October 12, 2012

Enrollment Solutions in the Shadow of PPACA

Exclusively for:

FAHAM

October 12, 2012

October 12, 20122

PPACA

October 12, 20123

Outline

• Today’s Challenges

• Politics versus Reality

• Risk vs. Opportunity

• Risk Aversion Strategies

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October 12, 2012

Increasing Financial Risk

Increased Administrative

Cost

Growing/shifting Uninsured Population

Provider Challenges

Reimbursement Challenges

Resources to manage this segment of the AR

Regulatory Pressures

Financial Risk

Increased Compliance and Fraud audits

Reductions in Reimbursement and DSH

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October 12, 20125

Wall Street Journal Article

…13,069 uninsured patients were interviewed who had received emergency medical treatment. A five-question eligibility test found that 80% of the people seeking care were eligible for government coverage but weren’t signed up.

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October 12, 2012

Eligible but not enrolled

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25%

43%

74%

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October 12, 2012

Politics vs. Reality

What we don’t know?• What extremes the political parties will go to make a statement• The timing and outcome of legal challenges• How the upcoming elections will change the course• How the government intends to enroll between 161 and 242 million people on

to Medicaid*• What States will implement the Basic Health Plan and its impact• Where the funds to pay for the program will really come from

• How all the details will come together: Exchanges, ACOs, Individual Mandate,

and the impact on both small and large businesses

1. CBO. Analysis of the Major Health Care Legislation Enacted in March 2010. Statement of Douglas W. Elmendorf. March 30, 2011 -- http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf. The CBO estimates exclude individuals with primary coverage through employer-sponsored plans who enroll in Medicaid for supplemental coverage

2. These estimates include approximately 2 to 3 million individuals with primary health insurance coverage through employer-sponsored plans who are enrolled in Medicaid for supplemental coverage.

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October 12, 2012

Legal Challenges

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October 12, 2012

Politics vs. Reality

Understanding Reform– Patient Protection and Affordable Care Act

– Health Care Education and Reconciliation Act

Can it be undone? Is that what we really want/need?

What will be the lasting effects of this legislation?

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October 12, 2012

Change is Coming

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October 12, 2012

Key Elements of the ACA

Medicaid Program changes (under the Affordable Care Act of 2010)

• Expand eligibility (more people are covered)

• Simplify eligibility rules and reduce confusion

• Streamline enrollment and eliminate barriers

• Minimize lapses in coverage (churning)

• Expand Federal Match (FMAP) to help states finance coverage expansion.

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October 12, 2012

New Medicaid RulesSeveral rule changes will create new challenges and raise new questions:

• Lack of an asset test

• Self Attestation (allowed for everything except citizenship and immigration status)

– Potential for audits and take backs

• Modified Adjusted Gross Income test

– Point of income vs. annual total

– Household income

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October 12, 2012

How will reform impact Healthcare Utilization Changes

• More insured, less uninsured

– Do patients who now have access to insurance increase utilization when care is in theory more affordable?

– Will there be a shift away from using the ED for primary care?

• Accountable Care Organizations

– Does disease and patient care management mean more utilization or less?

– How will patient management by ACO’s impact length of stay?

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October 12, 2012

Medicaid Expansion Impacts

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Enrollment in 2019 State Spending Federal Spending Total Spending

United States 27% 1% 22% 13%

California 20% 2% 23% 12%

Florida 35% 2% 24% 14%

Maryland 32% 2% 30% 16%

New Hampshire 39% 1% 21% 11%

Ohio 32% 2% 19% 13%

Texas 46% 3% 39% 25%

Virginia 42% 2% 35% 18%

October 12, 2012

Application and Enrollment Impacts

• “The adult group” & disabled patients• Income & Assets

– Modified Adjusted Gross Income test (MAGI)

– Household income

– No asset test

– The “point in time” rules

– Face to Face

• Medicaid Agency Responsibility– Assistance, Outreach

• Verifications• Premium credits & tax credits

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Filling the Gap

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FL US

Employer 42% 49%

I ndividual 5% 5%

Medicare 16% 12%

Medicaid 13% 16%

Uninsured 21% 16%

* Source: www.statehealthfacts.org/healthreformsource

Health Insurance Coverage by type

October 12, 2012

Filling the Gap

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FL US

Population 18,413,600 305,191,100

% Below Poverty 21.0% 20.7%

Unemployment Rate 9.4% 8.3%

% of population that are uninsured 21.0% 16.0%

Below 138% FPL 28% 29%

Gap - 139 to 400% FPL 42% 39%

% of Adult Population with Disabilities

9.9% 10.4%

% of population that are uninsured Children

16.0% 10.0%

* Source: www.statehealthfacts.org/healthreformsource

October 12, 2012

Filing the Gap

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Income (% FPL) Coverage Premium & Cost Sharing

< 138% FPL Medicaid No Premium Cost sharing limited to nominal amounts for most services

139% - 250% FPL Exchange Sliding scale tax credits limit premium costs to 3 – 8.05% of income Sliding scale cost-sharing credits

251% - 400% FPL Exchange Sliding scale tax credits limit premium costs to 8.05 - 9.5% of income No Cost sharing credits

Notes: Exchange coverage and tax credits are limited to lawfully residing individuals who do not have access to employer‐sponsored insurance. Lawfully residing individuals who are barred from enrolling in Medicaid during their first five years in the U.S. may receive Exchange coverage and tax credits. Premium credits will adjust annually. Source: “Summary of New Health Reform Law”, Focus on Health Reform, the Kaiser Family Foundation, June 18, 2010.

Premium and Cost Sharing Limits for Individuals up to 400% of Poverty Under Health Reform

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October 12, 2012

Financial Risk

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Challenged Reimbursement

Connecting more patients to 3rd Party Payer

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October 12, 2012

The Enrollment Dilemma

Who has the most to lose if consumers are not enrolled in the healthcare coverage that best meets their needs?

• Federal Government

• State Government

• Insurance Carriers

• Providers

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October 12, 2012

Risk Aversion Strategy

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• Segment

• Partner & Expand.

• Educate, Navigate & Connect

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October 12, 2012

Risk Aversion Strategies

Segmentation• Avoid the collection agency approach• Use technology to create efficiencies not short cut the

screening process

• All claims are not created equal

• Use automation to identify opportunity

• Stratify work segments to improve efficiency

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October 12, 2012

One out of every ten (12.6%) working age Americans(ages 21-64) has a DISABILITY

The Disabled Patient Gap• In a recent APA study we found that of the patients

admitted to the hospital with a medical condition that would qualify as disabled under SSDI/SSI 80% presented with commercial insurance

• Six months later, only 20% of that patient group had claims that were paid by commercial insurance and more than 63% were classified as bad debt, self pay or charity as a final disposition

Disabled Patient Utilization

What do we know about disabled patients?

- They are frequent utilizers of healthcare service

- When they use services their services are usually high balance services

- They frequently max out benefits for private insurance coverage

- Less than 3 out of every 10 people who apply for Social Security are denied

- 65% of Social Security approved disabled patients are dual eligible

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October 12, 2012

Impact of focused Disability enrollment a program

SSA Case Study This study measured the impact Bon Secours Health System in Richmond, VA experienced as a result of a focused disability program and the use of electronic medical records transfer directly to SSA for disability determination.

RESULTS

- 42% improvement in the processing time of disability applications

- $2.1 million in additional revenue recovered that was previously classified as uncompensated care

* as reported in “Using the Nationwide Health Information Network to Deliver Value to Disability Claimants: A Case Study of Social Security Administration and MedVirginia Use of MEGAHIT for Disability Determination.”

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The Disability Opportunity

Strategy: Focus on disabling diagnosis and consider patients entire situation. Do not rely on the patient to achieve success.• Be proactive

– Patients are high utilizers of hospital services

– Compassionate allowance cases

– Data scrubbing and trending

• Accelerate disability process

• Maximize Disproportionate Share reimbursement

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October 12, 2012

Not all uninsured patients are created equal

Categorical Patient Mix

Do you know the categorical breakdown of your patient population?

- It does not matter how poor your patients are if they don’t meet a category…NO category, NO Medicaid

- Once you understand your patient mix then you can target the populations most likely to qualify for assistance programs

- Focus resources and customize the enrollment strategy

- Develop an outpatient strategy that delivers enrollment assistance at the time and place eligible patients access services

Inpatient

Outpatient/ED

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ED Case Study This facility previously worked with an ED screening & enrollment process that focused on post-discharge contact. A 12 month evaluation period was established to man the ED from 10 am – 10 pm and they experienced the follow:

RESULTS

- 56% increase in the number of Medicaid approvals

- Increase converted charges by $1.1 m annually

- At a reimbursement rate of 16%, approximately $176,000 cash annually

- Increased staffing by adding 2 FTEs and other cost of $125,000

- Return visit rate of 4 times annually on average (future charges of $4.4 m covered) with annual reimbursement estimated at $500,000

Point-of-service modeling

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October 12, 2012

Account Management

Strategy: Initial contact during inpatient visit or at the time of care is not enough, a strong follow-up program is essential.

– Over-reliance on the patients word and diligence (no contact with patients attorney, etc.)

– Set standard abbreviations and ensure all team members consistently document activity

– Establish a post discharge follow-up program that includes outreach and ensures filing deadlines are met

– Eligibility verification process that is consistent and strategic

Recommend using an account management process, software or tool. This would ensure patients are not falling into gaps, increase conversions and help with performance measurement.

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October 12, 2012

Are you getting the maximum return on your enrollment solution investment?

A broad enrollment solution will reduce your level of uncompensated Care

An effective enrollment program must be more than just Medicaid!

- Social Security Disability Insurance

- Supplemental Security Income

- COBRA

- Pre-existing condition coverage

- New Minor group for Medicaid

- Veterans Benefits

- Indian Health

- SCHIP

- Immigrant programs

- Motor Vehicle

- Workers Compensation

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Medicaid77%

Non-Med-icaid23%

Medicaid50%

Non-Medicaid30%

Dis-abilty20%

October 12, 2012

Go Broader and Deeper

Strategy: Assist patient’s with programs outside of traditional Medicaid.

– Leverage existing programs like SCHIP

– Higher reimbursement opportunities and better coverage programs like PCIP, COBRA, Disability, Crime Victims, MVA, etc.

The math behind expanding your enrollment program in the ED or other outpatient points of access?

– Staffing cost

– Low reimbursement rates

– Future utilization rates (three to five times ED use per year)

October 12, 2012

Expand Screening and Enrollment

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• Be a citizen or national of the United States or reside legally in the United States.

• Without health coverage for at least the last six months.

• Have a pre-existing condition.

Florida Premiums:

Age Standard Option Extended Option HSA Option0 to 18 $118 $158 $122

19 to 34 $176 $237 $18335 to 44 $211 $284 $22045 to 54 $270 $363 $280

55+ $376 $505 $390

October 12, 2012

Risk Aversion Strategies

Expand Screening and Enrollment

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Florida Healthy Kids covers only children 5-18. Currently have over 280,000 kids enrolled.

If your children are older, younger, have special needs or have a lower income, your family may be served by other Florida KidCare partners (Medicaid, MediKids and Children’s Medical Services).

However, families apply for all of these programs using the same application. Florida KidCare will place your child in the program that will best meet their needs.

October 12, 2012

Risk Aversion Strategies

Look beyond the hospital’s four walls!• Expand partnerships with community organizations• Take enrollment process to patient access points • Participate in school enlightenment programs• System-wide communication strategies• Eliminate redundancy

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October 12, 2012

Risk Aversion Strategies

Educate, Navigate & Connect• Providers will find themselves in a unique position

• Consumer/Patients will struggle to understand options

• Insurance exchanges will provide new guidance

Educated consumers connected to insurance programs that best meet their financial and healthcare needs will yield the greatest reimbursement to providers.

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October 12, 2012

Summary

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Segment• Customized enrollment programs for different patient groups• Use technology to expand opportunities not limit them

Partner & Expand• Build relationships in the community that can increase the number

of insured patients• Take a broad approach to eligibility beyond traditional Medicaid and SSI• Expand communication and share information system wide.

Educate, Navigate & Connect• Ensure your patients are knowledgeable about their options• Mitigate financial risk by connecting patients to programs with better

reimbursement• Become the resource for coverage information

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October 12, 2012

Important Sources

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J. Angeles, Explaining Health Reform: The New Rules for Determining Income Under Medicaid in 2014, The Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, 06-02-2011, http://kff.org/healthreform/8194.cfm

P.. F. Short, K. Swartz, N. Uberoi et al., Realizing Health Reform’s Potential: Maintaining Coverage, Affordability, and Shared Responsibility When Income and Employment Change, The Commonwealth Fund, May 2011, http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/May/1503_Short_maintaining_coverage_affordability_reform_brief.pdf

S. Dorn, Implementing National Health Reform: A Five-Part Strategy for Reaching the Eligible Uninsured, Robert Wood Johnson Foundation, Urban Institute, May 2011, http://www.rwjf.org/files/research/72371urban201105.pdf

S. Dorn, The Basic Health Program Option under Federal Health Reform: Issues for Consumers and States, Robert Wood Johnson Foundation, State Coverage Initiatives, May 2011, http://www.statecoverage.org/node/2918

Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010, 42 CFR Parts 431, 433, 435, and 457, [CMS-2349-P], RIN 0938-AQ62, Centers for Medicare and Medicaid Services (CMS), HHS, August 12, 2011, http://www.ofr.gov/OFRUpload/OFRData/2011-20756_PI.pdf.

October 12, 2012

Thank You

Michael D. Wilmoth, Esq.mwilmoth@apallc.com

(703) 403-3521

www.aparesults.com

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