Health reform puts spotlight on enrollment, retention of adults in Medicaid

Many state Medicaid programs have made impressive headway in streamlining enrollment for children. Now, health care reform is causing them to turn their attention to the adult population.

"Research shows that Medicaid enrollment and retention among eligible adults is significantly worse than among eligible children. There is a real gap that needs to be addressed," says Benjamin D. Sommers, MD, PhD, an assistant professor at Harvard School of Public Health in Boston.

One reason is that there has simply been more focus on these issues for children, with more research and grant funding for outreach. "There are also procedural reasons," says Dr. Sommers. "Some states have continued to use more restrictive or burdensome enrollment requirements for parents applying for Medicaid, compared to children."

States are more likely to use asset tests for adults. "This can be an obstacle to coverage even among eligible individuals, since these tests require more documentation," says Dr. Sommers. "But many states have tried to align these enrollment procedures for children and adults, which is a good step."

Lessons learned

Nearly 5 million uninsured children who are eligible for public coverage are currently uninsured. "We're doing better for children and can apply some of those lessons to adults. The challenge is that while states are doing better for children, there is still a lot of work to be done there too," says Dr. Sommers. "We're in need of improvements in enrollment and retention for everyone eligible for Medicaid, regardless of age."

Rhonda Seltz is coordinator of Radford University's FAMIS (Family Access to Medical Insurance Security) Outreach Project, which has increased the number of eligible children enrolled in Virginia's program. Here are some of the approaches used for outreach:

• Strong partnerships with schools are utilized.

Back-to-school campaigns distribute flyers advertising state-sponsored health coverage with contact numbers for local departments of social services and the central processing unit. Phone numbers for local outreach projects are also provided.

Families identify whether they have health coverage for their children on the required school health information cards. This allows the school nurse to refer the family to an outreach project that will make every effort to get the children enrolled in coverage.

"These workers go the extra mile to help the family complete the application," says Ms. Seltz. "That may mean a home visit in the evening or meeting the family at their place of employment during a lunch break."

• Outreach workers send reminders of upcoming renewal dates.

They also offer face-to-face assistance with completing renewal forms and assist with retrieval of income verification and citizenship documents if needed.

Retaining coverage of children is a challenge, in part, because families move without providing new addresses. "There are changes in eligibility rules from year to year that confuse families," says Ms. Seltz. "Families may just not understand that they need to renew, or may not be able to provide adequate income documentation in time."

• Media outlets are utilized.

"This not only increases awareness, but also adds credibility to the program," says Ms. Seltz. "Recent budget cuts have created less visibility via television and radio ads, which previously were able to reach numerous families."

• Partnerships with local workforce centers and unemployment offices are used.

"These have been very effective in many areas across the state in getting children and pregnant women signed up for state-sponsored health insurance programs," says Ms. Seltz.

Outreach workers onsite at a local workforce center in Southwest Virginia found that many people had never heard of the FAMIS program.

"Most families assume that their children are not eligible for Medicaid, because the family may have some income and assets," says Ms. Seltz. "It is upsetting to know that many of these kids could have been covered by Medicaid all along, as assets are not counted for Medicaid eligibility."

Big contrast in process

Ms. Seltz says that these successful outreach strategies will be helpful for the adult population coming onto the program in 2014. "In Virginia, at least, adult and children's Medicaid are two totally different 'animals,'" she says. "Virginia ranks near the very bottom when looking at income eligibility guidelines for adult Medicaid. In 2014, when adults with income under 133% of the poverty line can qualify for Medicaid, the need for education, coordination, and advocacy will be even greater."

Today, in order to qualify for adult Medicaid in Virginia, the individual must be a parent, disabled, pregnant, or over age 65. Disabled and elderly people must meet asset requirements, and parents "have to be almost destitute to qualify," says Ms. Seltz. The application process in Virginia is quite extensive, requiring the completion of a 14-page application, and documentation for applicable income and asset rules, and citizenship.

In contrast, Virginia has made great strides over the years in simplifying the application process for children's health insurance. There is a much smaller four-page application, no mandatory cooperation with child support enforcement requirement, and no face-to-face interview required. Parents can apply for their children by mail with their local DSS, online, by phone, by mail with the central processing unit, or with their local outreach project.

This "No Wrong Door" policy allows families to have their children assessed for both children's Medicaid and FAMIS at the same time. The eligibility worker can often verify citizenship and incomes, such as unemployment, Social Security, or child support without asking for hard-copy verifications.

There are several reasons for the discrepancy in the current application processes between adults and children. "There is the issue of limited funding and the belief held by many voters that children, unlike adults, are not 'responsible' for their situation. They think adults should be able to pick themselves up by their boot straps, work, get insurance, and pay their own bills without the taxpayers' help," says Ms. Seltz. "Unfortunately, though, individuals' lives do not fit neatly in a nice black and white box."

Ms. Seltz says that a long history of streamlining enrollment for children's health insurance is particularly useful at this juncture. "States can take the very valuable lessons learned over the last 12 or 13 years to coordinate, simplify, and expedite the influx of new adult Medicaid applicants when health reform is fully implemented in 2014," says Ms. Seltz.

One possible complication, though, is that there are insufficient numbers of Medicaid providers. "In rural communities, there are often shortages of providers. The Medicaid reimbursement rate is quite low in Virginia, as well," says Ms. Seltz. "You can have all the insurance in the world, but if you cannot locate a provider, the coverage is worthless — even if it is 'free.'"

Contact Ms. Seltz at (540) 831-7693 or rgseltz@radford.edu and Dr. Sommers at (617) 432-3271 or bsommers@hsph.harvard.edu.