Welcome to the Illinois Health Matters Blog

What health reform means for the people of Illinois

A blog by IllinoisHealthMatters.org

Wednesday, September 28, 2016

Our Section 1115 Recommendations

HDA's Emily Gelber-Maturo testified at a hearing September 9th and Barbara Otto submitted testimony at the joint hearing on September 20th on an 1115 waiver draft released the Illinois Department of Healthcare and Family Services. The waiver draft details a proposed overhaul of the behavioral health delivery system. Proposed expanded Medicaid benefits extend from care coordination in health homes to pre-tenancy services for supportive housing.

Recommendations to improve our 1115 Behavioral Health Transformation Waiver:

What’s an 1115 waiver?

Recently, the state proposed an ambitious plan to transform the Medicaid behavioral health system in Illinois. As part of its plan, the state proposes to use an 1115 waiver which would allow certain federal rules to be used so that federal funds could be used in ways that are otherwise not allowed. The catch is that the state must keep all efforts budget neutral for the federal government meaning that services provided have to be equal to what the feds would have spent within the state without the waiver.

The state plans to use both the 1115 waiver and state plan amendments to realize its transformation plan

As a reminder, Medicaid is paid for jointly by both federal and state funding. Illinois has proposed several things within this waiver, some of which will be allowed through the waiver, and others that will be included in state plan amendments. State Plan amendments are used to change program policies, benefits, or operational approaches of the Medicaid State Plan for Illinois. 1115 waivers and state plan amendments both change the way that Medicaid is delivered, but there is a significant difference between the two. The 1115 waiver is a demonstration that will last five years and allow the state to try new ideas within Medicaid that are not necessarily permanent, and can target certain populations. By contrast, the state plan amendment codifies (into law) Medicaid services that apply across the State. The 1115 waiver and state plan amendments will be used together to transform the Medicaid Behavioral Health delivery system.

Expanded benefits and new initiatives

The long-term vision for Illinois’ behavioral health system as articulated in the Behavioral Health Transformation 1115 waiver draft deserves applause. It includes a commitment to addressing social determinants of health, and expanding the Medicaid benefit package for people with serious mental illness and substance use disorders.

Expanded benefits proposed in the draft waiver include supported employment services and pre-tenancy supportive housing services, and new initiatives such as loan forgiveness and training for providers, integrated behavioral health homes, and expanded use of telemedicine. There’s even more, if you would like to read the draft yourself.

Recommendations for the transformation of the behavioral health system in Illinois

With any great system transformation, we need to contend with the realities of the short term. In order to implement many of the benefits and initiatives proposed in this waiver, we need to address systemic capacity, clarify roles of payers and providers, as well as improve infrastructure and accountability.

Invest in Mental Health Workforce and Infrastructure

Illinois would be wise to use the waiver to make much needed strategic investments in workforce and infrastructure in the short and long term. In order to enhance access to services and reduce unnecessary expenditures, prioritizing the assessment and diagnosis of mental illness and substance use disorders outside of the Emergency Department, the most expensive entry point to the health system, is paramount. Assessment and diagnosis should happen in community and outpatient settings. Because eligibility for services proposed in the waiver is closely tied to diagnoses, Illinois’ workforce challenges must be adequately addressed. Without much needed workforce improvements, the work simply can’t be done, and Illinois will fail to take full advantage of services promised through the proposed waiver.

Further, while the services are critical to proposed cost savings, Illinois needs enough providers, who are paid enough to cover their costs. This is not the current reality. Illinois needs rate reform for behavioral health providers, as well as reform to allow providers to work at the top of their license. Loan forgiveness and training, as described in the 1115 waiver draft, by themselves, are simply not enough. Though the waiver does reference expanding telehealth, which will likely help increase access to care, adequate rates are still needed to pay a provider on the other end of the screen.

The state should incorporate Medicaid infrastructure dollars to allow providers to keep pace, build capacity to bill, contract, and hire to provide services. We need to make sure that providers are sufficiently armed to do what is expected and best within their roles by investing in the infrastructure of the behavioral health system.

Clarify Roles of Providers and Payers

The waiver as drafted needs greater clarity on the roles of Managed Care Organizations vs. the roles of providers. As currently crafted, it appears the State is outsourcing a good deal of responsibility to MCOs and that Managed Care Organizations will be expected to implement service delivery. But the problem is that MCOs are payers, not providers. When the waiver addresses implementation of health homes and subsequent creation of a state plan amendment, providers and other stakeholders must be at the forefront of designing them. We don’t call our MCO when we need care, we call our doctor because that’s where the expertise lies.

Establish an Illinois Behavioral Health Transformation Team

In line with providing greater clarity of roles, the State needs to remain accountable for service delivery. The State should establish an Illinois Behavioral Health Transformation Team, comprised of stakeholders representing providers, advocates, and consumers, to provide guidance on the implementation of the waiver. With our state at a crossroads, operating with limited resources, taking advantage of the time and expertise of smart, dedicated, caring providers, advocates, and consumers, can help to shape the long-term transformation envisioned within this demonstration waiver. Advocates and others stand ready to help.

This waiver proposal contains several promising elements, but more is needed. The State must have a commitment to:
  • Increase capacity in the short term with Medicaid infrastructure investments and rate reform
  • Clarify roles - to make sure the right people are doing what they are best suited to do
  • Create responsive mechanisms for accountability

Without this, all the good ideas within this proposal will lack the critical support necessary to transform our behavioral health system for the better.

Emily Gelber-Maturo
Associate Director, Strategic Health Initiatives
Health & Disability Advocates

Monday, July 25, 2016

Consumer Alert for Individuals and Employer Groups Insured by Land of Lincoln Health

Land of Lincoln Health insurance coverage will end for consumers as of October 1, 2016.  Land of Lincoln is no longer offering health plans for individuals on the Federal Health Insurance Marketplace (HealthCare.gov). Land of Lincoln has also stopped offering health plans for employer groups. Please note: it is very important that until October 1, 2016, consumers and employers must continue paying premiums.

Below is an excerpt from the Land of Lincoln Health website instructing consumers and employer groups on coverage options:

IL Department of Insurance Director Dowling has been working with the Centers for Medicare and Medicaid Services (“CMS”) for purposes of having a special enrollment period opened in order to allow individual insureds an opportunity to obtain replacement coverage during 2016 on the Federal Health Insurance Marketplace (HealthCare.gov). CMS will provide Land of Lincoln individual insureds with a special enrollment period (“SEP”) due to a loss of Minimum Essential Coverage (MEC).

Under this SEP,individual insureds have two options:

  1. Individuals may report their upcoming loss of MEC to the Marketplace from August 2, 2016 through September 30, 2016 and enroll in a new plan for coverage commencing on October 1, 2016; or
  2. Individuals may report their recent loss of MEC to the Marketplace from October 1, 2016 through November 29, 2016 and enroll in a new plan for coverage commencing on the first day of the following month.

It is important that individual insureds take note that if they enroll in a new plan on the Federal Health Insurance Marketplace prior to their loss of MEC they will have no gap in coverage or any financial assistance they’re receiving, but that if they wait until after they’ve lost MEC to enroll in a new plan there will be a gap in their health insurance coverage and any financial assistance they’re eligible for.

Employer groups should work with their agent or broker to explore their options. If you are an employer group that enrolled in a Land of Lincoln plan on the open market, please work with your agent or broker. Questions for Small Business Health Options Program (“SHOP”) customers can be directed to the call center for the SHOP Marketplace,which is part of HealthCare.gov, at 1-800-706-7893 (TTY711) Mon-Fri, 9 a.m. to 7 p.m. (ET). Agents and brokers may also use this number.


If you are denied services from a Land of Lincoln provider, please notify the Illinois Department of Insurance. Please call the Consumer Assistance Hotline at (866) 445-5364, and then submit your complaint in writing. Complaints may be submitted in the following ways: Keep your originals and send only copies of information. For a printed copy of the Department’s complaint form, contact the Consumer Assistance Hotline at (866) 445-5364. When your complaint is received, a file number will be assigned and you will be sent written notification of that number. Please refer to the complaint file number when you call or write to the Department. To read the entire Land of Lincoln Health notice, visit their website and read their alert.

Thursday, July 14, 2016

Illinois Needs to Protect Consumers in Wake of Land of Lincoln Debacle

The liquidation of Land of Lincoln Health is just the first of mounting hurdles for Illinois consumers and small-business owners shopping for health insurance coverage in the Affordable Care Act marketplace.

Not only do Illinois consumers wait longer than others across the country to see annual rate increases, but they also have fewer resources to help navigate the marketplace. The state's budget morass means the two state agencies charged with protecting consumer interests and helping consumers connect with coverage options—the Department of Insurance and Get Covered Illinois—are underfunded and ill-prepared to serve the public.

Who will protect consumers' interests in the demise of Land of Lincoln? We keep hearing that the state's insurance department doesn't have the staff to provide information on rate increases to the public until Aug. 1 (even though the department received them from insurers in April). If regulators can't meet the requirements of the ACA in a timely manner, how will they manage the liquidation details for Land of Lincoln? Can consumers count on them to answer critical questions about their now-defunct Land of Lincoln plans?

Questions like: Should I keep paying my premiums to Land of Lincoln? (Yes, you should if you want to be eligible for the special enrollment period plan holders will be offered.) Will I be able to find another plan with my providers in the network at the same price point? What happens if I already met my deductible with Land of Lincoln? Will that carry over to the new plan? And, who will help me find a new plan? Because Get Covered grant funding to help consumers is gone, and insurance carriers reduced or eliminated broker commission for working with clients, Illinois consumers are left with fewer resources when faced with complex health insurance decisions.

We should all be watching how the Department of Insurance addresses the needs of Land of Lincoln policyholders. When Blue Cross & Blue Shield narrowed its networks offered in the marketplace, thousands migrated to Land of Lincoln because of its broader networks with academic medical centers like the University of Chicago. The loss of Land of Lincoln leaves consumers and small-business owners worrying about continuity of care—for themselves and their employees.

This development ensures one thing for the upcoming open enrollment season: Illinois consumers and small businesses will have even less choice, and fewer affordable options that cover a broader network of health care providers.

How the Department of Insurance responds to this crisis is important for all Illinois consumers. We only hope the Rauner administration redirects resources to make sure the Department of Insurance can do its job and do it well.

Barbara Otto and Michelle Thornton Health & Disability Advocates
Reprinted with permission from Crain's Chicago Business

Tuesday, June 14, 2016

NOTICE Act Could Do More for Patients

Starting August 6th, the Notice of Observation Treatment and Implication for Care Eligibility Act, or NOTICE Act, will go into effect. This new law requires hospitals to give written and verbal notice to Medicare beneficiaries who have been on observation status for more than 24 hours.

What is observation status? 

In a nutshell, observation status is a term hospitals use to bill Medicare. Observation status is based on a doctor’s medical determination. Doctors place patients on observation status if their condition is not serious enough for inpatient admission status, but still requires monitoring in case health worsens.

The NOTICE Act is a step in the right direction because patients are often unaware of their observation status or its potential consequences. Prior to the NOTICE Act, the only way to know your status was to ask. Part of the reasoning behind the law is that beneficiaries get hit with serious financial consequences including higher than expected hospital bills and that Medicare won’t cover skilled nursing care needed after discharge from the hospital. However, the law could do better to prevent those consequences.

The issue for many patients is that being on observation status also means they are classified as an outpatient, not an inpatient. That means that rules for Medicare Part B (outpatient services) and D (prescription medication coverage) apply to their hospitalization rather than part A (inpatient).

To understand this better, here is a chart comparing estimated costs. Let’s say a patient stays at the hospital for 4 days, and the care provided ends up costing $10,000. Keep in mind that costs can vary greatly depending on the type of care provided during that time.

Oftentimes, Medicare beneficiaries learn about their observation status when arranging for the skilled nursing facility care they need after discharge. These patients make the very valid assumption that because they are wearing hospital gowns, in a hospital bed, eating hospital food, meeting with nurses and taking tests administered by doctors that they are an inpatient. They learn their actual status, and its consequences, too late and have little recourse.

How could the law be improved?

An appeal process is needed.
The NOTICE Act ensures people know about their observation status and the financial consequences of this determination. And that’s it. They don’t know the medical reasons a doctor made the decision and they aren’t given any avenues to appeal this determination. Patients will be informed of their observation status and the possibility of higher medical costs, but have no recourse to fight the decision.

Use plain-language in the notice to ensure comprehension. 
The Medicare Outpatient Observation Notice, or MOON, used to inform patients about their observation status is not written using easy-to-understand language. In its current form, the MOON is written for a 12-grade reading level, a break from the common practice of writing consumer materials for no more than an 8th grade reading level.

Do you agree Medicare patients deserve more?

Tell the federal government. They are asking for your comments right now in response to the proposed rules. You can use this comment template or submit comments on your own. Submit your comments with these simple steps:

  • Go to the website where comments are submitted. Enter the phrase "Medicare Program: Hospital Inpatient Prospective Payment Systems" in the search box. The first hit will be the rule you want to comment on. Click the "Comment Now!" blue box. 
  • Use our comment template to show how people you know have been hurt by observation status and why changes need to be made by including personal information where indicated with yellow highlights. Adding specific examples of real people makes your case more compelling.
  • You can also write your own feedback directly in the comment box.

Go ahead, make your voice heard! The greater number of people that speak up, the more likely changes will be made.

How can you get ready? 

While the law could be improved, it will be implemented August 6th. Prepare for the changes by getting informed:
Going to the hospital is already stressful. Deciphering complex notices, understanding jargon and dealing with unexpected medical bills increases the strain. Armed with knowledge, you can act as a more effective advocate for yourself, your clients or patients, and loved ones so they can focus on their health and recovery.

Bryce Marable
Health Policy Analyst
Health & Disability Advocates

Wednesday, May 18, 2016

Health Care Changes for Small Businesses in 2016

It’s been about six years since the passage of the Affordable Care Act, but some provisions of the health care law that can improve health care options for small businesses are still being implemented – like employee choice. By learning about this addition and other aspects of the law, small business owners can empower themselves to make the best decisions regarding health coverage for themselves and their employees. In many ways, health care options for small businesses are remaining the same this year. For instance, the Small Business Health Options Program in Illinois will continue offering an array of cost-competitive insurance plans from which employers can choose. And as always, qualified small businesses that purchase health insurance through SHOP may receive federal tax credits to help offset the cost of coverage.

Employee Choice, a Positive New Change

There are several new features of the law being implemented this year, though. One of the biggest and most promising changes is the implementation of employee choice, which is now available in every state. Employee choice allows small business workers to choose from a number of plans from different insurance carriers. Under employee choice, workers choose which carrier they’d prefer to use, instead of business owners choosing for them. This option plays a key role in distinguishing SHOP from the outside health insurance market, and it’s popular among small business owners. In fact, Small Business Majority’s polling found two-thirds of small employers believe allowing employees to choose among multiple carriers is an important element of the health care marketplaces.

While employee choice is a great development for small businesses, options under Illinois’s employee choice program aren’t as robust as they could be. In some parts of Illinois, only one or two insurance providers are participating in SHOP. While employers can still choose different levels of coverage from participating providers, more providers will need to participate to boost options for small businesses.

Taking Advantage of the New Opportunities 

If your business has fewer than 51 full-time employees, you can enroll in SHOP at any time during the year to take advantage of employee choice. In order to begin the enrollment process now, entrepreneurs should visit www.getcoveredillinois.gov or the National Association of Health Underwriters to contact a health insurance broker who is trained and certified to enroll small businesses for SHOP Marketplace plans. Brokers are well-versed in the ins-and-outs of the ACA, and there’s often no extra cost to utilize their services.

While 2016 offers changes in Illinois’s small business health insurance landscape, small business owners shouldn’t be concerned. Changes like employee choice are a step in the right direction for entrepreneurs. The best bet is for employers to arm themselves with information; that way, they can choose health coverage that maximizes benefits for their business.

Geri Aglipay
Outreach Manager, Midwest Region and Greater Chicago
Small Business Majority 

Friday, March 11, 2016

The Budget Crisis Impact on Centers for Independent Living

Like many other human services providers, the Illinois Network of Centers for Independent Living
(INCIL) is being hit hard by the Illinois budget crisis. Access Living is one of the 22 Centers for Independent Living (CILs) in Illinois. The CILs serve 95 of the 102 counties in Illinois. INCIL’s Executive Director, Ann Ford, shared the following, based on reports from 19 of the 22 CILs, which employ between 450-500 people:

•39 CIL staff have been laid off state wide since July 1, 2015
•93 CIL staff are working reduced hours because of furlough days, experiencing pay cuts ranging from 20% to 40%
•21 vacant CIL positions remain unfilled throughout the state (delaying hires is one way to save money)
•Two CILs are in the process of closing satellite offices
•All CILs are restricting travel, including in some areas travel to consumers’ homes
•At least four CILs are developing contingency plans to close in the event funding doesn’t come within the next six months
•It is difficult to determine how many consumers have gone without services. A reasonable estimate would be 800 to 1,000 people statewide
•The impact includes the enormous emotional toll this issue is taking on staff at all CILs, as they take on increased workloads while losing a portion of their income.

The CILs are doing the very best they can to continue to provide services to empower people with disabilities to live as independently as possible in the community. Quite often they are a real lifeline for many people with disabilities. During this difficult state budget crisis, know that your local CILs have been doing everything they can to show why their programs matter to the local community. The CILs are still waiting for just over $4 million in FY 16 budget money for CILs from the state of Illinois, as well as other funds specific to certain disability programs they run.

While Access Living has been holding on, we are very concerned about our fellow CILs at risk of closing. Please contact Ann Ford at annford@incil.org if you have questions about the network; you can also check www.incil.org to see what CILs serve your area. We also urge you to contact your Governor, state senators and representatives to urge them to work on a budget solution ASAP so that disability services are not further impacted.

Ann Ford
Executive Director
Illinois Network of Centers for Independent Living 

This was originally shared as an Advocacy Alert from Access Living.

Friday, February 19, 2016

Key Lessons from Health & Medicine’s Budget Forum

On January 15, 2016, Health & Medicine hosted a meeting of The Chicago Forum for Justice in forum proceedings notes as a reference guide for the forum’s content.

Our notes are written as a summary and while they can’t fully capture the presentations, videos of each of the five mini panels are available on the event webpage, as are slides from speakers who used them in their presentations. We thank CAN TV for recording, editing, and sharing videos of the forum, extending the potential impact of our panelists’ presentations.

We hope these notes will be useful for advocates and policymakers seeking to understand issues related to the budget, think about potential revenue solutions, and consider strategies, framing, and narratives likely to advance progress.  Health & Medicine will be convening a small group soon to review the forum proceedings and discuss next steps for our work on this critical area, which we’ll share on our website.

While the budget problems and solutions are more complex than this, here are some main points that have emerged for me from conversations and from the presentations and discussion at the conference:

  • Illinois lacks sufficient revenue, which represents a structural budget problem, priming the State to have recurring budget shortages and hampering our ability to provide Illinoisans with the public services they need and want, thus harming the health of the public, and disproportionately harming vulnerable communities.
  • The structural budget problems have several potential revenue solutions, including a progressive income tax structure and efforts to ensure corporations pay their fair share, both of which are more equitable than our current system and would better grow revenue in proportion to the size of Illinois’ economy.
  • State elected officials are collectively responsible for passing a budget and using a selection of revenue solutions that will help preserve and improve the vital health, social, and education programs and services that support people’s health and Illinois’ economy.  Inaction on the structural revenue shortages that Illinois faces is an unacceptable abdication of the governing duties our public officials share.

Of course, these salient points are based on a range of facts and history about Illinois’ taxes and budgets, beyond the scope of this post.  A significant amount of such relevant detail is covered in the forum proceedings notes, as well as the slides and videos on the event webpage (linked to above).

Also, related to this subject, Health & Medicine’s Executive Director, Margie Schaps, had two letters focused on Illinois’ budget published in the last couple of weeks:

Wesley Epplin
Director of Health Equity
Health & Medicine Policy Research Group

Tuesday, February 16, 2016

Blacks Hit Especially Hard in Illinois Budget Impasse

February is Black History Month – and Illinois’ eighth month without a State budget. As we highlight black people’s contributions to the American narrative, the message sent by Illinois’ budget impasse is hardly celebratory.

All Illinoisans are suffering as the fragile web of supportive services slowly unravels. Communities across the state are feeling the ripple effects of layoffs, reduced services, slow State payments and the tension that comes with sustained uncertainty.

In the midst of our shared suffering, we must acknowledge this sad truth. People of color, especially black people, are enduring the deepest battle scars from this budget stalemate. And if history is our teacher, these will become the scars of future generations. America’s tortured racial history is embedded in the laws and policies that govern all of us, resulting in widening social, health and economic gaps that operating without a state budget only exacerbates.

Earlier this month, Heartland Alliance’s Social IMPACT Research Center issued a report that illustrates how pervasive these disparities are in Illinois. The study reports that despite significant dips over the past several decades, the number of Illinoisans living in poverty today, 14.4%, is almost the same as it was in the late 1960s (14.7%). While under 10% of whites in Illinois are living in poverty and Hispanic and Asian populations each have poverty rates of close to 20%, a whopping 30.6% of black people are living in poverty statewide, while making up less than 15% of Illinois’ population. And what is even more disheartening is that 43.2% of black children under the age of 17 are poor. In fact, poverty among black people outpaces that of whites, Latinos, and Asians in all age categories.

The report lays out a number of health and economic disparities by race. But what is at least as important as the data is the case the authors lay out for the “legacy of inequality” that colors public policy in America. The report offers a historical soundbite of the legalized racist policies of the past that benefited whites and created barriers for people of color, policies and practices that ignore the generational impact of those benefits and barriers, and the practice of mid-twentieth century redlining that seems to have intertwined race, ZIP code and opportunity into perpetuity.

This budget impasse threatens any progress made towards reducing inequalities in Illinois. For example, last year, for the first time in decades, Chicago saw fewer than 1,000 new HIV cases. That does not happen without a network of community organizations and institutions focused on communities hardest hit by the epidemic — black bisexual and gay men, transgender women of color, and black heterosexual women living in communities with high HIV rates. Blacks make up only 15% of the State’s population but account for 50% of new HIV cases. Yet, the governor’s proposed budget includes a devastating 66% cut to the African-American HIV/AIDS Response Act, a dedicated line of HIV funding that supports the black community, the community hardest-hit by HIV. This at a time when an estimated 6,525 Illinoisans do not know their HIV status and nearly 50% of people living with HIV in this State are not receiving any medical care or HIV medications.

One thing is abundantly clear this Black History Month in “the land of Lincoln:” Elections have consequences. We must continue to put pressure on the Governor and our state Legislature to approve a humane budget with a revenue increase even as we prepare ourselves for the next budget battle. As the late poet Maya Angelou often said, “When you know better, you do better.” We can do a lot better, Illinois.

This article was originally posted on RebootIllinois.com.

Kim Hunt
Executive Director, Pride Action Tank
AIDS Foundation of Chicago

Tuesday, February 2, 2016

Food Keeps Illinois Families Healthy: Help Illinois Reduce the SNAP Gap

Forty-eight million Americans live in food insecure households, meaning they worry about where and how to find their next meal. Many of these individuals and families are covered by Medicaid but are not receiving critical nutritional support. They are eligible for SNAP which could help support their nutrition and improve their health, but they are not enrolled.

What is SNAP?

The Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) helps low-income households purchase adequate, nutritious food. Benefits are distributed monthly on an Electronic Benefits Transfer card, known as “Link” in Illinois, which acts much like a debit card. Money from SNAP can be spent at authorized retailers, and some farmers markets, on any foods that recipients prepare and eat at home. SNAP recipients nationally spend over 85 percent of benefits on fruits and vegetables, grains, dairy, meat and meat alternatives. Beneficiaries also increase the amount of money they spend on groceries each month, instead of simply replacing their food budget with SNAP dollars. By supplementing, not replacing, grocery budgets and allowing for the purchase of more nutritious food, SNAP reduces food insecurity in low-income households. This is particularly true of households with children.

Why Help Consumers Apply for SNAP Benefits?

Connecting more Medicaid recipients with SNAP benefits can address food insecurity and inadequate nutrition, which this population experiences at high rates, and improve health outcomes. In addition to helping a family afford healthier food, children who receive nutrition supports are healthier and more likely to finish school while participating in the program. A report recently released by the White House Council of Economic Advisers details the long-term benefits of this program, including: for mother’s receiving support during pregnancy, reductions in incidences of low birth-weights; and for adults who received support when they were children, reductions in obesity rates and metabolic syndrome, increased likelihood of having completed high school, and significant improvements in overall health and economic self-sufficiency among women.

New Opportunities in Illinois to Reduce the SNAP Gap

The Affordable Care Act has made it easier for low-income individuals and families to access public benefits by helping states pay for electronic systems to apply for benefits. In Illinois, the new Application for Benefits Eligibility enables applicants to submit a single application for both SNAP and Medicaid. However, despite this improved online application, we have not fully reduced the “SNAP Gap”—the number of Medicaid clients who are income-eligible for SNAP but do not receive this benefit.  We need to work with medical providers, medical plans, social service organizations and other partners to make sure that everyone who is eligible for SNAP gets the help they need to pay for healthy food.

The newest change to the Illinois SNAP program is that on January 1, 2016, Illinois raised the gross income limit for SNAP from 130% to 165% of the federal poverty level, making nearly 40,000 low-income working families newly eligible for SNAP. With more families in Illinois now eligible for SNAP and the ability to submit a single application for both SNAP and Medicaid benefits, it’s time to close the SNAP Gap and make sure families have the food they need to stay healthy. If you’re not familiar with SNAP’s application process join us on HelpHub for more information and resources for both providers and consumers.

MacKenzie Speer
Advocacy Program Associate
Sargent Shriver National Center on Poverty Law

Wednesday, January 20, 2016

Clarifying, Eliminating and Enforcing Special Enrollment Periods

As the Health Insurance Marketplace grows and matures, we continue to listen and learn to find ways to make it work even better for consumers and those who serve consumers. We know that each year, as the Marketplace evolves, we must seek to continually adapt and refine the way we operate. In addition to continually improving the consumer experience, we also must make changes to keep the Marketplace vibrant, stable and strong.

The fundamental principles to achieve this are simple: the Marketplace must be attractive for consumers, and the Marketplace must be attractive for insurance companies that offer plans on it.

Consumers need to know that affordable options are available and that insurers are competing for their business. We know that consumers want affordable health care and value the insurance they’re finding at the Health Insurance Marketplaces. This Open Enrollment we’ve seen a significant influx of new consumers – many of them young – making it clear there is still a large untapped market for insurance companies to serve.

The Marketplace must also be attractive to insurers, so that they make quality plans available at affordable prices and continue to drive innovation, and so consumers can find plans that meet their health and budget needs. Building an attractive Marketplace starts with establishing a predictable, stable set of rules that help to keep the risk pool balanced. As the Marketplace grows and evolves, we continue to analyze data to understand how our rules are impacting insurers and consumers and to make sure they are working to sustain a stable Marketplace. By having clear rules for how the Marketplace operates and making adjustments when needed, we are creating a more stable rate environment with more affordable plan choices for consumers.

One of the areas we have been reviewing closely is the special enrollment periods we offer. Special enrollment periods are an important way to make sure that people who lose their health insurance during the year or who experience a major life change like getting married or having a child, have the opportunity to enroll in coverage through the Marketplaces. People who experience these qualifying events have the opportunity to enroll in coverage outside of the normal Open Enrollment period from November 1 to January 31, similar to how enrollment works in the employer market. In addition, in the first two years of the Marketplace, a number of special enrollment periods were created for consumers who were still learning how to enroll in coverage for the first time.

As the Marketplace matures and consumers learn more about how and when to enroll, we continue to review the rules around special enrollment periods in order to keep them fair for consumers and for issuers. We are taking initial steps in adjusting how special enrollment periods work – and will continue to make further adjustments in the future based on what we learn from continued monitoring and analysis of special enrollment period usage and compliance.

The action we are taking today announces the elimination of several unnecessary special enrollment periods, clarifies the definitions of other special enrollment periods, and provides stronger enforcement so that special enrollment periods serve the purpose for which they are intended and do not provide unintended loopholes.

Eliminating Unnecessary Special Enrollment Periods

Last month, we announced that the Tax Season special enrollment period will no longer be offered. Today we are announcing the elimination of six other special enrollment periods that are no longer needed. Just as the Marketplace evolves, so too does consumer behavior. The rules we use to operate the Marketplace need to keep up with these changes. As such, special enrollment periods are no longer available for:

  • Consumers who enrolled with too much in advance payments of the premium tax credit because of a redundant or duplicate policy
  • Consumers who were affected by an error in the treatment of Social Security Income for tax dependents
  • Lawfully present non-citizens that were affected by a system error in determination of their advance payments of the premium tax credit
  • Lawfully present non-citizens with incomes below 100% FPL who experienced certain processing delays
  • Consumers who were eligible for or enrolled in COBRA and not sufficiently informed about their coverage options
  • Consumers who were previously enrolled in the Pre-Existing Condition Health Insurance Program
We’ll continue to monitor how special enrollment periods are used and may make changes in the future as Marketplace systems and operations continue to improve.

Clarifying Eligibility

Our review of current special enrollment periods also showed that some of the eligibility guidelines need to be further clarified so consumers can understand the intent and so they will not be abused. Today we are updating guidance to more clearly define the special enrollment period that is available to consumers who permanently moved, and as a result, gained access to new health plans. Specifically, we clarify that this special enrollment period cannot be used for a short-term or temporary move where the consumer doesn’t plan to stay in their new location, including situations in which a consumer is admitted to a hospital for treatment in a different area. This clarification is intended to assist consumers, brokers, issuers and others in understanding who is eligible for this special enrollment period.

If we identify other areas where the rules for special enrollment periods are unclear, we will issue additional clarifying guidance as needed.

Enforcing the Rules

Finally, we will take steps to make sure that consumers understand and comply with the rules. We will conduct an assessment of plan selections that are made through certain special enrollment periods to evaluate whether consumers properly accessed coverage. Our program integrity team will pull samples of consumer records nationally and may request additional information from some consumers or take other steps to validate that consumers properly qualified for these special enrollment periods. The findings from the assessment will help us to inform future policy and operational improvements to enhance program integrity. Additional details will be provided in the coming weeks.

We will also emphasize more strongly to applicants that the law requires that consumers provide accurate information to the Marketplace, and they may be subject to penalties under federal law if they intentionally provide false or untrue information.

There is still time for consumers who need coverage to enroll during the Open Enrollment period that ends on January 31st. While there will continue to be special enrollment periods for people who lose coverage mid-year or experience other life changes, this channel for enrollment will not be available for the vast majority of consumers. For example, special enrollment periods are not allowed for people who choose to remain uninsured and then decide they need health insurance when they get sick.  Consumers who do not currently have other health insurance coverage should enroll through the Marketplace now during these last two weeks of Open Enrollment, to make sure they have coverage if they get sick and to avoid the tax penalty.

This was originally posted on the CMS Blog.

Kevin Counihan
Health Insurance Marketplace 

Wednesday, January 13, 2016

Engaging Uninsured Cynics of the ACA

On a blistering cold Chicago night in November 2013, I met with Lorena, a 25-year-old uninsured Mexican-American bartender whose income fell below $18,000.  Lorena belonged to a group that health policy experts refer to as “newly-eligibles,” single able-bodied adults without children living in poverty who now qualify for Medicaid thanks to the Affordable Care Act.

Lorena could have enrolled herself with relative ease. At the time, outreach efforts for the ACA were in full swing. In her home neighborhood of Pilsen, health navigators, insurance brokers, and nonprofit organizations were at soup kitchens, schools, taxi stands, and social service organizations spreading word and enrolling thousands. Our conversation, however, revealed something surprising.

“Do you plan on applying for health insurance through the Affordable Care Act?” I asked sitting across from her at a south loop coffee shop near the bar she worked.

“No,” she bluntly replied.

“Why not?” I asked.

“Mainly because I don’t trust government. I think anything they’re going to be putting out is flawed.”  
“What makes you so distrustful?” I asked.

“My friend got these really strong stomach pains and almost fainted so I took her to the county hospital. We were there sitting for hours in the emergency room! The nurses were all hanging out at the desk giggling and laughing and talking to each other drinking their coffee and my friend is bent over like this [Lorena hunches over as she speaks] ready to pass out! I yelled at one of them, “are you gonna take care of her?” They came back to me laughing [telling me], “I’m sorry, we’re actually really professional.”

“What happened to your friend?”

“She was really dehydrated and had a bad urinary tract infection. She spent the night at the hospital which cost her $2300.”

“That experience made you distrustful?”

“Yeah, it’s terrible. When I look at the actual doctors [at the county hospital], they’re very professional and educated but everything else is downhill. With these county clinics, the staff sucks! It’s like they’re hiring just anybody.”

Being Uninsured a Conscious Decision

From November 2013-April 2014, I interviewed 45 uninsured adults like Lorena (between 21 and 35, single, without children, low-income) as part of an ethnographic study of the uninsured in the age of the Affordable Care Act. To my surprise, two-thirds refused to enroll or even inquire about the ACA because of their cynicism in government or the quality of health care provided by Cook County. For people like Lorena, their lack of health insurance did not stem from a lack of outreach or access. Being uninsured was a conscious decision to distance themselves from government and health care agencies.

As outreach efforts continue in Cook County and elsewhere, it is important for health care professionals to remember that the ACA is just one of many arms by which government shapes the lives of the uninsured working poor. For Latinas like Lorena, many of whom have undocumented family members, the ACA is part of the same government body that is deporting family members. For many of my Black respondents, the ACA was seen as part of the same government body whose police force is excessively using deadly force against Black citizens.

Although Medicaid enrollment has exceeded Cook County’s expectations, nearly 600,000 remain uninsured. It’s possible that people like Lorena, with distrust and cynicism toward government and health care, will be the most difficult to enroll.

Lorena’s story highlights the importance of bringing more nuance and strategy to ACA outreach efforts. For cynics of the ACA, simply informing them of their options is not enough to persuade them to enroll. Instead, cynics need to have their opinions validated (no matter how inaccurate or outlandish they might appear) and be empowered to enroll.

Convincing the Skeptics

Two weeks after my interview with Lorena, I observed Abram (a health navigator) put these face-to-face outreach strategies to work during his interaction with Joyce, a 32-year-old cynical and uninsured Black woman. It was family fun night at a Boys and Girls Club in Pilsen. Joyce brought her niece to the event and was sitting at a table eating a sandwich when Abram approached and introduced himself.

“Hi, I’m Abe.”

“Nice to meet you, I’m Joyce.”

“I’m here working for an organization and we’re trying to sign people up for the ACA.”

“Really?” asked Joyce.

“Yes, do you have health insurance now?”


Abe pulled out a bright yellow pamphlet and said, “That’s ok. I can assist you with enrolling. In the end, it is completely up to you to make that final decision if you want to enroll in anything at all. I can start you off to see what’s out there. There’s Medicaid, which is completely free public assistance. With the new Medicaid, insurance companies can no longer deny you for pre-existing conditions.”

Joyce raised her eyebrow asking “Really?”

In response, Abe raised both hands in the air to gesture he meant no harm stuttering “I, I, I, don’t want to make any promises because, obviously, we have to see what plan you are eligible for…”

Joyce interrupted, “But that really means a lot to me because I’ve been denied lots of things in the past.”

Abe continued, “I’m going to leave you with my information [hands her his business card]. [Abe pulls out another sheet of paper] This is a list of documents that we are going to need in order to fill out your application, and I can actually sit down with you, with your permission, to go through the entire application. That is something you could do by yourself if you wanted to, or I could sit down with you and assist you.” One week later, Joyce made an appointment with Abe and enrolled.

Like Lorena, Joyce was skeptical that the Affordable Care Act would benefit her. In my interview with Joyce, she shared frustrating stories of seeking medical treatment for health problems only to be told she was ineligible for assistance.

Abram, however, never discounted or diminished Joyce’s skepticism. Nor did he make any promises that he could not keep. Instead, he validated Joyce’s concerns and reminded her that she was the one in control of the interaction, that she could walk away at any time.

Abram did not have to persuade Joyce to trust government or even health care providers. He just had to convince her to trust him, and he was successful by validating her concerns and empowering her.

The Outreach Road Ahead

As the ACA enters its third year, it is now entering a phase where those with the easiest access have enrolled and where many of the remaining uninsured are the hardest to reach. These include many uninsured adults whose negative experiences with government or health agencies have formed the basis of their outlook toward the ACA.

With face-to-face outreach strategies designed to validate and empower the low-income uninsured into enrolling, organizations conducting outreach for the ACA may be able to continue closing the cracks in the Illinois health insurance safety net. As Joyce said in recalling her interaction with Abe, “He didn’t try to sell me. He just say, once we do this it’s strictly up to you just because you talk with us and give us your information doesn’t mean you have to sign up, the ultimate decision is up to you.”

Robert Vargas
Assistant Professor of Sociology
University of Wisconsin-Madison

Robert is currently conducting research on the Affordable Care Act in Chicago, and the publications from his health care research are available at his website www.robvargas.com.