EFFECTIVE ELIGIBILITY DETERMINATION

IN THECARE ACT AND OTHER SYSTEMSA Workshop Funded by the Suburban

Maryland Title I Program

EFFECTIVE ELIGIBILITY DETERMINATION

IN THECARE ACT AND OTHER SYSTEMSA Workshop Funded by the Suburban

Maryland Title I Program

Julia Hidalgo, ScD, MSW, MPH

Positive Outcomes, Inc. Harwood MDwww.positiveoutcomes.net

julia.hidalgo@positiveoutcomes.net

Ground Rules

I do not represent DHMH, HAB, or CMS

Let me know if you do not understand

We can share our feelings at the end of each section

You will be rewarded for staying awake

Shut off your electronic devices

A 15 minute break means 15 minutes!

Why conduct eligibility determination (ED) for HIV+ clients?

Ensure clients receive the optimal benefits that they are legally eligible

Ensure access to health care and medications through enrollment in MADAP, MAIAP, or other public programs

Through enrollment in commercial insurance, ensure access to a full range of health care benefits not commonly covered by the CARE Act

Ensure income maintenance through disability income and other income maintenance programs

Ensure that HIV clinics and other health care providers are compensated for their services

Adhere to federal Ryan White CARE Act requirements Now referred to as the Ryan White HIV/AIDS

Treatment Modernization Act of 2006

The CARE Act is the payer of last resort (PLR)Grantees and subgrantees (i.e., contractors)

must ensure that clients meet eligibility criteria for CARE Act services Including MADAP, MAIAP, and direct services

CARE Act grantees and subgrantees must ensure that alternate payment sources are pursued before providing CARE Act-funded services

Grantees must establish and monitor procedures to ensure that their subgrantees verify and document client eligibility

CARE Act Payer of Last Resort PoliciesCARE 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, 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 PLR Including coordination with the VA

These and other HAB requirements are subject to audit

CARE Act Payer of Last Resort PoliciesCARE Act Payer of Last Resort Policies

DC Metro Area Title I Eligibility Criteria

Be a resident of the jurisdiction funding the services to be provided

Be HIV+ or have been diagnosed for AIDS or HIV-related illness by a primary medical practitioner

A completed Medicaid application and documented submission date for all clients with incomes below the federal poverty level (FPL) and T-cell below 200 is required when providing Medicaid reimbursable services What does this mean?

Which DC Metro Area Title I agencies are responsible for eligibility determination (ED)?

The Title I Request for Proposals (RFP) states that Title I case management agencies are responsible for EDCare coordination is that element of case management that is focused on arranging and scheduling coordination for the various service elements a client may require, and for eligibility determination, including determination of income eligibility and “last resort” requirements

Which DC Metro Area Title I agencies are responsible for eligibility determination (ED)?

Title I-funded case management agencies must ensure case managers or care coordination staff Provide counseling and assistance to ensure eligible

clients receive entitlementsScreen clients for all third party payer sources

including, but not limited to, Medicaid, Medicare, MADAP, and private insurance

Complete and submit Medicaid applications for eligible clients, follow up on the application, and initiate third-party retroactive collections for the cost of care paid by Title I while awaiting Medicaid determination

Re-determine eligibility every six monthsDocument the status of Medicaid, Medicare, and

MADAP applications for all Title I-eligible clients

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 Security Income (SSI)

Severely disabled, 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 Substantial state variability in the acceptance rates of

SSI applications from HIV+ individuals Initial denial rates tend to be very high in most states

Social Security Administration (SSA) delegates the review of SSI applications to the MD State Department of Education Division of Rehabilitation Services, Disability Determination Services (DDS)

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 What has been your HIV+ clients’ experience applying

and enrolling in Maryland Medicaid?

Medicare Eligibility For HIV/AIDS BeneficiariesAssistance 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 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

Individuals with end-stage renal disease, any age

Sufficient number of work credits to qualify for Social Security payments

Adapted from Kaiser Family Foundation HAB presentation

Medicare Part D Enrollment

Year 1 implementation was challenging

HIV+ Medicare beneficiaries continue to express challenges in comparing plans

What has been your HIV+ clients’ experience with Medicare Part D?

Commercial Insurance Coverage is primarily through group benefits via

employers or association membership Individual coverage can be purchased through

carriers 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, home health visits) HIV+ beneficiaries of these plans may receive

CARE Act benefits during waiting periods or while services caps are exceeded

Commercial InsuranceSome 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

Case managers should not facilitate dual enrollment in CARE Act-funded programs to address these concerns

It is important to counsel clients To retain or seek coverage during “open season” Seek improved coverage if they have limited

benefits or high premiums, co-payments, 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 help them to navigate 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 benefitsIn recent years, VA eligibility requirements

have become increasingly strict

QUICK QUIZ

1. Identify Maryland-funded programs in which HIV+ indigent clients obtain coverage for HIVmedical care and medications

2. Identify three publicly-funded programs in which HIV+ indigent clients obtain income support

3. Identify two publicly-funded housing assistance programs

MD HIV Program Eligibility CriteriaHouse-

hold Size*

Federal Poverty Level (As of

01/01/07)

MD Primary Adult Care

(PAC) Program (As

of 07/01/06)

MADAP and

MADAP Plus

(As of 02/07)

MAIAP(As of

02/01/07)

Title II CARE Act

(As of 01/01/07)

1 $10,210 $11,376 $51,050 $30,630 $40,840

2 $13,690 $13,200 $68,450 $41,070 $54,760

3 $17,170 $16,600 $85,850 $51,510 $68,680

4 $20,650 $20,000 $103,250 $61,950 $82,600

5 $24,130 $23,400 $120,650 $72,390 $96,520

6 $27,610 $26,800 $138,050 $82,830 $110,440

7 $31,090 $30,200 $155,450 $93,270 $124,360

8 $34,570 $33,600 $172,850 $103,710 $138,260

Asset   $4,000 per person $10,000 per person

Limits   $6,000 per couple or couple

MD HIV Program Eligibility CriteriaMD PAC Program

MADAP and MADAP Plus

MAIAP Title II CARE Act

HOPWA

HIV+ HIV+MD residentMeet income

guidelines

HIV+MD residentBe enrolled in a health insurance

planMeet income

and asset guidelines

Be unable to work due to HIV infection

HIV+MD residentUninsured / underinsured

HIV+Resident of

HOPWA service areaIncome at or below 80% of average

income in county of residence

What challenges have your HIV+ clients experienced enrolling in these programs?

HOPWA MD County-Specific Income Criteria

County Median Income 80% of Median Income

Charles $62,199 $49,759

Frederick $60,276 $48,220

Montgomery $71,551 $57,241

Prince George's $55,256 $44,205

St. Mary's $54,706 $43,765

*Based on average family size of approximately two.

Eligibility for Other Publicly Funded Services

Under the CARE Act PLR policy, if a client is eligible for services through other publicly funded services they should be referred to those services before CARE Act-funded services should be provided

Examples include Substance abuse treatment services Mental health services Food/pantry services Transportation Utilities assistance

What challenges have your HIV+ clients experienced enrolling in these programs?

QUICK QUIZ: TRUE OR FALSE

1. Physicians and other clinicians can help HIV+ patients to enroll in Medicaid2. The reception staff at HIV clinics can assist in periodic re-determination of health insurance coverage3. Re-determination should only be done once per year4. I am very familiar with eligibility requirements for MD Medicaid, MADAP, and MAIAP

Partners In Eligibility Determination (ED)

Case managers or other ED staffPhysicians documenting disabilityReception staff Other payers and other systemsLegal advocacy programs

Direct service agency managers and HIV program directors

Link with HIV clinics to obtaining documentation of clients’ HIV serostatus documentation Case managers working in clinics must document

HIV serostatus in your clients’ case management charts

Use standardized forms and train personnel to use them Ensure forms are linguistically appropriate to the

subpopulations served Address the varied literacy level of clients

Clearly identify expectations to case managers regarding chart documentation

Require tax returns or credit checks to document income, assets, and employment

Role of HIV Program Directors and Case Management Supervisors

Role of HIV Program Directors and Case Management Supervisors

Role of HIV Program Directors and Case Management Supervisors

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

Reflect the availability of state and local programs Review your policies and procedures with your ED

staff to determine what is actually being done Talk to your staff, assess data, and conduct your

own audits Develop continuous quality improvement (CQI) to

improve ED Train and retrain ED staff and test their knowledge

periodically Use trained and experienced supervisors

Role of HIV Program Directors and Case Management Supervisors

Systematically assess the ED processes by applying performance standards and auditing charts

Use benchmark data to compare the performance of ED staff

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

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 system-wide barriers

How do supervisors in your agency monitor ED functions of your HIV case managers?

Routinely monitor changes in entitlement and discretionary programs that impact eligibility and adjust accordingly Changes to major payers in your community should

be rapidly communicated to ED workers Meet with county DSS staff to become familiar with

their processes, get on the list for program announcements, and ask if your staff can participate in training

Do not assume another agency will take care of ED unless that explicit role is assigned to them 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

Role of HIV Program Directors and Case Management Supervisors

Role of HIV Program Directors and Case Management Supervisors

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 may be available (through CARE Act-funded 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 disability determination staff regarding HIV disease

Are there other actions your HIV program director or supervisor can do to help you do ED?

Role of HIV Program Directors and Case Management Supervisors

Role of HIV Program Directors and Case Management Supervisors

Strategies For HIV Programs Receptionists should ask ALL clients at EACH visit for a

copy of their health insurance card, including Medicare Part D enrollment card Any changes should be reported to the case

management staff 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 Scheduling staff should confirm through the online

Medicaid system that the client is newly or still enrolled Confirm Medicaid enrollment the day before the client’s

appointment What if our agency is not a Medicaid provider?

Copies of new health insurance cards should be made and filed in the client’s chart

Effective Strategies Used By ED Staff 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

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

Knowing how to complete the paperwork, document claims, and making sure clients follow through are the keys to success

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

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 clients to prepare valid, accurate

applications for benefits Partner with legal aid staff to prepare well documented

applications and address discrimination issues What other strategies do you use?

Effective Strategies Used By ED Staff

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 What other strategies do you use?