Transcript Slide 1

Impact of CMS and HRSA
Policies on CARE Act Grantees
and Subgrantees:
A Florida Case Study
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc.
And George Washington University
Purpose of Today’s Presentation
 Apply information gathered from earlier HAB Policy
Meeting Series sessions to the actual impact on
CARE Act grantees and subgrantees
 Provide a positive example of HAB-funded joint
federal, Title II, State Medicaid, and local planning
effort to undertake training and TA
 Offer rapid feedback regarding challenges and
opportunities in local communities related to current
and future implementation of federal policies
 Let you know what is on the minds of grantees and
subgrantees
Background
FL TA and Training Initiative
 TA and training request received by HAB DSS PO officer in
Summer 2005 from JAX Title I EMA
 HAB PO queried other EMAs and FL Title II regarding interest in
sponsoring similar TA and training for their subgrantees
 Substantial interest was expressed and topics added to the
training curriculum
 Write Process TA engagement initiated with POI
 Audience expanded to include Titles III and IV grantees and
subgrantees
 Planning Committee formed with HAB (DSS and DCBP), FL Title
I grantees, FL Title II, and POI staff
 FL Medicaid actively participated in planning of the initiative to
ensure latest developments in FL Medicaid reform were
reflected in curriculum
 Curriculum designed to address requirements of HAB,
grantees, and subgrantees
FL TA and Training Initiative
 Planning committee agreed to
centralize sessions in urban areas
 Rural grantees and subgrantees
invited to attend sessions that
were most convenient to them
 Two sessions were offered
 8-hour Making Every Dollar Count
 4-hour Intensive Third Party
Reimbursement Workshop
 Most Title I grantees made attendance
at training sessions mandatory for their
subgrantees
 Web-based registration
 Trainer did thorough review of relevant
State and EMA-specific materials to
become well informed and individual
each session to the environment in
which the audience works
 Sessions conducted in May and June
2006
 105 organizations participated in the
sessions
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TA and Training Objectives
 Assist CARE Act grantees and subgrantees in FL to expand
their understanding and adherence to payer of last resort and
other HAB fiscal policies
 Identify ways to engage in third party reimbursement (TPR)
contracting arrangements to expand the sources of funding
supporting FL HIV/AIDS clinical and psychosocial support
programs
 Inform FL grantees and subgrantees about the implementation
of FL Medicaid reform, including mandatory managed care
enrollment, and assist HIV programs to participate in managed
care networks
 Educate FL CARE Act grantees and subgrantees about best
practices in the organization and management of client or
patient-level record systems, unit cost estimation, eligibility
determination processes, billing and accounting systems,
marketing to managed care and other health insurers, and
other program management topics
 Individualized TA provided in Broward and Duval Counties
105 organizations participated in the Initiative
MAI
Managed Care
Organizations
SPNS
Commerical
Insurance
DRP
Title IV
TPR
Title III
MEDC
Medicare
Title II
Medicaid
Title I
0
50
100
150
0
200
50
100
Number of Registrants
Number of Registrants
Direct Service MEDC Registrants
Direct Service TPR Registrants
Hosp / Uni Clinic
7%
Com m unity Health
Center
20%
CBO
24%
7%
22%
28%
8%
10%
County Health
Dept
Sub Ab/ Mental
Health Tx
41%
33%
150
MEDC Evaluation Responses
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Unknown
52.1%
45.2%
1.4%
0%
0%
1.4%
The speaker was
knowledgeable
76.0
24.0
0
0
0
0
The information provided was
too BASIC for me
4.1
4.1
21.2
50.7
18.5
1.4
The information provided was
too ADVANCED for me
3.4
4.8
27.4
49.3
13.7
1.4
The meeting room was helpful
to learning
17.1
44.5
27.4
7.5
1.4
2.1
Meeting with other CARE Act
grantees was beneficial
16.4
46.4
29.5
2.7
0.7
4.1
The session was too long
5.5
14.4
34.9
38.4
5.5
1.4
The session was too short
2.1
4.1
34.2
45.2
12.3
2.1
Overall, I was satisfied with the
training session
38.4
54.1
6.2
0
0.7
0.7
I found the session useful in
carrying out my job duties
43.2
40.4
12.3
2.7
1.4
0
I found the handouts to be
informative
TPR Evaluation Responses
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Unknown
52.1%
45.1%
2.8%
0%
0%
0%
The speaker was knowledgeable
80.3
19.7
0
0
0
0
The information provided was too
BASIC for me
8.5
11.3
26.8
39.4
12.7
1.4
The information provided was too
ADVANCED for me
2.8
2.8
26.8
47.9
15.5
4.2
The meeting room was helpful to
learning
11.3
45.1
23.9
11.3
7.0
1.4
Meeting with other CARE Act
grantees was beneficial
19.7
31.0
38.0
2.8
0
8.5
The session was too long
1.4
5.6
35.2
47.9
8.5
1.4
The session was too short
1.4
8.5
38.0
42.3
8.5
1.4
Overall, I was satisfied with the
training session
38.0
54.9
5.6
0
0
1.4
I found the session useful in
carrying out my job duties
31.0
53.5
12.7
1.4
0
1.4
I found the handouts to be
informative
Slide sets available at:
www.positiveoutcomes.net
Florida Medicaid Reform
 Authorized by FL Legislature in May 2005
 Waiver was submitted to CMS in October
2005
 Waiver was approved by CMS in 2005
 Approved by the FL Legislature in December
2005
 Roll out will begin in Duval and Broward
 Enrollment throughout FL by July 2008
What Florida Medicaid Reform Will Not Do
 Reform will NOT change who receives Medicaid
 Eligibility does not change
 Reform will NOT “cut” the Medicaid budget
 The budget will continue to grow each year
 Reform is NOT correlated with Medicare Part D
 Florida will NOT limit medically necessary services for
pregnant women
 Florida has NOT asked to waive Early and Periodic Screening
Diagnosis and Treatment (EPSDT) for Children
 Children will be able to access all medically necessary
services
 Florida will NOT increase beneficiary cost sharing requirements
What Florida Medicaid Reform Will Do
 Increase access to appropriate care
 Benefits that better meet recipients’ needs
 Access to services not traditionally covered
by Medicaid
 An opportunity to provide choice and control
to recipients in regard to health care
decisions
 Ability to earn credit to pay for non-covered
services
 Bridge to private insurance
Key Elements of Medicaid Reform
 New Options/Choice
 Customized Plans
 Opt-Out
 Enhanced Benefits
 Financing
 Premium Based
 Risk-Adjusted Premium
 Comprehensive and Catastrophic Component
 Delivery System
 Coordinated Systems of Care (PSN and HMOs)
 HMOs are capitated
 Provider Service Networks (PSNs) are FFS for up
to three years, then capitated
What will change with Medicaid reform?
 A roll-out of mandatory enrollment for most assistance
categories (e.g. TANF, SSI), with full implementation slated for
July 2008
 Comprehensive choice counseling by an independent
enrollment broker
 Counseling will be provided in person, by phone, in writing,
or through the media, with Internet-based enrollment offered
 Detailed information will be provided to enrollees
 Eligible enrollees must chose a plan
 New enrollees will receive only emergency services until they
enroll or are “auto-assigned” to a plan
 Enrollment broker must employ a culturally diverse
counseling staff
 Florida State University will offer a Choice Counselor
Certificate and develop outreach materials
 Education needs will dramatically change
 Recipients will need to understand differences in the benefit
packages plans offer
 Information on opting out of a Medicaid plan will be provided
Customized Benefit Packages
 Plans may vary amount, duration, and scope of certain services
for non-pregnant adults
 Certain services must be provided at or above
current coverage levels
 Other services must be provided to meet
sufficiency standards for the population
 Remaining services must be offered, but amount,
scope and duration are flexible
 Reform plans can enhance any service above
current levels
 Reform plans can add services not currently
covered
Customized Benefit Packages Required at Least to
Current Limits
 Physician and
physician extender
services
 Hospital inpatient care
 Emergency care
 EPSDT and other
services to children
 Maternity care and
other services to
pregnant women
 Transplant services
 Medical/drug therapies
(chemo, dialysis)
 Family planning
 Outpatient surgery
 Laboratory and
radiology
 Transportation
(emergent and nonemergent)
 Outpatient mental
health services
Additional Required or New Benefits
Required for sufficiency
 Hospital outpatient services
 Durable medical equipment
 Home health care
 Prescription drugs
Required to be offered, but amount, scope and duration are flexible
 Chiropractic care
 Podiatry
 Outpatient therapy
New or expanded benefits
 Over-the-counter drug benefit from $10-$25 per household, per month
 Adult preventative dental, including x-rays, cleanings, and fillings
 Newborn circumcisions
 Acupuncture/medicinal massage
 Additional adult vision: < $125 per year for upgrades such as scratch
resistant lenses
 Additional hearing: < $500 per year for upgraded digital, canal hearing aid
 Home delivered meals for a period of time after surgery, providing
nutrition essential for proper recovery for elderly and disabled
Medicaid Reform Plans And Networks: Broward & Duval
Applicant
Plan Type
County
Access Health
FFS PSN
Broward & Duval
Amerigroup FL
Prepaid Health Plan HMO
Broward
FFS PSN
Broward
FL NetPass
HealthEase Health Plans of FL
Prepaid Health Plan HMO
Broward & Duval
Humana Medical Plan
Prepaid Health Plan HMO
Broward
Preferred Medical Plan
Prepaid Health Plan HMO
Broward
Shands Jacksonville (First
Coast Advantage)
FFS PSN
Duval
South FL Community Care
Network
FFS PSN
Broward
Total Health Choice
Prepaid Health Plan HMO
Broward
United Healthcare of FL
Prepaid Health Plan HMO
Broward & Duval
Vista Healthplan of South FL
Prepaid Health Plan HMO
Broward
Wellcare of FL (Staywell Health
Plan of FL)
Prepaid Health Plan HMO
Broward & Duval
How will impact of Medicaid reform on HIV+ enrollees?
 HIV+ enrollees must chose a plan
 HIV+ enrollees identified in Medicaid claims files may be autoassigned to a plan agreeing to provide HIV enhanced benefits or
be assigned to a general plan and have to ask to be move to a
plan with the enhanced HIV benefits  stay tuned
 All plans can access an enhanced capitated monthly payment that
adjusts for the higher cost of HIV
 Protease inhibitors and other HIV medications are included in
the HIV/AIDS capitation rates
 Plans will be required to meet HIV access standards which are
being developed now
 Home and community-based waiver services will be “carved out”
of the covered benefits package
 PAC Waiver clients can continue to receive their services
through that program
 Plans must provide case management directly or by contract
 The HIV disease management program will be phased out in
counties as the Medicaid reform roll-out is implemented
Proposed Per Member Per Month Capitated AIDS, HIV, TANF and
SSI Rates: Duval and Broward
Rate
Enhanced Rate
TANF* & SSI Rates
Duval County
General Rate 21-54 YOA
$201 - $783
AIDS
$2,174
HIV
$1,078
AIDS (Dual Enrolled)
$179
HIV (Dual Enrolled)
$73
Broward County
General Rate 21-54 YOA
$199 - $903
AIDS
$3,253
HIV
$1,584
AIDS (Dual Enrolled)
$365
HIV (Dual Enrolled)
$223
* Rate for TANF female enrollees
Other Issues Identified Regarding DRA Implementation
 State AHCA and DCF programs have not announced
their policies
 Written DCF policy was prepared in July 2006 but not
posted for the public
 Some county DCF offices implemented citizenship
documentation requirement by June 2006
 By end of June, audience participants reported that
some of their clients had been denied Medicaid
recertification because they had not brought in a
birth certificate to their re-determination
appointment
 In Dade County, audience participants reported
that joint TANF, Food Stamp, and Medicaid recertification was being impacted by citizenship
documentation
Feedback From Audience
 Many audience members were unaware of or had
variably applied HAB’s PLR policies, with many
challenges identified
 Lack of disclosure about commercial health insurance, inability
to gain enrollment in Medicaid due to rejection of disability
claims, inadequate billing and accounting systems (including in
large hospital systems), inability to implement sliding fee scale
 Case managers are reported to be untrained in eligibility
determination or too busy to address this service need
 Few programs in the audience reported that they had
calculated their unit costs and were unsure if their
grants or contracts covered their costs
 Many problems identified by Titles I and II grantees
regarding poor chart documentation and inaccurate
invoice
 Title I grantees also reported significant TA needs regarding
establishing more sophisticated invoice claims processing
Feedback From Audience
 Few Duval or Broward grantees or subgrantees
had planned for Medicaid mandatory managed
care
 Most of their parent institutions had, with little
communication between them
 Little experience with Medicaid or commercial
insurance contracting
 Significant concern raised regarding CARE Act
reauthorization
 Particular concern raised in all MEDC sessions
regarding how medical case management will be
defined and implemented