Overview Health Care Reform Impact: Incorporating the need to directly enroll clients in health insurance and monitor eligibility into a clinic setting Lisa Blanchard, MA Program Director- Spectrum Health Systems Margaret Milani Director of Reimbursement- Spectrum Health Systems

AIM (Plan) Massachusetts Health Care Reform meant access to health insurance to all member of the commonwealth Expanded Medicaid (Masshealth) coverage for children up to 300% of poverty ($60,000/family of 4) Established the Commonwealth Care Health Insurance Program which provided sliding-scale, subsidized coverage for low income uninsured individuals and families below 300% of the federal poverty line. Beginning in July 2007, all residents required to obtain health coverage if it is determined that people in their income bracket can afford insurance. Programs needed to manage their practice in this changing environment with less state funded clients and less self pay= more insured individuals

AIM (Plan) In 2006 prior to health care reform the payer mix was estimated at 65% Medicaid 20% State DPH funding for uninsured 10% Third party commercial insured 5% Self Pay In 2010 our current payer mix is estimated at 65% Medicaid 10% Commonwealth Care (state supported insurance) 10% State DPH funding for uninsured 12% Third party commercial insured 3% Self Pay Spectrum’s goal was to ensure that our clients were covered by health insurance and that we ran eligibility to catch changes and coverage termination as close to daily as possible (particularly for Opiate Treatment Programs providing billable services on a daily basis)

CHANGE (Do) CHANGE #1: We trained patient account staff on the Massachusetts Medicaid and Commonwealth Care enrollment system on the online Virtual Gateway This allows staff to directly enroll a client or potential client into a state supported insurance plan or identify coverage issues (need to pick a plan or primary care physician, or submit income verification or update forms) so that we can assist clients with to avoid coverage problems CHANGE #2: We strengthened our insurance verification procedure to include daily review of insurance eligibility via both running batch eligibility checks for clients in OTP programs who receive daily services and individual checks as clients present to appointments

RESULTS (Study) Typically assist 25 clients to enroll in insurance or correct eligibility issues per week Many have a minimal or zero copay, which decreases clients paying for part of their treatment and increases collections and revenue Due to eligibility verification efforts- Process approximately 60 insurance changes per week in outpatient Proactively catching insurance changes improves the collection rate of claims submitted

NEXT STEPS (Act) Spreading the training for insurance enrollment/virtual gateway to central intake staff and front desk staff at smaller locations in order to provide expanded access for clients to received insurance enrollment assistance Utilizing the Virtual Gateway system to assist clients to receive other types of state assistance (child care, food stamps, WIC, special services) Many clients are required to take employer sponsored health insurance- but cannot afford premiums- can apply on VG for premium assistance by the state if within income level

IMPACT (Business Case, Lessons Learned) Difficult to follow this model at smaller clinics with only one administrative staff Increase in 3 rd party commercial payers, however many have poor benefits for substance abuse resulting in high deductibles, copays and uncovered services, slow claims processes and cumbersome authorization processes