Enrollment and Beyond
ACA Efforts and Implications in California
Webinar
Presented by
AcademyHealth and
The Center for the Study of Social Policy
February 13, 2013
Welcome!

Gerry Fairbrother, PhD
– Senior Scholar AcademyHealth

2
Webinar sponsored by AcademyHealth
and the Center for the Study of Social
Policy
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Overview and Purpose


Grant from The California
Endowment
Products
– Four Issue Briefs that
focused on eligibility and
enrollment

Now we want to look
beyond enrollment
www.cssp.org
www.academyhealth.org
6
Webinar Objectives

7
Showcase California’s efforts around
enrollment and delivery system reform

Describe how ACA implementation comes
together at the local level

Draw lessons for other states on enrollment
and delivery system changes related to the
implementation of ACA
Agenda

Tara Trudnak, Ph.D, Senior Research Manager at
AcademyHealth
– Overall discussion of the eligibility and enrollment under the
ACA

Richard Figueroa, M.B.A, Director of Prevention
and the Affordable Care Act for The California
Endowment
– Discuss efforts to enroll people in the Exchange, what is
happening in California with implementing ACA, plans and
efforts for enrollment and delivery of care.
8
Agenda

Erica Murray, M.P.A, Senior Vice President of the
California Association of Public Hospitals and
Health Systems (CAPH)
– Discuss delivery system response to anticipated influx of
patients in the public hospital system

Alex Briscoe, Director of Health and Public Health
for Alameda County, CA
– Discuss local county perspective, county level decisions,
enrollment efforts and delivery system changes at local level

9
Questions and Discussion
The ACA, Eligibility and
Enrollment
Tara Trudnak, PhD, MPH
AcademyHealth
ELIGIBILITY RULES UNDER
THE ACA
11
How Does Eligibility Change
Under the ACA?

Two major changes
– All citizens and legal residents will be eligible
for coverage through some program
• Issue is finding the appropriate program and level
of subsidy
– The income eligibility thresholds will be
determined through Modified Adjust Gross
Income (MAGI)
12
MAGI Based Eligibility Rules

Based on income, not income plus
assets.
– Intended to be simpler
– Determine household composition based
on number of tax dependents
• This may shrink household size for some,
especially split custody
– Some individuals will not be eligible for the
MAGI program and will be screened using
the old rules.
13
Eligibility Framework Under the ACA

Three main categories for of publicly subsidized coverage
under ACA
1. Medicaid/Medi-Cal will be expanded for those up to age 65 with
income up to 133% (138%) FPL
2. State CHIP/Healthy Families- covers children whose family’s
incomes is above 133% (138%) FPL up to 400% FPL
• In CA, transitioning Healthy Families into Medi-Cal
3. Subsidized coverage via the State Health Insurance Exchange
• California was the first state in the nation to create an
independent Health Insurance Exchange.
• Coverage for 133% (138%) to 400% FPL (subsidy declines as
income increases)
14
State Exchange Decisions
(as of Jan 4, 2013)
15
Figure taken from Kaiser Family Foundation Statehealthfacts.org
Employer Sponsored Insurance

Employer Sponsored Insurance
– The ACA includes both additional requirements
and incentives (tax credits)
• Pay or Play- medium to large employers must offer
health insurance to full-time workers or pay a penalty
• Federal small business tax credits- available to
small employers with ≤ 25 employees and average
annual wages of < $50,000
• Small Business Health options Program (SHOP)for businesses with up to 100 employees.
16
ENROLLMENT PROCESS IN
CALIFORNIA
17
No Wrong Door
Consumers may apply using four mechanisms
Figure taken from “The California Health Board Exchange: Design Options” discussed at the September 27,
2011 California Health Insurance Exchange Board Meeting
18
Systems put into Place to Determine
Eligibility and Facilitate Enrollment

19
California Healthcare Eligibility,
Enrollment and Retention System
(Cal-HEERS)
Key Functions of Cal-HEERS





Single rules engine for MAGI‐related eligibility
determination
Coordination with county Statewide
Automated Welfare System (SAWS) systems
for non‐MAGI eligibility determination
Single application
On‐line verification
Support for selecting among offered health
plans
Source: Kulkarni (2006) The Guide to Medi-Cal Programs Third edition.2 and Aid Codes Master
Chart , March 20123
20
Key Functions of Cal-HEERS


Functionality for
– plan management, including certification of
issuers
– financial management, including data
collection and accounting processes
– consumer assistance online, over the phone,
and by mail
On‐line support for service and financial
transactions for those assisting in enrolling
consumers (e.g. Navigators or Agents)
Source: Kulkarni (2006) The Guide to Medi-Cal Programs Third edition.2 and Aid Codes Master
Chart , March 20123
21
Navigators

The ACA requires states to establish
navigators to help individuals and small
businesses with enrollment

The Navigator program can build upon the
current public and private third party assistor
systems.
– County eligibility workers
– Certified application assisters network
– The broker/agent community
22
How it all comes together

Eligibility and Enrollment is intended to be
streamlined and easier but it is unfamiliar
territory
– How will this work for complex families?
– Will the enrollment engine facilitate enrollment
into other welfare based programs?
– What are states doing beyond enrollment?
– How will delivery systems accommodate?
– How does this all come together at the local
level?
23
California’s Implementation of
the ACA
Richard Figueroa, M.B.A,
The California Endowment
California Leading on Health Reform

California needs to maximize the benefit—our
health system needs all the help it can get

California leads, and can show the way among
states with significant uninsured populations…
25
Fulfilling the Promise:
California 2010-11 Legislation
–
Created a Health Benefits Exchange (now called Covered California) AB 1602 (Perez)
& SB 900 (Alquist/Steinberg)
–
–
No Turn-Downs for Children with Medical Conditions: AB 2244 (Feuer)
Established Public Premium Rate Review: SB 1163 (Leno)
–
Created Pre-Existing Condition Insurance Program: SB 227 (Alquist) and AB 1887
(Villines)
–
State/Federal Conformity including regulating rescissions, dependent coverage up to age
26, no cost-sharing for preventive care: AB 2345 and 2470 (De La Torre), SB 1088 (Price)
–
“No wrong door” philosophy for signing up Californians for coverage: AB 1296 (Bonilla)
–
Consumer Assistance: AB 922 (Monning) enhances & expands the Office of Patient
Advocate
–
Medical Loss Ratio: SB 51(Alquist) allows state regulators to enforce new federal
standards to ensuring premiums dollars go to patient care, not administration and profit
–
Maternity Care: AB 210 (Hernandez)/SB 222 (Evans) mandated maternity services as a
basic benefit by July 2012.
26
Fulfilling the Promise:
California 2012 Legislation
– Instituted new consumer protections and insurance
oversight to align with federal law:
• Essential Health Benefits: AB 1453 (Monning) / SB 951
(Hernandez)—set a minimum standard for health plans
(equivalent to a Kaiser small employer HMO plan), so consumers
have more confidence that their coverage is comprehensive.
• Small Employer Health Market Reforms: AB 1083
(Monning) prevents small businesses from seeing spikes in
insurance premiums if their workers get sick.
• Notice of Coverage Options During Life Changes: AB 792
(Bonilla) requires that consumers are informed of their coverage
options in the new Exchange when losing coverage--such as
during a job change, divorce, adoption, and other circumstances.
27
Reform is Real

Californians are experiencing the benefits already.
– 16,000 “uninsurable” Californians are enrolled in the Pre-Existing Condition
Insurance Program for those denied coverage due to pre-existing conditions.
– Over 500,000 Californians are enrolled in coverage through the Low Income
Health Program (LIHP) in 51 counties, which serves as bridge coverage for the
low-income uninsured who will qualify for Medi-Cal in 2014.
– 355,927 young adults in California have coverage who might otherwise have
become uninsured, since they are covered by their parents’ insurance.
– 8,978,000 insured Californians gained new consumer protections, including
Medical Loss Ratio requirements that require insurance companies to spend
more premium dollars on medical health care. 1.9 million California residents
received $74 million in rebates from insurance companies who did not meet
these minimums.
– California consumers saved over $100 million dollars in savings from rate hikes
that were retracted, reduced, or withdrawn due to rate review.
– 319,429 California seniors in Medicare saved $171,983,735 in prescription drug
costs, an average of over $500 a patient facing the “drug donut hole.”
– Over 12 million Californians no longer have a lifetime limit on their health
insurance plan.
– Millions are receiving preventive care without a copayment.
28
HEALTH REFORM
WHAT’S LEFT TO BE
DONE IN THE 2013
LEGISLATIVE &
SPECIAL SESSIONS
29
2013 & Special Session Agendas:
Ensuring Californians Get Coverage:

Eligibility and enrollment
–
2014 Medi-Cal Expansion:
•
•
•
Medicaid Benchmark Benefits
Eligibility and Enrollment Rules
Continuation of Current State Programs: FamilyPACT, EWC,
PRUCOL, etc

Individual Market Health Insurance Reform

Cost Sharing Limits

Affordability for Lower-Income Populations (“Bridge” Plans)
30
“Aim High” and Plan for Uncertainty
Exchange Subsidized & Unsubsidized Enrollment Projection Profile and Growth
2,500,000
2,000,000
1,500,000
1,000,000
500,000
Jan-14
Jan-15
Jan-16
Low / Slow
Low / Slow
Low
Base
Enhanced
Jan-14
150,000
240,000
300,000
430,000
Jan-15
490,000
780,000
970,000
1,380,000
Jan-17
Low
Jan-16
850,000
1,020,000
1,280,000
1,890,000
Base
Jan-18
Jan-19
Jan-20
Enhanced
Jan-17
1,240,000
1,240,000
1,550,000
2,300,000
Jan-18
1,410,000
1,410,000
1,770,000
2,380,000
Jan-19
1,560,000
1,560,000
1,950,000
2,430,000
Jan-20
1,560,000
1,560,000
1,950,000
2,440,000
Covered California is seeking to enroll as many Californians as possible. Covered California is working to
meet and exceed its goals, while at the same time planning for lower enrollment by developing budgets that
can be adjusted and constantly adjusting its marketing, outreach and operations as needed based on new
information and experience.
31
Target Populations
The primary target population of Covered California’s
marketing and outreach efforts are the 5.3 million
California residents projected to be uninsured or eligible
for tax credit subsidies in 2014:
– 2.6 million who qualify for subsidies and are eligible for
Covered California qualified health plans; and
– 2.7 million who do not qualify for subsidies, but now benefit
from guaranteed coverage and can enroll inside or outside of
Covered California.
32
Grant Funding
$43 million 2013 - 2014:
- $40 million targeting individual consumers who qualify
for Covered California enrollment.
- $3 million targeting small businesses eligible to
provide coverage to employees through the Small
Business Health Options Program (SHOP).
- Does not apply to Medi-Cal (Medicaid) enrollment
33
Outreach and Education Grant
Program
The Grant Program will have distinctive,
independent activities, which leverage
and align with the Statewide Marketing
and Assisters Program strategies that
are implemented.
 $58 dollar fee paid to Assisters for an
enrolled application is separate. Major
roll-out presentation last week.

34
Grant Program Main Goal and
Objectives
Goal: Educate eligible Californians about Covered California and
collect leads for Assisters and the Exchange Service Center who will
perform application assistance.
1. Ensure participation of organizations with trusted relationships
with the uninsured markets that represent the cultural and linguistic
diversity of the state.
2. Deliver a cost-effective program that promotes and maximizes
enrollment.
3. Disseminate clear, accurate and consistent messages to target
audiences that eliminate barriers, increase interest and motivate
consumers and small businesses to enroll into coverage.
35
Eligible Entities
List of Eligible Organization Types
Community or Consumer-focused non-profit organization; Consumer Advocacy, communitybased organization, or faith-based organization
Trade, industry or professional association, labor union, employment sector, Chamber of
Commerce targeting specialty populations
Commercial fishing industry organization, ranching or farming organization
Health Care Provider: such as hospital, provider, clinic or county health department
Community College, University, School, or School Districts
Native American tribe, tribal organization, or urban Native American organization
City Government Agency or Other County Agency
*For-Profit Entities are encouraged to apply as a subcontractor to a collaborative.
36
Outreach and Education Plan Phases
Outreach and
Start
Marketing Phase
Consumer Outreach May 1, 2013
and Education
End
Purpose
June 30, 2013
Raise awareness about the new consumer-friendly
health insurance marketplace.
September 30,
2013
Inform eligible Californians or small businesses that
opportunities for coverage are “coming” in 2014.
Get Ready, Get Set
July 1 , 2013
Enroll!
October 1, 2013 March 31, 2014
Guide consumers or small businesses to their
enrollment options and to shop and compare qualified
health plans.
Deliver the message that the time to enroll has come
and it is easy to apply.
Reinforcement and
Special Enrollment
April 1, 2014
July 31, 2014
Get Ready, Get Set
July 1, 2014
September 30,
2014
Promote enrollment of those who did not enroll during
year one during the Open Enrollment period.
Promote the Special Enrollment period when
consumers experience a change of circumstances
(e.g., marriage, birth, adoption, loss in health care
coverage).
Inform eligible Californians or small businesses of the
opportunities to enroll in coverage during the
upcoming Open Enrollment Period.
Enroll!
October 1, 2013 December 31,
2014
37
Guide consumers or small businesses to their
enrollment options and to shop and compare qualified
health plans.
Deliver the message that the time to enroll has come
and it is easy to apply.
$40 mil. Funding Pools
Funding Pool
Single County
Funding Pool
Multi-County
Funding Pool
Purpose
For Applicants
proposing to
conduct outreach to
target market(s)
located in one
county only.
Target Populations
 One population only
 Two or more
populations
For Applicants proposing
to conduct outreach to
target market(s) located in
two or more counties






Targeted or
Statewide
Funding Pool
38
For Applicants

proposing to

conduct statewide

efforts or
campaigns to target

populations not
defined by
geography.
Estimated Allocation
All uninsured individuals in one
County
Small businesses in
one County
One population only
Two or more
populations
All uninsured individuals
in two or more Counties
Small businesses in two
or more Counties
$25 million
One population only
Two or more
populations
Statewide campaigns to target
populations
Small businesses of
one or more types or
statewide
$15 million
Potential Grant Awards by Region
• Awards based on QHP
uninsured population.
• Maximum award is $1
million; minimum award is
$250,000.
• Less populated counties or
smaller target populations
(those with less than 5,000
estimated enrollment) are
highly encouraged to
participate in multi-county
initiatives and coalitions.
39
Foundations Role in Outreach
40

Providing resources for Medi-Cal
(Medicaid) outreach: assistance
payments and paid media

Partnering with the Exchange on
populations/organizations they could not
reach or fund

Identifying strategies for the remaining
uninsured.
For More Information

CoveredCA.Com

41
HBEX.ca.gov
California’s Public Hospital
Systems and the Road to
Health Care Reform
Erica Murray, M.P.A,
Senior Vice President
California Association of
Public Hospitals & Health Systems
Overview

Who are California’s public hospital
systems?

How are they preparing for health care
reform?

What are the major issues, questions,
challenges and opportunities for safety net
providers?
43
Overview of CAPH/ SNI

CAPH
• Non-profit trade association that represents 19 public hospital
systems throughout the state
• CAPH works to strengthen the capacity of our members
through research, policy and advocacy to provide high quality
care and advance community health

California Health Care Safety Net Institute
• Non-profit affiliate of CAPH which facilitates and encourages
the use of innovative practices throughout public hospital
systems that enhance quality, promote coordinated care and
eliminate health care disparities
44
California’s Public Hospital
Systems
19 Coordinated Systems of Care
• Serve 2.5 million patients annually with preventive, primary,
specialty, pharmacy, emergency and hospitalization services
• Deliver more than 10 million outpatient visits a year, operate
more than half of the state’s top-level trauma centers and almost
half of the burn centers
Provide Care to California’s Underserved Populations
• Two thirds of patients in CA’s public hospitals are either
uninsured or on Medi-Cal
Providers of High Quality Culturally Competent Care
• Serve a patient population that speaks hundreds of languages
45
Preparing for Health Reform
Public hospital systems will serve multiple roles
post health care reform:

Continued role as a safety net provider
• Expect demand for services to increase
• Provider of care to uninsured population

Increased role as a provider of choice
• Newly eligible Medi-Cal population, opportunities within Covered
California

Continued provider of essential community services
• Trauma, burn, medical training
46
Key Elements of
the “Bridge to Reform”
2010 Section 1115 Medicaid waiver, catalyst
for delivery system reform in public
hospital systems, especially through:
• Early coverage expansion for low-income
adults (Low Income Health Program, or LIHP)
• Delivery System Reform Incentive Program
(DSRIP)
47
Low Income Health Program

County-based coverage expansion to low income
adults up to 200% of Federal Poverty Level

Built on 2007-2010 pilot in 10 counties, which
demonstrated reductions in ER use & inpatient days

Benefits are comprehensive, Medicaid-like

Financing: Counties use local resources as the match
to receive federal funds. No State funding

48
Each enrollee is assigned to a medical home – a
county or community clinic, or private physician office
Low Income Health Program
Dr. Reeves,
I wanted to write a short note to let you know what a terrific service the county
is providing to people who can no longer either provide insurance coverage or
cannot afford it.
I lost my job over a year ago and have not found another. Fortunately, my wife
and I found out about the ACE program and enrolled. What a God send!
Through these services we have both received the care we desperately
needed. I am a type one diabetic and could no longer afford my insulin and
supplies. Patient assistance has been tremendously helpful here. I have taken
the classes on Roadmaps and learned a lot, been a diabetic over 30 years. The
people at Las Isles have been kind, caring and professional. I have to say that
I am getting better care now than I did when I had insurance.
In summary, I don’t know what I would have done without these services, been
on the street I suppose. Please continue to provide these services to those
families who have fallen on hard times, they are invaluable to the community!
Sincerely, Michael
49
Delivery System Reform
Incentive Program

Pay for performance based on Triple Aim goals
• Better care, better experience, better outcomes,
including population health

Unprecedented scope and scale
• An “everything all at once” approach
• 21 CA public hospital systems (including 5 UC
hospitals)
• Mix of across-the-board requirements and
individualized targets based on different starting points,
particular needs and challenges
50
Examples of Incentive
Program Projects
•
•
•
•
•
•
•
•
•
51
Expand Primary and Specialty Care Capacity
Increase Training of Primary Care Workforce
Implement Disease Management Registry Functionality
Integrate Physical and Behavioral Health Care
Expand Medical Homes
Expand Chronic Care Management Models
Improve Patient Experience
Reduce Sepsis Mortality
Prevent Central Line Associated Bloodstream Infection
Initial Results





52
A nearly 30,000 increase in the number of
primary care encounters provided
40 additional exam rooms opened
35 additional primary care staff hired
More than 300,000 patients assigned to a
medical home and/or primary care provider
team
Over 1 million patients entered into disease
registry IT systems
Looking Ahead (Again):
Multiple Roles, Big Questions

Continued Role as Safety Net Provider
• 3-4 million remaining uninsured in CA after ACA
• Will coverage be affordable or will this number be higher?

Competitive Providers of Choice
• How can we leverage the gains made through LIHP, DSRIP,
other transformation work to attract and retain newly covered
patients?

Continued Provider of Essential Community
Services
• How can these services be supported with reduced funding?
53
Policies to Support the Safety Net

California Covered
• Essential Community Provider: meaningful inclusion in
provider networks with sufficient rates
• Bridge plans to help with affordability, churning, and
safety net participation

Seamless transitions for LIHP, newly Medi-Cal
eligible patients
• Coordination with Medi-Cal managed care plans

54
Careful monitoring of DSH cuts to ensure that
reductions in funding correspond to reductions in
uncompensated care costs
Enrollment and Beyond an
Alameda County
Perspective
Alex Briscoe, Director of Health
and Public Health for Alameda
County
Agenda

Alameda County

Eligibility, Enrollment, and Retention
- Lessons Learned from LIHP
- County decisions

56
Access/ Delivery System Reform
Alameda County, California
Population, 2010: 1,510,271 (CA: 37,253,956)
Land area, 2010 (square miles): 738 (CA: 155,959)
Persons per square mile, 2010: 2,046 (CA: 239)
College graduates, persons 25 and over, 2010: 40.3% (CA: 30.1%)
Housing units, 2010: 582,549 (CA: 13,680,081)
Homeownership rate, 2010: 53.4% (CA: 55.9%)
Median household income, 2010: $67,169 (CA: $57,708)
57
58
59
60
Who Are the Uninsured?
Ethnicity broken out by percentage
7%
20%
38%
13%
22%
61
Latino
Asian
African American
Caucasian
Other
Alameda County Coverage Data
Currently enrolled in public health coverage: 325K





Medi-Cal Only = 169,028
CalWORKs MC = 41,928
Foster Care MC = 4,985
HealthPAC = 89,805**
Healthy Families = 20,635
**Breakout of Health PAC
participants
4,985
41,928
40,708
89,805
**
MCE
6,819
HCCI
169,02
8
62
42,278
20,635
County
The Achilles Heel of Health
Reform…

Eligibility doesn’t mean enrollment.

Enrollment doesn’t mean access.

Access doesn’t mean good health outcomes.
63
Eligibility Doesn’t Mean Enrollment

Experience with Medi-Cal has shown us that eligibility does
not mean enrollment.

Both the application and the renewal processes must be
simplified. While this is a goal of the ACA, we do not yet
know how simplified the process will actually be.


64
The functionality of CalHEERs and it’s ability to interface
with County systems will also have an impact on how many
people get enrolled and enrollment across programs.
Pricing in the Exchange will have major impact locally.
Counties will be left with the cost of people who are eligible
for the exchange, but cannot afford it.
Lessons Learned: Low Income
Health Program

Alameda County has been one of the most successful
counties in achieving high LIHP enrollment

Keys to success:
– Long-standing commitment to coverage in county.
– Web-based eligibility and enrollment system.
– Network of applications assistors. Alameda utilizes a
network of over 300 application assistors throughout
Alameda County. Assistors are employees of the Safety
Net clinics and hospital. The connection that the assistors
have with patients is critical to both enrollment and
retention.
65
Enrollment post January 2014

Maximizing enrollment and retention in 2014 will
require:
– Maintaining large and strong network of application assistors in
the community.
– Simplified eligibility and retention requirements
– Improved data sharing across systems- no wrong door (SAWs,
CalHEERs, Local systems/ MAGI Medi-Cal, non-MAGI MediCal, Exchange, County Indigent)

Barriers
– Open enrollment
– Multiple systems
– Existing labor agreements and California’s interpretations of
Title 19
66
Enrollment Does Not Mean Access

Even if we are successful with enrollment, access
remains an issue

Shortage of primary care providers:
– Increase salaries for primary care
– New delivery systems
– Payment reform
67
Access in Alameda County

After January 2014 there will still be a population of
approximately 60,000 residually uninsured.

The County will need to maintain funding.

Alameda County will need to continue to provide support
for the population
– Maintaining the health of safety net organizations.
– Determining the scope of services for the residually uninsured
– Systems reform
• Portals
• Behavioral Health Integration
68
Who Goes Where?
This is another way to break down the impact in
Alameda County….
Employer and
MediCaid
Expansion
0% FPL
56,000 newly eligible
The Exchange
133% FPL
107,000 eligible for subsidy
Approximately 60,000 Alameda County Residents
will not be insured, even under the most optimistic
implementation scenario
69
Individual
Mandate
400% FPL
35,000 required to
purchase or their
employer will be required
to purchase
Access Doesn’t Mean Health Outcomes
70
Questions and Discussion
Submitting Questions
To submit a question:
1.
2.
72
Click in the Q&A
box on the left side
of your screen
Type your question
into the dialog box
and click the Send
button
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Please take a moment to fill out the
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73