Stop loss of Medicaid coverage — $362K obtained in one case
Many beneficiaries lose coverage
A transplant patient at Cook Children’s Medical Center in Fort Worth, TX, was eligible for coverage with the state’s Children with Special Health Care Needs program, but no reimbursement was possible as funding for the program had run out.
However, financial counselors stepped in and assisted the family in qualifying for emergency Medicaid coverage.
"The hospital was able to get $362,494 in reimbursement for something that would have just been written off," reports Andrea Ayala, a financial counselor in patient registration.
Helping patients apply for Medicaid or the Children’s Health Insurance Program (CHIP) can dramatically increase the amount of revenue obtained by the hospital, because many eligible patients otherwise wouldn’t apply for the program, emphasizes Ayala. "Many get overwhelmed because they don’t understand the process, or they perceive it as redundant," she says. "Once they have an understanding of the process, they are cooperative." Ayala often sees patients’ Medicaid coverage terminated for these reasons:
• There is a variance in the family’s income based on the month the family applied.
For example, an applicant might have received an end-of-year bonus in December or worked some overtime during a particular month.
"Families will assume they can no longer qualify for coverage. They don’t realize they can reapply anytime there is a change in household income," says Ayala.
• Families have an incorrect assumption that a child can’t qualify for Medicaid if the guardian’s income is over income limits.
"Grandparents or temporary guardians may apply for assistance," says Ayala. In situations in which Child Protective Service (CPS) is involved but the parent has agreed to a voluntary placement of children with next of kin or a family friend, the child can qualify for Medicaid.
"The assumption by the guardians is that CPS will apply on their behalf, and that is not the case. The temporary guardian must take the initiative to apply," she adds.
In these cases, the guardian’s income is not counted. "The only countable income would be if the child is eligible for any income themselves, such as survivor benefits or SSI [Supplemental Security Income]," says Ayala.
• There are changing income levels for self-employed families.M
"The state prefers the current tax return as it is easier to process, but this does not always benefit the parent," says Ayala. Households with income that vary greatly from month to month, such as individuals who do seasonal work, often are better off completing a 1049 self-employment form that reports income over a three-month period instead.
"This is often the best reflection of the parent’s current earnings and can be a deciding factor in Medicaid and CHIP eligibility," says Ayala.
"Churn" is common
The average Medicaid beneficiary is covered for only part of the year, largely due to the problem of "churn," according to a new report.1 Otherwise-eligible beneficiaries are often disenrolled and re-enrolled in the program because of paperwork issues, temporary changes in income, or changes of address.
Leighton Ku, PhD, MPH, the report’s lead author and professor and director of the Center for Health Policy Research at George Washington University in Washington, DC, says, "Sadly, it is common that low-income patients who were on Medicaid lose their insurance and become uninsured."
Ku says churning hurts hospitals in several ways. "If they treat the patient as an uninsured person, they may incur uncompensated care losses," he says. "Even if they can successfully re-enroll the patient in Medicaid, the hospital has additional administrative costs for the application assistance."
Prevent revenue losses
Patient access leaders can work with state Medicaid agencies to identify ways to simplify enrollment, such as lengthening certification periods or requiring less documentation, suggests Ku. He offers these solutions:
• Let patients know what paperwork they need in advance.
"This can help make sure that the documents are ready when they enroll the first time," says Ku.
• Play a role in new health insurance "navigator" or "assister" programs, which are being developed to help people join the health insurance exchanges or Medicaid.
• Have "outstationed eligibility workers" who can access Medicaid enrollment systems.
These individuals can find out whether a patient was enrolled in Medicaid at one time and, if so, what problems occurred to cause the patient to lose coverage. They then can contact the patient to help get the necessary paperwork submitted.
"In some cases, the worker may be able to get the required information from another source, such as obtaining a birth certificate from the state health department," says Ku.
Benjamin D. Sommers, MD, PhD, assistant professor of health policy and economics at Harvard School of Public Health in Boston, says that to prevent churn, patient access employees can do the following:
• Remind patients that they have to renew their coverage once annually and that failure to do so can lead to a loss of coverage.
• If the patient access department starts someone’s application, schedule a follow-up phone call or meeting to be sure that everything has gone smoothly.
• Have information clearly indicated in patient waiting rooms that subsidized health insurance may be available, and that application assistance is available.
• Provide foreign-language assistance. "This is especially important in some populations with many non-English speakers, as this can be a major obstacle to getting or staying enrolled," says Sommers.
• Obtain retroactive coverage for Medicaid enrollees who have churned off the program but are still eligible.
"This can be a key way to help patients get insured and the hospital reimbursed for costly care," says Sommers. (See related stories on why churn will continue under healthcare reform, right, the importance of verifying eligibility, p. 88, and how healthcare reform will affect patient access processes for Medicaid patients, p. 88.)
1. Ku L, Steinmetz E. The continuity of Medicaid coverage: An update. Association for Community Affiliated Plans, April 19, 2013.
For more information, contact:
• Andrea Ayala, Financial Counselor, Patient Registration, Cook Children’s Medical Center, Fort Worth, TX. Phone: (682) 885-7113. Fax: (682) 885-6060. Email: Andrea.Ayala@cookchildrens.org.
• Linaka Kain, DE, Disability Examiner/Medicaid Specialist, Trinity Regional Health System —Rock Island, IL. Phone: (309) 779-2648. Email: Linaka.Kain@unitypoint.org. Are you sure email address is correct?
• Leighton Ku, PhD, MPH, Professor, Department of Health Policy, Director, Center for Health Policy Research, George Washington University, Washington, DC. Phone: (202) 994-4143. Fax: (202) 994-3996. Email: email@example.com.
• Benjamin D. Sommers, MD, PhD, Assistant Professor of Health Policy & Economics, Harvard School of Public Health, Boston. Phone: (617) 432-3271. Email: bsommers@hsph.
• To access the 2013 report, The Continuity of Medicaid Coverage: An Update, state-by-state maps detailing overall enrollment continuity ratios and rates broken out by population subgroups, go to www.coverageyoucancounton.org. At the bottom of the page, under "Related Documents," select the document’s title.