1. health and fitness

Date: April 7, 2015
To: Kim Belshé, First 5 LA Executive Director
From: The following Children’s Health Outreach Initiative (CHOI) Contractors
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Asian Pacific Health Care Venture
Child and Family Guidance Center
Citrus Valley Health Partners
Community Health Councils
Department of Health & Human Services City of Long
Beach – Health Access Program
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Maternal and Child Health Access
Northeast Valley Community Health Corporation
Valley Community Healthcare
Venice Family Clinic
Worksite Wellness
On behalf of agencies that are contracted through the Los Angeles Department of Public Health (LADPH) Children’s Health
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Outreach Initiative (CHOI), we are grateful that you met with some of us on March 30 to discuss continued funding of the
Healthy Kids Outreach Partnership also known as Children’s Health Outreach, Enrollment, Utilization and Retention (CHOEUR)
Services. As a follow-up to that meeting we wanted to provide you with some additional information on the program, the
enrollment assistance funding landscape, alignment with the new strategic plan, and sustainability options.
Background
For more than 10 years, funding from First 5 LA has facilitated the Los Angeles Department of Public Health (LADPH) Children’s
Health Outreach Initiative (CHOI) in building a strong community enrollment assistance infrastructure to support LA County
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families and inform the local and state health coverage landscape. Unlike other community enrollment assistance programs,
the CHOI program includes a set of clear metrics, training support, evaluation measurements, and a system for collecting realtime data.
Training is provided to ensure contractors are well-versed in all healthcare programs, not only Medi-Cal and Covered California,
which are offered on a free or low-cost basis in Los Angeles. The “We’ve Got You Covered” comprehensive training is from an
advocacy perspective, lasts two days and is supplemented with follow-up trainings after contractors begin seeing enrollees.
The trainers make themselves available to answer questions and assist with clients. The training is essential to be able to
conduct the activities below; training modules offered by the state are inadequate to fully support the activities required in the
CHOI program.
Services provided by the CHOI program are comprehensive and include:
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Outreach to inform the community about available health coverage programs and how to access services.
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Enrollment/Application Assistance to complete one or more applications for health coverage along with a 2-3
month follow-up to confirm enrollment status.
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Utilization assistance offered on an ongoing basis for clients experiencing problems as well as a standard follow-up
contact within 6 months of application submission to determine utilization of benefits.
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Redetermination assistance offered 11 months after application submission for clients enrolled by CHOI as well as
consumers originally assisted by other agencies or systems.
While it is hard to determine the exact amount of time spent each activity, it is can be estimated that enrollment staff spend
the majority of their time post-application activities. Putting aside system errors with the online applications, most enrollers
can complete an application in less than 30 minutes. What takes longer is when there is an error with the online application
or consumers receive an erroneous eligibility status. Contractors must contact 100% of those who applied to confirm their
enrollment status and follow up with utilization and redetermination support to everyone for whom they’ve confirmed
enrollment. In 2013-2014, 82% were confirmed enrolled (just over 23,000). Add on top of that the follow up calls, assistance
with a utilization issue, and completing a 6-page renewal form, and it becomes evident that most of the time is spent on postapplication assistance.
Enrollment Assistance Funding Landscape
As a result of the Affordable Care Act (ACA), over three million people are now enrolled in either Medi-Cal or a Covered
California Qualified Health Plan (QHP). However, enrollment has taken place in the context of new enrollment computer
systems with serious malfunctions, not just glitches, which has been likened to “flying the plane while we’re building it”. A
backlog of Medi-Cal enrollments that grew to more than 90,000 and a six-page Medi-Cal renewal form that replaced the former
simplified form are just two of the many issues. The backlog and other issues affect pregnant women, newborns, and children
alike, requiring extensive troubleshooting assistance and “hot line” status for people with serious health care needs. The high
enrollment numbers and issues with ACA implementation have in turn caused the need for troubleshooting assistance to
increase, however, funding for community enrollment services is diminishing. The following is an overview of the current
landscape and how the CHOI program and contractors leverage this funding:
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Covered CA Enrollment Program – Certified Enrollment Counselors (CEC): This program provides $58 per successful
QHP enrollment; CEC’s also receive Medi-Cal In-Person Enrollment Assistance Payments which is funding from The
California Endowment (TCE) to the Department of Health Care Services (DHCS) then passed to Covered CA. All
reimbursements will end June 30, 2015 when this program transitions to the uncompensated Certified Application
Counselor Program. While CHOI contractors are certified many are no longer eligible to receive reimbursements
because of the Medi-Cal Outreach and Enrollment Contracts (see below).
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Covered CA Enrollment Program – Navigators: This is a grant based program that primarily supports QHP enrollments.
Very few of the CHOI enrollment entities participate in the Navigator Program because of the unrealistic reimbursement
structure (i.e. funding only after confirmation of enrollment) and limited focus on troubleshooting activities. Covered CA
has stated that because of the amount of troubleshooting that current grantees have had to provide, they will be
making changes to the next cycle. However, the average grant will likely be $50,000 to $100,000 which is only a fraction
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of what CHOI contractors currently receive. More details are expected after April 16 .
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Medi-Cal Outreach and Enrollment Grant Funding: This is additional funding provided from TCE to DHCS for local
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counties to “to supplement, but not supplant, Medi-Cal O&E efforts associated with the implementation of ACA”. The
LA County grant funds a collaboration of five departments (Public Health, Health Services, Mental Health, Public Social
Services and Sheriffs) with LADPH being the lead agency. CHOI contractors received augmentations which were about
10% of their current grants and last through June 2016.
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Medi-Cal Renewal Funding: This funding was provided from TCE to DHCS and is expected to be added to the current
county Medi-Cal Outreach and Enrollment Grant Funding. However, nothing official has been released.
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Department of Health and Human Services (HHS): This agency oversees the “Connecting Kids to Coverage Outreach and
Enrollment Grants” which comes from the ACA and Children's Health Insurance Program Reauthorization Act (CHIPRA) of
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2009. Because of the competitive nature of this grant and limited funding, only two CHOI contractors currently receive
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this funding and it is uncertain if another cycle will open. The HHS Office of Minority Health just released a 2 cycle of
funding for their “Partnerships to Increase Coverage in Communities” to support Marketplace outreach and
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enrollments. Only 17 grants will be awarded nationally at a maximum of $250,000 for each.
Alignment with the New Strategic Plan
First 5 LA’s strategic move to have a greater impact on the policies and systems in order to “strengthen families and improve
outcomes for the greatest number of children prenatal to age 5 in L.A. County” is understandable given dwindling revenue.
The following are several examples of how the CHOI program currently aligns with this direction:
Increased Family Protective Factors
 There has been an increased demand for assistance because new consumers entering the system, changes to how the
systems operates and the amount of glitches and misinformation in the community. For the CHOI program it caused a
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133% increase in the number of issues assisted with from the 2012-2013 program year to 2013-2014. As of February 28 ,
the number of issues assisted in the current program year (23,062) has already surpassed last year’s.
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First and foremost, contractors advocate for the consumer, often going above and beyond to ensure that the
consumer obtains or retains their health coverage. Contractors also educate consumers on their rights and
responsibilities so that they can advocate for themselves.
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Because of their history in the community contractors also become trusted resources for more than just health
coverage. Parents come back time and time again knowing that these agencies will connect them to services for all of
their needs, be it medical, housing, nutrition, or social well-being.
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As for link families with nutrition resources, several contractors are also CalFresh contractors and all of the agencies
assist with applications through Los Angeles County’s YourBenefitsNow online system which completes the application
for Medi-Cal, CalFresh and CalWorks. All of the agencies are connected to WIC programs across LA County, either being
stationed at WIC sites or being administrators of a WIC program themselves.
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The CHOI contractors are also well connected to the Welcome Baby and Home Visitation Programs. Through the
training that is offered by MCH Access (a CHOI contractor) all Welcome Baby Parent Coaches are given a list of the
contractors as a resource for new parents and their infants. Contractors also have their own relationships with the
program and offer consultation, troubleshooting and advocacy services as well as referrals. Parent Coaches are able to
refer but are not usually able to spend the time and conduct the intensive work necessary to close a case situation.
CHOI contractors are essential to the home visitation programs’ clients’ ability to adequately navigate and obtain
prenatal and child health care.
Moving forward, if desired the CHOI program could collect additional data on the Welcome Baby and Home Visitation
participants who are assisted by CHOI contractors. This would assist with identifying where problems arise and inform where
program changes could be made to better support participants
Increased Community Capacity to Support and Promote the Safety, Healthy Development and Well-being of Children
Prenatal to Age 5 and Their Families
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Contractors are a strong network of advocates who are well connected to each other and the community. Over the
years contractors have forged a strong relationship and support system. They call upon each other when they have
questions, run into roadblocks and to clarify policy decisions. When necessary contractors are able to mobilize and
respond to health policies that may negatively impact the community. Contractors remain connected with health
agencies and advocacy groups in order to stay current on policy changes and raise awareness of barriers to consumer’s
access to health care. They participate in various coalitions and workgroups such as the LA Access to Health Coverage
Coalition, Everybody on Board, and the LA County DPSS/DHS Health and Nutrition Access.
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CHOI contracts with Maternal & Child Health Access (MCHA) to develop curriculums and materials to help enrollment
staff implement and advance effective outreach, enrollment, retention and utilization strategies. The MCHA training
“We’ve Got You Covered” provides an extensive in-depth knowledge from an advocacy perspective of all coverage
programs including local options for those not eligible for any public programs and tips on how to troubleshoot difficult
cases. First 5 can be proud that this training has been provided to county workers under the new augmentation grant,
and in various counties across the state. Welcome Baby Programs are all trained in a four-hour specific training on
pregnancy and early childhood health coverage eligibility. The number of referrals to Contractors from Welcome Baby
programs has surged in the last year, as 13 additional Welcome Baby programs opened.
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As a result of their training and connections, CHOI contractors have been a great support to all of the new
organizations that have recently become certified to conduct enrollment services.
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While it varies across sites, contractors have been engaged as participants of and resources for their local Best Starts.
Some are on the leadership councils, have connected parents to the sites, and provided valuable presentations on the
changing health coverage landscape.
Moving forward there could be a more formalized agreement between CHOI contractors and their local Best Starts to not only
provide enrollment assistance but collect site level data which would inform activities and services offered in these communities.
Furthermore with additional training and changes to the database, contractors could collect data on issues beyond health such
as access to food and physical activity resources as one example.
Increased access to quality early care and education
 Through partnerships with the Los Angeles County Office of Education (LACOE) and the Los Angeles Unified School
District (LAUSD) the CHOI program has been a resource for students and parents. CHOI contractors are able to be a
resource for their Head Start-State Preschool centers and Healthy Start Programs. Additionally the LAUSD CHOI contract
is primarily focused on supporting the Early Education and Primary Centers.
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CHOI contractors have always supported early care and education providers by being a resource for their families and
connecting them with health coverage. For example, Crystal Stairs, one of LA County’s premier child care resource and
referral agencies, is a CHOI contractor and offers enrollment services to all of the child care providers they serve.
Moving forward with additional training and changes to the database, contractors could collect data on early care
and education access issues and barriers which could further inform First 5 LA initiatives on this subject.
Improved capacity of mental health and substance abuse services systems to meet the needs of children prenatal to age 5
and their families
 The CHOI database is a critical and valuable resource for contractors and health advocates because it provides
quantitative data on enrollment, utilization and retention activities/issues that can’t be found elsewhere. This data
has been used by many advocates to not only showcase the importance of community based enrollment but to
highlight the impact that various policies have on the community.
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At the outset of the Deficit Reduction Act (DRA), CHOI contractors had the foresight to determine the need to
track barriers that were occurring in Medi-Cal as a result of the DRA so a new code was added. This data was
shared with DPSS to make further improvements to their protocols.
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In the past this data has been presented at various stakeholder meetings allowing contractors to then inform
policy decisions and recommendations.
CHOI Contractors have become skilled Policy Advocates and constantly contribute to the health coverage policy
discussion by educating health advocates about the barriers consumers face. Quite often they must educate County
Eligibility workers about policy changes and frequently provide the local Medi-Cal office and other agencies with case
examples of how consumer access to coverage is being compromised by program changes or uninformed workers.
Moving forward with additional training and changes to the database, contractors could collect data on issues beyond
traditional health coverage that would inform general health, mental health and substance abuse systems.
Sustainability
Because of the substantial investments already made, CHOI is an established program which means that when new
opportunities become available there are minimal startup costs. Contractors are able to adapt as necessary with
supplemental training and supports. For example, in response to the DHCS Medi-Cal Outreach and Enrollment grants, LA
County quickly mobilized itself and because of its track history allowed DPH-CHOI to take the lead. In recognition of the
importance of quality data collection, all of the counties involved require their sub-grantees to utilize the CHOI database.
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Moving forward the CHOI contractors stand ready to work with First 5 LA and LA County Department of Public Health
to develop a plan on how to continue supporting enrollment assistance. Over the next year we recommend having
time to work together to research the possibility of connecting CHOI with other funding opportunities, county
initiatives and First 5 LA Programs as noted above.
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Furthermore we would recommend there be a further analysis of the synergies between CHOI and the current and
future First 5 LA funded policy and system change projects to identify if there is additional data that CHOI contractors
could collect to inform these projects. Additionally CHOI contractors should be provided with information about all
First 5 LA funded projects in order to educate parents about ways to be engaged in these projects including advocacy
opportunities.
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endnotes
Community enrollment assistance includes the following entities: community based organizations, clinics and schools.
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Department of Health Care Services, Outreach and Enrollment Webpage http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/OEworkgroup.aspx
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Insure Kids Now, Connecting Kids to Coverage Outreach and Enrollment Grants Web page http://www.insurekidsnow.gov/professionals/outreach/grantees/
Department of Health and Human Services, Office of Minority Health, Funding Opportunity Application “Partnerships to Increase Coverage in Communities
II Initiative” MP-CPI-15-003http://www.grants.gov/web/grants/view-opportunity.html?oppId=275314