Transcript EFFECTIVE ELIGIBILITY DETERMINATION FOR CARE ACT …

EFFECTIVE ELIGIBILITY
DETERMINATION FOR THE
CARE ACT AND OTHER
SYSTEMS
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc.
Harwood MD
www.positiveoutcomes.net
[email protected]
CARE Act Payer of Last Resort Policies
The CARE Act is the payer of last resort
Grantees must ensure that clients meet
eligibility criteria for CARE Act services
 Including ADAP, insurance continuation,
and direct services
CARE Act grantees must ensure that
alternate payment sources are pursued
Grantees must establish and monitor
procedures to ensure that their
subgrantees verify and document client
eligibility
CARE Act Payer of Last Resort Policies
 Direct service grantees and subgrantees must
document that their clients are screened for and
enrolled in eligible programs and their benefits are
coordinated after enrollment
 Medicare, Medicaid, VA health care benefits, private
health insurance
 Other programs include public housing, drug or
mental health treatment, or Food Stamps
 Income assistance, including disability income and
Temporary Assistance to Needy Families (TANF)
 Grantees must coordinate with other funders to
ensure that CARE Act funds are the payer of last
resort
 These and other HAB requirements are subject to
audit
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Eligibility Determination: Pieces of the Puzzle
There is a vast array of
entitlement and discretionary
programs that HIV+ clients may
be eligible for today and
tomorrow
Eligibility criteria (the short list)
 Geographic residency, US citizenship,
legal residency status, age, gender,
previous financial contributions by client,
employment status, type of employer,
preexisting medical condition, disability,
employability, income, assets, HIV
serostatus, CD4 count, annual or lifetime
utilization of benefits, criminal convictions
Medicaid Eligibility For HIV/AIDS Beneficiaries
Assistance Category
Eligibility Criteria
Mandatory/Optional
Supplemental
Severely disabled,
Security Income (SSI) unemployable, low-income
Mandatory
Parents, pregnant
women, children
Low income, with income and
asset criteria vary by assistance
category and State
Mandatory, States may
offer higher income
threshold
Medically needy
Severely disabled and low
income (median=56% of FPL)
after subtracting medical
expenses
Optional, 35 States use
this option for disabled
individuals
Workers with
disabilities
Severely disabled, low-income,
for persons returning to the
workforce
Optional
Poverty level
expansion
Allows for income above SSI
levels up to the FPL
Optional, 19 States use
this option
State Supplemental
Payment (SSP)
Allows for coverage of
beneficiaries receiving SSP
Optional, 21 States use
this option
Adapted from Kaiser Family Foundation HAB presentation
Medicaid and HIV/AIDS
 Social Security Administration (SSA) delegates
the review of SSI applications to States
 Substantial variability in the acceptance rates of
SSI applications from HIV+ individuals
 Initial denial rates tend to be very high
 Significant changes are being made to State
Medicaid programs due to the Deficit
Reduction Act (DRA)
 Example: beneficiaries and applicants must
document their US citizenship
 Disability claims are taking longer than ever to
process
 Many State and federal entitlement programs have
had layoffs or are working with inexperienced staff
Medicare Eligibility For HIV/AIDS Beneficiaries
Assistance Category
Eligibility Criteria
Individuals age 65 years or
older
Sufficient number of work credits to quality for
Social Security payments
Individuals under 65 years of
age
 Sufficient number of work credits to quality
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Individuals with end-stage
renal disease, any age
for Social Security Disability Income (SSDI)
payments due to disability; also includes
spouses and adults disabled since childhood
Have been receiving SSDI payments for at
least 24 months
Sufficient number of work credits to qualify for
Social Security payments
Adapted from Kaiser Family Foundation HAB presentation
Commercial Insurance
 Coverage is primarily through group benefits via employers or
association membership
 Individual coverage can be purchased through carriers
 Some states fund health insurance pools in which individuals
and families can purchase premiums
 Benefits vary substantially among carriers
 ED must address
 Waiting periods for pre-existing medical conditions
 Annual or lifetime caps
 Service utilization limits for specific services (e.g., number of prescriptions,
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home health visits)
HIV+ beneficiaries of these plans may receive CARE Act benefits during
waiting periods or while services caps are exceeded
 Some eligible HIV+ individuals do not seek insurance or drop
their coverage due to
 Concern about HIV disclosure and discrimination
 Growing premiums, co-payments, and deductibles
 Important to counsel clients
 To retain or seek coverage during “open season”
 Seek improved coverage if they have limited benefits or high premiums, copayments, or deductibles
What is HAB’s policy regarding veterans?
 In 2004, HAB clarified their policy about providing CARE
Act services to HIV+ veterans who also are eligible for
VA benefits: http://hab.hrsa.gov/law/0401.htm
 CARE Act providers
 Should inquire if a client is a veteran and enrolled in the VA
 May not deny services, including medications, to veterans who
are otherwise eligible for the CARE Act
 Should be knowledgeable about VA medical benefits, including
medications
 Must coordinate health care benefits for veterans
 Make HIV+ veterans aware of VA services available procedures
for getting VA care and helping them navigate care systems to
secure HIV care
 Even if enrolled in the VA, a veteran does not have to
use the VA as their exclusive health care provider
What are the eligibility criteria for veterans to receive
services from the VA?
 Eligibility information is available at:
http://www.va.gov/healtheligibility/HECHome.htm
 Eligibility for most veterans health care
benefits is based on active military service in
the Army, Navy, Air Force, Marines, or Coast
Guard, and other criteria
 VA health care benefits are not just for
veterans who served in combat or have a
service-connected injury or medical condition
 Not all veterans are eligible for VA benefits
 In recent years, VA eligibility requirements
have become increasingly strict
Partners In Eligibility Determination (ED)
Grantees
Direct service agency managers
Case managers or other ED staff
Physicians documenting disability
Reception staff
Other payers and other systems
Adoption of System-wide ED Processes
 Some grantees use unified, coordinated ED processes
 Fund trained ED workers
 Set clear eligibility criteria and apply them for all
clients
 Centralized intake on behalf of all HIV providers in
the system
 Use standardized forms and train personnel to use
them
 Ensure forms are linguistically appropriate to the
subpopulations served
 Require tax returns or credit checks to document
income, assets, and employment
 Use contractual language regarding ED
requirements that is auditable and enforceable
 Determine how client-level data will be transmitted
effectively between agencies, with HIPAA requirements
addressed for data transfer
Adoption of System-wide ED Processes
 ADAPs that delegate ED to case managers, should
determine if they screen effectively for eligibility for
other programs
 Particularly critical in jurisdictions with waiting
lists
 Collaborate with other care systems to identify
resources and coordinate referrals
 Other systems include substance abuse and
mental health treatment, affordable housing,
pantry/nutrition programs, transportation, etc.
 Legal services must be available (through CARE Actfunded programs or referral) to pursue administrative
procedures following rejected disability or other
claims and to assist clients in employment
discrimination cases
 Establish processes with SSA to fast track
applications and to train public and commercial claim
assessment staff regarding HIV disease
Adoption of System-wide ED Processes
 Ensure that culturally and linguistically competent ED
processes are in place to address the needs of
subpopulations (e.g., undocumented residents)
 Systematically assess the ED processes of HIV
subgrantees by applying performance standards and
auditing charts
 In systems with multiple agencies conducting ED,
benchmark data can be used to compare the
performance of subgrantees
 Subgrantees failing to document ED processes
might be subject to progressive discipline,
including withholding payments or other penalties
 Effective coordination with Medicaid and other
payers to expand eligibility is critical
 Changes to major payers in your community
should be rapidly communicated to subgrantees
and their ED workers
Strategies For HIV Programs
 Do not assume another agency will take care of ED
unless that explicit role is assigned to another
agency in your community
 Coordinate with community partners if another
agency is responsible for ED
 Determine how client-level will be transmitted
effectively between agencies, with HIPAA
requirements addressed for data transfer
 Do not assume that your program’s case managers
are “handling it”
 Many case managers report that their case loads
are too high and that they are not trained to
handle ED
 Assess if case managers are the most cost-effective
personnel model for ED
Strategies For HIV Programs
 Receptionists should ask ALL clients at EACH visit if
their health insurance status has changed since their
last appointment
 It is important that receptionists not assume that
no change has occurred
 At the beginning of each calendar year, it is
important to confirm insurance status
 Have them confirm through the online Medicaid
system that the client is newly or still enrolled
 Copies of new health insurance cards should be
made and filed
 Intake and re-determination forms should be tailored
to screen for the unique set of health and other
programs in your community
 It is not enough to ask a client if he/she is enrolled
but assess eligibility based on the criteria used for
relevant programs
Strategies For HIV Programs
 Review your policies and procedures with your ED staff to
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determine what is actually being done
 Talk to your staff, assess data, and conduct your own audits
 Develop CQI to improve ED
Some agencies find electronic case management software helpful
in ED screening
 It is important that the software be updated regularly to reflect
new programs or changes in existing programs
Train and retrain ED staff and test their knowledge periodically
Use trained and experienced supervisors
Use benchmark data to compare ED workers’ performance
Identify entitlement and discretionary programs for which there
are barriers to enrollment
 Document the problem and establish ongoing processes for
resolution; an important advocacy role
 Communicate with other HIV programs to document systemwide barriers
Routinely monitor changes in entitlement and discretionary
programs that impact eligibility and adjust accordingly
Effective Strategies Used By ED Staff
 Knowing how to complete the paperwork, document
claims, and making sure clients follow through are
the keys to success
 Provide ED in England and other languages spoken
by your target population
 Do not front-loaded ED at entry in care
 Screen for eligibility on a routine basis (e.g., every six to
twelve months)
 Use rolling re-determination to normalize required staffing
 Medical providers must communicate with ED staff
about eligibility “triggers”
 Loss of employment due to disability, inability to be
employed due to the side efforts of HAART, inpatient
admissions, changes in clinical condition
 Do not assume that clients’ disability claims should
only be HIV-related, they may have other chronic
conditions
Effective Strategies Used By ED Staff
 Encourage clients with health insurance,
income, or assets to disclose honestly
relevant information
 Coordinate applications for benefits
 Avoid flooding the system with completed forms
to “see what sticks”
 Do not advise clients to “get a Medicaid
rejection letter” so they can access CARE
Act-funded services
 Rather, work with the client to prepare valid,
accurate applications for benefits
 Partner with legal aid staff to prepare well
documented applications and address
discrimination issues
Effective Strategies In Working With Clients
 Communicate with clients that to continue to operate,
your program must have revenue
 Avoid the attitude “don’t ask, don’t tell,” giving the clients
the impression that there is a free lunch
 Providers are often unaware that clients are already enrolled
or eligible for care
 Concerns about discrimination and stigma are real and may
result in lack of complete disclosure
 Do not assume that clients can navigate the system,
read, or complete forms
 Conversely, do not assume that clients cannot navigate the
system when some can
 ED processes that rely heavily on clients are
commonly doomed
 Paperwork is not the highest priority when you are trying to
survive
 Ensure that clients receive the maximum benefit to
which they are legally entitled