Grantmakers for Children, Youth and Families Conference October 10, 2012

1. Partnering with Communities: How Funders can Reach and Enroll Eligible but Uninsured Children Grantmakers for Children, Youth and Families Conference October 10, 2012

2. What we hope you take away

3. Panelists Three Colorado foundations • The Colorado Health Foundation • The Colorado Trust • The Telluride Foundation

4. Continuum of Benefits Access Efforts Source: Waters-Boots, Shelley, Improving Access To Public Benefits, April 2010

5. Foundation Roles Organizational capacity builder Policy/ Advocacy Research and evaluation Direct services Benefits access Education and awareness Systems infrastructure

6. Scope of the problem Nationally • Between 2008 and 2009, witnessed an increase in Medicaid and CHIP (Children’s Health Insurance Program) participation (82.1% to 84.8%); between 2008-2010, uninsured rate for children fell from 9.7% to 8.5% • Reduced eligible but not enrolled (EBNE) by 340,000 • Still an estimated 4.3 million EBNE children (total 6.6 million uninsured in 2009) Sources: Urban Institute, Gains for Children: Increased Participation in Medicaid and CHIP in 2009, August 2011 SHADAC, Keeping Kids Covered: Number of Children with Health Coverage Increases During Economic Downturn, August 2012 Colorado • In 2010, 132,000 (10.3% of Colorado’s children) were uninsured, 82,000 EBNE children • Hispanic children disproportionately affected • Hispanic children comprise 31% of all Colorado children but account for nearly 2/3 of EBNE children Source: Colorado Health Institute

7. Lack of health insurance Uninsured children • 5x more likely to have an unmet need for medical care, especially heightened with special needs children • 3x more likely not to get a needed prescription drug • Less likely to receive preventive services (immunizations, dental and vision care) • Almost 1/3 less likely to receive medical treatment if they’re injured • 2009 Johns Hopkins study: seriously ill uninsured children are 60% more likely to die than if they didn’t have insurance Source: InsureKidsNow.gov

8. Why the EBNE challenge exists? Complex eligibility determination Stigma Awareness and education Onerous application process Onerous renewal process Language and/or cultural barriers Disconnected data systems Accessibility and capacity of assistance Failed or inconsistent recruitment strategies Transient populations

9. Source: Colorado Covering Kids and Families, Colorado’s Maze to Enrollment in Medicaid and CHP+, June 2012

10. EBNE Efforts Federal • CHIPRA 2009 reauthorization provisions • Accountable Care Act • Under full ACA implementation, Medicaid enrollment expected to increase by 39% BUT even with this increase, an estimated 38% of those uninsured would be eligible for Medicaid or CHP but not enroll (Urban Institute, Gains for Children: Increased Participation in Medicaid and CHIP in 2009, August 2011) State • Enrollment simplification • Presumptive eligibility • Continuous eligibility • Express lane enrollment Foundations • RWJF – MaxEnroll and Covering Kids and Families • Local and state foundations Partnering with “community”

11. Where do you fit? What did you learn and what advice would you share with other funders?

12. Grantmakers for Children, Youth and Families Conference October 10, 2012

13. Who we are • Our vision is to make Colorado the healthiest state in the nation. • Statewide foundation • $2.2 billion in assets • In 2010, we provided $97 million in community benefits • Grantmaking, policy, communications and graduate medical education

14. How we do it

15. Health Coverage

16. Simplify Enrollment Increase Benefits Ensure Access Optimize coverage available through Medicaid, CHP+ and other public programs

17. Simplify enrollment and renewal processes • Automating the process (Enrollment Strategic Assessment, PEAK) • Changing the culture of eligibility workers to one that prioritizes enrolling all eligible individuals rather than serving as gatekeepers (Colorado Eligibility Process Improvement Project Phase I and II) • Streamlining administration of Medicaid and CHP+ (Covering Kids and Families) • Pursuing policy changes that simplify the eligibility and renewal processes (All Kids Covered, Continuous Eligibility, Express Lane Eligibility)

18. Increase eligibility and expand benefits  • Pursuing policy changes that increase eligibility for Medicaid, CHP+ and Medicare subsidy programs (Children’s Campaign, Colorado Coalition for the Medically Underserved, Colorado Center on Law and Policy) • Supporting efforts to expand benefits in Medicaid, CHP+ and other public coverage programs, including mental and dental health services (Colorado Consumer Health Initiative re: SB12-108)

19. Ensure access to covered health care services • Increasing the number of providers willing to treat people covered by Medicaid, CHP+ and other public programs (Colorado Children’s Healthcare Access Program) • Providing case management to enrollees on how to access needed services and maintain coverage (Servicios de La Raza)

20. What has worked • Foundation partnership with state Medicaid administration • Learning collaborative among advocates and enrollment sites • Regional and state coalitions • Partnership among community-based organizations, county and state (e.g. FQHC, county and HCPF) • Regional planning • Strong advocacy partners

21. Challenges • Changes in administration • Policy implementation • Sustainability of enrollment sites/lack of funding • Placement of local enrollment sites • Colorado Benefits Management System • Confusion among consumers about what sites provide

22. Thank you Erica Snow, Senior Program Officer email@coloradohealth.org (303) 953-3656

23. Trusted Hands: Partnering with Community-Based Organizations to Reach and Enroll EBNE Children Deidre Johnson The Colorado Trust

24. Continuum of Benefits Access Efforts Source: Waters-Boots, Shelley, Improving Access To Public Benefits, April 2010

25. Trusted Hands • Grantee Partners - Trusted community organizations with established relationships with the target EBNE population • In-Reach • Medicaid • Children’s Health Plan Plus (CHP+) • Services - Comprehensive enrollment assistance including: • Eligibility Determination • Application Assistance Throughout the Enrollment Process • Utilization of Services • Redetermination Assistance

26. Outreach and Enrollment for Children and Youth Community Grants (2009-2011) • $3.4 million investment • 19 CBOs received 3-year grants • Community Clinics • School District • Head Start • County-wide collaborations • Drop-in/After-School Programs • Agencies Serving Low-Income Families, Homeless Families and Abused Children • Affordable Housing Provider • Hospital Emergency Department • American Diabetes Association’s Ventanilla De Salud

27. Outreach and Enrollment for Children and Youth Technical Assistance • Department of Health Care Policy and Financing (Colorado Medicaid) • Community Outreach Specialist • Online Outreach and Enrollment Mapping Tool • Colorado’s Maze to Enrollment in Medicaid and CHP+ Colorado Covering Kids and Families

28. Outreach and Enrollment for Children and Youth Evaluation (2009-2012) • University of Colorado Denver • Client Assistance Tool (CAT) • Reach: Which populations do CBOs reach and not reach? • Implementation: What outreach and enrollment strategies are CBOs using? • Effectiveness: What is the impact of these CBO models and strategies on enrollment, renewal and use of benefits? • Cost Analysis • Sustainability

29. Results • Grantees reached more than 35,000 children to determine eligibility • Grantees provided application assistance to 30,812 families applying for Medicaid or Child Health Plan Plus • 85% Medicaid Applicants • 15% CHP+ Applicants • The HCPF Community Outreach Specialist • Department point of contact for 19 grantees • Provided training and certification to 381 community-based enrollment assistance sites in 50 counties. With this training, these sites are better able to outreach to families and help them successfully complete applications.

30. Lessons Learned & Advice to Funders • The relationship between outreach and systems change • Capacity of grantees to impact service utilization • The need for technical assistance not only on how to execute a new function but also on how to integrate it into existing business processes • Efficiency of enrolling children in multiple benefits at once rather than focusing solely on health coverage • The importance of data: Client Assistance Tool (CAT) • Enrollment events can be effective under certain conditions

31. Partnering with Communities: How funders can reach and enroll eligible but uninsured children Lessons learned from community-based entity Grant makers for Children, Youth and Families Conference October 10, 2012

32. Telluride Foundation • Community foundation • Grants • Capacity building • Initiatives (run programs) • Southwest Colorado • Serve 13,000 population; 4 people/sq. mile; rural • $2.8 million grants annually • $1.5million unrestricted grants • $1.3 million foundation partnerships/DAF’s grants

33. Tri-County Health Network • 501c3 supporting organization of Telluride Foundation • Programs • Entitlement Assistance • Kids oral health • Immunization registry • Medical shuttle • Chronic disease care management outreach • Population health management

34. Why Entitlement Enrollment? • Rural southwest Colorado has some of the highest rates of uninsured children not only in Colorado but also the nation • ~ 32% of children in three county region were Eligible But Not Enrolled (EBNE) • ~ 43% of all children attending school are on Free & Reduced Lunch/National School Lunch Program

35. Elements to Success:Partnerships • School Districts • Childcare Providers • County Social Services • Medical Community • Advocacy Groups for minority populations • State Department of Health & Human Services • Local non-profits • Faith-based Organizations

36. Elements to Success:Enrollment Navigator • Employ local community members who live and are active in their communities • Become Certified Application Assistors (CAAs) • Be mobile performing outreach efforts in the field not in an office behind a desk • Regionally located • Navigators are considered a “trusted hand” in their communities • Must be persistent!

37. Elements to Success:Tracking System • System to electronically document/track: • applicant demographic information • tracking enrollment process work • storing legal documentation and application • daily task list associated with uncompleted applications • tickler system for annual renewals • type of outreach activities resulting in highest enrollment rates • System that can interface with the State enrollment verification system to easily confirm successfully enrolled applicants

38. Barriers to Success • Trust • Cultural differences • Language and literacy • Geographical isolation • Perceived stigma • Complexity of application process • Procrastination • Confusing approval & renewal letters

39. Program Costs • Staffing Plan based on geography & population • Travel Budget • Application Tracking Software – license/maintenance • Laptop/printers • Supplies (paper/printer ink) • Postage • Funds to assist in securing birth certificates • Business cards/enrollment brochures

40. Measuring Success • Monthly reporting • Number of people assisted • Number of applications processed • Number of applications approved • Number of renewals approved • The Network’s success to date: • Over 800 individuals enrolled/retained eligibility

41. Funder’s Role:Policy Change • Provided under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the Express Lane Eligibility (ELE) option gives States new processes to ensure a fast and simplified process for determining Medicaid/CHP+ eligibility for children. • Through ELE, States can use eligibility findings from other public benefit programs (i.e. SNAP, School Lunch, WIC, etc) to determine children’s eligibility in Medicaid or CHIP/CHP+ • States must receive approval (State Plan Amendment) from CMS in order to be designated as ELE

42. States with ELE Source: http://www.kff.org/medicaid/8272.cfm

43. Funder’s Role:Proactive RFP • Develop RFPs specific to Entitlement Enrollment Activities • Ask about existing partnerships • Staffing plan that includes community members • Strategy to partner with County & State • Knowledge of existing E&E efforts • Provide multi-year funding

44. Contact Information Lynn Borup Executive Director, Tri-County Health Network 719.480.3822 lynn@telluridefoundation.org Paul Major President, The Telluride Foundation 970.728.8717 paul@telluridefoundation.org

45. Table discussions Questions • What role(s) can funders play to ensure that children, especially the most disadvantaged and least-resourced, have access to public health insurance programs? What have you already done and learned? • How can funders engage community partners in their endeavors? How are you thinking about “community”? • The 2 S’s – “Sustainability” and “Scale”. How do funders support sustainability and/or scale? • What can philanthropy do?