Revised, September 20, 1999
How Health Care Providers Can Help Link Children
to Free and Low Cost Health Insurance Programs
by Donna Cohen Ross
Health care providers can be instrumental in efforts to enroll eligible children in Medicaid or low-cost health insurance. Staff at community health clinics and hospitals — including doctors, dentists, nurses, therapists, medical social workers, pharmacists and workers in registration and billing office — not only interact directly with patients, but often are trusted advisors to families. Many families rarely think about needing health insurance until a child gets sick or hurt and needs care. At the same time, routine preventive care is virtually impossible to obtain without health insurance. Health professionals are in a good position to help families unravel this dilemma — they can emphasize the importance of prevention and help families get coverage for their children.
In addition to providing an important service to families and communities, getting involved in outreach also is in the best interests of the health care providers themselves. Making sure children have the insurance coverage for which they are eligible can bring financial resources into hospitals and clinics that may be hard-pressed to maintain quality care. Providers that have the capacity to hire staff or help finance outreach activities — either within their own hospitals or clinics or in conjunction with other community-based organizations — may view such activities as a way to help generate future revenues.
Here are ten ways health care providers can help:
1. Inform families about the availability of free and low-cost health insurance for their children. Disseminate information about free and low-cost health insurance at every opportunity. Display posters and distribute flyers and brochures in clinic waiting rooms, registration areas, cafeterias, lounges, pharmacies and other locations. Include an article about free and low-cost health insurance for children in staff and community newsletters. Remember that hospital trustees are community leaders; ask them to share this information in other community settings. If your hospital or clinic has access to the airwaves — through local radio or TV talk shows or consumer affairs programs — produce a segment on the availability of free and low-cost health insurance. Be sure to tell readers or listeners how they can obtain an application. If your state has a short, mail-in form keep a supply on hand for families. Let families know if they can complete an application at the hospital or clinic or if they need to go to somewhere else to apply. Let applicants know what documents to bring with them.
2. Enlist all staff in outreach efforts. Physicians and nurses may have the most direct contact with patients, but often — due to heavy caseloads and busy schedules — they may not be best-suited to talking with families about the details of obtaining health care coverage. Receptionists and other "point of entry" hospital and clinic staff who help families sign in and complete patient information forms are in an excellent position to raise these issues with families. Make sure all hospital and health center staff — especially hospital social workers and hospital volunteers — have a basic knowledge of eligibility rules and application procedures for Medicaid and other health insurance programs, or can quickly refer a family to a staff member who does.
Making good use of clinic waiting rooms in New York. The Court Street Diagnostic and Treatment Center in Utica, NY found a way to help make sure patients who are eligible for Medicaid or other health insurance get covered. The clinic's executive director realized that a lack of accurate and up-to-date eligibility and enrollment information at the registration desk was hampering the clinic's efforts to get patients insured. Court Street established new procedures, and trained its staff so that a patient's first encounter with clinic staff was also a vehicle for providing accurate information about insurance. The clinic's Americorps volunteer is central to this effort. She staffs an information table and "circulates" in the waiting room to answer questions and help patients complete Medicaid application forms. She also assists families with Medicaid applications in their homes. A second Americorps volunteer will be added to the project in the Fall of 1998 to accommodate the large number of families requesting assistance.
3. Encourage your state to outstation Medicaid eligibility workers in hospitals and clinics in your community. States are required to provide opportunities for pregnant women and children to apply for Medicaid at locations other than the Medicaid office. These locations — called outstations — can eliminate barriers that may arise when families are required to go to the Medicaid office to apply. Under the law, states must outstation Medicaid eligibility workers in two types of settings: hospitals that serve a large number of low-income patients and federally qualified health centers. Work with your state to make sure the hospitals and clinics in your community have outstationed workers who can enroll children in Medicaid. If this is not feasible in every community, work to ensure that hospital and clinic staff are trained to conduct initial processing of Medicaid applications — that is, to prepare applications for formal eligibility determination by state eligibility workers.
The most effective outstations respond to the specific needs of families in their community. For example, outstations may need to operate during hours that are most convenient for working families or they may need to provide interpreters for families that speak languages other than English. Hospital and clinic staff who are trained to help applicants sign-up for Medicaid are assisting families in community settings beyond the walls of their institutions. If your state has initiated a separate child health insurance program, outstationed staff can assist families with children not eligible for Medicaid with applications for the new program.
Hospital staff team up with Medicaid workers in South Carolina. There's a lot of Medicaid outreach going on inside — and outside — Greenville Hospital in Greenville, South Carolina. The hospital produces fact sheets to help clinicians identify pregnant women and children who may be eligible for Medicaid and refer them to outreach workers employed by the hospital. Hospital outreach staff and state Medicaid enrollment workers help patients complete applications properly, and the processing time for Medicaid applications for hospital patients has been significantly reduced. Hospital outreach staff also make presentations about Medicaid benefits to community residents in housing projects, churches, and Head Start programs and invite families to apply. Each month, over 300 Medicaid applications originating from the Greenville Hospital outstation are approved.
Outstationing on the border between Missouri and Kansas. For the last ten years, Children's Mercy Hospital in Kansas City has been working with the Medicaid agencies in both Missouri and Kansas to ensure that eligible patients from either state can receive health insurance coverage. The Missouri Department of Social Services (DSS) has provided the hospital with a Medicaid eligibility worker and a computer station linked with DSS. Patients who are Missouri residents can easily enroll in Medicaid at the hospital. In addition, hospital staff arrange for Medicaid eligibility workers from Kansas to visit the hospital regularly and patients who are Kansas residents can see those workers by appointment. The hospital's Director of Social Work and Community Services has tried to hire former state Medicaid staff to work in the hospital's admitting office. Because these staff are familiar with the Medicaid enrollment system, they can easily identify patients likely to be eligible and send them to the outstationed worker for help in applying.
4. Persuade your state to adopt the Medicaid Presumptive Eligibility option. Under the Balanced Budget Act of 1997, states now have the option to make Medicaid presumptive eligibility determinations for children. This option, previously available only for pregnant women, allows certain "qualified entities" — including health care providers that receive Medicaid reimbursements — to directly enroll children in Medicaid if, based on the family's declaration, their income is below the state's eligibility guidelines. Families have until the end of the month after the presumptive eligibility determination is made to file a formal Medicaid application and provide verification documents. A child presumed eligible can receive all Medicaid services pending formal determination of Medicaid eligibility; providers receive payment for services delivered during this period. Presumptive eligibility can ensures that children get routine health care and medical treatment without delay. Clinic or hospital staff can assist families in completing the formal Medicaid application process so that eligible children maintain their insurance coverage after the presumptive period.
Streamlining enrollment for children in Nebraska. Nebraska is one of nine states that have adopted the Medicaid presumptive eligibility option for children. Staff of community health centers and local health departments are currently authorized to make presumptive determinations for children who appear to be eligible for coverage. To presumptively enroll a child, they assist families in completing a simple, two-page form. The family keeps a copy of the form, which serves as a temporary "enrollment card" and will be accepted by health care providers as proof of coverage if the child needs medical care before the final Medicaid eligibility determination is made. Another copy of the form is submitted by the health center or health department staff to the local Medicaid office within five days. The family has several weeks to complete the process by providing proof of income. Provider staff are available to help families complete this last step. Several providers implementing the process say their early experiences are promising. For example, the Lincoln-Lancaster Health Department receives feedback from the local Medicaid office regarding the number of its presumptive applications that are approved and denied. The health department recently reported a 93 percent approval rate. With presumptive eligibility, staff of the Panhandle Community Services health center are able to provide better service to their community. Health center staff attend activities at schools, Head Start centers and WIC clinics and are able to enroll children on the spot.
5. Forge connections in the community. Community-based organizations and health care providers often work with the same families and therefore have a mutual stake in their health and well-being. Critical skills for outreach workers include understanding the concerns and fears some families may have about participating in public programs and being able to establish trust and communicate effectively. Thus, health care providers may wish to recruit members of the local community to conduct outreach activities. In many cases, community-based programs that are already established in the community are best able to conduct outreach activities. Health care providers may be in a position to provide financial and in-kind support for such efforts. Working side by side, providers and community groups can identify children who are potentially eligible for health insurance coverage, and can join forces in helping them get enrolled.
Building an "outreach army" in New York. The Peekskill Area Health Center in upstate New York has undertaken a major effort to recruit and train community members to serve as health education and outreach workers — to be "tentacles" stretching into areas of the community that are often unreachable by professionals. The clinic spends approximately $10,000 per year on stipends for about 150 teens and adults who serve as outreach workers. Medicaid and other health insurance enrollment has increased among the groups served by the clinic's "army" of outreach workers.
Providers lend financial support for outreach in Pennsylvania. Concerned about a decline in children's Medicaid enrollment, Philadelphia Citizens for Children and Youth (PCCY) brought together community leaders to develop a plan for increasing awareness about the availability of children's health insurance. A coalition of funders that included the Keystone Mercy Health Plan, a local managed care provider, teamed up to assist the effort. With funds contributed by members of the coalition, PCCY placed over 5,000 posters in pediatricians' offices, in health clinics, and on the inside and outside of city buses. The posters were designed by RBT/Strum, a local advertising agency, that donated its time and creativity to the effort. The slogan on the posters, "Just for Kids, Just for Asking" emphasized that children's health insurance is available and enrollment is easy.
6. Incorporate application assistance into home-visiting and mobile health van programs. Providers can help enroll families who live in very remote areas or who have difficulty leaving their homes by incorporating child health insurance outreach into home-visiting and mobile health van programs.
Mobile health van programs around the country provide a broad range of health care services, from mammograms, HIV/STD prevention and migrant farmworker safety training to mental health and substance abuse counseling and flu shots. Vans are used in rural areas to increase access to health care. They also are useful in urban areas to serve homeless families, people unable to get time off from work, or runaway youth. Mobile health van staff can be trained to assist families in completing applications for Medicaid and other child health insurance programs. This will be easiest in states that have short, simple application forms.
Home visits also can be an excellent opportunity for providing families with information about children's eligibility for health insurance. Home visitors can arrive supplied with an application and offer help in completing it. Parents are more likely to be comfortable and attentive in their own homes — especially when the visitor has been invited — and they may have easier access to needed documents.
Home visitors sign children up in Virginia. The Child Health Investment Program (CHIP) of Virginia links over 4,000 children in the state with physicians and dentists who can assure appropriate care in a consistent setting. Home visits are the key to the program. Home visitors help families keep doctor appointments and follow through with recommended medical treatment. At the first CHIP visit, the home visitor finds out if children in the family are covered by Medicaid. If not, the home visitor can help the parent complete the two-page Medicaid application and mail it to the local Department of Social Services. If there is a need to visit the Medicaid office or if families need help assembling required documents, the home visitor can provide transportation. One CHIP home visitor took eight mothers to Richmond to obtain official copies of their babies' birth certificates. CHIP home visitors also help families maintain their Medicaid coverage by assisting them with the recertification process. Another tip: Virginia's CHIP home visitors carry cell phones, which they can use to call the Medicaid office with questions while they are in a family's home helping them with the application.
Reaching into rural counties in Indiana. The Caylor-Nickel Medical Center in Bluffton, Indiana worked with the local Office of Community and Family Services and five other agencies to purchase and share use of two mobile health care vans. The vans serve six rural counties in which residents face significant health care access barriers. Social workers or nurse practitioners, who staff the vans, provide information and assistance with Medicaid applications, which can be mailed in to the Medicaid office. Van staff report seeing a great number of eligible families who are not yet signed up for coverage.
A specialized health services van gets the application process started for children in California. The Asthma and Allergy Foundation is using its mobile unit, the Breathmobile, to help link families with Medi-Cal, California's Medicaid program. The Breathmobile offers treatment to children suffering from allergy- and asthma-related problems at 18 Los Angeles public schools. Physicians, nurses and a financial services worker staff the mobile unit. The financial services worker is responsible for helping children register to receive services and for gathering information about their families' insurance status. Families who appear to be eligible for Medi-Cal are offered assistance with the application process. The financial services worker does the initial processing of the application and mails it to the Medi-Cal eligibility worker. Families take home a copy of the completed form, as well as detailed instructions on any further information they need to supply to the Medicaid office in order for an eligibility determination to be made. Families also receive a notice from the Medicaid office confirming that the application was received and indicating what additional information may be needed to process the application.
7. Partner with schools. A recent GAO study found that 69 percent of uninsured, Medicaid-eligible children were either in school or had school-age siblings and so could be reached through school-based efforts. Health care providers can help identify and enroll eligible children at school-based clinics, health fairs, registration events and extracurricular activities. Since health concerns are often first identified by school professionals, such as teachers, social workers and school-based health care staff, enrolling children in this way will help assure that children receive treatment for health needs before they become serious problems.
Partnership between hospitals and schools is growing in Idaho. The Hospital Consortium of North Idaho recently received a three-year, $600,000 Rural Health Demonstration grant from the federal government to enhance school nursing in 12 school districts in five northern Idaho counties. The Coeur d'Alene school district contracts with the Kootenai Medical Center for a nurse who has 14 schools to cover. This busy nurse says she is inseparable from her cell phone. If she's called to help out when a child is injured on the playground, she can keep in constant touch with the school until she arrives at the scene. The phone also comes in handy for helping uninsured children get coverage through Medicaid. She's often on the line with local Medicaid workers, arranging application appointments or ensuring that papers are processed. The nurse has helped convince lots of families to submit applications even when they thought their children wouldn't qualify.
Building partnerships with Federally Qualified Health Centers in West Virginia. New River Health Association is a federally qualified health center that operates four school-based health clinics and also provides technical assistance to other school-based clinics in elementary, middle and junior high schools across West Virginia. Clinic staff ask parents whether or not their children are eligible for free or reduced-price school meals to assess whether the children are likely to qualify for Medicaid or other state-funded health services. Staff at the in-school clinics provide the families of potentially-eligible children with a Medicaid application form and material explaining program benefits. They follow up with a phone call to offer further assistance, if necessary. New River staff maintain a good working relationship with the local Medicaid office so they can troubleshoot if there are problems.
8. Play a role as a member of the business community and as an employer. Hospitals, clinics and MCOs often are respected members of the business community. They may have both customers and employees who have children eligible for Medicaid and other state child health insurance programs. There are a number of steps hospitals and clinics can take to help their employees take advantage of this coverage, including providing information on bulletin boards and with paychecks, periodically making outstationed Medicaid eligibility workers available to staff, and offering paid leave time so that employees can get their children enrolled. Health care providers also can have a positive influence on their business partners. For example, they can give preference to physician groups and other providers that serve patients enrolled in Medicaid or other public health insurance programs. They can encourage their suppliers to promote the availability of free or low-cost health care coverage to their employees.
Enrolling the children of hospital employees in Oklahoma. Social workers at St. Francis Hospital in Tulsa, Oklahoma are helping hospital employees enroll their children in Medicaid. After conducting a successful outreach campaign in the community, social work staff recognized that hospital employees also may have children who are eligible for Medicaid. Information on Medicaid was mailed with paychecks, and applications were placed outside the social work office. St. Francis received more than 70 inquiries about Medicaid from staff members as a result. A specific social worker was assigned to assist employees who needed help completing the application. The next stop in their campaign to reach hospital staff — the employee cafeteria.
9. Promote outreach through professional associations. State or local professional organizations may be willing to lend support to health insurance outreach and enrollment efforts. In a number of communities hospital associations, pediatrics societies or similar associations have catalyzed outreach activities with financial support to community groups or have encouraged their members to become involved in efforts undertaken at the hospitals or clinics in which they work.
Medical Society takes a lead role in Massachusetts. The Massachusetts Medical Society has taken a number of steps to engage physicians in efforts to help children get health insurance coverage. The Medical Society mailed to all physicians in the state a poster and two brochures about the availability of health insurance for children. Physicians also were provided with a rolodex card containing the phone numbers needed to get more information, as well as a postcard they could mail back to the Medical Society to request additional materials. To enhance these efforts the Medical Society recently launched a $60,000 outreach project aimed at publicizing the availability of free and low-cost health insurance in Massachusetts. The project will target all practicing physicians and their office staffs, through training, one-on-one discussions, and dissemination of information.
10. Participate in national efforts. There are a number of national initiatives aimed at increasing health care coverage, with which you can join forces:
In January 1997, the American Hospital Association, in partnership with its state and metropolitan hospital association partners, launched the "Campaign for Coverage," to reduce by 4 million the number of people without health care coverage by linking health care providers with other care givers, businesses, government agencies and community leaders to devise local solutions. To date, more than 1,000 hospitals and health systems around the country have committed to participating in the campaign. For information about Campaign for Coverage efforts in your state or community, call AHA at (800) 555-7218, or see their website at www.aha.org.
In July 1997, the Daughters of Charity National Health System (DCNHS), Carondelet Health System (CHS) and Catholic Charities USA launched the Children's Health Matters initiative to support local Catholic Charities agencies and health ministries in the development of community Medicaid outreach programs to identify and enroll eligible children. Children's Health Matters advocates a two-pronged approach for increasing health care coverage among children: One is to conduct a community education campaign to increase awareness of the availability of Medicaid, the eligibility guidelines and the benefits it provides. The other is to encourage state Medicaid officials and state legislators to use the flexibility they have under the law to simplify the Medicaid application process. For more information, call Lisa Smith or Jamillia Ferris at (703) 549-1390, or visit the Child Health Matters website at www.dcnhs.org.
For more information on outreach activities, contact Donna Cohen Ross , Jacqueline Patterson or Laura Cox at 202-408-1080.