1. ENROLLMENT ISSUES FOR SPECIFIC POPULATIONS: PEOPLE EXPERIENCING HOMELESSNESS Barbara DiPietro, Director of Policy

2. ROLE OF HCH PROJECTS (AND OTHER HEALTH CENTERS) In 2012, 246 HCHs served 837,000 people →1.1 million total homeless patients served by entire health center program Provide primary care, addictions and support services to those who are homeless Engage in outreach & enrollment in benefits where eligible Identify underserved populations and engage them in care Partner with others in community to ensure comprehensive approach

3. ROLE OF NATIONAL HCH COUNCIL Unite the best practices in homeless health care Provide training and TA to HCH grantees (and others) Support the HCH Community in its work to serve vulnerable population Engage in research, policy analysis and advocacy w/on behalf of providers and consumers Strive to prevent and end homelessness

4. IMPORTANCE OF TARGETED FOCUS ON HOMELESS POPULATION Vulnerable population in poor health →High rates and co-occurring presence of illness & disability, chronic & acute disease, trauma & mental illness & addiction, injuries & infectious conditions Asthma, diabetes, high blood pressure, skin rashes, depression, schizophrenia, alcoholism, brain injury, bronchitis, hepatitis C, TB, etc. Intensive services needs →Primary care, specialty care, behavioral health, case management, care coordination, case management, supportive housing, medical respite care, transportation, etc.

5. IMPORTANCE OF TARGETED FOCUS ON HOMELESS POPULATION Multi-system involvement →Health care, shelter & housing, employment, income/food benefits, legal help, energy assistance, child care, etc. Lack of housing complicates health care →Competing priorities for food & shelter, historically not well- served by mainstream agencies/settings, at-risk for violence & exploitation, tend not to self-present for care/assistance, may stay in remote areas Insurance disparities →Historically not eligible for Medicaid (or can’t navigate system) →Lack of coverage limits access to comprehensive care

6. INSURANCE DISPARITIES

7. ENROLLMENT IMPROVEMENTS 1. NO PAPER DOCUMENTATION! 2. Electronic verification of identity & citizenship 3. Simplified categories 4. No wrong door 5. Single (short) application 6. Based on income 6. No requirement for a home address! 7. No interviews 8. Annual re- determination up to 5 years 9. Assistance available 10. Must be accessible (disability, language, etc.)

8. FRONTLINE: 10 PROVEN STRATEGIES 1. Place enrollment assisters at service venues (soup kitchens, shelters, encampments, employment centers) 2. Conduct *repeated* outreach & education 3. Prepare to spend more time on education than on actual enrollment 4. Ask what health services someone needs & tailor insurance discussion around access to those 5. Ensure outreach workers are culturally competent, trained on homeless services & have info on area resources

9. FRONTLINE: 10 PROVEN STRATEGIES 6. Hold group discussions about health insurance and eligibility changes 7. Follow up with 1:1 opportunities (in private) to discuss individual circumstances & conduct enrollment 8. Explain what changes are happening → Broader eligibility, easier enrollment 9. Explain what doesn’t change → VA, Medicare, those currently eligible for Medicaid → Access to health center services not dependent on insurance status 10. Don’t stop with enrollment; focus on engagement in services

10. THE DANGER OF THE “COVERAGE GAP” FOR THIS POPULATION The gap: Those earning <100% FPL not eligible for new insurance options (though may be Medicaid-eligible under current rules) Lack of trust already inhibits service engagement Made worse with more “false promises” of eligibility Anticipate confusion and stress when clients deemed ineligible Mitigate confusion with “truth-in-advertising” at provider level Explain that this is a state-level decision Register clients to vote (in compliance with National Voter Registration Act)

11. STATE POLICY ACTIONS Assign appropriate providers & ensure networks →Is PCP accessible, willing & capable to serve assigned individual? →Are provider networks adequate to ensure access for entire community? Increase service capacity in communities →How can primary care, behavioral health & specialty care systems expand to meet local needs? Plan for transition to Marketplace plans as income increases →How do deductibles, co-pays & co-insurance remain affordable at modest incomes?

12. STATE POLICY ACTIONS (CONT’D) Suspend Medicaid (rather than terminate) →How to seamlessly reconnect those exiting institutions? Maximize state Medicaid options →What populations (e.g., MH or SUD) or additional services (e.g., supported housing, dental, case management) are needed? Implement SOAR approach to SSI/SSDI ( disability ) →How can access to insurance facilitate better documentation for disability? Evaluate access as well as enrollment →How can data be used to ensure access and/or plan for expanded services?

13. PREVENT & END HOMELESSNESS: POSSIBILITIES THROUGH THE ACA Prevent: Insurance reforms & affordable marketplace plans will prevent bankruptcies, address health conditions earlier, prevent “slide” into homelessness due to illness & medical debt End: Connect to needed health services to address health problems, improve health outcomes, work on housing & income from more stable place, allow for services in supportive housing

14. CONTACT & RESOURCES Barbara DiPietro, Director of Policy: bdipietro@nhchc.org bdipietro@nhchc.org Website: www.nhchc.org www.nhchc.org Twitter: @NatlHCHCouncil & @BarbaraDiPietro Resources: Enrollment toolkit, ACA policy briefs & webinars, outreach training & TA, consumer & frontline worker FAQs, library of publications, government documents, dedicated outreach page Health Reform Webpages: http://www.nhchc.org/policy-advocacy/reform/