Moving Forward with the ACA Part I: Enrollment Challenges

1. Moving Forward with the ACAPart I: Enrollment Challenges Health Care for the Homeless Regional Training August 14, 2014 Kiwon Yoo, MPH – Insure the Uninsured Project

2. About ITUP ITUP is a non-partisan, non-profit health policy “think tank” based in Santa Monica, CA. We are funded by generous grants from The California Wellness Foundation, The California Endowment, Blue Shield of California Foundation, California Community Foundation, Kaiser Permanente, and The California HealthCare Foundation.

3. A Really Brief ACA Overview

4. Coverage Expansions • The ACA expands healthcare coverage through two major systems: • Medicaid(Medi-Cal): public coverage program for low-income Californians • Covered California: Virtual “shopping mall” where individuals, families, and employers can purchase affordable health insurance

5. Medi-Cal On January 1, 2014 Medi-Cal extended coverage to allcitizens and legal permanent residents ages 19 - 64 with incomes up to 138% of the federal poverty level ($16,105 for an individual and $32,913 for a family of four). Increased income standard for parents from 100% to 138% FPL Extended coverage to adults without dependent children to 138% FPL

6. Medi-Cal • Expanded Benefits • Mental health services are now more accessible. • Mental health services for the severely and chronically mentally ill are available through the county Mental Health Departments. • Psychological services for those with less severe mental illness are provided through the Medi-Cal Managed Care plans and their provider networks. • Expanded Substance Use Disorder treatment services are available to all Medi-Cal members.

7. Medi-Cal • Expanded Benefits • Dental services are now more accessible. • On May 1, dental benefits for adults were restored. • Office visits • Cleanings • X-rays • Fillings • Crowns • Complete dentures • Root canals

8. Medi-Cal Enrollment • The ACA helps to streamline and modernize the enrollment process for Medi-Cal applicants. • Central application and enrollment system for both Medi-Cal and Covered California – CalHEERS • Electronically processed applications with income and residency information verified electronically • Eliminated asset tests • Except for seniors, Medi-Medis, and individuals in long-term care • Improves renewal process with pre-populated forms

9. Medi-Cal for Former Foster Youth Young people who were in the foster care system on their 18th birthday qualify for Medi-Cal up to age 26. • Regardless of income • Regardless of state residency while in foster care • Simplified one-page application • No recertification until age 26 • Exempt from managed care • Apply via county social services offices • Foster Care Ombudsman available for assistance – fosteryouthhelp@dss.ca.gov or 1-877-846-1602

10. Immigration U.S. Citizens and Lawful Permanent Residents (LPRs) have full access to coverage and financial assistance based on income. There is no waiting period or 5-year ban for legal immigrants newly in the U.S. • Undocumented Immigrants • Not eligible for full scope Medi-Cal or Covered California • Eligible for Emergency Medi-Cal (limited scope) • Deferred Action for Childhood Arrivals (DACA) • Not eligible for Covered California • Eligible for Medi-Cal • Temporary Immigrants and Non-immigrants • May or may not be approved for Medi-Cal • Eligible for Covered California

11. Year 1: Results & Lessons Learned

12. 1,395,929 individuals enrolled in plans through Covered California 1,930,000 individuals newly enrolled in Medi-Cal

13. Enrollment (Covered California: April 15, 2014)

14. Enrollment(Covered California: April 15, 2014)

15. Covered California Enrollment(Covered California: April 15, 2014)

16. Vulnerable Populations

17. Enrollment Challenges We have to improve Medi-Cal enrollment, period • ACA promised streamlined applications, but due to technical problems, a 400,000+ backlog persists • Continued education of outreach, education and enrollment staff is still needed • Misinformation about asset tests, immigration statuses, etc. • Streamlined, express enrollment opportunities should be taken advantage of • CalFresh, re-entry/parolee populations

18. Enrollment Challenges We need additional resources for enrollers • Financial compensation for successful applications have been promised, but payments have been delayed • Many clients have been auto-enrolled through LIHP transitions, but are unaware of it • Resources needed to correct primary care providers, medical home assignments, and plan choices • Redeterminations may lead to confusion • Renewal packages being sent to incorrect addresses • New renewal forms request tax information

19. Enrollment Challenges We don’t have enough data • Homeless population requires additional outreach/education and special services, but we need to be able to identify them at the plan/provider level • Unreliable means of communications complicates matters, making follow ups difficult • Mailings (plan choice, medical home placement)

20. Enrollment Challenges We need to break bad habits • Coverage is effectively meaningless if care isn’t sought • Need to encourage health care utilization at appropriate sites of care, instead of relying on ERs • Instill importance of preventive and primary care • Mental health and substance use disorder services are now a benefit for all Medi-Cal enrollees. If needed, these services should be taken advantage of

21. Enrollment Challenges We must improve coordination of services • With the majority of homeless individuals requiring behavioral health/substance use disorders, coordinating medical and behavioral health is critical • The state and local entities need to make case management a priority • Such services are currently not funded by Medi-Cal, so we need to identify other funding sources

22. Enrollment Challenges We need more permanent supportive housing • Health coverage alone is like putting a bandaid on a broken leg • Coverage is only meaningful if clients become healthier • Housing and intensive case management are critical components of health • Must identify and maximize funding for PSH and case management • Fragmented funding for housing and health a significant hurdle

23. What Kind of Work is Underway?

24. Housing for Health • Established in November 2012, Housing for Health (HFH) is a new division within the Los Angeles County Department of Health Services (DHS) • Focused on creating housing opportunities for clients who are homeless and have complex physical and behavioral health conditions • Provide permanent housing, recuperative care and stabilization housing linked to intensive case management services

25. Housing for Health • DHS provides services to almost 14,000 annually who are homeless, including 2,300 who have inpatient stays • ALOS overall is 6.4 days; homeless patients’ ALOS is 10.6 days (at $2-3k per day per bed) • A comparison of hospital utilization by homeless patients 12 months before and after being housed found a 77% reduction in ER visits, 77% in inpatient admissions, and an 85% reduction in inpatient days • Housed clients used an average of $32,000 per year less in DHS services in the year following housing compared to the year prior to housing

26. Housing for Health • Emphasis on intensive case management services (ICMS), which are provided to every client, and includes: • Outreach and engagement • Case management with ongoing monitoring and follow-up • Linkage to health, mental health, and SUD services • Assistance with benefits establishment • Assistance with life skills, job skills and educational/volunteer opportunities • Crisis intervention • Provided on-site at supportive housing locations by staff who have offices on-site, or by mobile teams • Provided by experienced homeless services providers who have contracts or provider agreements with DHS

27. Housing for Health • Housing is county-wide and based on the needs of the client. Uses a wide range of community-based housing options including: • Non-profit owned supportive housing, affordable housing, and private market housing • Single units, blocks of units, and master leases • Scattered site and project-based • Rental subsidies a combination of tenant-based Section 8, Project Based Vouchers, Shelter Plus Care, LAHSA subsidy, Flexible Housing Subsidy Pool (DHS subsidy) and tenant rent • Tenants are asked to contribute 30% of income, with an average contribution of $168/month

28. Flexible Housing Subsidy Pool • Flexible Housing Subsidy Pool (FHSP) established in January 2014, and is funded by the LA County DHS, the Conrad N. Hilton Foundation, and the Office of Supervisor Mark Ridley-Thomas • Provides 300 rental subsidies in year one (2014), 600 in year two, 1200 in year three, and 2400 in year four • Operated by West Bay Housing Corporation • Set up so that other public and private entities can participate, with discussions underway with other county departments and with health plans

29. Housing for Health • Funded largely by DHS • System savings are put towards housing • Funding to be ongoing indefinitely • In 2013, had 280 new permanent housing units, and 68 interim housing beds • DHS plans to add 390 more permanent housing units in 2014, for a total of 670 • Also plans to add 146 interim housing beds in 2014, for a total of 214 • Retention rate of 96%

30. FAQs & Resources

31. Troubleshooting For questions about coverage, call your insurance company. If you have a complaint, file a grievance or appeal with the insurance plan. For Medi-Cal eligibility issues, contact your county DPSS office. For benefits issues, contact the managed care plan. Persistence is key.

32. Enrollment Systems To become a certified enrollment counselor: Call 888-402-0737 Or email assisterinfo@ccgrantsandassisters.org Training is free and can be online or in person Counselors must be connected to a Certified Enrollment Entity

33. Resources Health plan help: Department of Managed Health Care 888-466-2219 www.dmhc.ca.gov Department of Insurance 800-927-4357 www.insurance.ca.gov Medi-Cal questions: Managed Care Ombudsman 1-888-452-8609  MMCDOmbudsmanOffice@dhcs.ca.gov Health Care Options 1-800-430-4263 www.healthcareoptions.dhcs.ca.gov Access & eligibility issues: Health Consumer Alliance (800) 896-3203 www.healthconsumer.org Medicare questions: Center for Health Care Rights 213-383-4519 www.healthcarerights.org

34. Final Thoughts Get informed. Know the details of your plan and the benefits you are eligible for. Everyone is learning together, and there will be a steep learning curve. Persistence is key. Use your coverage (and wean off of any over-reliance on emergency departments). Need help? Ask! Call your Medi-Cal plan, your provider, and additional resources. Collaborate with non-traditional partners.

35. For resources and additional information: kiwon@itup.org (310) 828-0338 http://www.itup.org