 3 – 3 3 3 – 3 3 3 3 3 3 3 3 12 Hospitals 3 – 3 3 3 3 3 3 3 3 3 3 3 3 13 Media Brochures/Flyers 3 3 3 3 3 3 – 3 3 3 3 3 3 3 13 Mail – – 3 3 3 – 3 3 – – – – 3 3 7 Media/Ads – – – – 3 – – 3 – – – – 3 3 4 County Website 3 3 – – 3 – 3 – 3 3 3 3 – 3 9 Other – 3 – – – – – – – 3 3 3 – 3 5 “3” = Yes “–” = No Notes: (1) CMSP refers to the County Medical Services Program, which is a consortium of 35 counties. Yolo joined CMSP on July 1, 2012. (2) “Other” includes school-based health centers, information hotlines, human services agency offices, a network of Certified Application Assistants who are trained to do outreach, and training webinars for network providers on program rules and eligibility. Source: Data from UCLA’s survey of LIHPs on outreach, enrollment, retention, and redetermination. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 13 Information Technology: Facilitating Distribution of Information and Identifying Eligible Populations Enrollment Strategies One innovative approach is to use information technology (IT) to train workers for outreach and to help identify LIHPs take applications and process enrollment at eligible populations. When working with a large, an array of sites; however, the most commonly used dispersed workforce, webinars are an effective and low- type of site was health and social service agencies. All cost tool for training hospital and clinic staff, county LIHPs surveyed reported collecting applications where eligibility workers, and behavioral health personnel in individuals seek care, including community health LIHP eligibility criteria and enrollment processes. CMSP centers, county hospitals, emergency rooms, and privately held a series of 16 training webinars two months prior to contracted facilities (Exhibit 7). Applications were also launching LIHP. Another innovative approach is to convert commonly collected at partnering county departments, enrollees of the existing medically indigent program such as mental health departments and social service or other charity care venue to LIHP using existing data agency offices. At all locations, public and community sources (Alameda County and CMSP). health workers such as certified county workers, Certified Application Assistants (CAAs), county social workers, and staff from the Department of Public Social Services and the Department of Mental Health were available to screen, fill out applications, and assist applicants in various languages. Spanish-speaking workers or materials in Spanish were available at all LIHPs. Six LIHPs also reported having workers who could assist in Vietnamese, Chinese, Armenian, Korean, Tongan, and Tagalog languages, and three LIHPs utilized translation services that covered multiple languages remotely. The type of enrollment site with the highest number of completed applications was partnering county departments (Exhibit 7). Under this umbrella, four LIHPs reported that social service agencies collected the most completed applications, while three LIHPs reported that county hospitals received the most completed applications. These sites also engaged in significant outreach efforts, with LIHPs reporting these sites as their most utilized outreach venues. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 14 The reasons for certain facilities having higher completed reported as major reasons. Another key factor affecting numbers of applications varied. Access to a higher number application completion was having the capability to of uninsured patients and having trained clinical or onsite process applications, determine eligibility, and enroll enrollment staff to educate uninsured patients about the individuals onsite, which led to the handling of large program and assist them with their applications were volumes of applications. Exhibit 7. Enrollment Sites by LIHP San Bernardino San Francisco Contra Costa Los Angeles Santa Clara Santa Cruz San Mateo San Diego Riverside Alameda Ventura Orange CMSP Total Kern LIHP Enrollment Sites Service Providers Community Health Centers 3 3 3 – 3 3 – 3 – – 3 3 3 3 10 County-Based Clinics/Doctor’s Office 3 3 3 – 3 – 3 3 – 3 3 3 3 3 11 Privately Funded Clinics – 3 3 – – 3 – – – – – – – – 3 Private Hospitals – 3 3 – – 3 – 3 3 – 3 – 3 – 7 County Hospitals 3 – 3 3 3 – 3 3 – 3 3 3 – 3 10 Emergency Room 3 – 3 3 3 – – 3 – – 3 3 3 3 9 Community-Based Locations Family Resource Center – – – – – – – – – – 3 – – – 1 Community-Based Organizations or – – – – – 3 – – – – 3 – – 3 3 School Districts School Clinics – – 3 – – – – – – – – – – – 1 Partnering County Departments Medically Indigent Services 3 – 3 – – – 3 3 3 3 3 3 3 3 10 Mental Health Department 3 – 3 – 3 – 3 3 3 3 3 3 3 3 11 Social Service Agency – 3 3 – – – – 3 3 3 3 – – 3 7 Remote-Access Systems Website – 3 – – – 3 – 3 3 – – – – – 4 Centralized Phone Unit – – 3 – – – – 3 3 – – – – – 3 Electronic Self-Service Kiosks – – – – – – – 3 – – – – – – 1 “3” = Yes “–” = No Notes: (1) Light-blue shaded areas denote sites that had the highest number of completed applications. (2) CMSP refers to the County Medical Services Program, which is a consortium of 35 counties. Yolo joined CMSP on July 1, 2012. (3) CMSP could not determine which facility had the highest number of completed applications due the large number of counties in the consortium. Source: Data from UCLA’s survey of LIHPs on outreach, enrollment, retention, and redetermination. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 15 Challenges in Enrolling Eligible Adults Another effective method was to streamline screening and LIHPs faced various challenges specific to enrollment, which enrollment processes. LIHPs reported placing outreach and they noted as being a complex process for the applicant. eligibility workers, including financial counselors, in high- A few LIHPs noted that personnel could not attend to the volume service provider locations to enroll eligible adults high volume of work involved in processing applications (Contra Costa and San Bernardino counties). To reduce long due to limited staffing. Several counties reported that wait times, Los Angeles County established a “fast track” applicants struggled to navigate the application process, option for applicants who were dropping off documentation including collecting all required documentation. Obtaining and did not require the full services of a certified application required documentation, such as birth certificates, was assistant (CAA). Applicants were given a voucher that the most difficult part of the citizenship and verification instructed them to report to a specific window to avoid long process. Verifying identity can be problematic as well, wait times when returning to submit required documentation. especially for the homeless, those born outside California, In addition, utilizing available information systems to verify and individuals coming out of the criminal justice system. documentation was reported as an easy method of validating In some cases, financial hardship for applicants was also a an applicant’s eligibility. Examples of information systems barrier to obtaining the necessary documentation. include the California Birth Record Database, Experian credit reports, and Social Service Information Technology systems, Revamping Enrollment Systems such as the Statewide Automated Welfare System (SAWS). to Streamline Processes Decreased Time in Determining Eligibility A unique solution for lifting some of the enrollment A few LIHPs reported a decrease in the amount of time burden was to collect application data via a kiosk system. it took to determine eligibility since they were launched. San Bernardino County has self-service kiosks placed at Eligibility determination is measured from the time the the county’s regional medical center (one in the lobby LIHP receives a complete application to the time when of outpatient specialty care, the other in the insurance an enrollee receives a coverage card or is granted access to verification office) to collect demographic and other receive medical services. Alameda County decreased its eligibility information for applicants interested in public eligibility determination time from six or seven weeks coverage. The kiosk first screens for eligibility and then in July 2011 to one or two weeks by March 2012. Since creates an electronic application for the program that the launching its LIHP in July 2011, Los Angeles County applicant is eligible for. These kiosks enable enrollees decreased its determination time from two or three weeks to fill out an electronic application, which eliminates to one to three days. Riverside and San Francisco counties the need to use an eligibility worker’s time to enter have similar systems, with an applicant able to walk in to an applicant’s information from a paper application. submit an application and be determined eligible within Verification to determine eligibility is still administered in the same day. Similarly, Santa Cruz County can determine person, where the eligibility worker reviews and verifies an eligibility in 30 to 45 minutes, and an enrollee can walk applicant’s eligibility. In the future, the kiosks will have a out with a notice of action letter and seek medical services scanning capability for eligibility documentation, with the the same day. San Mateo County had reduced eligibility exception of documents to verify identity and citizenship, determination from 45 days to 2 days since launching as required by the Deficit Reduction Act (DRA). Original its LIHP. By observing these decreases in the reported documentation to verify identity and citizenship would time needed to determine eligibility, we can infer that the still need to be reviewed by an eligibility worker to verify counties’ efforts in streamlining the enrollment process authenticity of the document and then to verify eligibility. were effective. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 16 Reasons for a decrease in the time to determine eligibility varied. Los Angeles County can determine eligibility in an Retention and hour or less if an enrollee submits a complete application Redetermination Strategies with all required documentation to a Department of Health Services (DHS) eligibility worker; however, it still takes about one to three days for an applicant to receive a benefits card. LIHPs not only focused on how to recruit and enroll Riverside County is able to determine eligibility quickly potential LIHP enrollees, but they also developed due to extensive outreach to educate potential enrollees and comprehensive approaches for retention and prepare them for the application process. Stationing staff at redetermination. The most frequent retention strategy various point-of-service facilities assists with this process. was mailing notifications to enrollees whose enrollment Lastly, a “fast track” for those who come in only to submit period was due to expire (Exhibit 8). Timing of documentation decongests the primary office. San Francisco notification in counties ranged from 30 to 90 days prior County can determine eligibility within 30-45 minutes if to the end of the enrollment period, and some counties an applicant provides all the necessary paperwork and an used multiple reminders. Another common method, eligibility worker can easily determine eligibility, similar used by seven LIHPs, was reenrollment during a medical to Los Angeles County. Use of an application assistor and appointment. While this may be the simplest method of One e-App facilitate this process. Access to the Medi-Cal reenrollment for some counties, it is not the most effective Eligibility Data System (MEDS) for linking data assists for enrollees who do not seek care within their allowable Santa Cruz County in determining eligibility in such a redetermination time. short time span. Exhibit 8. Retention and Redetermination Strategies by LIHP San Bernardino San Francisco Contra Costa Los Angeles Santa Clara Santa Cruz San Mateo San Diego Riverside Alameda Ventura Orange CMSP Total Kern Retention Strategy Community-Based Calling Members – – – – 3 – – – – 3 – 3 – 3 4 Mailing Notifications 3 3 3 3 3 3 3 3 3 3 3 3 3 3 14 Prefill Application for Members – – – – – – – – – 3 3 – – 3 3 Renew During Medical Appointment 3 – 3 3 3 – – – – 3 3 – 3 – 7 Other – – – – – – – 3 – 3 3 – – – 3 Total 2 1 2 2 3 1 1 2 1 5 4 2 2 3 – “3” = Yes “–” = No Note: CMSP refers to the County Medical Services Program, which is a consortium of 35 counties. Yolo joined CMSP on July 1, 2012. Source: Data from UCLA’s survey of LIHPs on outreach, enrollment, retention, and redetermination. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 17 Challenges in Retention and Redetermination LIHPs have also employed other strategies for retention LIHPs reported that efforts to retain enrollees are not and redetermination. San Bernardino County has planned always successful. Enrollees’ frequent eligibility changes to regularly release a report to clinic staff listing enrollees caused them to leave the program. The redetermination whose enrollment term is near expiration. San Mateo process was complex and potentially daunting for some County has deployed a Web-based renewal option that enrollees, particularly those without immediate health allows clients to renew their coverage via the Internet. care needs who may not have been incentivized to reenroll. In addition, the county reviews the data of enrollees Some LIHPs encountered difficulties in contacting who fail to reenroll in order to identify characteristics or enrollees, who did not always notify the LIHP of new factors that can contribute to discontinuity in enrollment. contact information. In all of these instances, LIHPs The data can inform targeted retention efforts for these expressed interest in developing more refined processes populations. to retain enrollees, but most have limited capacities for uniformly implementing successful strategies. Patient-Centered Care Another approach to retention is to invest in medical Effective Approaches to Retaining and care that is more patient-centered. Identifying what Redetermining LIHP Enrollees matters most to patients can enrich their experience and increase retention. Dr. Mitchell Katz, director of the Los LIHPs developed effective approaches for simplifying Angeles County Department of Health Services, noted in the redetermination process and preventing disruption of a webinar that changing the culture in a medical office coverage for enrollees. Notifying and reminding enrollees can have a big impact on retaining enrollees.2 Treating of redetermination deadlines by mail was an effective employees well, building pride in their work, encouraging practice. San Francisco County included automated staff to seek care at their own centers, and creating unit- telephone calls, with enrollees contacted 45 days prior to based management teams can have positive effects on the termination in addition to being notified by mail. The morale of staff, which is then evident in their services county then followed up with a live telephone call in the to enrollees. Offering services in the patient’s native enrollee’s preferred language within 15 to 30 days prior to language can help the individual feel comfortable with the enrollment end date. the provider. Extending hours for individuals to see their doctors after work hours can help retain enrollees. Even Prefilled renewal forms are another effective approach offering amenities such as ample parking, decreasing to simplifying redetermination. Populating known or eliminating long wait lines, and maintaining a clean information on behalf of renewal applicants was seen facility can increase patient satisfaction. as an essential tool for recertification and retention. A few counties sent enrollees prefilled renewal forms, with a postage-paid envelope for returning the completed form and documentation. San Mateo also implemented 2 UCLA Center for Health Policy Research. 2012. Engaging enrollees in the this method in April 2012, and the county received redetermination process: Innovative strategies for retention. Video webcast. Retrieved from https://connectpro72759986.adobeconnect.com/_a782517175/ back approximately 10 percent of the 1,000 prefilled p57jxv3gz13/?launcher=false&fcsContent=true&pbMode=normal. applications within one week. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 18 Conclusions: Data Source and Methods The information in this policy note is based on responses to a Looking Forward to 2014 UCLA qualitative survey of LIHPs on outreach, enrollment, retention, and redetermination that was administered to the 14 operating LIHPs in February 2012; on LIHP enrollment data submitted to UCLA as of April 30, 2012; and on current deferral Despite the various challenges, LIHPs have successfully poverty levels, extracted from LIHP contracts with the California enrolled more than 400,000 individuals during the first Department of Health Care Services. Estimates for the number nine months of operation. Moreover, LIHPs have identified of adults potentially eligible for the program at the maximum allowable income level (200% FPL) in each area are based on and implemented innovative strategies to mitigate the small area estimates (SAEs) using the 2007 and 2009 California challenges they have encountered. LIHPs have developed Health Interview Survey (CHIS) and the American Community customized approaches to dealing with problems reported Survey (ACS). Small area estimates were not generated for CMSP, by clinics, public agencies, and enrollees, with the given that the direct estimate using CHIS 2009 was stable when combining counties into one group. goal of improving the enrollment and redetermination processes. While LIHPs continue to face challenges, The method of producing small area estimates (SAEs) was developed efforts to improve outreach, enrollment, and retention and by the Center for Health Policy Research and has been used over redetermination continue. the past 10 years. It can be characterized as a design-oriented and model-based synthetic estimation. The method uses CHIS survey data with ACS3 data to build models predicting estimates for the The efforts made by LIHPs can better prepare counties “finite” population in larger geographic areas, with patterns of for the full implementation of the Affordable Care Act associations used to derive estimates for smaller geographic areas. (ACA) in 2014. Given that the Medi-Cal Expansion will Predicted values for the outcomes of interest in the population data are calculated and then aggregated to derive the final SAEs for the absorb eligible individuals beyond those currently enrolled desired area level. For the SAEs in this policy note, the model was in LIHP, these existing outreach and enrollment systems built on CHIS 2007 and 2009 data, accounting for year-to-year act as a training ground for enrolling eligible low-income differences. The model parameter estimates were then applied to individuals into Medi-Cal. Counties will be able to use decennial U.S. Census population data from ACS, representing the population from which CHIS 2009 survey data were drawn. their existing resources and apply new methods from learned lessons and experiences. Though counties are Rigorous attention was given to assessing the accuracy of SAEs. The independently undertaking these enrollment efforts, they variances were derived through bootstrapping, a computer-intensive still face multiple burdens. Lack of human and/or financial statistical method. The final SAEs were checked for consistency with survey direct estimates. Confidence intervals and coefficients resources and difficulties in obtaining documentation to of variation of the final estimates were calculated and presented. As verify eligibility continue to be issues that counties face. a final review, experts within the Center were asked to examine the Providing additional funding for IT systems or creating results based on their expertise and then compare them to external a more simplified, yet comprehensive, enrollment/ data sources, when available, to assess their validity. redetermination process could assist counties in improving the efficiency of their outreach and enrollment efforts, and thus increase enrollment to the maximum allowable number of individuals. 3 For more information on the ACS and CHIS small area estimate methods, please visit http://www.census.gov/acs/www/methodology/methodology_main/ and http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/ PDF%20ChronicConditionsCHIS2007.pdf. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 19 Author Information Suggested Citation Ying-Ying Meng, DrPH, is Co-Director of the Chronic Disease Meng YY, Cabezas L, Roby DH, Pourat N, and Kominski GF. Program and a senior research scientist at the UCLA Center Successful Strategies for Increasing Enrollment in California’s Low Income for Health Policy Research. Livier Cabezas, MPAff, is project Health Program (LIHP). Los Angeles, CA: UCLA Center for Health manager for the Low Income Health Program Evaluation at the Policy Research, 2012. UCLA Center for Health Policy Research. Dylan H. Roby, PhD, is Director of the Health Economics and Evaluation Research The views expressed in this report are those of the authors Program at the UCLA Center for Health Policy Research and an and do not necessarily represent the UCLA Center for Health assistant professor of health services in the UCLA Fielding School Policy Research, the Regents of the University of California, or of Public Health. Nadereh Pourat, PhD, is a professor of health collaborating organizations or funders. services in the UCLA Fielding School of Public Health and Director of Research at the UCLA Center for Health Policy Research. Gerald F. Kominski, PhD, is Director of the UCLA Center for Health Policy Research and a professor of health services in the UCLA Fielding School of Public Health. Acknowledgments The authors would like to thank Hongjian Yu and Yueyan Wang for their SAE programming support. In addition, we thank Rick Brown, David Grant, and the California Health Interview Survey team for their support in using CHIS data for small area estimates of the uninsured in each county. We also thank Ken Jacobs, Shana Lavarreda, and Anna Davis for their thoughtful reviews and insights. Special thanks to the numerous individuals from participating LIHP counties who provided information on their respective programs. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu 20 Appendix 1. Local LIHP Federal Poverty Levels, Enrollment as of March 31, 2012, and Estimated ACA-Eligible Population Currently Enrolled Estimated ACA-Eligible Population LIHP Local LIHP’s Federal Poverty Level (as of March 31, 2012) (95% Confidence Interval) 52,000 Alameda 200% 38,731 (26,000 – 77,000) 34,000 Contra Costa 200% 12,711 (16,000 – 51,000) 153,000 County Medical Services Program (CMSP) 100% 47,131 (142,000 – 177,000) 62,000 Kern 100% 5,478 (35,000 – 90,000) 637,000 Los Angeles 133% 137,557 (490,000 – 783,000) 19,000 Merced 100% NA (10,000 – 28,000) Monterey 100% NA 23,000 (12,000 - 33,000) 147,000 Orange 200% 33,406 (78,000 - 216,000) 9,000 Placer 100% NA (4,000 – 14,000) 157,000 Riverside 133% 16,140 (88,000 – 225,000) 61,000 Sacramento 67% NA (28,000 – 94,000) 127,000 San Bernardino 100% 7,830 (70,000 – 184,000) 133,000 San Diego 133% 25,740 (101,000 – 166,000) 30,000 San Francisco 25% 10,676 (15,000 – 45,000) 40,000 San Joaquin 80% NA (21,000 – 58,000) 21,000 San Mateo 133% 8,219 (10,000 – 32,000) 15,000 Santa Barbara 100% NA (7,000 – 22,000) 47,000 Santa Clara 75% 9,284 (23,000 – 71,000) 15,000 Santa Cruz 100% 1,307 (8,000 – 23,000) 31,000 Stanislaus 50% NA (17,000 – 45,000) 33,000 Tulare 100% NA (18,000 – 47,000) 32,000 Ventura 200% 9,877 (16,000 – 48,000) Sources:The estimated number of ACA-eligible individuals is based on small area estimation using the 2007 and 2009 California Health Interview Survey (CHIS) data, with the exception of CMSP, which used the CHIS 2009 direct estimate. The methodology for these estimates can be found in Data Sources and Methods. Current enrollment estimates are based on enrollment data submitted to UCLA by operating LIHPs as of March 31, 2012. UCLA Center for Health Policy Research | 10960 Wilshire Blvd. | Suite 1550 | Los Angeles, CA 90024 | t: 310.794.0909 | f: 310.794.2686 | chpr@ucla.edu www.healthpolicy.ucla.edu