Increasing Benefits Access for People with Medicare: Lessons Learned from the Second Generation of Benefits Enrollment Centers (BECs)

Increasing Benefits Access for People with Medicare: Lessons Learned from the Second Generation of Benefits Enrollment Centers (BECs) A report from the Center for Benefits Access at the National Council on Aging May 2014

Table of Contents Introduction... 1 Outcomes... 2 Applications submitted by the BECs... 2 Outreach and Enrollment Activities... 5 Following up on applications... 7 Ensuring success of applications... 7 Partnerships... 8 Initial and ongoing challenges... 9 Conclusions: Lessons Learned... 12 Looking ahead... 12

Introduction In 2009, the U.S. Administration on Aging (AoA, now part of the Administration for Community Living [ACL]) awarded a grant to the National Council on Aging (NCOA) to establish the National Center for Benefits Outreach and Enrollment (the Center). 1 The establishment of the Center was one component of an initiative to support outreach activities to assist beneficiaries understand and apply for Medicare benefits and other federal and state benefits. One of the key tasks of the Center has been to establish and support Benefits Enrollment Centers (BECs) to help low-income seniors and younger adults with disabilities find and apply for all the benefits programs for which they are eligible. In 2009, the Center established the first generation of BECs in 10 areas of the country. In 2010, the Center issued another request for proposals from local and state organizations to create the second generation of BECs. 2 The purpose of the grants was to develop and implement coordinated, community-wide, person-centered systems for benefits outreach and enrollment with the primary focus being on core undersubscribed public benefits programs, including: Medicare Part D Extra Help (or Low-Income Subsidy, LIS) Medicare Savings Programs (MSP) Medicaid Supplemental Nutrition Assistance Program (SNAP, formerly the federal Food Stamp program) Supplemental Security Income (SSI) Low-Income Home Energy Assistance Program (LIHEAP) The BECs could also opt to include other benefits programs in their efforts, such as State Pharmacy Assistance Programs (SPAPs 3 ), state property tax relief, state tax credits, and pharmaceutical manufacturer-sponsored Patient Assistance Programs. BECs were tasked with developing coordinated person-centered systems for benefits outreach and enrollment in their communities. A person-centered approach to benefits outreach and enrollment entails personalized, one-on-one assistance mechanisms for potentially eligible seniors and younger adults with disabilities, and their families, through benefits eligibility screening, and 1 In 2013, the National Center for Benefits Outreach and Enrollment formally changed its name to the Center for Benefits Access. 2 In its second funding iteration, the Center continued to support the first cohort of BECs with small sustainability grants. For more information on the first generation of BECs, see our report at: http://www.ncoa.org/enhanceeconomic-security/center-for-benefits/content-library/becs-lessons-learned.html. 3 Currently, 22 states have the SPAP benefit. Center for Benefits Access 1

assistance with the application processes. A person-centered approach consists of conducting eligibility screenings and providing assistance in completing and submitting applications for multiple local, state and federal benefits. The BECs utilize the assistance of web-based decision tools, such as NCOA s online benefits screening tool BenefitsCheckUp. Community mapping is an integral component of carrying out person-centered activities. Community mapping involves determining the right partners to engage, figuring out the commitment levels and appropriate roles for each of the partners, and working together to determine which outreach and enrollment strategies will best fit the community being served. In addition, community mapping is critical to leveraging the strengths of each partner and achieving a seamless referral process. By focusing on coordination among partners and capacity building to provide technology-driven personalized assistance, a person-centered approach also fosters sustainability of outreach and enrollment efforts beyond the grant period. Nine new BECs were given funding: AARP Foundation; Centura Health LINKS; Senior Resources Agency on Aging; ElderSource in Action; Isabella Geriatric Center; Legal Aid of the Bluegrass; Washington County (OR) Disability, Aging and Veteran Services; WISE & Healthy Aging; and the Honolulu Elderly Affairs Division. 4 This report focuses on these nine BECs, their achievements, and provides an analysis of their outreach and enrollment efforts, and the challenges they faced. Outcomes Applications submitted by the BECs During their two-year grant period (March 2011 through February 2013), the nine BECs aided thousands of seniors and younger adults with disabilities to find assistance with their medical, food, and housing costs through one-on-one benefits counseling and enrollment in public benefits for those eligible. Through their outreach efforts, the BECs reached more than 993,580 individuals. Furthermore, due to the BECs person-centered approach, 100,621 had one-on-one benefits counseling sessions. The BECs screened 26,650 individuals for benefits eligibility. Of those screened, 60% were found eligible for at least one benefit. Additionally, 72% of those screened had applications for benefits submitted. 4 A tenth grantee, the Coalition of Wisconsin Aging Groups, was initially selected as part of the second generation of BECs, but was unable to complete the functions of the grant and is therefore not included in this report. Center for Benefits Access 2

It is significant to note the large number of individuals reached by outreach, particularly in light of the smaller number of individuals counseled and screened. This large gap demonstrates that, in some areas, the BECs cast a wide net in their outreach efforts. Though the outreach number far exceeds those counseled, it reflects positively on the BECs, as they sought to reach and inform as many individuals, and underserved populations as possible. Also, as discussed later in this report, some of the BECs began altering their methods to attempt to close this gap. For example, some BECs began focusing on setting up future counseling and screening appointments at large fairs/public outreach events, instead of attempting to conduct enrollment in a public environment. It is also important to examine the number of applications submitted in comparison to those found eligible for at least one benefit. As the number of applications submitted exceeds the number of individuals, it is evident that the BECs submitted more than one application for benefits for some of those individuals. Analysis from BenefitsCheckUp screening data reveal that 4 out of 5 individuals who are eligible for one core benefit are likely eligible for additional benefits. Evaluating eligibility for multiple core benefits improves the economic security of seniors and adults with disabilities. It is often through the combination of multiple benefits that individuals are able to live independently and remain in their communities. The fact that the BECs evaluated and submitted applications for multiple benefits for eligible individuals is at the heart of the holistic approach envisioned by the grant. Figure 1: Outcomes of the BECs Outreach and Enrollment Efforts 26,650 Screened for Benefits 15,961 Found Eligible for at Least One Benefit 11,598 Helped with Applications Source: National Council on Aging, BenefitsCheckUp.org BEC Reporting System, March 2014 Center for Benefits Access 3

The BECs focused their applications essentially equally on all application types, as no single application type received even 25 percent of the total applications submitted. This is also reflected in the comments of the BECs regarding which benefits were most sought after at their particular BEC, and which ones were simplest to complete. These seemed to vary by BEC, resulting in this relatively even distribution of benefit applications. The breakdown of application submissions by benefit included (see also Figure 2): The majority of the applications submitted by BECs were for optional benefits: 24% (including patient assistance programs, tax relief, and other state and local programs) MSP: 20% SNAP: 19% The Medicare Part D Low-Income Subsidy: 16% Medicaid: 8% LIHEAP: 7% SPAP : 6% Figure 2: Distribution of Applications Submitted by BECs by Benefit 5000 4500 4000 Number of Applications 3500 3000 2500 2000 1500 1000 500 0 SNAP LIS LIHEAP MSP SPAP Medicaid Optional Benefits Benefit Program Source: National Council on Aging, BenefitsCheckUp.org BEC Reporting System, March 2014 Center for Benefits Access 4

Outreach and Enrollment Activities All of the BECs conducted a wide range of activities to identify potentially eligible beneficiaries, and to encourage and assist them in applying for benefits. The number of people reached varied by the type of activity. The most successful outreach activities included presentations at senior centers, activities at local pharmacies, outbound call centers, and targeted advertisements. For example, Senior Resources found that the most successful outreach methods included flyers distributed at expos, and having small displays of information placed in public areas, like libraries and medical centers. Some of the least successful outreach activities included widespread dissemination of flyers (i.e., not targeted to specific populations or geographic areas), and information stations at fairs targeting a much younger audience, rather than the senior populations in the area. A key lesson from their efforts was that while no single approach or activity necessarily worked best, knowing the local community was critical to maximizing outreach strategies. For example, Legal Aid of the Bluegrass reported that outreach activities at a local pharmacy proved successful. Many of the BECs also found that while using an outreach mechanism that was broad in scope intended to reach many people, the most effective approach centered on more targeted campaigns. All of the BECs found that through their efforts they were able to reach more individuals, and expand their reach to isolated individuals including those isolated by geography and disability or lack of mobility. Additionally, many BECs cited word of mouth in the community as the most effective outreach tool. Therefore, once a member of the senior community had a positive experience at a BEC, they were likely to inform other members of the community of these successes, thereby encouraging additional people to request assistance and apply for benefits through the BEC. Some findings from the BECs on the effectiveness of common outreach methods include: Fairs and events. Several BECs included fairs as part of their outreach strategy. This often included a stand set up at a town fair. The results of the BEC presence at fairs were varied, depending on the nature and target audience of the fair. Some family friendly fairs, for example, had stronger turnout from younger families and lower turnout from seniors. Additionally, some BECs noted that even at fairs where there was a significant senior population, the environment at the fair lead to distractions that made it difficult for audiences to absorb the information presented on benefits and eligibility. Another problem posed by the public setting of the fair was that many seniors were uncomfortable providing private information to people they did not know, without necessary privacy protections. Also, if the fair was a singular event, many people who had difficulty attending would miss the opportunity to learn about the benefits presented. Despite these obstacles, there were Center for Benefits Access 5

BECs who addressed the above concerns, and therefore found the fairs and events to be successful outreach programs. Fairs and events that were targeted to seniors and recurring events lead to better results. For example, ElderSource in Action conducted outreach at an Alzheimer s Walk, a monthly event conducted with partners on a consistent date and location, so that people could expect the BEC to have a presence, and could slowly become familiar with the staff of the BEC. Another difficulty with fairs is the small window of time that BEC counselors have to gain the clients trust. This also leads to difficulties in combining outreach with enrollment, which requires giving out personal financial information to complete the applications. Isabella Geriatric Center successfully addressed this obstacle by opting to make appointments for individuals at these outreach events, and then following up with phone calls, rather than focusing on screening and enrolling individuals at the event. Advertising. Advertising was generally viewed as an effective outreach tool by the BECs. However, success rates differed with the advertising approach. Senior Resources Eastern Connecticut determined that having information regarding the BEC presented on local radio shows was more effective than having generic newspaper announcements. Centura Health LINKS noted that bright, glossy postcards with simple messages mailed out to seniors were effective in increasing the number of seniors informed of the services available at the BEC. Flyers. Flyers presented varying success for the BECs, generally correlated with the strategy employed to disseminate the flyers. Broad, generic, and widespread flyer mailings and posting did not yield many new individuals to the BECs for screening. However, some BECs found that targeted distribution in areas with a large senior population, such as senior affordable housing buildings, did result in increased traffic at the BECs. Despite this, many BECs found that the costs of producing and distributing flyers outweighed the minor increase in traffic, when compared to more successful outreach measures. Targeted public displays. Some of the BECs found that working with health care providers, who either specialized in geriatric care, or were frequented by seniors, provided an effective avenue for outreach. Legal Aid of the Bluegrass placed brochures in examination rooms at a doctor s office, and at a local pharmacy. Isabella Geriatric Center cited programs where they placed flyers at a popular geriatric doctor s office. Both of these BECs found these targeted outreach methods effective. Center for Benefits Access 6

Following up on applications Despite the perceived successes of outreach and enrollment For every 10 individuals the activities, it is rare that a client can be served completely in a single BECs screened, more than screening or event. Follow-up is often required to encourage the 7 submitted applications client to complete the application, and to gather supporting for benefits. documentation. Understanding the importance of this step in benefits enrollment, the Center required that the second generation of BECs include mechanisms for following up with clients in their grant activities. The frequency and type of follow-up with potential beneficiaries, however, varied across the BECs. Several of the BECs found that following up on applications after submission was both the most challenging aspect of their work, and also one of the most crucial steps in ensuring that individuals actually received benefits. The main challenges in the follow-up included a lack of adequate volunteers to devote time to follow-up, and ensuring that individuals brought all necessary documents to their appointments at the BECs. The BECs developed various methods to address these problems. Centura Health LINKS devised a checklist of required documents for specific applications, and sent those to clients prior to their appointment. Additionally, Centura Health LINKS called the clients the day before the appointment to remind them of the appointment, and the documents needed for the various applications. Through a database that Centura Health LINKS designed, they were able to automatically generate dates and timelines of application submissions and approvals, so that they could follow up after the appointment regarding the status of the client s application. Legal Aid of the Bluegrass also developed a database for scheduling follow-up calls and appointments, and hired one specific person tasked with screening and follow-up. Ensuring success of applications The processes employed by these BECs were designed to ensure that clients provided all necessary documents in a limited number of visits. Many of these clients have mobility limitations, do not have ready access to transportation, or may become frustrated with the process if multiple visits become necessary. Therefore, limiting the number of visits for clients was essential to client satisfaction in the process, and success in application submission. Some BECs also found that it was essential to reinforce the understanding with clients that the relationship with the BEC is an ongoing partnership that is not severed at the point of application submission. The BECs strove to emphasize that they remained a continuous resource for Center for Benefits Access 7

individuals, encouraging individuals to seek assistance if an initial application was denied. If an application was denied due to inadequate documentation, for example, the BECs would work with their clients to supplement the application, so that the eligible individuals could receive benefits. AARP Foundation became an authorized representative for clients, thereby receiving notices directly from government agencies, and having the authority to contact the agencies on behalf of clients, in order to assist them more seamlessly. Partnerships All of the BECs stated that partnerships were instrumental in carrying out their activities, and thereby boosting the capacity of the centers to serve more low-income seniors and younger persons with disabilities. The BECs found that through these The BECs strove to emphasize that they remained a continuous resource for individuals, encouraging individuals to seek assistance if an initial application was denied. partnerships, they were able to expand on existing trusted relationships resulting in an increased number of individuals assisted. Collaborating with state and community organizations was a key building block in achieving the goal of creating communitywide systems of benefits outreach and enrollment. Partnerships were valuable to the BECs in several ways. Many local partner organizations had experience working with specific, often underserved, populations and had trusted relationships in these communities, thereby enabling the BECs to better target these groups. For instance, Washington County Disability, Aging and Veteran Services partnered with Meals on Wheels in their area. The BEC provided brochures and information to those delivering meals to be passed on to the meal recipients. The BEC found that due to the existing, trusted relationship between the Meals on Wheels representative and the recipient, the information from the BEC was more likely to be trusted as well. Through this partnership, Washington County Disability, Aging and Veteran Services was able to expand its reach to isolated individuals with limited mobility. The BEC likely could not have reached this group through traditional outreach methods, thereby underscoring the necessity of partnerships. It should also be noted that BECs found that the most successful partnerships, in terms of increasing awareness and enrollment among seniors, were developed when the BEC s partner organization encouraged seniors to trust the BEC and to apply for benefits. As WISE & Healthy Aging noted, some seniors did not initially trust the BEC staff, and did not feel comfortable providing personally identifiable information to unfamiliar people. This concern lessened, however, through the support and encouragement of the directors of the senior centers with whom the BEC partnered. Center for Benefits Access 8

The BECs noted some lessons on partnerships: Choose partners that clients trust, and have an existing presence in the community. Successful partnerships included medical centers, hospitals, and pharmacies. Legal Aid Bluegrass partnered with local hospitals and medical centers in order to increase outreach and enrollment through the assistance of a trusted source. Using trusted organizations with an existing presence in the community as partners provided a trusting background for clients at the BECs. For example, seniors were familiar with and trusted the directors at the senior centers. Therefore, the fact that these directors actively encouraged clients to use the BEC, and vouched for its authenticity, resulted in the clients trusting the BEC, and therefore availing themselves of the BEC s resources. As discussed above, the partnerships that the BECs develop and utilize to promote the BEC, and encourage enrollment, are inextricably linked to the BECs outreach plan. Constantly evaluate the partnership strategy. Some BECs learned that reexamining, and perhaps modifying, partnership strategies midcourse improved outreach. WISE & Healthy Aging found that when a senior center the BEC initially worked with did not support the BEC, it made it extremely difficult for the BEC to gain the trust of the seniors at the center. In fact, this counselor at WISE & Healthy Aging found that not only did the senior center not encourage seniors to seek assistance with benefit screening and enrollment, but it did not even vouch for the BEC on a basic level in order to engender trust. The counselor noted that one needs to cultivate a relationship with the individuals who serve seniors for my outreach to be successful...the director and staff [of a partner organization] to not only be supportive of our program, but to understand and promote it internally... One needs to develop strong relationship[s] with partners, and really try to educate them on the value of the program, so that they encourage their clients to apply. Initial and ongoing challenges The BECs cited several common challenges as they began outreach and enrollment of seniors and individuals with disabilities; these can be categorized into initial challenges that many were able to overcome, and ongoing challenges that continue to affect the BECs throughout the grant period and into the future. 5 A few of the initial challenges faced by many of the BECs included: 5 Eight of the nine second generation BECs continue to serve as enrollment centers. The Center for Benefits Access continues to provide small sustainability grants to all BECs, and recently awarded new BEC grants to several additional organizations. Center for Benefits Access 9

Trust and stigma. A significant challenge that several BECs faced was the perception among those eligible for benefits that receiving such benefits carries an associated social stigma. Also, many seniors were concerned that accepting benefits would result in unintended consequences (the government confiscating their home, for example). AARP Foundation found that creating handouts with simple language explaining the impacts of benefits was helpful in mitigating these concerns. Despite attempts to address these problems, many seniors continue to tie a social stigma to receiving benefits. All of the BECs also noted that the lack of trust among those eligible for benefits and the BEC hindered the BEC s ability to assist more eligible individuals. All of the BECs listed this as a major obstacle that required thoughtful and continuous effort. Isabella Geriatric Center summarized the importance of this topic, in stating that gaining the client s trust is the key to the success of the BEC. Correct documentation at initial visit. Having applicants bring all necessary documentation on the first visit, so that applications can be completed and submitted with limited follow-up appointments, was another barrier to assisting clients. As discussed previously, several BECs developed checklists of necessary documents for clients, called clients prior to the appointment to remind them of this checklist, and created databases to determine timelines for follow-up calls and appointments. Limited transportation availability and homebound individuals. Reaching underserved, vulnerable populations was a central goal for the BECs. Included in this group are individuals with limited transportation abilities, and those who are homebound. As discussed in the partnership section of this report, this was an area where partnerships were instrumental in addressing these barriers. Language barriers. All of the BECs were tasked with expanding assistance to the populations that often fall through the cracks of social benefits. Included among these were new immigrants and those with limited English proficiency. Many of the BECs noted that working together with partners in order to gain access to vulnerable and isolated individuals expanded their ability to reach new populations. Several BECs hired bilingual staff, and incorporated bilingual advertisements into their outreach strategies. Despite being able to address many of the above challenges, several remain. Cooperation between some BECs and state agencies is tenuous; often these relationships require incremental steps in building trust over a long period of time before any data sharing or referrals can be put into effect. A few of the continuing challenges faced by many of the BECs include: Center for Benefits Access 10

Need for online applications. Many of the BECs noted that increasing the availability of online applications for benefits programs would make their work more efficient, and be less onerous for the applicants and benefits counselors. However, at the time of reporting, in many states LIS was the only benefit program for which people could submit applications online. Expanding reach to underserved populations. Despite tremendous effort in attempting to reach underserved populations, another frequently cited challenge by many of the BECs, is being able to penetrate the communities with the most underserved populations. These populations are often those with multiple barriers such as being homebound, having limited English proficiency, and living in remote areas. The BECs reported that increased outreach, specifically targeting these populations, coupled with the use of partners familiar with these populations, resulted in higher levels of trust, and broader access to these communities. Despite the intense focus on reaching these groups, obstacles continue to exist that limit expanding this reach. Limited staff and volunteer training. All of the BECs found that, due to budget constraints, they were only able to hire limited staff. Therefore, many of the BECs relied heavily on the support of volunteers. Some BECs expressed a need for additional volunteers generally, and for additional volunteers with specific skills. AARP Foundation struggled with not having enough computer literate volunteers. WISE & Healthy Aging addressed some of the challenges associated with these staffing limitations by providing extensive training for volunteers and creating user friendly guides for the volunteers to assist with applications. Several of the BECs found that volunteers were particularly important in ensuring proper follow-up with clients after appointments. Inefficiency of government agency. A continuing difficulty for BECs is that applications are often not processed in a timely manner by the administering government agency. Partnerships between the BECs and the local government agencies can reduce this problem. If the BEC partners with the agency, they can develop open lines of communication to address issues that may lead to delay, and avoid those problems in the future while working on the common goal of enrolling eligible individuals in these necessary benefit programs. However, limited staff and budgets at the government level indicate that this issue will continue to pose a challenge for BECs. Center for Benefits Access 11

Conclusions: Lessons Learned It is important for the BECs to constantly evaluate the effectiveness of their outreach, enrollment and follow-up strategies, as different methods yield varying results for different areas. Even within a BEC s area of influence there were variations in which programs were most successful. BECs determined that evaluating partners was essential when trying to gain the trust of the target population. Some BECs modified their model when they realized that a specific person dedicated to screenings and follow up was necessary to run the process efficiently, and made staffing changes accordingly. Though the BECs did not report major changes in their programs from the grant proposal, minor tweaks resulted in major successes. Therefore, it is essential for BECs to continuously review their methods and procedures, and to be confident in making adjustments to their plans in order to improve efficiency, access, and client satisfaction with the process. In order to address a significant obstacle of gaining the trust of seniors, younger adults with disabilities, and their families, the BECs all found that it was essential to address this concern, often relying on many of the same tools. Some BECs found it useful to conduct events (often with trusted partners) on a consistent date and location on a recurring basis, so people could slowly become familiar with the staff of the BEC. All of the BECs also found that in addition to clearly explaining the application process in a friendly tone, it was crucial to develop relationships with clients, encouraging them to continue to seek out the assistance of the BEC for additional support. Looking ahead Regardless of the challenges they face, all of the BECs were able to advance further with implementing a person-centered approach to benefits outreach and enrollment. Their successes come, in large part, from having strong partnerships and organizational capacity already in place and being able to draw upon and strengthen their organizations further during the grant period. Over the course of the grant period, BECs made a significant difference in their communities and the lives of seniors and younger adults with disabilities. During these difficult economic times, BECs assisted almost 20,000 individuals apply for benefits that help pay for their food, prescriptions, utilities, and health care costs. Furthermore, the work of the nine BECs carries on into the future, as AoA and the Center have committed to provide additional financial and technical support that will enable BECs to enact methods of sustaining their activities in the long term. Center for Benefits Access 12

At the same time, new opportunities emerge for other organizations to become part of the established BEC network. These new BECs will expand the community-wide and person-centered systems across the nation, to reach new geographic areas and underserved populations. The work conducted by the BECs is a source of invaluable knowledge to the aging network. They have provided a vast number of promising practices, outreach materials, and other experiences and resources that have strengthened the Center s expertise as a resource center and will equip the new BECs (and MIPPA grantees) to do a better job. The Center also continues to support enhanced collaboration between the BECs and other organizations carrying out benefits enrollment (e.g., MIPPA grantees) in order to increase information sharing and drive forward improvements needed at the systems level. The BECs success will further ACL s commitment to benefits counseling and enrollment, and the importance of continued support of benefits enrollment activities. Above all, BECs will have longlasting effects on the well-being of thousands of individuals, by helping them toward achieving greater economic security and the ability to lead healthy, independent lives. Center for Benefits Access 13