By Jessica Kendall and Jennifer Sullivan | September 2012
Starting in 2014, millions of Americans will become eligible for health coverage offered through health insurance exchanges and through Medicaid, which will dramatically alter the landscape for health centers. Health centers have long played a crucial role in providing affordable, high-quality, community-based care to vulnerable populations. Based on interviews with staff from health centers and primary care associations in four states (Arizona, Michigan, Texas, and Washington), this piece and its companion, “Best Practices in Outreach and Enrollment for Health Centers,” highlight the crucial role health centers play in outreach and enrollment and the best practices they can implement as health coverage opportunities are expanded.
As a result of the Affordable Care Act, all states will have the opportunity to expand Medicaid coverage with generous federal financial support, and a health insurance exchange will exist in every state (run by the state, the federal government, or a partnership between the two). The majority of people who are uninsured will become eligible for some form of coverage.1
Health centers will play a critical role in making sure that the uninsured patients they serve, as well as the new patients who come through their doors in 2014 and beyond, can connect to the new coverage options. Doing so will help their patients get the health coverage they need, and it will bring in additional funding to support health centers’ work.
Health Centers and Enrollment: A Natural Link
Ensuring that the uninsured learn about the coverage that will be available to them, believe that the new forms of coverage are right for them, and take the necessary steps to enroll in coverage will take a great deal of work. Recent research funded by CVS Caremark found that 78 percent of those who are likely to be eligible for coverage through a health insurance exchange had never heard of the term.2 Once the term was explained, 60 percent said that they expected they would need help with learning how to enroll in coverage through an exchange. Research in three states on those who are likely to be newly eligible for Medicaid found a similar lack of awareness among this group: People do not know or expect that they will ever qualify for Medicaid, and they perceive the enrollment process to be daunting.3
People who become newly eligible for coverage will need to hear about their options from trusted messengers who can guide them through the enrollment process, from learning about coverage to getting help with the application to enrolling in a health plan. Health centers are one of the most logical partners in any enrollment effort, since they already provide health services to such a large portion of the uninsured. Consumers trust health centers with their health care, so trusting them to provide assistance with getting health coverage is a natural fit. In fact, research suggests that health care settings are one of the most popular places people would like to go for enrollment help.4
Health centers’ current role in promoting enrollment takes many forms, including providing access to traditional outstationed eligibility workers, using technology to maintain strong connections with key populations, and/or training staff to conduct outreach and serve as application assisters.5 Health centers can also serve as “qualified entities” that are allowed to determine whether a child or a pregnant woman is temporarily eligible for Medicaid or the Children’s Health Insurance Program (CHIP) while a full application is being processed. This opportunity will be expanded in 2014, when states will have the option to allow presumptive eligibility for anyone who qualifies for Medicaid because of their income.6
Under the Affordable Care Act, states are required to use a simple, streamlined application process for Medicaid, CHIP, and coverage through health insurance exchanges starting with open enrollment in 2013. They will also need to use a simple, streamlined renewal process for all of these programs (regardless of whether or not the state expands Medicaid). However, these simplifications will not diminish health centers’ important role in making sure that people get enrolled and stay enrolled. Many enrollees will need special assistance with the renewal process to ensure that they keep their coverage for as long as they remain eligible. In particular, lower-income individuals experience more frequent fluctuations in income, which can cause changes in eligibility, potentially resulting in bigger gaps in coverage.7 Health centers’ efforts to enroll people should be coupled with strategies to ensure that people retain coverage over time.
Enrollment and the Bottom Line
Heading into 2014, health centers’ participation in outreach and enrollment will be absolutely critical. Not only is it part of health centers’ mission to connect their patients to health coverage, it also makes good business sense. Health centers are reimbursed for the services they provide at a higher rate if a patient is enrolled in Medicaid than if the patient is uninsured and paying on a sliding scale.8 And although reimbursement rates for patients who will be enrolled in coverage through health insurance exchanges have not yet been determined, the Affordable Care Act suggests that these rates will be at least equal to the rates for Medicaid enrollees.9
The per-patient revenues that health centers collect is much higher for patients enrolled in Medicaid than it is for those paying on a sliding scale (who are uninsured). Table 1 (on pages 6 and 7 of the PDF) shows per-patient revenues for Medicaid compared to sliding scale patients in each state. Differences vary by state, but on average, health centers collected nearly $500 more per Medicaid patient in 2011 than they did for each sliding scale patient. The lower per-patient revenues for sliding scale patients are to be expected. Patients who pay on a sliding scale and whose incomes fall below the federal poverty level ($11,070 for an individual in 2012) are not required to pay more than a nominal amount, and those with incomes between 100 and 200 percent of poverty (between $11,070 and $22,340 for an individual in 2012) still may not be able to afford to pay very much. Many of these individuals will become eligible for Medicaid in 2014, which creates the opportunity for a significant financial boost for health centers across the country.
Table 2 (on pages 8 and 9 of the PDF) shows the number of uninsured patients who were served by health centers in each state in 2011, as well as the percentage of health center patients who were uninsured. Nationally, 36.5 percent of the patients that health centers served in 2011 were uninsured. A significant number of these patients will likely be eligible for Medicaid or for exchange coverage beginning in 2014.10 The more patients who are successfully enrolled in coverage, the better the financial outlook for health centers. For example, the Michigan Primary Care Association estimates that health centers in Michigan could see up to $47.7 million in additional reimbursement if all the patients who will likely be eligible for Medicaid in 2014 are enrolled.11
Maximizing coverage among eligible patients will be particularly important in future years, since research suggests that, as coverage is expanded, demand for health center services will grow.12 Getting eligible people enrolled will allow health centers to continue to serve those who are ineligible for coverage and expand services for those who need them most.
Health centers and primary care associations both have a vested interest in reaching out to people who will be newly eligible in 2014 and helping them enroll in coverage. This is consistent with their mission, and it is essential to their bottom line. Around the country, health centers are already doing this important work, and there are numerous lessons to be learned from groups that have been actively reaching out to and enrolling people in existing programs. By streamlining internal systems, using innovative technology, and coordinating outreach activities now, health centers will be better prepared to reach and serve the millions of newly eligible people in 2014.
This piece was written by Jessica Kendall, Director of Outreach, and Jennifer Sullivan, Director of the Best Practices Institute. Assistance was provided by Rachel Klein, Executive Director, Enroll America.
The authors wish to thank the following individuals for their input and guidance:
- Tara McCollum, Plese Arizona Association of Community Health Centers
- Phillip Bergquist and Natasha Robinson, Michigan Primary Care Association
- Dawn McKinney, Robert Kidney, and DaShawn Groves, National Association of Community Health Centers
- Jana Blasi, Texas Association of Community Health Ceners
- Rhonda Hauff and Annette Rodriguez, Yakima Valley Neighborhood Health Services
Enroll America thanks Families USA for their editorial and design support in the production of this brief.
1 In most states, Medicaid will be available for people with annual incomes up to 138 percent of the federal poverty level ($15,415 for an individual and $31,809 for a family of four). People with incomes higher than this will be eligible to purchase health coverage through health insurance exchanges. Those with incomes between 138 and 400 percent of poverty will qualify for tax credits to help offset the cost of their premiums. A health insurance exchange will exist in every state. However, some states may not expand Medicaid, as the Supreme Court ruled that the Secretary of Health and Human Services is prohibited from withholding federal financial assistance for Medicaid in states that do not expand coverage.
2 CVS Caremark, CVS Caremark Research Finds 78 Percent of Consumers Who Qualify for Health Care Reform Subsidies Never Heard of State Insurance Exchanges (Woonsocket, RI: CVS Caremark, June 2012), available online at http://info.cvscaremark.com/newsroom/press-releases/cvs-caremarkresearch- finds-78-percent-consumers-who-qualify-health-care-ref.
3 Lake Research Partners, Preparing for 2014: Findings from Research with Lower-Income Adults in Three States (Washington: Robert Wood Johnson Foundation, June 2012), available online at http://www. rwjf.org/files/research/74456fullreport.pdf.
5 The degree to which outstationed eligibility workers are present in health centers varies significantly by state.
6 Patient Protection and Affordable Care Act, Public Law 111-148 (March 23, 2010), as modified by the Health Care and Education Reconciliation Act of 2010, Public Law 111-152 (March 30, 2010), Title 2, Subtitle C, Section 2202.
7 Benjamin D. Sommers and Sara Rosenbaum, “Issues in Health Reform: How Changes in Eligibility May Move Millions Back and Forth between Medicaid and Insurance Exchanges,” Health Affairs 30, no. 2 (2011): 228-235.
8 National Association of Community Health Centers, FQHC Prospective Payment System: Essential to the Health Center Model (Washington: National Association of Community Health Centers), available online at http://www.nachc.org/client//Health%20Center%20PPS%20Fact%20Sheet_final. pdf, accessed on July 27, 2012.
9 National Association of Community Health Centers, Health Centers and Health Care Reform: Payment and Participation (Washington: National Association of Community Health Centers, April 2010), available online at http://www.nachc.com/client/Health%20Reform%20Fact%20Sheet%20-%20 Payment%20%20Participation.pdf.
10 Eligibility is based on a number of factors in addition to income, including citizenship/ immigration status.
11 The Michigan Primary Care Association generated this estimate based on data from the Uniform Data System. They examined the populations that health centers in the state currently serve and estimated the number of people who have incomes below 138 percent of the federal poverty level, then multiplied that number by the state average revenue per visit and the average number of visits per patient per year.
12 Leighton Ku, Emily Jones, Brad Finnegan, Peter Shin, and Sara Rosenbaum, How Is the Primary Care Safety Net Faring in Massachusetts? Community Health Centers in the Midst of Health Reform (Washington: Kaiser Commission on Medicaid and the Uninsured, March 2009), available online at http://www.kff.org/healthreform/upload/7878.pdf.