Norma Doyle, BSN, MPA Director of Maternal Child Health County of Sonoma

1. Sonoma County Child Health Care Access-Health Care Coverage for Every Child Ages 0-18 Years at 300% of Poverty and Under Norma Doyle, BSN, MPA Director of Maternal Child Health County of Sonoma

2. Background • Sonoma County has a population of 500,000 with 112,000 Children ages 0-18 years. • 8,000 children are estimated to be without health care coverage. • The majority of these children are below 200% poverty, age 12 and older, Hispanic, living in a single parent family with a woman as head-of-house. • Lack of health care coverage limits access to health care, impacts the early diagnosis and treatment of health conditions or developmental concerns and appropriate linkage with resources.

3. Child Health Problem Analysis SOCIETAL/POLICY LEVEL/TERTIARY PRECURSORS Societal belief that undocumented families don’t deserve health care Public insurance programs have complex regulations, slow or faulty eligibility determination process Health system has minimal providers who take children under public insurance Health systems may have staff who show disdain for families using public insurance Stigma attached to using Medi-Cal FAMILY/INSTITUTIONAL LEVEL/SECONDARY PRECURSORS Family leaves USA seasonally and drops insurance Family may have lack of knowledge about the importance of preventative health care Complexity to application process and annual redetermination for eligibility makes retention of coverage difficult for family Family has working parent(s) but no access to insurance through work Cultural perception that when health care is needed parent will pay for it or use a public program Medi-Cal seen by family as government aid rather than insurance Family may be very mobile or homeless and misses mailed notification of need to re-establish insurance eligibility Medi-Cal seen by family as government aid rather than insurance Seasonal work creates changing income and may impact families eligibility for coverage Family has difficulty making health insurance payments Family may have children under different insurance coverage and had difficulty understanding varied retention and utilization policies INDIVIDUAL LEVEL/PRIMARY PRECURSORS School age children appear “healthier or less in need of care: then their young siblings Child is able to get free immunizations thus doesn’t need health coverage Child appears well, and not in need of health care Child is undocumented Targeted Indicator: Children under 18 at 300% poverty or less need health care insurance Consequences: Less preventive care, exacerbation of higher levels of disease and misuse of emergency room

4. Objectives • Create a community plan with key participants to provide policy development, fund raising and a detailed work plan for outreach, enrollment and retention of uninsured children in health coverage. (3-6 months) • Contract with a plan administrator for a product, which covers children who are uninsurable under public programs. (6-9 months) • Enroll children through a single portal, which links health care coverage and education on appropriate uses of health care. (9 months and ongoing)

5. Anticipated Results • Maximize enrollment of children in health insurance plan by three years. • Maximize retention within the health plan. • Improve use of preventive care and reduced use of emergency room use. • Long term funding identified to maintain available health insurance products .

6. Steps in Creating the Initiative • Key leaders met regarding the lack of health care coverage in Sonoma County. • They focused their efforts on children. • Contractor helped obtain funds for planning and creation of the system.

7. Key Partners • Health Services Department • Human Services Department • Redwood Community Health Coalition (coordinating agency for community clinics) • Family Action (childhood advocacy group)

8. Health Services Role • Convener • Provision of key staff • Administrative support • Processes contracts • Media Releases • Quality assurance • Evaluation

9. Early Accomplishments • Business plan with enrollment projections, proposed expenses and revenues • Outreach and media plan • Funding plan • Incorporation of other “like-minded” local efforts

10. Current Coverage • Medi-Cal • Healthy Families • Kaiser • California Kids

11. Training Plan for Assistors • 12 hours state sponsored training • Training on new product • 1 week with a mentor on applications • Monthly meetings with other assistors • Access to Retention Specialist

12. Inreach Eligibility Worker Intake Flow Chart 1. Outreach/ Inreach and information & referral 5. Post-enrollment education & retention 3. Product enrollment 4. Enrollment or denial follow-up 2. Program Screening including education & application assistance Medical EW 800# Healthy Family Family Utilization Referral Resource Education Family Cal Kids CHI Representative CHI Rep Kaiser 800# Outreach CAA New Product • OVERSIGHT ENTITY • Oversight for CAA/CHI Rep - Training • Regular information sharing meetings - Ongoing support • Troubleshooting team

13. Legend: MC = Medi-Cal K = Healthy Kids CK = CalKIDs K = Kaiser HF = Healthy Families TPA = Third Party Administrator Family Applies Family comes into HSD seeking services. Reception screens to see what they want to apply for: • Family wants a Children’s Health Program only • Family wants a Health Program and Food Stamps Onsite CAA assists family with Children’s Health program application(s), provides benefit information and directs family to mail premium to TPA and provide verifications to assigned EW. Family is interviewed for all programs by an EW. Family is directed to provide verifications to assigned EW. Family is directed to pay premiums to TPA. Application is referred to HF, CK or K Application MC or HK is passes on to Mail in EW (MIM) for eligibility determination. EW certifies eligibility for:  Medi-Cal or Healthy Kids EW sends (faxes?) Healthy Kids certification to TPA or carrier. HK information is entered into database.  Healthy Families referral made if appropriate. Intake EW determines eligibility for Food Stamps and MC and HK programs. EW sends notices to family. EW makes HF referral if appropriate. EW sends certification to HK or TPA or carrier. Case information is forwarded to CAA or Clerk Typist for retention activities. Case is passed to continuing worker.

14. Insurance Retention • Address updates with consumer at every contact • Consumer friendly and accessible documents • Reminder letters, postcard and/or phone calls for annual redeterminations • Consistent relationship with assistor

15. Major Accomplishments • Funding from endowment for implementation and program coordination • Formation of a steering committee with high level decision makers for credibility, sustainability and funding • Formation of an operations Committee for detailed direction to the Coordinator on implementing multiple activities • Formation of a Single Portal Committee who design the methodology for identifying, enrolling and retaining children on health insurance

16. Major Accomplishments (continued) • Release of a RFP to obtain a product and project administrator for coverage of those children who are ineligible for public programs • Release of a RFP to obtain a funding consultant and media plan • Identification of additional funding

17. Lessons Learned • Have the right people at the table • Plan for time intensity within first year • Identify crucial information and take advantage of opportunities rather than delaying actions • Fix the current system before enhancing it

18. Barriers • People who believed this couldn’t be done • Lack of status as a Managed Care County • Complexity and rigidity of Medi-Cal eligibility and redetermination system • Decreasing level of available health care services • Changes occurring in the California Medi-Cal system • Lack of a product for “uninsurable” children

19. Overcoming Barriers • Involve those who are doubtful • Work with state regarding options of becoming Managed Care • Involve Human Service staff in “personalizing eligibility” • Use family planning residents across local health care clinics • Reframe the issue based on the audience while maintaining the vision • Use the available products and heighten enrollment and retention efforts

20. Evaluation • Measure all progress by: • Sustainability • Effectiveness • Efficiency • Will our children be better insured and better able to access health services than before?

21. Sonoma County Child Health Care Access-Health Care Coverage for Every Child Ages 0-18 Years at 300% of Poverty and Under Thank you