Helping obtain Medicaid is more complex’
Helping patients obtain financial assistance in the form of Medicaid has "clearly gotten more complex" for patient access areas, as a result of the Affordable Care Act (ACA), says Gwynne Mesimer, vice president of operations for Union, NJ-based Chamberlin Edmonds, an Emdeon company. Emdeon is a provider of revenue and payment cycle management and clinical information exchange solutions.
Patient access is seeing the following changes:
• In states that have opted in to Medicaid expansion: "The most significant change for hospitals is the new regulation related to presumptive eligibility [PE] for patients in a hospital setting," Mesimer says.
All patients for whom eligibility can be determined through the use of modified adjusted gross income (MAGI) will be eligible for Medicaid presumptively.
"Obviously, more patients will qualify for Medicaid in an opt-in state, and this process is likely to be simpler and faster," Mesimer says. She adds that the combination of real-time data matching and the elimination of a medical disability requirement "will usher in a significant increase in the Medicaid-eligible population."
The question that remains is how many of these individuals will seek Medicaid proactively. "If patients continue to wait until they are admitted to either an emergency department or inpatient hospital stay for an episode of care, the hospitals will still be required to screen, apply, and see that enrollment is complete for these patients," Mesimer explains.
• In Medicaid "opt-out" states: "There could be an increase in interest to apply for Medicaid — the woodwork’ effect — if patients see publicity about health insurance and consider this as a personal opportunity for them," says Mesimer.
PE for Medicaid is available in opt-out states. "However, the scope of patients that can be considered for PE remains fairly narrow with the audience generally being limited to pregnant women and children," she says.
Hospitals will need to be able to determine which patients get what type of application and screening criteria in opt-in and opt-out states. "One of the most common forms of Medicaid, related to the long-term care patient who is being discharged with services that they cannot afford, such as skilled nursing facility care, still requires a complex application," adds Mesimer.
Proactive approach needed
Many hospitals have traditionally used for-profit enrollment vendors to help patients obtain Medicaid coverage, notes David A. Roos, PhD, executive director of Covering Kids & Families of Indiana, an Indianapolis-based outreach program that assists families with completing paperwork required for the Hoosier Healthwise and Healthy Indiana Plan.
"The biggest problem with that sort of approach is that it’s reactive rather than proactive," Roos says. "That is, the hospital has already incurred costs for services they’ve provided to individuals."
As most states have Medicaid available on a retroactive basis, notes Mesimer, "even if a person waits until they have a healthcare encounter, it is still likely to cover that expense with Medicaid for those persons who meet the income requirements."
Although the ACA does allow hospitals to offer presumptive eligibility for Medicaid programs, Roos says that this strategy is also reactive.
Patients still will be going to the hospital without coverage. "At some point, the hospital will discover they are uninsured and then will react and exercise presumptive eligibility to get them into a Medicaid or CHIP [Children’s Health Insurance Program] program," he explains.
Some hospitals have adopted a different approach, by working with community-based agencies to reach patients before they present for services. "By working with community partners, hospitals can come up with creative ways where they can get much further up the stream’ and increase the total number of people with coverage," says Roos.
