Uninsured doesn’t need
to mean uninformed
r e a d e r t a k e - away
How your practice’s staff can help patients
without health insurance
• Get Web sites and phone numbers of
organizations that can help your
patients
• Grasp the extent of the crisis of Americans lacking health insurance
• Learn a number of ways your medical
practice can inform and educate uninsured patients about coverage options
• Learn five questions to ask patients to
determine insurance eligibility
P
By Philip Lebherz
hysicians and other health care providers
nationwide wrestle with how to provide
health care services to the uninsured. Doctors, nurses, therapists and medical group
administrators stand on the front lines of
the complex issue. Politicians debate ways to
fix the system, but health care providers
need solutions today. New initiatives, many
funded by nonprofit organizations, seek to
offer immediate relief to the uninsured by
providing physicians and other health care
professionals with information and
resources that can help them help their
patients.
The uninsured in America
a b o u t t h e au t h o r
Philip Lebherz, founder and
executive director, Foundation
for Health Coverage Education,
San Jose, Calif., plebherz@
coverageforall.org
Solving the health insurance crisis must
begin with an understanding of the nature
and scope of the problem. Federal statistics
now put the number of uninsured at 47
million.1 However, some industry experts
believe that does not take into account millions more who are eligible for insurance
and, through ignorance or choice, don’t take
advantage of options.
About 15 million Americans are eligible
for some type of health care coverage but
have never signed up.2 Another 15 million
are considered self-insured because their
incomes are 200 percent above the federal
poverty level 3 (approximately $41,300/year
for a family of four, according to 2007 federal poverty level data). No matter what the
figure, we know people experience hardships
because they lack health care coverage.
Overview of resources
Health insurance options for the uninsured
range from the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA)
and the Health Insurance Portability and
Accessibility Act to programs such as California’s Healthy Families. Healthy Families provides families at less than 250 percent of the
federal poverty level with affordable insurance, starting at $4 a month with $5 copays. At the federal level, the State
Children’s Health Insurance Program also
provides health insurance coverage to uninsured children of families with income that
is relatively low but too high to qualify for
Medicaid.4
2008 National Medical
Group Practice Week –
Group practice: Building
relationships for quality
patient care
p a g e 2 6 • MGMA Connexion • January 2008
©2008 Medical Group Management Association. All rights reserved.
Reprinted with permission for six months from Medical Group Management Association. MGMA Connexion, Vol. 8, No. 1.
3/31/08
B u s i n e s s a n d C l i n i c a l O p e ra t i o n s
Five simple questions to ask your patients to determine
insurance eligibility
1. Do any of these
circumstances apply
to you?
• Had company-sponsored
insurance within the last 63
days. If so, you may be eligible
for continued coverage under
COBRA.
• Could be turned down for
health insurance because of a
health condition. You may
qualify for coverage under a
state-sponsored high-risk
insurance program, although
not all states have them.
• Lost your insurance due to
fraud or failure to pay your
monthly premium. You could
be turned down for private
health insurance if you have
committed fraud or had your
insurance canceled.
• Work at least 20 hours per
week as an employee or business owner. You could qualify
for a small-group guaranteedissue plan.
• You are uninsured — e.g., you
have no coverage for health
care expenses through work,
spouse or other outside
source. You may be able to
obtain an individual health
insurance policy.
• You receive Supplemental
Security Income (SSI) or Trade
Adjustment Assistance (a program that provides assistance
to workers laid off due to
increased imports from any
foreign country). SSI is considered income or a type of
health insurace credit. Organizations such as the Foundation
for Health Coverage Education
can help patients understand
whether they qualify for these
programs.
2. Do any of these
describe you?
Each of these categories has
associated public health insurance programs. Qualifications
for each state vary.
• American Indian
• Child – State Health Insurance
Program
• Parent of dependent child living in household (or full-time
college student)
• Senior
income as it relates to the
federal poverty level.
4. How old are you?
• 0 to 18 years
• 19 to 39 years
• 40 to 64 years
• Undocumented immigrant
• 65 and over
• Veteran
• Woman
5. Do you have any special
3.
• Pregnant
health conditions?
How many people are
in your household, and
what is your household
income?
Family size:
Annual income:
• Serious medical conditions
or disabilities (physical or
mental)
• Chronic illness or genetic
disorder
1
$0-$25,525
2
$25,526-$34,225
3
$34,226-$42,925
4
$42,926 or above
• Cancer, hyperalimentation,
kidney dialysis
• AIDS/HIV
This question pertains to the
federal poverty level guidelines.
All public assistance programs
base eligibility on household
Each of these categories has public health insurance programs that vary by state. State and federal agencies request this information
to determine eligibility. Nonprofit organizations such as FHCE can gather this information via a Web-based questionnaire and quickly
identify resources to provide insurance coverage.
In addition, many states are developing
other health care coverage programs for the
uninsured. For example, Massachusetts
recently enacted legislation that will provide
coverage to all residents — regardless of
employment status.
What medical groups can do
The challenge facing health care providers
and advocates for the uninsured is how to
inform and educate patients about options.
Here’s where your medical office staff can
play an important role. Your employees can
help identify patients who have lost coverage, and, more important, they can describe
and provide information about insurance
options. Your practice can take a number of
steps to help inform patients about health
insurance options:
Listen to your patients — Many patients
lose health insurance due to divorce or job
loss and may be reluctant to ask for help.
Medical staff can help by looking for clues.
Does a patient express concern about paying
for prescription drugs or tests? Does a
patient hesitate to make appointments?
Front-office staff, nurses and physicians can
all watch for signs that patients lack health
insurance.
Ask the right questions — Once you
know a patient has no insurance, find out
what type of coverage he/she may qualify
for. Advocates for the uninsured suggest that
providers ask patients five simple questions
to determine their eligibility for one of the
many programs that provide health insurance (see box above).
Educate your office staff — One of the
best places to start is with your state or
county health department. It can usually
see
Uninsured, p a g e
©2008 Medical Group Management Association. All rights reserved.
Reprinted with permission for six months from Medical Group Management Association. MGMA Connexion, Vol. 8, No. 1.
Celebrate patient-centered care with
your clinicians, support staff and
other professionals during the 2008
National Medical Group Practice
Week, Jan. 21-25. For celebration
ideas and information about patientcentered care, visit www.
medicalgrouppracticeweek.com.
28
MGMA Connexion • January 2008 • p a g e 2 7
3/31/08
Uninsured
from page 27
provide a list of insurance resources in your
area, as well as important guidelines.
Another resource is Foundation for Health
Coverage Education, a nonprofit organization dedicated to informing people about
available resources. It offers a health care
options matrix that helps health care professionals, employers, brokers and others
quickly identify various programs available
for patients nationwide. The foundation
provides a user-friendly chart that addresses
nearly every demographic category, as well
as public, private and free or low-cost health
coverage options.
Provide easy-to-understand patient
information — Health care providers too
often overlook the problem of low health
literacy in the United States. Most health
care materials are written at a 12th-grade
level, but nearly one in two Americans can’t
understand health care information beyond
the fifth-grade level.5 The complexities of
some insurance application forms deter
many patients from enrolling. Therefore,
helping to simplify the process is an important step. Organizations such as the Institute
for Healthcare Advancement have programs
to translate complex health insurance forms
into simpler language. For example, they
will define the term co-pay as “you will pay
a small amount” instead of “guaranteed
issue,” and they will explain that insurance
coverage is guaranteed.
Ensure that information is easy to
obtain — Don’t just make sure your prac-
tice’s health care information is understandable. Also ensure that patients can obtain it
easily. The financial industry has done a
great job of providing applications online,
streamlining the application process. The
Foundation for Health Coverage Education’s
Web site gives health care providers information for patients. You can view the health
care options matrix in a printable PDF format, as well as every available application
for health insurance throughout the nation.
Reach out to your community —
Through job fairs and other community
events, your practice can reach out to the
community with news and information
about insurance options. Include information about insurance options when your
organization participates in health fairs or
other community events.
A time for action
Public debate about the future of our health
care system will only grow louder and more
contentious. Parties on all sides of the issue
will offer solutions. While health care
providers must be part of the debate — and
part of the solution — they must also be able
to provide answers to patients today.
First, understand the nature of the uninsured in America and the many resources
available to patients.
notes
1. U.S. Census Bureau. Income, Poverty and Health
Insurance Coverage in the United States: 2006:26.
www.census.gov.prod/2007pubs/p60-233.pdf,
accessed Nov. 26, 2007.
2. FHCE’s interpretation of a 2004-2005 State Health
Facts report, Kaiser Foundation.
Web sites and phone numbers to
help uninsured patients
Foundation for Health Coverage Education: www.coverageforall.org
3. www.statehealthfacts.org/comparebar.jsp?
ind=125&cat=3, accessed July 18, 2007.
4. Congressional Budget Office, The State Children’s
Health Insurance Program, May 2007.
5. Partnership for Clear Health Communication,
National Patient Safety Foundation, 2006.
Medical groups can download or order the health care options matrix for their
state.
The U.S Uninsured Help Line: 800.234.1317
Operators are available to speak with health care professionals or patients 24
hours a day, seven days a week.
Institute for Healthcare Advancement: 800.434.4633 or online at
iha4health.org
For information on obtaining easy-to-understand health insurance applications.
p a g e 2 8 • MGMA Connexion • January 2008
©2008 Medical Group Management Association. All rights reserved.
Reprinted with permission for six months from Medical Group Management Association. MGMA Connexion, Vol. 8, No. 1.
3/31/08