Behavioral Health Needs of
the Newly Eligible and
Enrollment Assistance Best
Practices
Kevin Malone
Office of Policy, Planning, and Innovation
Substance Abuse and Mental Health Services Administration
THE BEHAVIORAL HEALTH ENROLLMENT
CHALLENGE
•
•
•
•
•
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Uninsured populations have disproportionate rates of
behavioral health conditions
Symptoms and income/housing volatility cause challenges for
accessing and maintaining coverage
Periods of un-insurance lead to increased inpatient and
emergency visits, longer lengths of inpatient stays, poorer
psychiatric outcomes, and higher healthcare expenditures
Behavioral health providers have limited enrollment
experience
Traditional outreach workers have limited training on working
with individuals with behavioral health conditions
Behavioral health conditions cross demographic boundaries
DATA SOURCES AND METHODS
• National Survey of Drug Use and Health
• Sponsored by SAMHSA
• National and state estimates on prevalence of
behavioral health conditions and treatment
• 2008 – 2010 data
• 70,000 interviews per year
• American Community Survey from
Census
• Literature Review
THE UNINSURED
• 37.9 million uninsured <400% FPL
(2010 NSDUH)
• 19.9 Million ACA Exchange eligible*
• 18 Million ACA Medicaid eligible
• 11.019 million (29%) currently
uninsured <400% FPL have
behavioral health conditions
(2010 NSDUH)
*Eligible for premium tax credits and not eligible for Medicaid
PREVALENCE OF BEHAVIORAL HEALTH
CONDITIONS AMONG MEDICAID EXPANSION
POPULATION
18.0%
16.0%
14.9%
14.0%
14.2%
12.0%
10.0%
8.0%
7.0%
6.0%
4.0%
Percent with a Serious
Mental Illness (1,283,000)
CI: 6.3%-7.7%
Percent with Serious
Psychological Distress
(2,731,742)
CI: 14.0%-15.9%
CI = Confidence Interval
Sources: 2008 – 2010 National Survey of Drug Use and Health
2010 American Community Survey
Percent with a Substance
Use Disorder (2,603,405)
CI: 13.2%-15.2%
PREVALENCE OF BEHAVIORAL HEALTH
CONDITIONS AMONG EXCHANGE
POPULATION
18.0%
16.0%
14.6%
14.0%
13.3%
12.0%
10.0%
8.0%
6.0%
6.0%
4.0%
Percent with a Serious Mental
Illness (1,195,600)
CI: 5.5%-6.6%
Percent with Serious
Psychological Distress
(2,650,247)
CI: 12.4%-14.2%
CI = Confidence Interval
Sources: 2008 – 2010 National Survey of Drug Use and Health
2010 American Community Survey
Percent with a Substance Use
Disorder (2,909,294)
CI: 13.7%-15.6%
CHARACTERISTICS OF UNINSURED WITH SMI IN
MEDICAID EXPANSION POPULATION
Female
64%
Age 18-34
53%
Race/Ethnicity
67%
Non-Hispanic White
12%
Non-Hispanic Black
4%
Non-Hispanic Other
17%
Hispanic
EDUCATION
31%
< High School
39%
High School Graduate
30%
College
Population Density
42%
CBSA: 1 Million +
33%
CBSA: < 1 Million
25%
Non-CBSA
Overall Health
9%
Excellent
22%
Very Good
31%
Good
37%
Fair/Poor
CBSA: Core Based Statistical
Area
Typical person with SMI in Medicaid
expansion population is:
• Female
• White or Hispanic
• HS education or less
• Living in a metropolitan area
• Rating her health as fair or poor
CHARACTERISTICS OF UNINSURED WITH SUD IN
MEDICAID EXPANSION POPULATION
Male
73%
Age 18-34
63%
Race/Ethnicity
Non-Hispanic White
Non-Hispanic Black
Non-Hispanic Other
Hispanic
EDUCATION
< High School
51%
18%
3%
28%
43%
32%
25%
High School Graduate
College
Population Density
47%
CBSA: 1 Million +
32%
CBSA: < 1 Million
20%
Non-CBSA
Overall Health
13%
Excellent
28%
Very Good
36%
Good
23%
Fair/Poor
CBSA: Core Based Statistical Area
Typical person with SUD in Medicaid
expansion population is:
• Male
• 18-34 years old
• White or Hispanic
• HS education or less
• Living in a metropolitan area
• Rating his health as good/very good
CHARACTERISTICS OF UNINSURED WITH SMI IN
EXCHANGE POPULATION
Female
60%
Age 18-34
59%
Race/Ethnicity
74%
Non-Hispanic White
9%
Non-Hispanic Black
4%
Non-Hispanic Other
13%
Hispanic
EDUCATION
17%
< High School
40%
High School Graduate
43%
College
Population Density
52%
CBSA: 1 Million +
29%
CBSA: < 1 Million
19%
Non-CBSA
Overall Health
12%
Excellent
33%
Very Good
32%
Good
23%
Fair/Poor
CBSA: Core Based Statistical
Area
Typical person with SMI in exchange
population is:
• Female
• 18-34 years old
• White or Hispanic
• HS education or less
• Living in a metropolitan area
• Rating her health as good or very
good
CHARACTERISTICS OF UNINSURED WITH SUD
IN EXCHANGE POPULATION
Male
73%
Age 18-34
71%
Race/Ethnicity
60%
Non-Hispanic White
12%
Non-Hispanic Black
4%
Non-Hispanic Other
23%
Hispanic
EDUCATION
24%
< High School
40%
High School Graduate
36%
College
Population Density
56%
CBSA: 1 Million +
28%
CBSA: < 1 Million
15%
Non-CBSA
Overall Health
15%
Excellent
40%
Very Good
31%
Good
13%
Fair/Poor
CBSA: Core Based Statistical
Area
Typical person with SUD in exchange
population is:
• Male
• 18-34 years old
• White or Hispanic
• HS education or less
• Living in a metropolitan area
• Rating his health as good or very good
STATE PREVALENCE OF SMI AMONG MEDICAID
EXPANSION POPULATION
40%
35%
30%
25%
20%
15%
10%
5%
*
0%
l
Line indicates 95% confidence interval
* Suppressed for imprecision
STATE PREVALENCE OF SUD AMONG MEDICAID
EXPANSION POPULATION
60%
50%
40%
30%
20%
10%
0%
l Line indicates 95% confidence interval
STATE PREVALENCE OF SMI AMONG EXCHANGE
POPULATION
25%
20%
15%
10%
5%
0%
l Line indicates 95% confidence interval
STATE PREVALENCE OF SUD AMONG
EXCHANGE POPULATION
40%
35%
30%
25%
20%
15%
10%
5%
0%
l Line indicates 95% confidence interval
STATE-PROFILES
• State-by-state profiles of prevalence of
behavioral health conditions among
newly eligible vs. current Medicaid
enrollees
• Demographic profiles
• National comparisons
• For profiles and more, please visit:
http://www.samhsa.gov/healthReform/
EFFECTIVE PRACTICES TO ENCOURAGE
ENROLLMENT/REENROLLMENT
• Key research findings
• Types of organizations with demonstrated
success
• Specific core competencies of successful
outreach workers
• Effective messages/mechanisms
• Key eligibility/enrollment process fail points
• Practices to minimize adverse impact of churn
• Role of providers
KEY RESEARCH FINDINGS
• Individuals require the same types of outreach
and enrollment services as “hard to reach
populations” but need more intensity and a
longer duration of services
• Behavioral health providers have unique
access to uninsured consumers with
behavioral health conditions
• States can identify those likely to be at risk of
administrative disenrollment/ reenrollment and
target enrollment assistance effectively
ORGANIZATIONS WITH DEMONSTRATED
SUCCESS RE: ENROLLMENT
• Health providers, including behavioral health
providers
• Legal Services/Justice Centers
• Shelter and Homeless Outreach Groups
• Minority Interest Groups
• Advocacy Groups (health & behavioral
health)
• Family/Peer Support Groups
CORE COMPETENCIES OF SUCCESSFUL
OUTREACH WORKERS
• Solid understanding of eligibility requirements,
forms, and appeal mechanisms (ongoing
training/technical assistance)
• Comfort in working in non-traditional settings
(clinics, shelters, etc.) and non-traditional hours
(nights/weekends)
• Cultural/linguistic competence reflective of those to
be reached
• Easily accessible for follow-up – in person, by phone,
email
• Ability to connect folks with other needed services
(housing and primary care identified as two critical
services)
EFFECTIVE MESSAGES/MECHANISMS
• Messages must be simple and clear – “Open this
Envelope, Stay Covered”
• Consistent messages across populations adapted
for particular audiences (e.g. messages that appeal
to woman with children won’t reach single males)
• Messaging must be done over a prolonged period of
time to be effective
• Think outside the box – use of pizza boxes as a way
to reach 19-26 yr. olds
• Use of broad based “access” coalitions to agree on
key messages and hone outreach strategies
ELIGIBILITY/ENROLLMENT PROCESS
FAIL POINTS
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Limited hours of operations
Poor customer service
Complexity of communications
Comprehension difficulties especially about
the consequences of changes in enrollment
status
ELIGIBILITY/ENROLLMENT PROCESS
FAIL POINTS
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Housing instability (failure to receive notices)
Income volatility
Difficulty assembling support documents
Repeated hospitalizations or program
changes
• Lack of a consistent primary care
provider/medical home
REDUCING AND ADDRESSING CHURN
• Housing instability: Provide recertification forms to
social service staff in housing systems
• Proactive: Identifying heavy users and targeted
outreach work prior to disenrollment
• Used “eligibility representative designees” to help
monitor coverage status and to help rapid reenrollment
• Provider involvement in monitoring enrollment
status and assisting in recertification
ROLE OF BEHAVIORAL HEALTH PROVIDERS
• Providers need training on eligibility
determination, enrollment and recertification
assistance
• Effective provider assisted enrollment can
help mitigate impact of churn when it
happens
• Behavioral health providers have unique
access to behavioral health consumers
SAMHSA STRATEGY
• Consumer Enrollment Assistance Subcontracts
• Consumer Assistance
• Outreach/public education
• Enrollment/re-determination assistance
• Plan comparison and selection
• Grievance procedures
• Develop eligibility/enrollment communication materials
• Challenge.gov Projects
• Enrollment marketing campaign for uninsured18-34 yr men
• Innovative eligibility redetermination communication strategies
for population at high risk for churn
• Communication strategy
• Enrollment assistance best practices TA for State BH Leaders
• Provider-assisted enrollment TA
Thank you!
www.samhsa.gov
Kevin Malone
Kevin.malone@samhsa.hhs.gov
240-276-2239