While states’ budget problems are limiting interest in attracting new people to the Medicaid program, that situation will surely change at some point, and then states will be looking for ways to reach out to those eligible for Medicare. A study by Mathematica Policy Research senior health researcher Suzanne Felt-Lisk says one model that states can use to improve outreach to Medicare beneficiaries is the SCHIP program and its intense focus on enrolling all who are eligible for it.
Even with the state budget constraints, Ms. Felt-Lisk tells State Health Watch she has been "pleasantly surprised that the Centers for Medicare & Medicaid Services [CMS] has been involved in outreach and encouraging states" to reach out to Medicare beneficiaries.
Ms. Felt-Lisk says barriers to enrollment of Medicare beneficiaries are similar to those for SCHIP. First, people often don’t know enough about Medicaid to recognize that they may be eligible. Next, there is a stigma attached to Medicaid, although Kaiser Family Foundation focus groups have suggested that the stigma issue recedes if officials are able to talk with those who are eligible. A third concern is with the Medicaid eligibility rules and the reliance on an assets test.
It can be important for Medicare beneficiaries to participate in Medicaid, she says, because Medicaid can cover some or all of the out-of-pocket expenses that remain after Medicare coverage for low-income elderly or disabled people. But, at best, only about 60% of the elderly who are eligible for Medicaid are enrolled in it.
In an Operational Insights paper written for Mathematica, Ms. Felt-Lisk looks at the barriers and at steps that can be taken to overcome them. She writes that many of those who are dual-eligible Medicare beneficiaries don’t recognize themselves as low-income people and are used to getting by on their own.
CMS has several programs under way to promote Medicaid enrollment for eligible Medicare beneficiaries, she says. These include mailing notices to prospective enrollees, distributing pamphlets about the program, advertising in the media, developing a three-page model application form for states to adapt or adopt, and developing a section on the Medicaid program in the Medicare & You handbook CMS distributes to beneficiaries.
Also, the National Medicare Education Program, designed to educate beneficiaries about their benefits, includes several components that can link beneficiaries to information and assistance about Medicaid eligibility and enrollment, including a toll-free telephone help line and beneficiary counseling and other services from State Health Insurance Assistance Programs.
CMS (when it was known as HCFA) wrote to state Medicaid directors in October 1998 suggesting they develop outreach and enrollment strategies modeled on those used for SCHIP. Regional training sessions were held in 1999, and several grants were awarded in 2000 to encourage states to build partnerships for innovative ways to do outreach.
Ms. Felt-Lisk says implementation of SCHIP led to an unprecedented focus by policy-makers, advocates, and others on how to reach a population that needs financial assistance with health care costs but does not necessarily seek it out. The following strategies have emerged from their experience:
1. Developing partnerships. To improve access to insurance coverage under SCHIP, states have recognized the importance of partnerships with other public- and private-sector organizations. Many states work with community-based organizations, advocacy groups, and other relevant units within their state. The organizations interact with the target population of children, allowing the state to leverage existing community resources and relationships for more effective outreach.
Within that structure, Ms. Felt-Lisk points to a number of SCHIP efforts that should be useful in enrolling dual-eligibles. First is the need to project an appealing image of the program. She reports that attractive and compelling ad campaigns promoting the message that SCHIP provides affordable health coverage for uninsured children in working families help reduce the stigma of public programs and encourage enrollment. Some states also use the media effectively, with some reporting that radio was particularly effective in rural areas. Many have found that advertising on foreign-language radio and TV stations is a good way to reach minority populations. Creative approaches include persuading the business community to stuff promotional cards in retail bags at discount department stores, pharmacies, and retail outlets; distributing program information with employee paychecks; placing program information and a toll-free hotline number on grocery store bags and milk cartons; and developing bus and subway cards. Providers often help with outreach, and the National Governors Association has suggested developing a promotional video to play in physician offices and at sites where SCHIP eligibility is determined.
2. Simplifying enrollment. Most states have streamlined their SCHIP application and renewal policies and forms. Application and renewal processes also have been made more user-friendly. About 40 states now accept mail-in applications for SCHIP, often even including postage-paid return envelopes. Many states also have eligibility staff working in communities.
3. Reaching adult caregivers. SCHIP’s outreach efforts focus directly on adult caregivers, including parents and grandparents.
4. Creative initiatives to promote SCHIP. Once enrolling uninsured children became a national priority, according to Ms. Felt-Lisk, financial and non-financial assistance began to come from many disparate sources. The federal government increased the match rate for SCHIP, while foundations funded outreach efforts.
The researcher reports that while most states use pamphlets and posters, and many have used direct mail to advertise the dual-eligibles program, they have not partnered, translated materials into other languages, or market-tested the materials as extensively as they have for SCHIP. "Ad campaigns similar to those used for SCHIP could reduce stigma where it is a barrier to enrollment and help low-income elderly become aware that they might be eligible for assistance," she says. "Another idea that showed promise in a demonstration is to send letters to likely eligible Medicare beneficiaries. States could do more to build relevant partnerships, even using some of the same relationships built for SCHIP."
Ms. Felt-Lisk says researchers have found that education beyond a single-phrase message is critical. More than for the SCHIP population, dual-eligibles prefer learning from other people face to face.
Addressing the application issue, she says that in contrast to SCHIP enrollment processes, the process for enrolling low-income elderly people in Medicaid typically remains cumbersome, due in large part to the assets test. She says states have flexibility under section 1902(r)(2) of the Medicaid law to eliminate the assets test or loosen or eliminate verification requirements to streamline the process. Alternatively, federal policy-makers could decide to eliminate or lessen requirements for the assets test as a way to expand access to care. But, she says, Medicaid still has a long way to go to become more consumer-friendly in its application process for dual-eligibles.
Ms. Felt-Lisk says states that want to do a better job of reaching out to dual-eligibles can use some of the SCHIP creative strategies, such as creative partnering, without changes in state policy or processes. Other changes, such as streamlining and simplifying the application process, require a concerted effort by state Medicaid agencies, which may not come until the budget crisis eases.
"Thoughtful translation of some of the strategies and lessons from the SCHIP experience should help boost the health of low-income older and disabled Medicare beneficiaries for whom enrolling in Medicaid is now either an unknown option or too formidable a process," she says. But she says she does not yet know of any state that is doing particularly good work in this regard, which leaves a lot of room for improvement.
[Download CMS information from www.cms.gov. Contact Ms. Felt-Lisk at (202) 484-4519.]