impact of cms and hrsa policies on care act grantees and subgrantees: a florida case study julia...
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Impact of CMS and HRSA Policies on CARE Act Grantees
and Subgrantees: A Florida Case Study
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
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
0 50 100 150 200
Number of Registrants
Title I
Title II
Title III
Title IV
DRP
SPNS
MAI
TPR
MEDC
Direct Service MEDC Registrants
20%
8%
41%
24%
7%
Direct Service TPR Registrants
22%
10%
33%
28%
7%
Hosp / Uni Clinic
Community HealthCenter
CBO
County HealthDept
Sub Ab/ MentalHealth Tx
0 50 100 150
Number of Registrants
Medicaid
Medicare
CommericalInsurance
Managed CareOrganizations
MEDC Evaluation ResponsesStrongly
AgreeAgree Neutral Disagree Strongly
DisagreeUnknown
I found the handouts to be informative
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
TPR Evaluation ResponsesStrongly
AgreeAgree Neutral Disagree Strongly
DisagreeUnknown
I found the handouts to be informative
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
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
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 non-emergent)
Outpatient mental health services
Medical/drug therapies (chemo, dialysis)
Family planning Outpatient surgery Laboratory and
radiology Transportation
(emergent and non-emergent)
Outpatient mental health services
Additional Required or New BenefitsRequired for sufficiency Hospital outpatient services Durable medical equipment Home health care Prescription drugsRequired to be offered, but amount, scope and duration are flexible Chiropractic care Podiatry Outpatient therapyNew 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
Required for sufficiency Hospital outpatient services Durable medical equipment Home health care Prescription drugsRequired to be offered, but amount, scope and duration are flexible Chiropractic care Podiatry Outpatient therapyNew 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
FL NetPass FFS PSN Broward
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
HIV+ enrollees must chose a plan HIV+ enrollees identified in Medicaid claims files may be auto-
assigned 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
How will impact of Medicaid reform on HIV+ enrollees?
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 re-certification 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