1. Medicaid Expansion &
Health Insurance Exchanges
Strategies for Successful
Outreach & Enrollment
Michigan Primary Care Association
August 29, 2012
1

2. Agenda
• Update on Michigan & Medicaid expansion - Doug
• Update on Michigan & health insurance exchange - Doug
• Discuss impact on Health Centers - Harry
• Discuss outreach and enrollment strategies utilized in
other states - Harry
• Discuss what opportunities Michigan health centers have
to grab populations impacted by ACA – Harry/Natasha
2

3. Doug Paterson M.P.A.
Director of State Policy
Michigan Primary Care Association
Michigan Primary Care Association
Webinar
August 29, 2012
3

4. Affordable Care Act
Expansion of Community Health Centers
• $11 billion up-front investment thru Trust
Fund
Medicaid Expansion
• Tax Subsidies making health insurance
affordable for low and moderate income
families and employers
4

5. Supreme Court Decision
• Upheld constitutionality of individual mandate
• Upheld insurance reforms
• Prohibits denial based on conditions
• Lifetime caps
• Kids to 26
• New coverage standards
• Establishes Exchanges
• Medicaid expansion is unconstitutional
coercion
5

6. Medicaid Expansion
Potential to reach 1.9 million more Health
Center Patients
Ten states have indicated they will not
expand:
Florida Iowa
Louisiana Mississippi
Missouri Nevada
New Jersey New York
South Carolina Texas
6

7. Insurance Exchanges
Purpose
◦ To provide individuals and small business
employees with access to health insurance
coverage beginning January 2014.
◦ Creates competitive marketplaces for direct
comparison based on price, quality and
options.
 Facilitates the purchase of Qualified Health Plans by
individuals
 Establishes a Small Business Health Options Program
(SHOP)
7

8. Types of Exchanges
• State based exchange
• State operates all activities
• Governance
• Consumer and Stakeholder Engagement and Support
• Eligibility and Enrollment
• Plan Management
• Risk Adjustment and Reinsurance
• SHOP operation
• Organization and Human Resources
• Finance and Accounting
• Technology
• Privacy and Security
• Oversight, Monitoring and Reporting
• Contracting
8

9. Types of Exchanges
• State Partnership Exchange
• State operates
• Plan Management
• Consumer Assistance
• Both
• Federally-facilitated Exchange
• HHS operates all components but state MAY
elect to use federal services for Medicaid and
CHIP eligibility assessment or determination
9

10. Harry Perlstadt, PhD, MPH
Medical Sociologist and Professor Emeritus
Michigan State University
Michigan Primary Care Association
Webinar
August 29, 2012
H Perlstadt <perlstad@msu.edu> 10

11. Passing the Affordable Care Act:
Medicaid Expansion and Community
Health Centers
Special Deals to get the 60 votes in US Senate
◦ Sen. Ben Nelson (D-NB)
 Feds to pay 100% of Nebraska's costs for
expanding Medicaid indefinitely;
◦ Sen. Bernard Sanders (I-VT)
 Extra funds to Vermont for Medicaid expansion
 plus $10 billion for Community Health Centers
nationwide.
H Perlstadt <perlstad@msu.edu>
11

12. Medicaid Expansion
Affordable Care Act (ACA) expands Medicaid
to nearly all individuals under age 65 with
incomes up to 133-138 percent of the federal
poverty line (FPL) which will extend coverage
to large numbers of the nation’s uninsured
population, especially adults.
However, the ultimate reach of the program will
depend heavily on both federal and state actions
to implement the new law.
Kaiser Commission Medicaid and the Uninsured
H Perlstadt <perlstad@msu.edu>
12

13. Medicaid Expansion
The federal government will pay a very high
share of new Medicaid costs in all states
 Increases in state spending are small compared
to increases in coverage and federal revenues
and relative to what states would have spent if
reform had not been enacted.
Kaiser Commission Medicaid and the Uninsured
H Perlstadt <perlstad@msu.edu>
13

14. Standard
Lower Participation Scenario
Assumes moderate levels of participation
similar to current experience among those
made newly eligible for coverage and little
additional participation among those currently
eligible.
Assumes 57 percent participation among
the newly eligible uninsured and lower
participation across other coverage groups.
Kaiser Commission Medicaid and the Uninsured
H Perlstadt <perlstad@msu.edu>
14

15. Higher Participation
Outreach Scenario
Assumes more robust participation among
those newly eligible (75 percent participation
among the newly eligible that are currently
uninsured and lower participation across other
coverage groups)
Assumes higher participation among those
currently eligible for coverage than in the
standard scenario.
Kaiser Commission Medicaid and the Uninsured
H Perlstadt <perlstad@msu.edu>
15

16. Medicaid Expansion: Michigan
Medicaid Expansion to 133% of FPL,
Impact of Reform on Uninsured Populations:
Increase in Enrollment in 2019 Relative to Baseline
T New Previously % Baseline % Change
Enrollees Uninsured Decrease Medicaid in
Newly Uninsured Enrollment Enrollment
Enrolled Adults
<133%
Lower
Particip 589,965 430,744 50.6% 1,952,376 30.2%
Rate
Higher
Particip 812,818 635,231 74.6% 1,952,376 41.6%
Rate
 Kaiser Commission Medicaid and the Uninsured
H Perlstadt <perlstad@msu.edu>
16

17. Medicaid Expansion: Michigan
Medicaid Expansion to 133% of FPL
Changes in Total Spending 2014-2019
Percent Change in Spending Federal Matching
Rates
State Federal Total Baseline Reform
Lower
Particip 2.0% 21.5% 14.8% 65.8% 69.6%
Rate
Higher
Particip 3.2% 25.6% 17.9% 65.8% 70.1%
Rate
Kaiser Commission Medicaid and the Uninsured
H Perlstadt <perlstad@msu.edu>
17

18. Medicaid Expansion: Michigan
Estimated Impact of Medicaid Expansion Decisions on
Health Centers’ Growth Capacity by 2019
Total Patients
No With Medicaid N New % New Total
Medicaid Medicaid Expansion Patients Patients State
Expansion Expansion Impact Eligible Eligible Population
on New for for Eligible for
Patients Medicaid Medicaid Medicaid
972,900 1,129,500 156,600 76,300 49% 730,000
 Estimates based on state proportion of uninsured children and adults
(potentially) eligible for Medicaid by Urban Institute
Hayes, Shin, and Rosenbaum
 By 2014 between 106,000 and 110,000 currently uninsured adults patients
served by Health Centers in Michigan will be eligible for Medicaid
Bergquist
H Perlstadt <perlstad@msu.edu>
18

19. Building the Exchange: Massachusetts
Tool Kits
Toolkit #1 – Building an Effective Health
Insurance Exchange
Toolkit #2 – Implementing a Successful Public
Outreach and Marketing Campaign
Toolkit #3 – Determining Health Benefit Designs
Toolkit #4 – Mitigating Risk in a State Health
Insurance Exchange
Toolkit #5 – Effective Education, Outreach and
Enrollment for Populations Newly Eligible for
Health Coverage
MAHealthConnector
H Perlstadt <perlstad@msu.edu>
19

20. Building the Exchange: Providers
States need to consider how providers will be
invited to participate in the exchange.
States are required by the ACA to present
provider information on their websites that
allows easy comparison across insurance plans
(Gold-Silver-Bronze).
States may require providers to have necessary
information and to participate in any training
concerning the website.
MAHealthConnector
H Perlstadt <perlstad@msu.edu>
20

21. Building the Exchange: Providers
In Massachusetts first phase focused on
enrolling low-income uninsured residents who
had already been receiving uncompensated care
at hospitals and community health centers.
Many became eligible for fully subsidized health
insurance.
State used database of past uncompensated
care to users to convert them automatically to
public insurance.
MAHealthConnector
H Perlstadt <perlstad@msu.edu>
21

22. Building the Exchange: Website
Informational materials on websites distributed to
community health centers, community based
organizations, school nurses, hospitals
Healthcare providers and patient advocate and
community service agencies
◦ Use website to assist in signing up residents for
coverage.
MAHealthConnector
H Perlstadt <perlstad@msu.edu>
22

23. Outreach and Marketing:
Community Events, Health Fairs etc.
Partners Comcast, CVS, H&R Block
Regular Media—TV, Radio, Print Ads
◦ Less effective as more are insured
Digital Marketing—Browsers Google AdWords
◦ Aimed at uninsured individuals and small
businesses
Digital Marketing—Social Media
◦ Use TweetDeck to track “followers”; respond to
them
◦ MAHealthConnector
H Perlstadt <perlstad@msu.edu>
23

24. Outreach and Marketing:
Federally Facilitated States
Call Centers
◦ By Oct 2013, Center for Medicaid and Medicare
(CMS) will have a call center to answer
questions about open enrollment, eligibility, and
assist in plan comparisons.
Small Business Health Options Program (SHOP)
◦ Employer chooses plan and cost sharing level
◦ Employee enters info on self and dependents
and then chooses plan based on net price after
employer contribution.
CMS Consumer Support CMS Small
Business
H Perlstadt <perlstad@msu.edu>
24

25. Churning: Medicaid & Exchange
Expanded eligibility for Medicaid to <133% FPL
Subsidized health insurance 133% - 400% FPL
People near the cut-off (133%-200%) will have to
shift enrollment as income goes up or down.
Estimate churning for families <200% FPL
◦ within first 6 months 35% will shift once
◦ within first year 50% will shift once; 24% twice
Disrupted coverage. May not even seek insurance
since low income exempts them from mandate,
Increase administrative costs (new enrollments)
Sommers and Rosenbaum Health Affairs
H Perlstadt <perlstad@msu.edu>
25

26. Managing the Churn
Minimum guaranteed eligibility period to avoid
churning due to short term income fluctuations.
Plans dually certified to serve both Medicaid and
exchange enrollees
Better ways to track/ report income changes
Align coverage between Medicaid and exchange
Coordinated marketing between Medicaid,
exchanges and community health centers
Raise Medicaid eligibility to <200% FPL
◦ Sommers and Rosenbaum / Hwang, Rosenbaum, Sommers
H Perlstadt <perlstad@msu.edu>
26

27. Partnering with CHCs
Neighborhood Health Plan (MA carrier) serving
Medicaid and other low-income populations
partnered with Community Health Centers
Currently has 35 percent of market for
unsubsidized individual and small business
products offered through the health exchange.
* * * * * * * * * *
In Michigan County Health Plans
◦ not insurance but provides limited health care
services [doctor visits, lab tests, x-rays and
prescriptions] to Adult Benefits Waiver (ABW)
recipients
H Perlstadt <perlstad@msu.edu>
27

28. Access
Assist low-income people to enter and navigate
through the health care system.
Help them determine
◦ Which plan is most appropriate for them
◦ How the health plan works,
◦ Costs– premiums, co-pays and deductibles
◦ The role of primary care
◦ Which providers are available,
◦ Finding and selecting providers,
◦ Scheduling appointments.
H Perlstadt <perlstad@msu.edu>
28

29. Tips from Oregon
Oregon will expand Medicaid and is establishing an exchange
Considerations include:
Patient navigator piece – The Exchange Corporation is
determining the criteria now for what defines a patient
navigator. FQHCs are monitoring to ensure eligibility workers
fulfill that role.
FQHCs are essential access point - Get training on how
exchanges are set up and how to navigate the portal.
Oregon Primary Care Association is weighing in on the
essential benefits package required by exchange; Workgroup
established to make sure FQHC model is protected in the
exchange.
If the federal government does the exchange, how involved
can we be at this level? Who do they consult with?
Information based on conversation with Mary Falls-Staley, Provider Outreach Coordinator, Office of Client and Community
Services - Office of Healthy Kids, Oregon 29

30. Tips from Massachusetts
 Network of more than 50 CBOs in Massachusetts trained to provide
outreach & enrollment assistance to consumers through rollout,
implementation, and post implementation.
 Without outreach efforts, enrollment wouldn’t have been as successful.
 CBOs were given grants for outreach & enrollment, so it would help to
seek funding. (MCO, state Medicaid agency, private foundations).
 State Medicaid staff didn’t do any enrollments themselves, they would
mail a blank application or advise you to go to an outreach grantee.
 Health Centers & CBOs set up financial counseling office. Do follow up
with patients. Assisting organizations get copies of notices sent to
clients, which is pivotal to make sure folks are informed on enrolling in
the appropriate coverage.
Information based on conversation with Kate L. Bicego, Consumer Education & Enrollment Manager, Health
Care For All, Massachusetts
30

31. Tips from Massachusetts
 Health Care For All is community based advocacy organization -
operates a toll-free helpline that people can use statewide. Operators
are trained in exchange technical assistance, website navigation, and
explaining terminology; offers multiple languages)
 Outreach methods: health fairs were effective way to enroll people
(take help line staff w/laptops to complete applications in real time),
make sure that outreach materials were consumer friendly and in
multiple languages, use faith-based community (people trust them),
ethnic media channels (radio, papers, etc.), outreach and enrollment in
small businesses, local neighborhood stores, barbershops, auto repair
shops, hospital emergency rooms and CHCs
Information based on conversation with Kate L. Bicego, Consumer Education & Enrollment Manager, Health
Care For All, Massachusetts
31

32. References
 Bergquist, P. (2012) Currently Uninsured Health Center Patients That will become
Medicaid Eligible in 2014. Michigan Primary Care Association.
 Hayes, KJ, Shin, P and Rosenbaum, S, (2012) How the Supreme Court’s Medicaid
Decision May Affect Health Centers: An Early Estimate. Policy Research Brief #30.
Geiger Gibson/ RCHN Community Health Foundation Research
Collaborative. George Washington University. Available at:
http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub
_uploads/dhpPublication_9BB1853A-5056-9D20- 3D3DCBB99318306E.pdf
 Hwang, A, Rosenbaum, S and Sommers, BD (2012) Creation Of State Basic Health
Programs Would Lead To 4 Percent Fewer People Churning Between Medicaid
And Exchanges Health Affairs June 2012 31:61314-1320
H Perlstadt <perlstad@msu.edu>
32

33. References
 Kaiser Commission on Medicaid and the Uninsured (2011) Medicaid Coverage
and Spending in Health Reform: National and State-by-State Results for Adults at or
Below 133% of FPL Available at:
http://www.kff.org/healthreform/upload/Medicaid-Coverage- and-
Spending-in-Health-Reform-National-and-State-By-State- Results-for-Adults-at-
or-Below-133-FPL.pdf
 MAHealth Connector Health Reform Toolkit Series: Resources from the
Massachusetts Experience. Available at:
 https://www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e8
8a23468a2dbef6f47d7468a0c?fiShown=default
 CMS Consumer Support: Web and Call Centers Available at:
 http://cciio.cms.gov/resources/files/hie-consumer-support-web-call-center.pdf
 CMS Small Business Health Options Program. Available at:
http://cciio.cms.gov/resources/files/Files2/15_shop.pdf.pdf
 Sommers, BD and Sara Rosenbaum S (2011). Issues In Health Reform: How
Changes In Eligibility May Move Millions Back And Forth Between Medicaid
And Insurance Exchanges Health Affairs February 2011 30:228-236;
H Perlstadt <perlstad@msu.edu>
33

34. Questions?
For further information, please contact:
Harry Perlstadt, PhD, MPH
Medical Sociologist and Professor Emeritus
Michigan State University
517.316.5658
perlstad@msu.edu
Doug Paterson, MPA
Director of Public Policy, MPCA
517.827.0463
dpaterson@mpca.net
Natasha Robinson
CHIPRA Program Specialist, MPCA
517.827.0476
nrobinson@mpca.net