Working with Facilitated Enrollers to Increase Enrollment in New

April 2011
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KEY INFORMATION:
Grant Outcomes Report
Working with Facilitated Enrollers to
Increase Enrollment in New York State’s
Public Health Insurance Programs
I. Executive Summary
GRantEe
Children’s Defense Fund-New York
grant tITLE
Increasing Enrollment and
Retention in New York’s Public
Health Insurance Programs
Dates
December 2007–March 2009
Under this grant, the Children’s Defense Fund-New York (CDF-NY)
grant amount
proposed to increase health insurance enrollment and retention by
$102,691
working in partnership with community-based facilitated enrollers
through a Public Health Insurance Monitoring Project. CDF-NY
expected that this project could ultimately enable tens of thousands of New Yorkers to more easily
enroll in and retain health insurance by creating policies that are streamlined, efficient, and do not
create new barriers. While it is impossible to measure the broad impact of this program on the
ease of enrollment and retention, the program did achieve other expected goals regarding technical
assistance to facilitated enrollers, administrative advocacy, and monitoring enrollment trends.
II. The Problem
At the start of this grant period, the United Hospital Fund estimated that more than 2.3 million New
Yorkers, including 400,000 children, were uninsured. Many of the uninsured were eligible for, but not
enrolled in, public health insurance (1.2 million). A contributing factor to the high number of eligible but
uninsured residents—in New York and other states around the country—is the public insurance system
of eligibility, documentation, enrollment, and renewal policies, which directly impact a family’s ability
to obtain public health insurance.
III. Grant Activities
To address this problem, CDF-NY planned four major activities under this grant:
1.Community monitoring:
•Follow monthly trends in enrollment through public health insurance enrollment data (i.e.,
Medicaid, Child Health Plus, and Family Health Plus).
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
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•Convene facilitated enrollers to assess the impact of recent public health program policies
on enrollment. (New York State had recently authorized many new policies, including allowing
self-attestation of income and residency at renewal; expansion of Child Health Plus to children
up to 400% of the Federal Poverty Level; presumptive eligibility for children’s enrollment in
Medicaid; and elimination of temporary enrollment in Child Health Plus.) Facilitated enrollers
help public health insurance applicants complete and submit the application for benefits.
CDF-NY planned to meet with facilitated enrollers serving New York City, Westchester, and
Long Island on a bimonthly basis to identify any emerging issues from the field that negatively
affect enrollment, retention, and program utilization. CDF-NY would develop recommendations
to address any issues identified as a result of these meetings.
•Review health policies and procedures released by the New York State Department of Health
(NYSDOH) and the New York City Human Resources Administration (HRA). CDF-NY would help
educate facilitated enrollers in understanding these policies and procedures, and develop
recommendations to address any issues.
2.Administrative advocacy for systemic health policy changes:
•Advocate its recommendations for change with NYSDOH and HRA.
3.Technical support to facilitated enrollers:
•Advocate enhancements for facilitated enroller training offered by NYSDOH. CDF-NY would
begin by surveying frontline facilitated enrollers, quality assurance staff, and project directors to
assess their training needs. Based on findings of the survey, CDF-NY would work with appropriate
consultants, trainers, and NYSDOH to develop the curriculum and deliver the trainings.
4.Develop and disseminate an issue brief that summarizes public health
insurance enrollment trends in 2008.
FUNDING INITIATIVE
In April 2007, New York State Health Foundation (NYSHealth) issued a request for proposals (RFP)
for one-year projects under a major initiative, Expanding Insurance Coverage in New York State, to
support programs that addressed the persistent problem of enrolling 1.2 million New Yorkers who
were eligible for health insurance coverage, but not enrolled. This project aligned with NYSHealth’s
objective of finding practical approaches for simplifying enrollment and making it more efficient
and cost-effective. CDF-NY has an established relationship with facilitated enrollers, which
allowed it to capture stories of system inefficiencies that prevent the system from working as
intended. By highlighting these inefficiencies, the project will eventually help create more rational,
cost-effective, and seamless processes for enrolling the uninsured in health insurance coverage.
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org
Page 3 of 8
CDF-NY planned to evaluate its efforts by surveying facilitated enrollment agency staff on the content,
quality, and actual in-practice use of information presented in trainings. It also planned to continually
review State and local policies, protocols, and administrative directives to track changes that resulted
from CDF-NY’s administrative advocacy. Finally, CDF-NY planned to analyze monthly enrollment
in public insurance programs to understand the impact of policy changes. These analyses were
to be incorporated into community monitoring findings to demonstrate the impact that policies have
on access and retention, and ultimately, presented to State and local officials.
Through this work, CDF-NY hoped to increase enrollment and retention in health insurance for tens
of thousands of New Yorkers. Though an ambitious goal, CDF-NY proposed that the combination of
statistical analysis, community monitoring, and administrative advocacy could be an effective model,
perhaps even replicable in other areas and applicable to other public benefits.
IV. Key Findings
Community Monitoring
CDF-NY compiled and analyzed monthly enrollment data available through NYSDOH. The analysis
is presented in the CDF-NY issue brief, Review of New York State Public Health Insurance Policy
Changes and Enrollment in 2008.1 The analysis shows a total decline of 12,000 children in health
insurance enrollment from July 2007 to July 2008. While Medicaid enrollments in both New York City
and Upstate New York increased by nearly 20,000 children, Child Health Plus declined by more than
31,000 children. CDF-NY believes the elimination of Temporary Enrollment may have had a negative
influence in Child Health Plus enrollment. The implementation of Presumptive Eligibility for Medicaid
was expected to produce positive gains in children’s Medicaid enrollment; however, the data show
that gains to Medicaid did not entirely offset losses to enrollment in Child Health Plus.
Medicaid enrollments increased by approximately 26,000 adults from July 2007 to July 2008, which
was a result of increases in Medicaid rather than Family Health Plus. Three policies may have
influenced adult enrollment: elimination of the requirement to document income and residency at
renewal; increased Medicaid asset level to align with the Family Health Plus asset level; and the new
15-day application submission policy.
CDF-NY partnered with 17 Downstate Facilitated Enrollment Lead Agencies (in New York City,
Westchester, and Long Island) to hold four meetings with facilitated enrollers. These meetings
provided a forum for Lead Agencies to discuss operational challenges with public health insurance
policies. CDF-NY was able to identify real case examples of barriers, allowing it to identify patterns
and propose workarounds.
1
http://www.nyshealthfoundation.org/content/document/detail/1584/
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org
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CDF-NY and Facilitated Enrollment Lead Agencies reviewed all local and State policies governing
public health insurance programs. Because of the technical detail of many of these local and State
policies, CDF-NY served as the technical support to the Facilitated Enrollers by helping them
understand and implement the new policies.
Administrative Advocacy
Using the information gathered through its community monitoring activities, CDF-NY reached out to
the relevant stakeholder group to address administrative barriers to enrollment. CDF-NY advocated
for streamlined recertification processes, reinstatement of Temporary Enrollment, expansion of
presumptive eligibility for children beyond federally qualified health centers, inclusion of a grace period
with the 15-day application submission policy, flexibility regarding the waiting period for Child Health
Plus B enrollment, and some improvements for operational issues at the HRA. In these meetings and
interactions, CDF-NY shared its findings, provided evidence of concrete examples, and advocated for
solutions. For example, an advocacy issue that arose through CDF-NY’s community monitoring work
with the facilitated enrollers concerned health plan
protocols at renewal. Renewal is a process where
no face-to-face interview is required. Some families
still require assistance with renewal, and facilitated
enrollers guide these families through the process;
however, for many working families, meeting with
an individual would be a deterrent for following
through. Health plans are particularly diligent
about working hard to keep families covered and
reach out to beneficiaries months before renewal
deadlines to offer assistance in filling out paperwork
or gathering outstanding documents. CDF-NY
learned from facilitated enrollers that some health
plans were incorrectly telling families that their
coverage would not be renewed if they did not
come to the health plan office or allow a health
plan facilitated enroller make a home visit. After
gathering case examples of this problem, CDFNY reached out to the New York State Coalition of
Prepaid Health Services Plans (PHSP Coalition)
with its concerns. PHSP Coalition, in turn, reached
out to its participating health plans to communicate
the correct renewal process requirements. CDF-NY
is unaware of any further complaints.
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org
Page 5 of 8
Another example of CDF-NY’s administrative advocacy work was its attempt to increase the use
of Presumptive Eligibility for children. CDF-NY met with facilitated enrollers and argued the merits
of linking their enrollers to the federally qualified health centers to help translate this policy into
a positive reality. Facilitated enrollment is inherently competitive among facilitated enrollers. To keep
their enrollment levels at contractual levels, it was challenging to convince facilitated enrollers
to refer out their uninsured-yet-eligible families to other facilitated enrollers, rather than to enroll
the family themselves, and have them wait the 30 days processing timeframe.
Technical Support
CDF-NY surveyed Lead Agency project directors to identify staff training needs. The survey highlighted
the need for training on navigating the managed care system and the appeals process for families
denied coverage. CDF-NY worked with the New York City Managed Care Consumer Assistance
Program to hold a daylong training for Facilitated Enrollers, which was devoted to these two topics.
In a follow-up meeting after the trainings were conducted, CDF-NY sought feedback from the
Facilitated Enrollers on the quality of the trainings and how the information improved their work
with enrolling individuals in coverage. Across the board, the Facilitated Enrollers said they received
valuable training and technical support that they had not received from the State Department of
Health. They reported they were better equipped to advise consumers on how to choose a health plan
and change their plans, and learned under which circumstances they could advise consumers to seek
coverage outside their plan’s network. They also reported a better understanding of when it would
be appropriate to appeal a case versus conducting their own internal administrative advocacy.
Develop and Disseminate an Issue Brief
CDF-NY published this issue brief, Review of New York State Public Health Insurance Policy Changes
and Enrollment in 2008, in February 2009. The issue brief features CDF-NY’s analysis of New York State
health insurance enrollment from July 2007 to July 2008. Incorporating insights from its meetings
with facilitated enrollers, the issue brief reviews several changes to the State’s public health insurance
policies and how they may have influenced enrollment trends during this period of time. These include:
•Child Health Plus expansion;
•the elimination of documentation of income and residency at renewal;
•the implementation of Presumptive Eligibility for children’s Medicaid;
•the elimination of Temporary Enrollment for children in Child Health Plus;
•an increase of Medicaid asset test levels; and
•a new 15-day application submission policy.
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org
Page 6 of 8
The issue brief also makes recommendations
to address issues identified during CDFNY’s meetings with facilitated enrollers,
which could help program policies realize
their full potential. CDF-NY made three
recommendations.
1.Allow for presumptive eligibility
for Medicaid upon application,
regardless of where the child
applies. Presumptive eligibility was limited
to children enrolling in public health insurance
at federally qualified health clinics. CDFNY recommended that children enrolling at
locations other than federally qualified health
centers also be presumptively enrolled in Medicaid. This change would allow children immediate
access to coverage, rather than waiting 30 days for their applications to be processed.
2.Self-attestation of income and residency for renewals. This recommendation
assumes that the State has access to current third-party income and resource data, allowing public
health insurance applicants to truly self-attest to this information and avoids one of the primary
obstacles to renewing coverage. CDF-NY has found that the current lag in the information leads some
public health insurance beneficiaries to lose their coverage upon renewal due to inaccurate third-party
income and resource data.
3. Caveats to the 15-day application submission period. For families that are unable
to obtain eligibility documents (e.g., proof of income, birth certificates, passports) within the 15-day
timeframe, a grace period could be implemented, allowing them to submit outstanding documents
later. Without the grace period, CDF-NY learned that facilitated enrollers were submitting incomplete
applications to meet the 15-day window, which are generally rejected. These applicants generally
must go through the entire application process again when they are able to obtain the necessary
documents, lengthening the processing time and administrative expense.
Overall Outcomes
This program had an ambitious set of expected outcomes. At its core was the expectation that it
could enable tens of thousands of New Yorkers to more easily enroll and retain their coverage by
creating policies that are streamlined, efficient, and do not create new barriers. While it is impossible
to measure the broad impact of this program on the ease of enrollment and retention, the program
did achieve some of its other expected goals. For example, CDF-NY’s community monitoring efforts
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org
Page 7 of 8
and direct work with facilitated enrollers did produce a real-time view of what was happening on
the frontlines of health insurance application and enrollment processes. CDF-NY was able to
document systemic problems, develop case examples, and advocate for widespread changes and
application of better practices. In addition, CDF-NY produced a formal issue brief to document the
potential impact of policy change on monthly enrollment levels, though it was unable to statistically
link these policy changes to enrollment trends.
V. Lessons Learned
Convening facilitated enrollers helped CDF-NY to better understand how recent public health
insurance policy changes were being implemented. In doing so, CDF-NY learned that some changes
were not achieving their intended result and used this on-the-ground information to develop
recommendations to address identified challenges and advocate for their adoption to high-level State
policymakers.
The data analysis identified some potential effects of public health insurance policy changes on
enrollment, but it did not statistically link any of the policies to trends in enrollment. Since the analysis
was more qualitative than quantitative, it did not control for factors other than the new policies
(e.g., economy), which may be driving the enrollment trends.
VI. The Future
As significant new State policies are implemented, including the elimination of the face-to-face
interview, the release of a new Access New York application with a host of new enrollment questions,
and the launch of online renewal in New York City, CDF-NY will continue to monitor enrollment data,
review policies and procedures, and work closely with community-based and health plan facilitated
enrollers to gather information on enrollment and renewal. In addition, monitoring real-life on
the ground enrollment experiences against enrollment data will be critical as the State moves
toward implementing health care reform. These continued efforts will allow CDF-NY to work toward
increasing New Yorkers’ access to health insurance coverage.
Working with Facilitated Enrollers to Increase Enrollment in New York State’s Public Health Insurance Programs
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org
Page 8 of 8
BACKGROUND INFORMATION:
ABOUT THE GRANTEE
Since 1992, the Children’s Defense Fund-New York (CDF-NY) has served as a resource and
partner for children, families, and organizations throughout the tri-state area. CDF-NY is
committed to the health of children and families in New York. Through a range of community
organizing, public education, research and policy analysis, and advocacy work, CDF-NY has
worked since its founding to ensure that New York’s public health insurance programs are
meeting the needs of children and families.
GRANTEE CONTACT
Kinda Serafi
Director of Policy
Children’s Defense Fund-New York
15 Maiden Lane, Suite 1200
New York, NY 10038
Phone: (212) 697-2323
e-mail: kserafi@ cdfny.org
Web address: http://www.cdfny.org
NYSHealth contact
Melissa Seeley
GRANT ID #
1985472
Health Connections To Coverage Campaign:
The Push To Enroll New York’s Uninsured Children In Medicaid And Child Health Plus
Voice:
212-664-7656
FAX:
646-421-6029
Mail:
1385 Broadway, 23rd Floor, New York NY 10018
WEB:
www.NYSHealth.org