Identifying the Problem

A few weeks ago, a patient walked into my office looking for help applying for Medicaid. She was college-educated and interning in the social work field—helping people apply for public benefits is part of what she does. And yet, when she tried to apply for Medicaid on her own, she hit a series of roadblocks that proved too much to overcome by herself.

In theory, applying for Medicaid in Pennsylvania is simple. Qualifying individuals and families can apply online, over the phone, or in person at their local County Assistance Office. After applicants receive notice of approval and select a managed care organization, their coverage starts immediately. In a big-picture sense, the process works well: since the start of 2015, when Pennsylvania expanded Medicaid to cover everyone with household incomes up to 138 percent of the federal poverty line, Medicaid enrollment in the state has soared. And yet, every day people walk into my office who are uninsured but Medicaid-eligible, looking for help.

Why do so many people continue to slip through the cracks? Before starting the NHC program, my instinct would have pointed to a lack of awareness—the notion that many folks simply do not know that Medicaid (particularly in its recently expanded form) exists as an option for them. But hearing about the intern’s frustration confirmed to me that there is a breakdown occurring at another level. My first two months as an Insurance Specialist at Health Center 3 have shown me that most uninsured patients at the clinic have a basic understanding of Medicaid; moreover, many patients have applied for Medicaid in the past, but either had their coverage cut off unnecessarily or been stalled at some point in the application process. The problem seems to stem not from unfamiliarity but rather difficulty interacting with the welfare system.

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After patients submit an online Medicaid application, the file is sent to one of the Philadelphia County Assistance Offices and assigned to a caseworker who has 45 days to make an eligibility determination. During this time, applicants will often receive a letter requesting additional documentation to prove their identity, residence, income, and immigration status. This presents the hassle of tracking down birth certificates, printing off pay statements, and securing a letter from a past employer. Then comes the challenge of getting the documents in the hands of a caseworker, which requires either (1) a working fax machine; (2) a scanner, Internet access, and computer skills; or (3) the time, effort, and money involved with delivering hard copies in person. Even if an applicant successfully submits all documents by the deadline, it is often necessary to speak with a caseworker to resolve minor discrepancies, dispute income calculations, or further explain parts of the application. All these logistical hurdles become magnified for applicants who are low-income, sick, disabled, under-educated, non-English speaking, or who may have recently arrived in the United States.    

In light of all these obstacles, it becomes not only helpful but practically essential to have a third-party liaison facilitating the Medicaid application process. Perhaps nothing illustrates this need better than an Ethiopian cab driver who came to my office seeking insurance for his three children. After submitting the initial application online, several complications arose as we tried to cooperate with the district office. When the caseworker requested a Social Security card for the eldest child, I reminded her that the child’s application for a Social Security number had been delayed and called her back to update her when it was approved. When the caseworker requested verification of terminated income from the father’s previous job, I reached out to his former employer to obtain a letter stating his last day of work. Finally, when the caseworker mistakenly included the father’s previous income in her calculations, I called her again to clear up the confusion and ensure that the application was approved.

Had I not been involved to facilitate these interactions, the chances of a successful outcome look bleak at best. Navigating the back-and-forth with the Medicaid office proved daunting for an aspiring social worker with a bachelor’s degree, let alone a non-native English speaking single father of three who struggles daily to make ends meet. The example underscores the importance of the NHC insurance specialists and staff benefits counselors, who work hard to catch patients falling through the safety net; but it also prompts the search for a more efficient solution. How do we patch up the safety net itself? That is a question I will be thinking about as I fulfill the rest of my service term.
 

This blog post was written by NHC Philadelphia member Andrew Romaine.
Andrew serves as the Insurance Specialist at Philadelphia Department of Public Health-Ambulatory Health Services Health Center 3.