Enrolling and Retaining Uninsured and Underinsured Populations in Public Health Insurance Through a Service Integration Model in New York City

Abstract

Innovative strategies to identify uninsured and underinsured populations are critical to successful enrollment and retention in public health insurance. The New York City Department of Health and Mental Hygiene’s Office of Health Insurance Services has partnered with the department’s Early Intervention Program to implement a Service Integration Model to enroll special needs children, aged 0 to 3 years, into public health insurance. This model uses data from program databases and staff from children’s programs to proactively identify uninsured and underinsured children and facilitate their enrollment into public health insurance. The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

KEY FINDINGS.

■ Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance.

■ The Office of Health Insurance Services Service Integration Model has 3 key components allowing for comprehensive and continuous coverage for children with special health care needs: integration of program messages within the Early Intervention Program, data matching with child program data (Early Intervention data, Medicaid data), and incorporation of program staff (Office of Health Insurance Services child benefit advisors) to work directly with parents.

■ The combination of access to child program data to identify children and one-on-one assistance to complete public health insurance applications has successfully assisted more than 5000 families in the New York City Early Intervention Program.

IN NEW YORK STATE, AN estimated 12.7% of children have special health care needs.¹ According to McPherson et al., children with special health care needs are defined as

those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.^{2 (p.138)}

The 2005–2006 National Survey of Children With Special Health Care Needs found that 38% of families with special needs children had inadequate health insurance coverage.¹ Data indicate that 16% of children with special health care needs did not receive any health care services in the past year; 45% of uninsured children with special health care needs needed at least 1 service not received, compared with 22% of publicly insured children, 19% of children with dual coverage (public and private), and 11% of privately insured children. Services not received included dental care, mental health care, therapies, and specialty care.

In New York City, almost 40 000 children per year with a diagnosed developmental delay or disability receive services through the Early Intervention Program—a federal entitlement program for children aged 0 to 3 years. In New York City, the Early Intervention Program is administered through the New York City Department of Health and Mental Hygiene (DOHMH). Programs for children with special health care needs, such as the National Early Intervention Program, have been created to ensure that infants and children with developmental disabilities or delays receive needed services. To be eligible for services, children must be younger than 3 years and have a confirmed disability or established developmental delay, as defined by the state, in 1 or more of the following areas of development: physical, cognitive, communication, social-emotional, and adaptive.³ These children receive services free of charge for developmental disabilities or delays. The Early Intervention Program bills the child’s health insurance if the program is aware of the health insurance status of the child, including Medicaid and private or employer-based insurance. Parents are not responsible for paying for any services received through the Early Intervention Program. However, the Early Intervention Program does not cover services for routine medical care or specialized medical services (non-developmental disabilities or delays).

The Office of Health Insurance Services at the New York City DOHMH was created to expand the city’s health insurance enrollment capacity, maximize client choice regarding health plan and provider selection, and promote health care use and preventive health behaviors. Since 2000, the Office of Health Insurance Services has been a New York State–approved facilitated enrollment lead agency in New York City. The New York State Department of Health–facilitated enrollment program provides funding, through a Request for Application process, to community-based organizations and local entities to provide eligibility screening and application assistance services to New York State residents applying for public health insurance.

In 2009, the Office of Health Insurance Services assisted more than 10 000 applicants throughout New York City with a 97% enrollment success rate. The Office of Health Insurance Services maintains a presence at 9 New York City DOHMH centers and serves clients throughout the 5 boroughs, from all racial and ethnic backgrounds and with limited English proficiency.

The challenge of ensuring that children with special health care needs receive comprehensive and continuous health insurance coverage requires innovative strategies. Although New York State has made considerable progress in reducing barriers to enrollment in public health insurance for adults and children, challenges remain. To maximize comprehensive insurance coverage for children with special health care needs, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program at the New York City DOHMH.

INCLUSION OF INFORMATION ON SERVICES PROVIDED BY THE OFFICE OF HEALTH INSURANCE SERVICES TO THE EARLY INTERVENTION PROGRAM.

Information about services provided by Office of Health Insurance Services included in Early Intervention Program trainings and print materials

“Early Intervention Welcome Letter” to parents

“NYC Early Intervention Program Policy and Procedure Manual” for Early Intervention Program provider agencies

Office of Health Insurance Services brochure and poster for Early Intervention Program provider agencies

Letter to Early Intervention Program providers

Data Matching

Early Intervention Program data

New York State Medicaid data

Census data

Incorporation of Office of Health Insurance Services Staff to Work Directly With Parents of Children in Early Intervention Program

One-on-one in-person or telephone assistance

Available in multiple languages

Available at hours and locations convenient to parents

Educate families on public health insurance products

Help them apply for coverage

PROGRAM DESCRIPTION

The Service Integration Model has 3 key components: (1) inclusion of jointly prepared messages about health insurance benefits and enrollment assistance offered by the Office of Health Insurance Services through the Early Intervention Program, (2) data matching with the Early Intervention Program, and (3) incorporation of the Office of Health Insurance Services program staff (child benefit advisors) to work directly with parents of children in the Early Intervention Program (see the box on this page). The Service Integration Model focuses on minimizing enrollment barriers and reducing the number of uninsured and underinsured children receiving services through the Early Intervention Program (Table 1). A key strategy in this model is to prevent gaps in coverage resulting when parents fail to renew their children’s coverage.

TABLE 1—

Addressing Barriers to Enrollment and Retention in Public Health Insurance Through the Office of Health Insurance Services Service Integration Model: New York City

Barrier	Office of Health Insurance Services Service Integration Model
Gaps in awareness of eligibility and understanding of the programs	Proactive approach that uses program data to identify, mail out letters to, and contact parents to screen children for eligibility.
	Clarification by child benefit advisors, in clear and simple language, about health insurance programs and the application process.
	Information about other sources of health coverage and access to care, including the public hospital system and prescription patient assistance.
Burdensome enrollment requirements and eligibility rules	Provides one-on-one assistance to families, including assistance in completing the application and collecting the required documentation.
	Educates families about the application process, informing clients of next steps after submission of the application.
	Establishes an ongoing relationship with families for follow-up and troubleshooting with any issues that may arise.
	Monitors the enrollment of applicants and contacts families at renewal.
Limited hours and locations for enrollment and the time required to apply	Provides assistance to families at their convenience and location of their choice, including home visits.
	Meets with clients during business hours as well as evening and weekend hours.
	Provides assistance by telephone and in person.
Cultural linguistic barriers, especially among Hispanic families	Provides Spanish-speaking child benefit advisors and other bilingual staff who can work with families in their native language and who are sensitive to the needs of culturally diverse populations.
	Uses telephone interpretation, the “Language Line” when bilingual staff are not available.
	Provides program materials in multiple languages including English, Spanish, Russian, Chinese, Bengali, Haitian Creole, and Korean.
Stigma and privacy concerns	Provides an entry point to work with families whose children are receiving health services outside of a welfare setting.
	Addresses concerns about privacy by adherence to all regulations regarding the release of information as stipulated in the New York State Department of Health, Health Insurance Application (“Access NY Health Care”), the Early Intervention Program, and the Children With Special Health Care Needs program confidentiality policies.

First, the family of every new child enrolled in the Early Intervention Program receives an “EI Welcome Letter,” which introduces the child benefit advisor and indicates that a health insurance assessment will occur as part of the family’s participation in the Early Intervention Program. At the Early Intervention Program provider sites, posters and brochures, available in several languages, describe the services provided by the child benefit advisors. Early Intervention Program staff and providers are regularly trained in the services provided by the Office of Health Insurance Services and how to refer children to the Office of Health Insurance Services for eligibility screening. Information about services provided by the Office of Health Insurance Services are integrated into the general information parents receive about the Early Intervention Program (see the box on this page). This enables families to be familiar with the services of the Office of Health Insurance Services before initial contact with them and educates Early Intervention Program staff to support the work of the child benefit advisors.

Second, the Office of Health Insurance Services performs data matches using Early Intervention, Medicaid, and Census data to identify uninsured and underinsured children who are enrolled in the Early Intervention Program. Staff from the Office of Health Insurance Services working with data from the Early Intervention Program adhere to all DOHMH and program-specific security and confidentiality policies. Information about a child’s health insurance status is based on the self-report of the parent at the time of meeting with the Early Intervention Program staff. The Early Intervention Program staff then enter any of the following health insurance information into the Early Intervention Program database: private insurance name, policy number, group number, and Medicaid Client Identification Number.

In developing the Service Integration Model, the Office of Health Insurance Services reviewed criteria in existing research to define an underinsured special needs child, and evaluated the information available to target eligible children. Criteria include insurance type, level of financial protection based on family income, and child’s level of medical need, which are fields available from the Early Intervention Program database. The definition as operationalized by the Office of Health Insurance Services Service Integration Model is a child meeting the following criteria: the child has been evaluated and accepted into the Early Intervention Program as a high medical needs child with developmental delays or disabilities that warrant $2000 or more, monthly, in authorized early intervention services; insurance type (Medicaid, private, no insurance); and zip code of residence with family median income below 250% of the federal poverty level (area level poverty). The Office of Health Insurance Services mails the parents of identified children a letter that outlines the services offered by the Office of Health Insurance Services child benefit advisors, provides program contact information, and informs parents that they will be contacted for a health insurance assessment screening. In addition, for children identified as insured by Medicaid, letters detailing Office of Health Insurance Services assistance with Medicaid renewals are mailed to parents.

Third, Office of Health Insurance Services child benefit advisors help families apply for public health insurance, educate them about what to expect, and follow up with them to address any problems or concerns. Office of Health Insurance Services staff are strategically co-located at the offices of providers who serve children enrolled in the Early Intervention Program. Staff offer one-on-one assistance, including interpretation services for persons with limited English proficiency, and accommodate clients by meeting during business hours as well as evenings and weekends. Staff complete the application with the families, explain and collect the required documentation, inform clients of the next steps after submission of the application, and provide clients with their contact information so that families may get in touch with them for further assistance. For underinsured families, the child benefit advisors screen and assist families with enrollment into Medicaid, Medicaid Excess Income, or the Physically Handicapped Children’s program.

EVALUATION

An analysis of the National Survey of America’s Families by Kenney et al.⁴ found that many children enrolled in government programs are uninsured or underinsured, and therefore government programs are a key resource for creating linkages. The Office of Health Insurance Services Service Integration Model is built on this premise; it is based on a combined approach of educational messaging to clients and individual counseling or assistance to facilitate enrollment and renewal of health insurance serving a hard-to-reach and vulnerable population.

In New York State, research estimates that at least 30% of public health insurance enrollees fail to recertify and fall off, as found in a New York State Health Foundation report.⁵ Churning, when individuals go on and off insurance in a short period of time, is important because coverage gaps and underinsurance result in “significantly poorer” health outcomes in special needs children as described in an article by Oswald et al.⁶

Since 2008, more than 5000 children in the Early Intervention Program have been successfully enrolled and coverage renewed in Medicaid through the Service Integration Model. In 2008, we found that children in the Early Intervention Program had a 34% churning rate for Medicaid because of enrollment barriers and misconception of the Early Intervention Program as a replacement for Medicaid (the 34% is based on a 2008 point in time sample of 6500 early intervention children with a Medicaid number, 34% of whom had Medicaid coverage that was not active). By 2010, the churning rate for clients assisted through Office of Health Insurance Services was reduced from 34% to 8%.

NEXT STEPS

On the basis of feedback from Early Intervention Program staff and participating families, the Office of Health Insurance Services is planning to augment the benefits offered to families. Families consistently request nutrition services. In response, the Office of Health Insurance Services Service Integration Model is expanding to include assistance with screening and application for food stamps and the Special Supplemental Nutrition Program for Women, Infants, and Children.

The Office of Health Insurance Services will modify the Service Integration Model to respond to New York State’s implementation of the Health Insurance Exchange required by the 2010 Patient Protection and Affordable Care Act. The Office of Health Insurance Services will become more technology enabled by creating computer and printer stations with Internet access at its fixed sites, rolling out portable equipment with wireless connectivity to serve the medically needy off site, and implementing the use of electronic application and renewal tools while educating clients on the use of these tools. In addition, the Office of Health Insurance Services will expand its knowledge base on private insurance to be able to assist uninsured clients who may be eligible for the Health Insurance Exchange.

The Office of Health Insurance Services Service Integration Model is replicable by other government programs and agencies serving the uninsured and underinsured. The model reflects how government programs can work together to improve rates of enrollment and retention in public health insurance. We are focused on serving the children with special health care needs population, but the Service Integration Model can be adapted to serve other uninsured or underinsured populations. The key elements of integration of program messages, data matching, and staff involvement allow for the model to be tailored to the specific needs of other government programs.