Medicaid 101: The Basics for Homeless Advocates

Transcription

1 Medicaid 101: The Basics for Homeless Advocates July 29, 2014 The Source for Housing Solutions Peggy Bailey CSH Senior Policy Advisor

2 Getting Started

3 Things to Remember: Medicaid Agency 1. Medicaid is not a social service program it is an insurance program 2. Medicaid agencies have goals put supportive housing in their terms - Cost savings - Lead with service component of supportive housing 3. Come with suggestions 4. Medicaid isn t the only piece of the puzzle and may not work for all supportive housing providers

4 Things to Remember: Managed Care 1. Not unlimited flexibility 2. Must operate within construct of state contract arrangement 3. Only serve those in their network 4. Serving more and more high need members 5. Open to non-traditional partners 6. Cost savings and member HEALTH outcomes must be measured

5 Medicaid Basics

6 Medicaid Basics Authorized under Section XIX of the Social Security Act of 1965 Began As Health Insurance for: Low-Income Pregnant Women and Children Disabled Counterpart for Medicare Over the years populations have expanded

7 Federal/State Partnership Federal Oversight and Structure Significant State Flexibility Federal Payment Contribution is called Federal Medical Assistance Percentages (FMAP) FMAP differs by state Based on per capita income No lower than 50%, highest is Mississippi at 73% Territories rate - 55% Admin is reimbursed at 50% for all FMAP can also differ by benefit, mostly per ACA

8 Medicaid Fundamentals Eligibility Traditional Low-Income Kids and Pregnant Women Disabled Elderly For Expansion States: Newly Eligible those with incomes below 138% of FPL Benefits Traditional Mandatory Optional Medicaid Waivers and State Plan Amendments expanded benefits New Essential Benefits Package Provider Billing State Requirements vary Further variation based on benefit/population Can be Extensive States exploring ways to expand provider ability to bill ACA does not directly address

9 Eligibility

10 Eligibility Traditional Medicaid Pregnant Women Children Disabled Based on Supplemental Security Income Determination (SSI/SSDI) Does not include substance use population Those who need Home and Community-Based Care Low-income Seniors Low-income Parents (in some states) Expansion Medicaid Those with incomes below 138% of federal poverty level No longer based on disability or subpopulation Brings in childless adults and substance use populations

11 Benefits

12 Mandatory Benefits Inpatient Hospital Services Prenatal Care Physician Services Family planning Home health care for persons eligible for skilled-nursing services Pediatric and family nurse practitioner services FQHC services Outpatient Hospital Services Vaccines for Children Nursing facility services for those over 21 Rural health clinic services Laboratory and X-Ray Services Nurse-midwife services Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) for children

13 Optional Benefits Diagnostic services Intermediate care facilities for those with Developmental Disabilities Eye exams and glasses Transportation Rehab and physical therapy services Clinic Services Prescribed drugs and prosthetic devices Nursing facility services for children under 21 Case Management Home and Community-Based Services

14 Newly Eligible Benefits Affordable Care Act establishes 10 benefit categories Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Behavioral health services and treatment; Prescription drugs; Rehabilitative and habilitative services and devices; Laboratory services; Preventive and wellness services and chronic disease management; and Pediatric services, including oral and vision care. States determine specifics but must be equivalent to benchmark private plans People with Disabilities can qualify for traditional Medicaid and receive benefits needed for their conditions

15 Comparison of Medicaid Authorities for Supportive Housing 1115 Waiver 1915c and 1915b HCBS Waiver 1915i HCBS State Plan Option Health Homes State Plan Option Medicaid Rehab Option Targeted Case Management What is it? Flexible waiver for demonstration programs that enable States to pilot innovative care delivery models and coverage expansion that differ from federal rules Medicaid waiver to provide Home and Community-Based Services to populations leaving or at-risk of institutionalization; c is for state Medicaid depts and b is for MCOs State plan option to extend Home and Community Based Services to people with disabilities but who are not necessarily at-risk of institutionalization and without cost neutrality requirement CMS program enabling states to create highly integrated, coordinated, and flexible health/social services networks for people w/chronic conditions; enhanced federal match for 1 st 8 quarters Authority traditionally used to cover range of recovery and rehabilitative services for people with serious mental illness and/or developmental disabilities Authority to make case management available to specific populations, including in specific geographic locations to better access and coordinate medical, social, and other care Eligible/ Covered Populations Any Medicaid eligible Can also be used to expand Medicaid coverage beyond federal eligibility (e.g. to low-income singles pre-2014) Beneficiaries leaving or at-risk of institutionalization including seniors, people with SMI, development disabled, PLWAs, or people with TBI Beneficiaries with disabilities requiring HCBS who meet approved needsbased criteria Beneficiaries with serious mental illness or two or more other chronic conditions No specific guidelines, but typically states use for beneficiaries with serious mental illness or development disabilities States can define and limit coverage to certain beneficiaries, can include PWAs, seniors, parolees, children in foster care, people with disabilities inc. substance use Potential Coverage of SH Services High (gives States highest degree of flexibility) Medium (due to cost neutrality requirement) High (due to no cost neutrality standard) High (highly tailored services including intensive care management) Medium to low Medium to low (must be fee-for-service, limits coverage to one case manager per client) Considerations States must meet high standards for research methods that will demonstrate better outcomes, lower costs Limited to people leaving or at-risk of entering institutions Subject to costneutrality States adopting 1915i must extend coverage statewide; cannot restrict targeting by geography A hybrid between a payment system and a care model, Health Homes is very new with only a few states adopted Services tend to be more treatment or rehabilitative as opposed to care management focused Coverage limited for certain activities such as client transport. Cap on federal match at 50% makes less attractive to states.

16 Contact Info Peggy Bailey Senior Policy Advisor CSH ext. 30

17 Medicaid 101: The Basics for Homeless Advocates The National Alliance to End Homelessness July 29, 2014 Marti Knisley The Technical Assistance Collaborative

18 Medicaid Basics Are Important Most people you serve are eligible for Medicaid benefits covered by this insurance program; 2. It s complex, but knowing the basics helps you help people you serve; 3. Understanding the basics helps your agency make decisions about role you can play eligibility, enrollment, provider, network member, advocate ; 4. Medicaid policy and programs are changing rapidly, knowing the basics helps understand the changes; and 5. Access to health (and behavioral health) care (covered by Medicaid) is a stabilizing force in everyone s life it s part of a person s recovery.

19 Costs of care Health Outcomes The Why Service arrangements in the state Medicaid Plan to help promote people living in their own home Community Services and supports are in the state Medicaid Plan 19 Services and supports for people to live in their own home

20 The Basics: What and How The What: Benefits, eligibility, program and provider requirements; Questions you need answered for people you serve and for your agency (system); 20 The How: What is the best way to get your questions answered and help people you serve and your agency at the same time?

21 Understanding Medicaid Experts: HH, MC, HCBS, MFP, ACOs, Dual Eligibles, payment models, etc; tracks and analyzes data (cost and program) and performance, manages services across multiple programs 21 Agency Directors, Managers, Key Leaders: Manage, deliver and advocate for services in Medicaid programs Staff and consumers: Understand basics of enrollment, eligibility, benefits by major program types/ and billing requirements

22 The Basics Eligibility; Enrollment; Services/ Benefits----by program; Provider requirements; Billing, reporting, tracking processes; and 22 Business options

23 The How What are some ways to learn and use basic (and beyond) information to help persons and families who are homeless? 23 What are options for your community, your agency (as a whole) and your staff: to ensure Medicaid benefits are available, accessible, comprehensive and targeted to assure better outcomes?

24 The How Take steps to learn the processes, approaches, benefits: Sponsor or attend workshops/ training: Eligibility experts are available, Medicaid provider training, associations events, etc. Join a healthcare coalition; Check the web for materials and background papers; and/or Sponsor a coalition among your providers. 24

25 Options for Providers Establish a business plan; Become an Enrollment Center; Become a provider or join a Network; Help create opportunities to learn. 25 Examples: The Connecticut MISHA Institute; The SHRP Training Program in New Jersey; PSH Certification Program in Louisiana; Others???

26 26

27 The Source for Housing Solutions Medicaid Billing Quandary

28 Do you need a national accreditation or state certification

29 Agency Support Is the Board on board What about Senior Management There is a cost

30 Policies and procedures What is the state of agency policies and practices

31 Things to consider w Who do you serve Services you provide Clinical paperwork Staffing Billing capability QI plan for ongoing compliance

32 Target Population

33 Service Delivery What services are currently being delivered Type Volume Frequency Location Can the services be certified

34 Paperwork Current state of client charts Location and security of client charts Revisions needed for forms Diagnostic assessment Progress notes Individualized service plans

35 Staff Expertise and skill level Licensure Caseload size Supervisors Training

36 Billing Capability Type of current billing Keeping track of units Who should do the billing Can Medicaid billing be incorporated Should Medicaid billing be contracted to external vendor

37 Ongoing compliance QI Plan All levels of staff must be part of the ongoing process Process for reviewing policies and procedures Ongoing staff training Staying in compliance with standards Client chart review Audits and recertifications

38 Is it worth it COST VS REVENUE National accreditation Medicaid billing process Higher level staff QI process Training Type of services you will provide Estimating number of units Estimating revenue

39 Medicaid 101: The Basics for Homeless Advocates ~ A Provider Perspective Karen Batia, Ph.D. kbatia@heartlandalliance.org National Alliance to End Homelessness July 29, 2014

40 HHO Mission Heartland Health Outreach s mission is to transform healthcare for the most vulnerable particularly people experiencing homelessness, mental illness or addictions, or struggling with multiple chronic illnesses improving health for all and the well-being of our community. Heartland Health Outreach

41 Heartland Health Outreach Specialty FQHC Healthcare for the Homeless provider in Cook County, IL (medical encounters) Specialty Mental Health provider (MRO Rule 132) Assertive Community Treatment Community Support Teams Outpatient Services Specialty Alcohol and Substance Abuse Services (Rule 2060/2090) Continuum of housing options Training and Technical Assistance Heartland Health Outreach

42 HCH Program Vision Decrease health disparities and increase the lifespan of people experiencing homelessness. The average life expectancy of an adult experiencing homelessness is 30 years less than a housed adult. -Boston HCH Program Heartland Health Outreach

43 Heartland Health Outreach HCH Integrated Program Structure Primary Care Services Health Center(s) Outreach Oral Health Care HIV Care Mental Health and Substance Abuse Nutrition and Grocery Centers (for people with HIV/AIDS) Supported Housing Options (for people with chronic health issues) Permanent Supported Housing with Medical and Mental Health Services TB / Direct Observational Therapy Housing Subsidies Heartland Health Outreach

44 Heartland Health Center Uptown and James West Clinics Modified Open Access Scheduling Same day and future appointments Integrated Electronic Health Record System Lab Services Prescription Assistance 340b PAP Heartland Alliance for Human Needs & Human Rights

45 Heartland Health Outreach HCH Outreach Delivery of services to people experiencing homelessness where they reside Provide transportation to follow-up services Render services regardless of ability to pay Collaborate with community partners to provide comprehensive care Heartland Health Outreach

46 Heartland Health Outreach Services Offered Heartland Clinics Chronic disease management Preventative care (screenings) Immunizations Acute care Lab services Prescription services Psychiatric and counseling services Urgent and preventative dental care Smoking cessation Case Management Supportive Services Care Coordination Heartland HCH - Outreach Chronic disease management Preventative care (screenings) Immunizations Acute care Prescription services Urgent and preventative dental care Smoking cessation Case Management Supportive Services Care Coordination

47 Outreach locations Approximately 100 outreach sites Emergency shelters Permanent Supportive Housing Transitional Housing Programs Single Room Occupancies Street Meal Programs Heartland Health Outreach

48 Outreach Models Street outreach (PATH and HCH) Small integrated team (typically not billable to Medicaid) Focus on engagement Shelters and Housing Integrated team including medical assistant (FQHC Medicaid) Urgent care (return to medical home and engagement) Ongoing medical care Electronic health record follows participant Most services can be provided at outreach sites Heartland Health Outreach

49 Outreach Models HHO Supported Housing Provide on-site Mental Health services (MRO) if eligible Provide medical care Case management staff collaboration with housing property managers Non-HHO Supported or Subsidized Housing HHO teams work with property managers with limited ability to share information Continuity of care if participant evicted or struggling with tenancy more challenging for medical care Heartland Health Outreach

50 Lessons Learned It s all about building relationships with both participants, landlords and property management Engagement, identify mutual goals and be consistent Medicaid billing will depend on which service taxonomy, license and site regulations and medical necessity Integrated electronic record is critical Data, data and data Heartland Health Outreach