RISE Radio

Episode 19: Healthfirst’s Errol Pierre on the end of continuous enrollment, restart of Medicaid redeterminations, and lessons learned

• Ilene MacDonald

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Errol Pierre, senior vice president of state programs at Healthfirst, the largest nonprofit health plan in New York, joins us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health.

Pierre will be a featured speaker at RISE’s Medicaid Managed Care Leadership Summit, a virtual event, that will take place April 2-3. The virtual summit will explore how Medicaid managed care organizations can provide quality care to high-risk populations, connect with hard-to-reach patients, and ensure their financial viability.

During this 22-minute podcast, Pierre offers his thoughts on the end of the continuous enrollment provision, how to educate members about the recertification process, and his concerns about the impact on health of members who can’t be reached and drop off Medicaid. 

 

Ilene MacDonald:

Hello and welcome to the latest episode of RISE Radio. I'm your host, Ilene MacDonald, the editorial director at RISE. Today we will be discussing lessons learned since the end of the COVID-19 public health emergency and the restart of Medicaid redeterminations. My guest today is Errol Pierre, senior vice president of state programs at Healthf irst, the largest nonprofit health plan in New York. Errol is one of the featured speakers at RISE's upcoming virtual event, the Medicaid Managed Care Leadership Summit, which will take place April 2nd and 3rd. The virtual summit will explore how Medicaid managed care organizations can provide quality care to high-risk populations, connect with hard-to-reach patients and ensure their financial viability, as well as providers' financial viability. Errol will be on a panel discussing the status of Medicaid enrollments and the creative ways health plans have reached out to members about the renewal process. Welcome, Errol. Thank you for joining me today.

Errol Pierre:

Thank you for having me. It's great to be here.

Ilene MacDonald:

For a little background for our listeners, can you talk about the Medicaid redetermination process and why it's been such a heavy lift since the end of the COVID-19 public health emergency and the whole continuous enrollment provision?

Errol Pierre:

Sure. So the public health emergency came into effect during the pandemic as a way to help people keep their insurance active while the pandemic was happening, and so people could get their access to COVID tests and get their access to vaccines. The worst thing that would happen, that you would want to happen, is people lose coverage during a pandemic, not being able to renew their coverage because they were staying at home and quarantining, and not being able to get the information they needed from various organizations or their own company to submit to the state to determine their eligibility. So it was a great policy because it kept a lot of people enrolled that would have otherwise fell off the rolls. It's one of the reasons why we have the most people covered in the country ever. We have the highest rates of insurance rates in our history of our country, even after the Affordable Care Act. So this is a big deal, and so that's why unwinding it is such a big deal. Close to 90 million people get their coverage through the Medicaid program across the country and they all, most of them, most of them have to do an action, actively, stay enrolled, and they have to do that by, at least in New York, two ways going on to a website which New York State calls New York State of Health, which is our version of the health exchange.

Errol Pierre:

In other states they might have another website or HealthCare. gov. Also, some that are also getting benefits, like SNAP benefits and housing rental support, have to go through local districts, which means it's a different process. That's very complicated, and so just imagine trying to get 90 million people to do something in one year. That's basically been what we've been attempting to do. Educate folks in different languages, meeting them where they are, letting them know this is happening and then trying to create a sense of urgency around it, because usually the people who drop off first are the ones who feel they are the healthiest. So they say, oh, I don't need coverage, or there's a language barrier, education barriers, that we're saying the message but we're not reaching them, for whatever reason.

Ilene MacDonald:

And also, given that they hadn't had to do this before, that they hadn't had to renew, they might not be aware of it, especially if they never had that coverage previously.

Errol Pierre:

That's a great point. Yes, so this was something people were doing every year, and the emergency period started in 2020. So you're talking about now close to four years of not doing this, especially people who are getting Medicaid for the first time. The uninsured rates spiked when the COVID first hit because many people were laid off. They found themselves on Medicaid, so they've never tried to recertify before, and so this is new for them as well. Great point.

Ilene MacDonald:

What has your experience been like at Healthf irst with all this? I know you mentioned these outreach that you've tried to do, but overall and I know maybe it's for some listeners that this is staggered, right? Every month there's new people who are dropping off the rolls.

Errol Pierre:

Yeah, it's a great question. We are lucky in that, as you said, it's a rolling renewal process. So if you enrolled in June, for the most part your anniversary date is in June. So you have to wait till June of the next year to do your recertification so we're able to take all of our Medicaid lives and divide them up by into 12 cohorts. It's been, I'd say, nerve wracking but exhilarating. So it's like the best of times and the worst of times and I think one of the reasons is it's hard to educate that many people in that amount of time with the nuance that they have to recertify upon their recertification date or upon their anniversary date.

Errol Pierre:

I think that's the greatest complexity. So just telling everybody about redetermination and saying it's time to renew your coverage, the worst thing that can happen is you're telling people who aren't supposed to redetermine their eligibility until June to show up today and they get frustrated because these people who are on Medicaid, their income is roughly $15, $16 an hour, so they don't have a lot of disposable income. So imagine you leave work, you find childcare, you spend money to get a taxicab, you show up to an office only to find out that you're not supposed to do your redetermination process until June. You'd be frustrated, and so maybe in June you're like I tried it, they told me the wrong information, I'm not gonna do it. So that's been really the angina that we've been facing of how to educate people about the nuances of the rules. The other nuance is there are people, depending on the state, that are gonna get auto-reenrolled, and so they don't have to do anything and they'll renew, and so that's a tough messaging too, because you have to explain who those people are, what are the conditions that make them auto-renew, and it's different by state. So someone auto-renewing in California may be very different than someone who's auto-renewing in New York. And even in New York the health plans don't know who's auto-renewing. We know there are people auto-renewing, we just don't know specifically who they are. So we're talking to everybody, even though some people don't actually have to go through this process. And so an auto-renew would be someone, for example, who is getting SNAP benefits in New York, but if the health plan doesn't know that you're getting SNAP benefits, then we don't know that you're gonna be auto-renewed. So there's been some complexity on the communication.

Errol Pierre:

The last thing I'll say is, if you look at the Medicaid population across the country, many of them are immigrants, many of them are low income. Education attainment is in the high school level, a little bit of college. They speak many, many different languages. In New York alone we have staff that speak close to 50 languages to meet the needs of our members. And so try and think of a word redetermination at an eighth grade reading level in five, six, seven, eight languages leads to the complexity. So CMS calls a redetermination, New York state calls it recertification. People sometimes don't even know they're on Medicaid and it can be very confusing to explain that in a different language and meet members where they are.

Ilene MacDonald:

It does sound really confusing. How is Healthf irst prioritizing the member outreach? How do you find these cohorts of people that you're trying to reach, and at least make sure you're getting the message to them?

Errol Pierre:

This is the exciting piece. So, at Healthf irst, this was an enterprise initiative. It took our analytics team, our marketing team, our product team, our sales team, our compliance team to make sure we're doing everything in a compliant way. Our operations team this was cross-functional work at its best, all rowing in the same direction to try to recertify and renew these members. What we did was take a very data-driven approach, so we looked at the data that we had pre-pandemic in 2019 to find out who fell off the roles the most. Who were the people that disenrolled the most for Medicaid? People who disenrolled for Medicaid, you could probably break them down into three buckets. There's the first bucket that they lose eligibility. So they got a job that earns more income. That's great for them, but now they earn too much money to be eligible for Medicaid, so they fall off. That's the first piece. The second piece is Medicaid folks can tend to be transient. So they were here in America, they got their coverage and then they went back home and now it's time to redetermine their eligibility. They're not here, they're not in the country anymore, so we can't call them, we can't find them, so they just disenroll. And then the third bucket, which is the one that is the most problematic is what we call the Medicaid churn, and these are people who are eligible for Medicaid and for some reason it could be our fault, it could be their fault, they failed to renew their coverage. And that's probably the biggest population. And that's what we call the churn. Because they're eligible, they disenroll and then maybe three months later they go to use their health care benefits and that's when they find out they don't have coverage and then we reenroll them. But they had three months of coverage gap. Or they end up in emergency room and find out they don't have coverage and we reenroll them. And that's a churn bucket.

Errol Pierre:

So we have this data going into the pandemic and then we use that data coming out of the pandemic to say let's stratify our population based on who's the most likely to lose eligibility because of income, because we had a big surge of Medicaid growth when the pandemic hit and there was a lot of job loss and they were people who left the private sector, were unemployed, got Medicaid but then, very quickly, when the economy came back, they left Medicaid and they went back to the private sector and got the coverage through their employer. And we were able to look at that data and understand those are probably folks that aren't going to be eligible for Medicaid, so let's de-prioritize them. Then there were people who were here in America and they couldn't fly home because the pandemic kept them here, and then so, as soon as airlines started allowing flights, many of those folks went back, because they weren't stuck here, and so that's another tranche of folks that we could tell, based on when they enrolled, language spoken, ZIP code, those type of things. Most likely they were probably going to be a transient population. And then the third population is the one we really focused on, which was a churn, which was they're eligible for Medicaid, they should belong in Medicaid and, for whatever reason, maybe we didn't get to them in the right manner, maybe we didn't speak the right language, we didn't reach them, they changed their phone number, during the pandemic, they were living with their uncle so we were sending mail to a different address that they were living in. All these reasons, those were the populations we really focused on and that's how we prioritized it.

Errol Pierre:

The other thing we did is use an omnichannel approach, no wrong door, so we would send a messaging by text message. If they answered, then we knew that was a vehicle that they wanted to communicate with us. If they didn't answer, then we'd move to phone calls, outbound phone calls, and then we'd try phone calls in the morning, then in the afternoon, then at night. So maybe they didn't answer in the morning because they're working, but we got them at night. So we did three different tries at that level.

Errol Pierre:

Then, if we didn't get any response from them because maybe they changed their phone number, maybe their phone number's out of service because the pandemic, the emergency period was over three years, we'd actually did mailers to people's homes for the people that didn't respond to text or phone and then from there, like I said, sometimes many people and I'm sure you know folks that weren't living at home during the pandemic they went someplace else.

Errol Pierre:

So if that didn't work, in some instances, if the populations were very vulnerable, we actually knocked on doors and went to people's houses for our most vulnerable, oldest populations that we really wanted to make sure that they didn't lose their coverage because they had maintenance medication and this is medication that if they lost one month of coverage they would not have their heart medication, for example. So those were people we really focused on. So we kind of did an omni-channel approach. If they answered with the text message, then we stopped because we already got connection with them, so they wouldn't get the phone call and the letter and then the door-to-door service. But if they didn't answer the text message, then they get the phone. If they didn't answer the phone, they get the letter. If they didn't get the letter in their language, then we went to knocking on doors. So it was a very comprehensive approach, all data-driven.

Ilene MacDonald:

It sure was. It sounds like the entire approach was successful then, because you had these. strategies, Is there any one that you thought like was the most effective at all, or maybe anything you might do differently based on what you've learned so far?

Errol Pierre:

Yeah. So it's a great question. I think that we learned the value of SMS text messaging. I think we also had control groups on different messaging. So what words are the right ones to use to get the reaction? To say, you know it's time to renew. Is that as effective, as you will lose coverage, you know? So, like we were testing different messaging, so we learned from that perspective text messages seem to speak to certain groups of people, but not all. So we also learned how to put our populations in different cohorts based on the messaging that they listen to.

Errol Pierre:

And I think the biggest information that we gathered was around how to handle the volume of people once they respond. So I think the lesson learned for me is that human nature is we procrastinate. We, everyone does their taxes on April 14th, right? So if you procrastinate in life, you're gonna procrastinate in recertification. So we saw a surge during the last couple of days, right before people had their deadline to do their redetermination, and so we had to manage that and learn that we had to have enough staff to handle the surge, because you know, we were at for Health first, we were doing about a 115,000 to a 120,000 redeterminations every month across our portfolio. So it's a lot of people and if they all wait to the last minute, you know obviously the phone lines would have long wait times.

Ilene MacDonald:

What are you most worried about when it comes to the impact of health on these members that you're not reaching or that just don't understand these messages?

Errol Pierre:

Yeah, the biggest thing I'm worried about is the education and communication. So Medicaid is not the only product that's up for redetermination. In New York we have a product called Child Health Plus. That's for children that can and also get public health insurance. Undocumented children in New York can get Child Health Plus. So we're really focused on that population. We have another product called the Essential Plan. That's for people who make a dollar too much for Medicaid, so they just make a little bit too much and they fall into another product. That product also is up for redetermination, that we also have our duals.

Errol Pierre:

These are Medicare members, so they're over 65, that are dually eligible, not just for Medicare but also for Medicaid. So they're over 65 and they make less than 15, 16 dollars an hour. And there was a misnomer and some miseducation that seniors didn't have to redetermine eligibility, bu t they actually have to. So there was a lot of education that seniors that also have Medicaid need to do the enrollments. And those are vulnerable populations. Obviously, because they're over 65, they tend to English is not the first language they tend to, I think 30 percent of our book have disabled status. So those are people we're really focused on. So it was really communication so that everyone knew who that they were impacted. What I didn't want people to say is I don't have Medicaid, I don't have to worry, I have Medicare, I'm fine. It's like, no, you're not fine, because if you're dually eligible, you also have to recertify as well.

Errol Pierre:

The other big ticket item that's near and dear to us at Health first is health equity.

Errol Pierre:

Health equity is ensuring that everyone gets access to the health care they deserve, regardless of race, creed, color, or religion.

Errol Pierre:

And if the populations that have the highest health care disparities don't enroll, then our disparities that we have in our country will only exacerbate. So an example I always use is probably the most severe health disparity we have in our country is maternal mortality with women. If you look at Black women, four times more likely to die giving childbirth then their peers, this is roughly 65 to 70 mothers per 100,000 that die compared to the average of 15 or 20. So it's just so much higher. And any of those Black pregnant mothers that don't renew their Medicaid, when they go to the hospital for that birth, the last thing they should be worrying about is I'm uninsured, I don't have coverage, what am I going to do? And then, once that child is born, we also want to get the child covered as well. With the lack of insurance means, those disparities will just exacerbate. So we're really, really focused on a limit of reducing disparities, not having them grow because of the recertification.

Ilene MacDonald:

Is there any advice that you have for organizations that are struggling with their messaging and helping to verify coverage for people in their state? I know it's different per state so that might be harder, but I know that at the summit that you're going to be speaking at in April will be coping with that. So just any final advice that you may have for those who are facing what you're facing every month?

Errol Pierre:

Yes, I think the best thing is to look through the eyes of the consumer you're trying to help and have the voice of the consumer in mind and always have the member at the center of all your decision- making. At Healthf irst, we strive to do that. We say there's no mission without margin and we treat our members like the North S tar. That's what our CEO, Pat Wang, always says, and what that leads you to do is create strategies that are always focused on what the member needs, not what our assumptions are. So unfortunately, you know, fortunately, or unfortunately, unfortunately I make too much for Medicaid, so I'm not on Medicaid, so I don't know what it's like to have lower disposable income, to be worrying about rent, childcare, your cell phone bill, and so we have to ask those members, "how should we speak to you? What's the best way to give you this information" and learn from them, to perfect the way we reach out to them. And that calls for, like cultural competency, having multilingual reps who are well versed on these topics and ready to assist, that look like the population they're serving. So there's a trust factor there. We have 26 community office locations where people can come in and they can bring their paperwork and we can help them go through their paperwork, because it's very confusing to say you have to prove your income. You'll walk through people to show them which W2 they need to show their income, but they have to prove their immigration status. So we'll look through the documents and say this passport is expired, you need a new one, or this is the right visa form. It's a very confusing and it's very intimidating, and so I think the focus on cultural competency and the focus on meeting members where they are is probably the biggest tip, because that will tell you what to do.

Errol Pierre:

The last thing I would say to is the power of the physician. So in many populations, especially immigrant populations, the physician, the doctor, is a stakeholder in the community, and so they are very influential in explaining to members what they should do. And so bringing in the physician into the process of the recertification process around Medicaid, because the health plan can say it, but when a doctor tells you, you're more likely to listen, and so we use our physicians to reiterate our messaging, and we asked them to help us with recertification, because we said they're going to show up in your office and they're not going to be enrolled, and so how can we help you keep them enrolled so that when they do see you you can just render care, you don't have to worry about getting them re enrolled.

Ilene MacDonald:

That's really great advice. Thank you so much for taking the time out of your day today to talk to me about it. I'm looking forward to learning more at your session and the entire summit, which as a reminder to listeners is April 2nd and 3rd. It's virtual, so you don't have to travel and learn this great information. So I thank you and I wish you the best in your endeavor over the next year to try to do this recertification.

Errol Pierre:

Thank you so much, thank you.