New Mexico’s Medicaid machine is getting ready for the fast lane.
Starting Jan. 1, the federal government will embark on what is the biggest expansion of insurance since the introduction of Medicare, the social insurance program launched in 1965 for those 65 and older. Everyone will be required to have health insurance — if not through an employer, then with the government or a private provider.
Anticipating that deadline, in a few weeks the state hopes to start bringing some 150,000 more people — 7 percent of the state’s population — into Medicaid under expanded eligibility guidelines. (Medicaid is the federal-state partnership that helps provide health care for the indigent, disabled, blind and low-income families with children.)
For Julie Weinberg, director of the state Medical Assistance Division of the Human Services Department, it is a massive undertaking. But she hopes the project, along with new options for private insurance through the New Mexico Health Insurance Exchange, will transform health care in the state.
“Nothing this big goes in without bumps, but we’re hoping the bumps aren’t horribly large,” Weinberg said.
“It’s a very huge deal,” added Lauren Reichelt, health and human services director in Rio Arriba County. “I think we’ll see a huge jump in the number of those with insurance.”
A top state for uninsured
Statewide, 570,000 New Mexicans are already enrolled in Medicaid; 337,000 of the enrolled are children. But New Mexico still ranks among the top states for uninsured, with many of those being working adults who earn too much for the current Medicaid program, are too young for Medicare and can’t afford to purchase their own insurance, even if it is offered in the workplace. Many are construction workers, designers, freelance artists, seasonal workers, sole proprietors or people who have recently changed jobs. Many are young and single, the so-called “young invincibles,” who believe they don’t need insurance. Others are the working poor who have children already covered by Medicaid.
The Medicaid expansion, as it is called under President Barack Obama’s Affordable Care Act, aims to bring lower-income adults into the government insurance program. Under the old Medicaid system, only those whose income was at the federal poverty level could qualify — about $11,000 for an individual and $23,000 for a family of four. But the Affordable Care Act extended that to what is now 138 percent of the federal poverty level. That means $15,414 for individuals, while a family of four can earn $31,809 and still qualify for low-cost insurance.
New Mexico is no longer calling the program Medicaid, but Centennial Care. The new name, Weinberg said, emphasizes the initiative is a total wellness effort: Managed-care companies will work with individuals to integrate them into a network that includes prevention services as well as nutrition, counseling, addiction treatment and mental-health care, if necessary.
“We expect anywhere between 140,000 and 170,000 people to be eligible for the expansion in the next five years and the vast majority to come in the first year,” Weinberg said. Each will not only have to enroll in Centennial Care, but also pick one of four private networks: Molina Healthcare; Blue Cross Blue Shield; Presbyterian Health Plan; or UnitedHealthcare Community Plan.
Weinberg said the health companies have the software, staff and data capabilities to track care and treatments — resources the state doesn’t have. “We are all notoriously bad consumers of health care,” she said. “For us [the state] to do that, I’d have to hire hundreds of people.”
In Santa Fe County, 18,000 new people might qualify for Centennial Care, according to estimates. Reichelt expects some 2,000 to 3,000 new enrollees in Rio Arriba County.
Bracing for enrollment surge
The U.S. Supreme Court ruled that the federal government cannot force states to expand Medicaid — so only 28 states are doing so come January. New Mexico is one of a handful with a GOP governor moving forward, along with Arizona, Florida, Michigan and New Jersey.
New Mexico has been doing Medicaid enrollment for a long time. Under the new laws, half the administrative costs for expansion are covered by the federal government. The result is that 16 additional staffers have been hired by the state Human Services Department and will focus on Centennial Care enrollment.
More than 150 enrollment fairs are already scheduled in the next eight weeks at senior centers and community centers, schools, health centers, libraries, town halls and gymnasiums. Only legal residents are eligible for the program. Tribal members, while exempt from the federal requirement of having health insurance in 2014, can enroll if they qualify.
The state will blast information on the radio, through direct mailings and through newspaper placement. “The people who need Medicaid the most are in some of the most isolated parts of the state. It is hard to reach them,” Weinberg said.
A boon for clinics, hospitals
No one has to convince La Familia Medical Center’s John Cassidy, the chief executive of the community health center, that “getting people enrolled is a big deal.” La Familia provides services to anyone who shows up, whether they have insurance or not, and charges on a sliding scale. The provider has some 20,000 patients; perhaps one-third of those are undocumented residents who will not qualify for Centennial Care, nor will they be able to purchase insurance from the health exchanges.
But the four La Familia health clinics also see 4,000 Medicaid patients, and Cassidy thinks another 1,000 would be newly eligible for Centennial Care come January. In anticipation, his staff will undergo certification training so they can accurately enroll those people for their new health insurance.
For La Familia, it means the organization will get paid to provide health care that doctors and nurses are now giving for free. For patients, it means they can seek care at a clinic in Albuquerque, or any other clinic in the United States — not just La Familia. “When they go to the emergency room, when they go here and there and everywhere, it means they will be served,” Cassidy said.
Reichelt also has started her staff’s training. She said the online enrollment system is a challenge for a rural area without Internet access. Often that means that a staff member will take a paper application, then come back to the office and enter the information into the computer.
For Christus St. Vincent Regional Medical Center, more insured patients means fewer indigents who seek emergency care but can’t pay.
Christus CEO Bruce Tassin said Christus already enrolls those eligible for Medicaid upon discharge, and that effort will ramp up for those newly eligible for Centennial Care. He estimates the hospital might enroll another 750 people the first year with the new guidelines. He also estimated another 370 might gain insurance in the New Mexico Health Insurance Exchange when they get discharged from Christus.
“To get as many people signed up with some form of insurance is a great thing for the community,” Tassin said. But, he added, Medicaid reimbursements do not cover hospital costs — and the payments are less than the hospital would receive from the county indigent fund, which is earmarked for those who can’t pay for treatments. Still, insured patients are more likely to come into primary care clinics and seek other types of alternative care, which holds down emergency room costs and other expensive procedures.
Another advantage of signing people up is that even if they do not qualify for Centennial Care, the patient might be able to receive some advance tax credit and to buy private insurance through the exchange. Credits can be offered for individuals earning as much as $44,000 and families at $92,000, depending on the family’s size.
Overcoming challenges of a new system
The Centennial Care application and the insurance exchange process are supposed to work together, although Weinberg and others said glitches are inevitable.
Northern New Mexico has a lot of workers who freelance and change jobs. People get married, divorced, have and adopt children. People who change jobs and make more money might want better coverage, and those who move often will want to change doctors. Getting everyone insured and into the plan they want — and then allowing for changes and revisions — will be an incredible software and service challenge, said Anne Sperling, employee benefits manager of Daniels Insurance Inc. in Santa Fe.
For instance, if someone qualifies for Centennial Care and then gets another job in 2014, they might no longer be eligible for the free government program and have to buy insurance that carries a monthly premium through the exchange. Some of the premium will be paid by the individual, and some will be paid by the government. But the amount the government pays will change, based on a person’s income, and that can fluctuate.
“There are many moving pieces to Medicaid and the Marketplace,” said Sperling, a former director of the New Mexico Health Insurance Alliance. “People will be entering the insurance world for the first time with either Medicaid or the marketplace with a premium tax credit, and will not have a clear understanding on how to navigate the health care system. … People will get frustrated, and it won’t be easy to fix; but it will eventually get there.”
The kickoff for the New Mexico Exchange is set for Tuesday, and more information will be available later in the month. Administrators say it will be ready Oct. 1.
“In the next year there will be a lot of confusion, I’m sure,” added Reichelt, who is a self-described Pollyanna. “But it’s not bad confusion, it’s good confusion. There will be a lot of problem solving, and then we’ll see a sharp increase in the number of people covered. Then, we’ll see an increase in demand for health care, and then we can work to meet that need. That’s not a bad thing, it’s a good thing.”
Contact Bruce Krasnow at firstname.lastname@example.org.