Providers and plans target big push to boost Medicaid enrollment

One of Obamacare's biggest success stories this year was that millions of previously uninsured Americans got coverage through the law's expansion of Medicaid to low-income adults.

Hospitals, insurers, community health centers, navigator organizations and advocacy groups now face the challenge of re-enrolling all those new beneficiaries and signing up millions of additional Americans who qualify for the program. They will make their biggest push during the upcoming open enrollment starting Nov. 15 and lasting three months, though beneficiaries can sign up at any time. It's estimated that as many as 11 million more Americans will join Medicaid by the end of 2015, according to the Congressional Budget Office. This would significantly reduce the burden of uncompensated care on healthcare providers.

As part of the push, enrollment workers hope to sign up low-income adults who qualify under the healthcare reform law's Medicaid expansion as well as poor children and adults who previously were eligible but have not yet signed up. The workers will set up at festivals, street fairs, parks, after-school events, and church services with their name tags and clipboards.

Horizon Blue Cross and Blue Shield of New Jersey is planning to participate in at least 800 community events in the next year. The strategy was successful this year, when the plan enrolled 170,000 new Medicaid members. “There are all these things people are hearing, and it helps to have face-to-face conversation with people they know,” said Len Kudgis, director of marketing for NJ Health, the plan's Medicaid subsidiary.

New York-based Fidelis Care, which has signed up 100,000 members since last October, will be placing self-serve kiosks in shopping malls. “It's about taking any opportunity we can to educate people,” said Pamela Hassen, chief marketing officer at Fidelis. “Sometimes people are in a rush, and may not have time to sit through a presentation.”

But providers and enrollment groups are worried about the need to re-enroll people who signed up for this year. “One of the concerns as we enter year two is, will we be able to retain all the people that came to our plan last year,” said Geoff Bartsh, vice president of state public programs at Minnesota-based Medica, which has enrolled 30,000 new Medicaid members as of January. “We will need to be extra diligent.”

The re-enrollment issue was highlighted as a major concern in research released by the Medicaid and CHIP Payment and Access Commission, which found that there has been a lack of messaging that beneficiaries need to re-enroll in Medicaid each year. “Many do not know they need to renew to keep their coverage,” according to the report. “This is particularly true of first-time enrollees in Medicaid.”

As of October, 27 states and the District of Columbia had expanded Medicaid to low-income adults with incomes up to 138% of the federal poverty level, as allowed by the Patient Protection and Affordable Care Act. Previously, most states had limited Medicaid to pregnant women and children, disabled people and adults with almost no income. Counting both expansion and non-expansion states, nearly 8.7 million people enrolled in Medicaid or the Children's Health Insurance Program between Oct. 1, 2013, and Aug. 31, 2014, increasing total enrollment in the programs by nearly 15%, according to the CMS. Enrollment in states that expanded Medicaid grew by 22%, compared to only 5% in states that did not.

This year's Medicaid enrollment surpassed the Congressional Budget Office's earlier estimate that 7 million would sign up in all of 2014. Despite the successes, much more needs to be done to expand enrollment, including more aggressive communications strategies by states and insurance exchanges about the availability of Medicaid coverage, said Michael Perry, a partner at Perry Undem Research/Communication.

While people can sign up for Medicaid at any time of the year, providers, plans and enrollment groups will take advantage of the publicity surrounding the three-month open enrollment to reach Medicaid-eligible people. The still-unenrolled population includes people who speak limited English, lack health literacy, are homeless, have behavioral and/or substance-abuse issues, or are skeptical about Obamacare, according to Enroll for America data.

At the same time, enrollment workers need to make sure current beneficiaries understand they need to re-enroll in the program to continue coverage. Medicaid enrollees who sign up receive 12 months of coverage and then have to re-enroll. Under the ACA, states are expected to move toward automatic renewals based on use of information about beneficiaries' income, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families. Beneficiaries must be notified to report any income changes that would affect their eligibility.

Meanwhile, advocates expect tough outreach challenges in the 23 non-expansion states, mostly Republican-led states. They also worry that certain racial, ethnic and socio-economic groups such as Asian-Americans—who come from many countries and speak many different languages—will be overlooked by state and federal agencies.

Much of the government outreach and communications so far have been only in English and Spanish. That left community groups and Medicaid plans scrambling to get the word out to Asian-American communities, in which an estimated 1 out of 10 people qualify for Medicaid, said Priscilla Huang, senior director for impact at the Asian & Pacific Islander American Health Forum, an advocacy group based in San Francisco. Huang said there is no indication that the CMS intends to boost outreach or provide additional translated materials to the Asian-American community this time around.

The CMS declined to comment on upcoming outreach strategy related to the ACA and Medicaid.

Private Medicaid managed-care plans have a strong incentive to get the word out, since in many states they provide the coverage for the newly enrolled population. Enrollment of Medicaid and Children's Health Insurance Program beneficiaries in managed care will increase by 13.5 million individuals from 2013 to 2016, according to consulting firm Avalere. States that expanded Medicaid will see the biggest jump in the percentage of enrollees in managed care, from 73% in 2013 to 79%, or 10.2 million additional members in 2016.

Various states have different rules governing Medicaid plans' outreach to consumers. Some, such as Florida, prohibit any communication to non-members to prevent abusive marketing practices. In other states that allow Medicaid plans to engage in marketing, the plans will use print and TV advertisements and employ one-on-one counseling.

Horizon Blue Cross and Blue Shield of New Jersey has five mobile health vans roaming the state, staffed with nurses offering health screenings. This helps build a trust that can persuade people to sign up for Medicaid coverage, Horizon's Kudgis said.

Hospitals and health systems also are heavily engaged in efforts to enroll and re-enroll people in Medicaid. The Medicaid expansion has been credited as a major reason hospitals can expect to see as much as a $5.7 billion decrease in uncompensated-care costs in 2014, according to HHS.

Some providers say they have decided not to work in tandem with Medicaid plans around enrollment. “One thing that frankly didn't prove to be productive last year was working with external agents like health plans,” said Marvin Pember, president of the acute-care division at Universal Health Services. “They had their own approach and specific reasons relative to how they were approaching enrollment that did not sync with what we were trying to do.”

The tension arises from the fact that hospitals employing certified application counselors must be impartial and are not allowed to recommend specific plans.

LifePoint Hospitals also refused to work with Medicaid plans last year, said John Kerndl, senior vice president and operations chief financial officer for the hospital chain. LifePoint said allowing multiple insurers to set up booths in the system's facilities did not fit with its twin objectives of helping people enroll while respecting patients and their confidentiality. “We decided the right approach for our patients was to have hospital-certified application counselors work directly with them on an individual basis,” he said.

The Detroit Medical Center has found it is better to keep enrollment events smaller because some people feel a stigma about signing up for a government program that benefits the poor. “Doing a smaller event at a church, community center or police station is more intimate and personal,” said Conrad Mallett, the hospital's chief administrative officer. For attendees, “it seems like you're exposing yourself less.”

Enrollment groups say more efforts are needed to sign up low-wage workers in service industries who don't have job-based coverage. Recent announcements by Wal-Mart, Target, Home Depot and Trader Joe's that they will no longer offer coverage to part-time employees opens up new venues for outreach opportunities. Many employees at these companies are eligible for Medicaid based on their incomes.

“The (retail) industry may now be an opportunity to raise awareness on the national level,” said Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation.

A challenge even in states that did expand Medicaid is that consumers may have a negative image of Medicaid because of political rhetoric vilifying the program as part of Obamacare. So navigators and other enrollment groups have developed creative ways to promote enrollment. Community health centers in Kentucky have focused on getting people to go to the state's popular Kynect exchange website, knowing that many would qualify for Medicaid, said Lindsay Nelson, coordinator of community development and outreach at the Kentucky Primary Care Association.

Community health centers in West Virginia have used a similar approach. The state significantly exceeded the projected number of Medicaid enrollees. “People want health insurance, and enrollment was promoted as just that—insurance—and not stereotyped as 'Obamacare,' ” said Louise Reese, CEO of the West Virginia Primary Care Association.

Follow Virgil Dickson on Twitter: @MHVDickson