A PUBLICATION OF THE NATIONAL ACADEMY FOR STATE HEALTH POLICY October 2015 Health Centers’ Role in Affordable Care Act Outreach and Enrollment: Experience from Kentucky and Montana Alice M. Weiss and Najeia Mention Executive Summary The Affordable Care Act created new opportunities for health centers and primary care associations (PCA) to play a leading role in sup- Key Findings porting outreach and enrollment into new and expanded health • Kentucky and Montana Medicaid and coverage programs. Health centers and PCAs received new exchange/insurance agencies cultivated funding, sometimes from multiple state and federal entities, new important partnerships with PCAs and training and tools, and a new mandate to find and enroll eligible health centers to support outreach and individuals, both within their patient caseload and in the broader enrollment assistance activities under the community. In undertaking this charge, many health centers and Affordable Care Act. PCAs found themselves engaging new partners, building stronger • PCAs and health centers play a cen- relationships with state Medicaid and insurance or exchange agen- tral enrollment assistance role that has cies, and often playing a central role in coordinating outreach and supported success in two states with top enrollment activities in their state or community. enrollment performance in the first two years of enrollment. To better understand the new roles of these entities and identify • PCAs and health centers are reaching be- promising strategies in their coordination with state Medicaid and yond traditional health center populations insurance/exchange agencies, NASHP undertook a case study and adopting innovative strategies and review of Kentucky and Montana, two states with strong enrollment new partnerships to increase enrollment. • Health centers in Kentucky, a Medicaid performance where the state PCA and health centers played an im- expansion state, shifted more of their pa- portant role. With support from the Health Resources and Services tient population into coverage programs Administration’s National Organizations of State and Local Officials than health centers in Montana, possibly Cooperative Agreement, NASHP interviewed representatives from indicating an advantage for health centers the PCA, a health center, and a Medicaid agency in each state about in expansion states. their respective roles in and coordination of outreach and enrollment • Health center collaboration with state assistance during the first two years of Affordable Care Act imple- and federal agencies is central to effective mentation.1 Findings from these interviews are summarized here, outreach and enrollment activities and with case studies highlighting each state’s circumstances and ex- continued collaboration and funding can periences, followed by a discussion of common themes relating to support future efforts. collaboration with state and federal agencies, lessons learned, and • Low health literacy among the health future priorities for outreach and enrollment work with states. center population poses a continuing chal- lenge to supporting and retaining enroll- Background ment into new coverage programs. The Affordable Care Act and related federal regulations created new national standards for enrollment assistance entities to support en- rollment into new health insurance options. For Health Insurance Marketplace enrollment, new federal grants provided by the Cen- ter for Consumer Information and Insurance Oversight (CCIIO) at Health Centers’ Role in Affordable Care Act Outreach and Enrollment: Experience from Kentucky and Montana 2 the Centers for Medicare and Medicaid Services in the first year of open enrollment and as a com- (CMS) funded assistance entities, called either ponent of annual funding for the second and fu- in-person assisters (IPAs) in State-based Market- ture years.4 These funds support a range of health place (SBM) states or navigators in federally facil- center activities related to outreach and enrollment itated marketplace (FFM) states.2 (See Affordable into new insurance coverage options.5 HRSA has Care Act Glossary in the Appendix for definitions also provided $6.5 million annually to 52 state and of related terms.) Federal guidance also created regional PCAs to provide outreach and enrollment other assistance entities to support enrollment into related engagement, technical assistance, and Health Insurance Marketplaces, Medicaid, and coordination support to health centers within their the Children’s Health Insurance Program (CHIP), state or region. called certified application counselors (CACs). The general charge for these entities was the Enrollment into new health coverage options cre- same: provide needed education about coverage ated under the Affordable Care Act has been ro- options, answer questions, establish eligibility, fa- bust in the first two years. Estimates suggest that cilitate completion and submission of applications, more than 16 million individuals have gained new and support enrollment into coverage for eligible coverage through Medicaid, CHIP, and the market- individuals.3 places, with coverage gains the strongest among low-and middle-income individuals and among Recognizing that health centers could play an im- subgroups of young adults, non-white, and Latino portant role in identifying and enrolling newly el- populations.6 During the period since the Afford- igible individuals, the Health Resource Services able Care Act was implemented, national unin- Administration (HRSA) awarded $150 million in surance rates have dropped, from 17.1 percent in grants under the Affordable Care Act annually to the first quarter of 2013 to 10.1 percent in the first fund outreach and enrollment activities by feder- quarter of 2015.7 ally-funded health centers, as stand-alone grants Fig. 1. Overview of Case Study States Kentucky Montana Medicaid Expansion Type Expansion Non-expansion* Exchange Type State-based Marketplace (SBM) Federally facilitated Marketplace (FFM) Total Enrolled: Medicaid/CHIP 548,102 (90.3% increase) 24,918 (16.7% increase) Total Enrolled: Marketplace FY 15: 106,330 (72% renewals) FY 15: 54,266 (59% renewals) FY 14: 82, 747 FY 14: 36,584 Primary Assistance Entities In-person Assisters (kynectors) Navigators CACs8 CACs Agents/Brokers Agents/Brokers Number of HRSA-Funded HCs 23 17 HRSA Grants Supporting HC Out- FY 14: $500,000/20 health centers FY 14: $740,559/15 health centers reach/Assistance (Total/#)9 Total (FY 13-14): $2,883,522 Total (FY 13 -14): $2,217,598 HRSA Grants to PCAs10 $750,000 $148,730 * Expansion was legislatively approved in 2015 is pending implementation for FY 2016. NATIONAL ACADEMY FOR STATE HEALTH POLICY | Download this publication at www.nashp.org Health Centers’ Role in Affordable Care Act Outreach and Enrollment: Experience from Kentucky and Montana 3 As the Affordable Care Act offers new health cov- Benefit Exchange, the state agency that oversees erage options and incentives for enrollment, it is kynect. The exchange agency has worked col- profoundly impacting health centers’ business op- laboratively on all aspects of Affordable Care Act erations and patients’ access to new coverage op- implementation, including enrollment efforts, with tions.11 Given the new federal and state funding the Department of Medicaid Services (the state’s opportunities and health centers’ unique connec- Medicaid agency), the Department of Communi- tions to local communities, many health centers ty-Based Services (the state’s eligibility agency), are finding their roles shifting to focus more on ed- and the Office for Administration and Technology ucating and enrolling the communities they serve Services. on coverage options and seeing an increase in patient caseload.12 In addition, an increasing per- The exchange and Medicaid agencies are leading centage of patients are now either eligible for or en- initiatives to help the state identify and enroll hard- rolled into a coverage program that pays for health to-reach populations, including immigrants, jus- services.13 While this increase in coverage rates is tice-involved populations, and homeless individu- providing new revenues for health centers, it also als. Medicaid is also providing important funding poses new challenges for patients that may be support to sustain exchange operations in future unfamiliar with traditional coverage and insurance years. Since kynect processes eligibility and en- rules, including eligibility and renewal requirements rollment for a large number of Medicaid applicants, and rules about premiums, copayments, coinsur- approximately 75 percent of kynect’s outreach and ance, deductibles, and penalties. The Affordable education costs are allocated to Medicaid. This al- Care Act is also presenting new opportunities for lows the state to claim federal Medicaid matching health centers to proactively collaborate with state funds. State officials also noted that Medicaid ex- Medicaid and insurance agencies in outreach and pansion has been a primary driver in Kentucky’s enrollment efforts. In some cases, state PCAs and enrollment success, with a majority of those gain- health centers are taking on new leadership roles ing coverage enrolling in Medicaid. in their state or community to support other assis- tance organizations or stakeholders in coverage Kentucky has seen a dramatic growth in cover- expansion initiatives.14 This brief offers case stud- age under the Affordable Care Act, signaled by a ies to shed light on health center experience with drop