behavioral health needs of the newly eligible and enrollment assistance best practices kevin malone...
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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
• 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
CI = Confidence IntervalSources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey
PREVALENCE OF BEHAVIORAL HEALTH CONDITIONS AMONG EXCHANGE
POPULATION
CI = Confidence IntervalSources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey
CHARACTERISTICS OF UNINSURED WITH SMI IN MEDICAID EXPANSION POPULATION
Female 64%
Age 18-34 53%
Race/Ethnicity
Non-Hispanic White 67%
Non-Hispanic Black 12%
Non-Hispanic Other 4%
Hispanic 17%
EDUCATION
< High School 31%
High School Graduate 39%
College 30%
Population Density
CBSA: 1 Million + 42%
CBSA: < 1 Million 33%
Non-CBSA 25%
Overall Health
Excellent 9%
Very Good 22%
Good 31%
Fair/Poor 37%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 51% Non-Hispanic Black 18% Non-Hispanic Other 3% Hispanic 28% EDUCATION < High School 43% High School Graduate 32% College 25% Population Density CBSA: 1 Million + 47% CBSA: < 1 Million 32% Non-CBSA 20% Overall Health Excellent 13% Very Good 28% Good 36% Fair/Poor 23%
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
Non-Hispanic White 74%
Non-Hispanic Black 9%
Non-Hispanic Other 4%
Hispanic 13%
EDUCATION < High School 17%
High School Graduate 40%
College 43%
Population Density CBSA: 1 Million + 52%
CBSA: < 1 Million 29%
Non-CBSA 19%
Overall Health
Excellent 12%
Very Good 33%
Good 32%
Fair/Poor 23%
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 Non-Hispanic White 60% Non-Hispanic Black 12% Non-Hispanic Other 4% Hispanic 23%
EDUCATION < High School 24%
High School Graduate 40%
College 36% Population Density CBSA: 1 Million + 56%
CBSA: < 1 Million 28%
Non-CBSA 15% Overall Health Excellent 15% Very Good 40% Good 31% Fair/Poor 13%
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
l Line indicates 95% confidence interval
*
* Suppressed for imprecision
STATE PREVALENCE OF SUD AMONG MEDICAID EXPANSION POPULATION
l Line indicates 95% confidence interval
STATE PREVALENCE OF SMI AMONG EXCHANGE POPULATION
l Line indicates 95% confidence interval
STATE PREVALENCE OF SUD AMONG EXCHANGE POPULATION
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
• 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
• 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 re-enrollment
• 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
