LOS ANGELES ACCESS TO HEALTH COVERAGE COALITION

Transcription

1 LOS ANGELES ACCESS TO HEALTH COVERAGE COALITION Standards and Guidelines for Outreach, Enrollment, Retention and Utilization Committing to Excellence October 2008 (Edition 2) Los Angeles Access to Health Coverage Coalition is a project of Community Health Councils made possible by funding from The California Endowment.

2 Acknowledgments Community Health Councils thanks everyone who participated in the LA Access Coalition and Evaluation Workgroup and provided invaluable information, resources, and feedback that propelled the revision of these Standards and Guidelines for Outreach, Enrollment, Retention and Utilization. This project could not have been completed without their knowledge and insight. Asian Pacific Health Care Venture, Inc. Child and Family Guidance Center Citrus Valley Health Partners Community Health Councils Crystal Stairs, Inc. Korean Health Education, Information and Research Center Los Angeles Unified School District/Children s Health Access and Medi-Cal Program (CHAMP) Los Angeles County of Education Maternal Child Heath Access National Health Foundation New Economics for Women Northeast Valley Health Corporation Pasadena Public Health Department QueensCare Family Clinics Tarzana Treatment Center Valley Community Clinic Venice Family Clinic Authors: Mark Paredes, Policy Analyst, Community Health Councils Caroline Rivas, Policy Director, Community Health Councils Lark Galloway-Gilliam, Executive Director, Community Health Councils Edited by: Janice Taylor, Communications Director, Community Health Councils Community Health Councils is a non-profit, community-based health promotion, advocacy and policy organization. CHC s mission is to improve health and increase access to quality healthcare for uninsured, under-resourced, and underserved population. CHC acts as the lead agency in coordinating activities for the Los Angeles Access to Health Coverage Coalition funded by The California Endowment. Permission to copy, disseminate or otherwise use this work is permitted as long as ownership is credited to Community Health Councils and the Los Angeles Access to Health Coverage Coalition.

3 LA Access to Health Coverage Coalition Standards and Guidelines for Outreach, Enrollment, Retention and Utilization Committing to Excellence Background The Los Angeles Access to Health Coverage Coalition formed in 2002 to advance the quality of outreach, enrollment, retention, and utilization (OERU) activities for uninsured children and families in Los Angeles County. The Coalition consists of community-based organizations that work throughout the county to help uninsured individuals and families access and retain low and no-cost health insurance programs. LA Access-member agencies work in many different environments: schools, clinics, communitybased organizations, hospitals, and Women, Infant, and Children (WIC) Centers. All agencies use Assistors to conduct activities that educate families on health coverage programs; help with enrollment applications; provide information on program changes; ensure individuals maintain healthcare coverage through case management services; and present alternative healthcare options for those unable to qualify for government or private health insurance. In some agencies, Assistors help a family through every step of the process and in others responsibilities are divided among a team of Assistors who conduct outreach, data entry, enrollment, follow-up, or a combination of activities. Member agencies conduct OERU through two primary strategies: Inreach and Out-stationing. In-reach utilizes in-house staff and resources for OERU services; outstationing places Assistors in community settings to serve eligible children and families. The Coalition drew upon their cumulative knowledge and experience to develop Standards and Guidelines for Outreach, Enrollment, Retention and Utilization to help organizations and Assistors strengthen their efforts around OERU activities. 1 The Standards and Guidelines provide measures for members to adopt when conducting OERU activities and to hold each other accountable. The Standards and Guidelines were developed to: define outreach, enrollment, retention and utilization activities as a skilled area of expertise create a common language and vocabulary establish a universal set of performance expectations for organizations and Assistors. Assistors are involved in a wide range of case management activities. They educate families on health coverage programs; assist with accessing healthcare coverage; provide information on program changes; ensure individuals maintain coverage; and provide alternative healthcare options for those unable to qualify for government or private health insurance. For purposes of OERU, case management is defined as a comprehensive continuum of services that assesses and manages the needs of uninsured children and families to ensure they successfully maintain health coverage and use services effectively. October

4 The Standards and Guidelines represent an organizational commitment to excellence in customer service. They include Ethical Guidelines for Enrollment Entities and Assistors to pledge and abide by a professional code of conduct that protects the interests, confidentiality and welfare of the consumer, and an expectation that each encounter will result in better access to healthcare for children and families. Ethical Guidelines In conducting OERU activities, Enrollment Entities and Assistors commit to the following ethical guidelines: To comply with all state and federal regulations protecting an applicant s confidentiality To provide accurate and objective information on all available healthcare coverage options To represent no wrong door for gaining access to healthcare coverage programs regardless of organizational interest To serve all members of a family or household regardless of ethnic, racial, economic and national origin To limit advice on eligibility, immigration rights and benefits coverage to the scope of certified training and refer families to the appropriate agency or organization with the expertise to provide a definitive response To demonstrate respect and a judgment-free attitude at all times To advocate on behalf of each family s interest and support them in their issues and concerns. Recommended Standards and Guidelines for Outreach, Enrollment, Retention, and Utilization The Standards and Guidelines outlined here are rooted in the goal of creating an environment, systems and procedures that ensure the enrollment, continuous retention and appropriate utilization of healthcare coverage for all children and families in Los Angeles. The Standards and Guidelines advance and assume adoption of a comprehensive case management model based upon the principle of no wrong door that seeks to reduce barriers and shield families from behind the scenes eligibility systems inherent within each program. OERU covers a wide range of activities, strategies and practices applied towards the promotion, enrollment, retention, and utilization of publicly-sponsored health coverage programs. These programs include: Medi-Cal Healthy Kids California Kids Access for Infants and Mothers (AIM). Healthy Families Kaiser Cares for Kids Child Health and Disability Prevention Program (CHDP) The following pages describe Standards and Guidelines for organizations to adopt to provide the highly specialized and professional services that will maximize access to quality and affordable healthcare coverage. These Standards and Guidelines for Outreach, Enrollment, Retention and Utilization are designed to honor the capacity of each individual organization and advance a universal set of standards as our ultimate aspiration and objective (see Attachment A). The Standards and Guidelines outline comprehensive operational procedures to help guide assistors when conducting OERU activities. Organizations can use the Standards and Guidelines as a tool to assess, enhance, and/or establish operational procedures and expectations for assistors. October

5 Outreach OERU begins with outreach. Outreach increases a community s knowledge about public and subsidized programs; identifies potential applicants; and stimulates interest in accessing healthcare coverage opportunities. Outreach can be defined as activities that provide basic information on program eligibility, healthcare programs, and benefits to expand health coverage to uninsured individuals and families. These activities may include distribution of educational materials, presentations, mailings, mass marketing, promotions, general community outreach, and school-based outreach about available health coverage programs. Outreach services are based on the following Standards and Guidelines. Outreach Recommended Standards Guidelines Before informing individuals and/or families, Assistors must: All outreach and educational materials must be: Outreach activity must: After the initial outreach, Assistors must: Satisfactorily complete and obtain certification through a state-approved Certified Assistor Core Training Program Be fully trained and current with all health coverage enrollment policies Educate and present all available public coverage program options to families Be culturally and linguistically competent Participate in at least one content-related training per year to ensure knowledge of program requirements Access and review state CAA monthly newsletter updates and all county welfare letters to remain current on program changes as they occur Easy to read with a recommended reading level of 4 th -8 th grade for public information materials and public notices 2 High quality translations that are culturally and linguistically adapted for the consumers in your program 3 Include visual aids, pamphlets, incentives or other strategies to address issues of illiteracy Give the family the option of requesting or declining follow-up Provide for the collection of sufficient contact information to facilitate follow-up Contact individuals or families interested in applying for healthcare coverage within 5 days of the initial contact Be knowledgeable about additional healthcare-based referral resources in the community Have a completed background check before working directly with clients or providing services at any outreach or enrollment sites Wear an identification badge that at a minimum identifies their name, title and organization when working at any outreach or enrollment site Be aware of educational codes pertaining to direct contact with students when providing services on school sites Assist and provide individual(s) additional information around healthcare based referral resources Make at least 3 attempts to communicate with the family for each follow-up benchmark October

6 Enrollment Enrollment is the first comprehensive set of case management activities after a family is identified. It is a critical step in establishing a collaborative relationship between the family and the Assistor. Enrollment is defined as a series of activities informing, screening and helping individuals apply for and successfully enroll in a healthcare coverage program or gain access to healthcare services if they are ineligible for coverage. Enrollment services include helping a family submit all required documentation; reconciling any outstanding issues of program eligibility; follow-ups; and verification of the actual enrollment. For purposes of evaluation and performance measurement, there is a difference between application assistance and enrollment. Application assistance entails helping families complete a health coverage application, while enrollment combines assistance with the successful completion and submission of an application and the family s receipt of health coverage. Enrollment services are based on the following recommended Standards and Guidelines. Enrollment Recommended Standards Guidelines Before conducting any application assistance, Assistors must: During the time of application assistance, Assistors must: Be knowledgeable and trained in current health coverage enrollment policies Satisfactorily complete and obtain certification through a state-approved Certified Assistor Core Training Program Be trained in all health coverage programs Participate in at least one content-related training per year to ensure knowledge of program requirements Access and review state CAA monthly newsletter updates and all county welfare letters to remain current on program changes as they occur Assess individual or family needs and explain all available health coverage options Screen and assist with the completion of the appropriate health coverage application forms Ensure each application includes the appropriate documentation and required signatures Explain the timeline and process for reviewing the application for eligibility including the role of the Single Point of Entry (SPE), Healthy Families and county Medi-Cal agency Explain benefits and services provided through managed care plans Explain that, if eligible, Medi-Cal will cover any cost up to 3 months prior to enrollment Obtain an alternate or emergency contact to assist with follow-up Help successfully enroll at least 70% of all applications submitted 5 Be knowledgeable about additional healthcare-based referral resources in the community Have a completed background check before working directly with clients or providing services at any outreach or enrollment sites Wear an identification badge that at a minimum identifies their name, title and organization when working at any outreach or enrollment site Be aware of educational codes pertaining to direct contact with students when providing services on school sites Anticipate a scheduled enrollment assistance appointment to take approximately one hour per application Complete at least 40 applications per 1 full-time employee per month 4 Review client contact information with client to ensure that information is complete and accurate Assist and provide individual(s) additional information around healthcare based referral resources October

7 Enrollment Recommended Standards Guidelines During the period between the submission and the actual verification of enrollment, Assistors must: Conduct at least a 90-day follow-up call to verify enrollment and assist in responding to any inquiries the family may have received Contact the family to verify receipt of eligibility notification and provide additional assistance if necessary Utilize the Automated Eligibility Verification System (AEVS) or the Medi-Cal Eligibility Database System (MEDS) if accessible to verify enrollment on individuals and/or families they are unable to personally contact Tell those individuals accepted into Medi-Cal about Medi-Cal managed care. This includes voluntary versus involuntary enrollment, enrollment materials, choosing a health and dental plan/provider, and offering assistance with completing forms. Remind adult family members enrolled in Medi- Cal that they will receive a Mid-Year Status Report form after 6 months of enrollment and they must complete and submit it to retain their coverage. Encourage families to contact their Assistor if help is needed. 6 Remind the individual or family to maintain payment of monthly premiums (if required by the program) Notify the individual or family that they will be contacted again in 3 months to ensure retained enrollment, update contact information, and to inquire about utilization of services Conduct at least 3 attempts to communicate with the family for each follow-up benchmark Maintain at least an 80% successful completion rate on the 90-day family follow-up benchmark for all families assisted and not lost to contact 7 Access and review state CAA monthly newsletter updates and all county welfare letters to remain current on program changes as they occur Conduct more frequent enrollment follow-up calls at 30 days and/or 60 days to address issues and concerns or help the family access healthcare services until enrollment is confirmed When the individual or family cannot be contacted and is considered lost, Assistors must: Send a letter instructing the individual or family to contact the agency to provide a current phone number, updated contact information, and health coverage status October

8 Utilization Utilization services are critical to maintaining health coverage. Assistors may provide utilization services anytime after an individual has confirmed health coverage enrollment. Utilization services are defined as Case Management activities that promote an individual s understanding of how to effectively use his/her or their children s health benefits and navigate through the healthcare system. Utilization services also include advocacy and education, encouraging timely check ups and the regular use of preventative, prenatal, dental, immunization, vision, and mental health services. Utilization services are based on the following recommended Standards and Guidelines. Utilization Recommended Standards Guidelines During the 6- month period following enrollment, Assistors must: Conduct at least one follow-up call with the family at 6 months to assess enrollment status and to help resolve any problems among the family, the health coverage program administrator and their health plan Inform and encourage individuals and/or families on the significance and appropriate use of preventive healthcare Offer assistance to individuals and/or families in overcoming any barriers to utilization of services such as setting appointments, changing health plans/providers or retaining health coverage Offer assistance in completing the Medi-Cal Mid-Year Status Report form and assist with any managed care issues Confirm and document individual and/or family use and access of healthcare services Conduct at least 3 attempts to communicate with the family for each follow-up benchmark Ensure that 80% of those assisted utilized or attempted to use services 8 Tell the individual or family that they will be contacted again in 5 months to ensure retained enrollment, verify redetermination/ re-enrollment materials, and provide assistance When the individual or family cannot be contacted and is considered lost, Assistors must: Send a letter instructing them to contact the agency to provide a current phone number, updated contact information, and health coverage status October

9 Retention Families face many hurdles that could lead to the loss of health coverage, ranging from failure to pay the monthly premium required by some programs to forgetting to re-apply during annual renewal. Retention services are defined as Assistors helping families retain coverage by consistent contact through calls and case management. Retention services also include advocating on behalf of the family to ensure that reenrollment packages are received; helping families complete forms and submit the necessary documentation at the time of redetermination. 9 Individuals who successfully retain health coverage for at least 14 months constitute retention for the purposes of evaluation and performance measurement. Retention services are based on the following recommended Standards and Guidelines. Retention Recommended Standards Guidelines During the 11- month redetermination and 14-month retention period, Assistors must conduct follow-up calls to: Inquire if the individual or family received their renewal materials and encourage them to reapply and seek re-enrollment assistance Advocate on behalf of the individual and/or family to ensure redetermination packets are received and encourage them to seek assistance Ensure redetermination forms include the appropriate documentation and required signatures Assist with providing referral and enrollment services to other available coverage programs should the individual and/or family become ineligible for the currently enrolled program Assist with the completion of the appropriate health coverage program redetermination forms if requested by the family Confirm individual and/or families received redetermination/re-enrollment forms Utilize the Automated Eligibility Verification System (AEVS) or the Medi-Cal Eligibility Database System (MEDS) if accessible to verify re-enrollment on individuals and/or families they are unable to personally contact Make at least 3 attempts to communicate with the family for each follow-up benchmark Inquire and verify successful retention of health coverage and provide any additional assistance Generate an average of 70% or higher of individuals retaining health coverage Assist and provide individual(s) additional information around health care based referral resources When the individual or family cannot be contacted and is considered lost, Assistors must: Send a letter instructing them to contact the agency to provide a current phone number, updated contact information, and health coverage status October

10 Tracking OERU Activities Collecting information about families and maintaining a database will support and enhance OERU activities. Assistors should document contact information, describe the services provided to families (e.g., application assistance, follow-up, etc.), dates of service, and the status of applications. A reminder system with due dates for health insurance annual renewal forms will help ensure continuous enrollment. The table below outlines the information agencies should collect when assisting families during OERU activities. Tracking Activities Agencies interested in tracking OERU activities must: Recommended Standards Create or utilize a data tracking system to document activities around Outreach, Enrollment, Retention and Utilization that includes the following information for each set of activities: Outreach: outreach event dates; an outreach contact form and event summary sheet; sign-in sheets for participants; follow-up contact attempts with date(s); and scheduled enrollment appointment date(s) Enrollment: date of enrollment assistance; follow-up attempt(s) with date and time; enrollment status; and type of assistance provided Retention: follow-up attempts with date and time; enrollment status; services utilized and type of assistance provided Utilization: follow-up attempts with date and time; enrollment status; services utilized and type of assistance provided Document and maintain records of individual and/or families assisted Guidelines Ensure timely entry of data for reporting and program monitoring Conduct periodic reviews of records for accuracy and quality 1 For purposes of this discussion, Assistors are also defined as Certified Application Assistors (CAAs), Enrollment Specialists, Outreach Workers or Promotoras. 2 Harvard School of Public Health, Health Literacy Studies. Available at 3 Maximus Center for Health Literacy. The Health Literacy Style Manual. Available at 4 Based on a survey of individual LA Coalition members current practices and expectations of assistors and the County of Los Angeles Department of Health Services performance measurement for agencies providing community health coverage. 5 Ibid. 6 Effective January 1, 2009, children on Medi-Cal will be required to renew their application every six months because of policy changes implemented under California s State Budget. Organizations utilizing the Standards and Guidelines for OERU will need to adjust follow-up contacts accordingly based on an individual s health coverage program. 7 Based on a survey of individual LA Coalition members current practices and expectations of assistors and the County of Los Angeles Department of Health Services performance measurement for agencies providing community health coverage. 8 Ibid. 9 Redetermination is defined as screening and assisting individuals and/or families through the renewal process that occurs at 11 months. October

11 Attachment A (SAMPLE) Pledge to Support understands the purpose and mission of the Los Angeles Access to Health (Name of Organization) Coverage Coalition Standards and Guidelines for Outreach, Enrollment, Retention and Utilization: Committing to Excellence and as a member of the Coalition agrees to follow and implement these Standards and Guidelines to develop and enhance programs, policies, procedures and training revolving around OERU in effort to improve healthcare access for all individuals in Los Angeles County. Print Name Signature Date Contact Information: Title: Mailing Address: Telephone: Fax: Address: Please read and sign the agreement and submit to LA Access to Health Coverage Coalition. Mark Paredes LA Access to Health Coverage Coalition Community Health Councils 3731 Stocker Street, Suite 201 Los Angeles, CA x (fax) [email protected] October

12 COMMUNITY HEALTH COUNCILS 3731 Stocker Street, Suite 201 Los Angeles, CA