OLA#: 016-03Q

LEGISLATIVE ANALYST REPORT

TO: Honorable Members of the Board of Supervisors

FROM: Office of the Legislative Analyst

DATE: June 30, 2003

SUBJECT:Employee Suggestions #206, #220, #223, #254, #535: Medi-Cal Reimbursements

EMPLOYEE SUGGESTION

Several employees believe that individuals seeking services at Community Mental Health Services, San Francisco General Hospital, and other City health services are not systematically checked for eligibility for Supplemental Security Income and Medi-Cal; therefore, revenue that could be gained from reimbursements is lost.

EXECUTIVE SUMMARY

The Department of Public Health (DPH) reports that all of its divisions do systematically check for clients' Supplemental Security Income (SSI) and Medi-Cal eligibility. Potential revenue from reimbursements is lost, however, because too few clients are assisted through the complex application process or advocated for following a denial. SSI applications without advocacy have a 60 percent failure rate; with advocacy, there is an 85 to 90 percent success rate. A symptom of the lack of assistance through the process is that only 60 percent of Community Mental Health Services clients and 20 percent of Community Substance Abuse Services clients are currently on Medi-Cal. This leaves many more eligible but unenrolled. DPH has recently implemented a pilot project addressing the issue of expanding SSI and Medi-Cal reimbursements through client advocacy. The DPH SSI Advocacy Project is designed to represent disabled, uninsured clients and help them win claims for SSI and Medi-Cal. The goal of the pilot project is to transition 94 clients to SSI by March 2004, with expected savings to the City and County of San Francisco of $342,000 in the first year and ongoing annual DPH savings of $542,000.

The Board of Supervisors may wish to ask DPH for ongoing reports on the success of the pilot program. If successful, the Board may want to invest in expansion of the program, as the projected savings for the City are high.

ANALYSIS & RECOMMENDATIONS

Few clients receiving public health services in San Francisco are assisted through the Supplemental Security Income (SSI) application process, which requires an intensive collection of documents and evidence of disability, nor through the appeals process following a denial. Disabled immigrants and disabled substance users in particular (and the providers who treat them) believe they are ineligible for benefits. The Department of Public Health (DPH) reports that SSI applications that receive no advocacy services have a 60 percent failure rate. With advocacy, these applications have an 85 to 90 percent success rate.

DPH conducted an analysis of their current mental health clients and identified over 3,000 individuals who appear to have diagnoses that would meet the disability criteria set forth by the Social Security Administration and who were not insured. If only half of these individuals were considered eligible and were helped through the SSI application process, the City would realize great savings.

The Department of Public Health has recently implemented a pilot project addressing the issue of expanding SSI and Medi-Cal reimbursements. The DPH SSI Advocacy Project is designed to represent disabled, uninsured clients and help them win claims for SSI and Medi-Cal. Federal disability income in the form of SSI, as well as health insurance, will enable clients to achieve their therapeutic goals by improving their access to healthcare and by giving them the financial means to stabilize their living situation. The goal of the pilot project is to transition 94 clients to SSI by March 2004, with expected savings to the City and County of San Francisco as follows:

• Average Annual DPH¹ costs = $11,000 per client; recoupable from Medi-Cal per client = $5,700

• Average one-time cost to successfully transition each client on to SSI = $2,120

• First Year Return on Investment for each dollar spent = $2.70

• First Year Projected DPH Savings for 94 clients = $342,000

• Ongoing Annual DPH Savings for 94 clients following first year = $542,000

The target population for this pilot project is uninsured patients of DPH mental health centers. Emphasis is placed on reaching clients who have experienced recent episodes in the mental health system and who are currently receiving cash benefits from the County's SSI Pending program. This population may include multiple diagnosed people, people who have been or are currently incarcerated, active substance users or people with substance use history, people who are homeless, people of color, immigrants, women, people in the lesbian/gay/bisexual/transgendered community, and sex workers.

The goal of SSI Advocacy Project is to provide representation for 94 disabled, uninsured clients in claims for SSI and SSI linked Medi-Cal at initial, reconsideration, Administrative Law hearing or Appeals Council levels by March 31, 2004. Case files will indicate progress and success of obtaining benefits. The program's outcome objective is to have 85 percent of clients who are seeking benefits assistance receive the benefits for which they are determined to be eligible within the twelve-month pilot period.

Program staff maintain a database documenting how many clients are served, including relevant statistical information. Each advocate maintains client case files to document all relevant information, including when a claim is filed, the determination made upon the claim, when an appeal is filed for a claim denied at the initial or reconsideration level, and what decision is made. The files and database will be evaluated on an ongoing basis by the Program Director to determine percentage of claims awarded at each level and dollar amounts realized from the awards to determine whether the program's objectives are being achieved.

Community Mental Health Services held a training for providers on May 21, 2003. Two additional trainings are scheduled in July and August. SSI Advocacy Project began intake on April 16, 2003. Since this date 13 clients have been referred to the program, primarily as a result of the first provider training. Two clients' cases have been completed, both with successful outcomes.

The Board of Supervisors may wish to ask DPH for ongoing reports on the success of the SSI Advocacy Project pilot program. If successful, the Board may want to invest in expansion of the program, as the projected savings for the City are high.

¹ DPH cost analysis did not include cost of Forensic or AIDS Office treatment services. This information was not available.