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WAFCC November SummitUnderstanding FCC Liability & Compliance

ACA, The Marketplace & Health Insurance Literacy

Thank you to ECHO for sponsoring our summit!

Agenda

11am – Noon – Registration, Networking lunch provided by ECHO, Meet the WAFCC Board, Join WAFCC, Learn more about Molina Healthcare, Johnson, Covering Kids & Families, and Clear Choice Insurance.

Noon – 12:40pm – Welcome & WAFCC introductions

12:40pm - 1:50pm Stephen Frew & Kerri Zergoski from Johnson Insurance; Liability & Compliance Hotspots for Free & Charitable Clinics

1:50pm – 2pm BREAK

2pm – 2:40pm Traici Brockman from WI DHS and Kim E. Whitmore, Policy Section Chief State Health Plan Officer from Office of Policy and Practice Alignment Wisconsin Division of Public Health, Discussion on Volunteer Liability Provider Coverage updates and reporting requirements

2:40pm – 4pm Kathleen Falk from Regional DHS, Katherine Gaulke from WAFCC , David Liethen from Molina, Dustin Schlesner from Clear Choice Insurance – - ACA, Marketplace, & Medicaid/BadgerCare Updates, Insurance Assister models and FCC outreach opportunities

4pm – 4:25pm –Kathy Graham from St. Vincent de Paul Free Clinic in Merrill, a Virtual Tour and history of clinic

4:25 Drawing for NAFC Summit 2015 & Henry Schein PPE Kit (must be present to win)

Thank You ECHO

� Empowering Community Healthcare Outreach's (ECHO) mission is to empower churches and other community organizations to develop charitable healthcare clinics to serve the most vulnerable people in America. ECHO's primary goals are to facilitated the development of new free & charitable clinics, to encourage the appropriate expansion of existing safety net clinics, and to provide support and consultation to existing safety net clinics. ECHO's efforts are intended to strengthen the quality of clinic services in providing access to primary healthcare for those who are either uninsured or under-insured.

� ECHO's team of staff and consultants has over 100 years of experience in starting and managing charitable clinics. ECHO has 52 charitable clinics open or in various stages of development, and have developed a proven method to help organizations of all sizes be successful in this work. Where3ver there are vulnerable people who have healthcare and organizations willing to meet that need, ECHO can help.

� Mara Servaites (mervaites@gmail.com) or Marty Hiller (martyhiller@mac.com), website www.echoclinics.org – See handout

Get to Know WAFCC

The mission of the Wisconsin Association Free & Charitable Clinic (WAFCC) is to support, strengthen, and advocate for the uniqueness of the Wisconsin free and charitable clinics, the patients they serve, and the communities with whom they partner.

The vision of the WAFCC is a culturally appropriate health care community that provides free or affordable health services that promotes the elimination of health disparities among the uninsured, under-served, economically and socially disadvantaged, and vulnerable populations of Wisconsin.

WAFCC Inaugural Board of Directors

Board Officers Board Members

Terry Ladwig - Chair Dr. Barry Cash Judith Derozier

Jessica Osenbrügge - Vice Chair Dr. Katherine Gaulke Dr. Lindsay Hammons

Mary Reich - Treasurer Brad Lantzer Kenneth Maciolek

Christina Bell - Secretary Dr. Carol Mertins Angie Olson

Jean Randles Linda Smith

Robin Transø Molly Zuehlke

Katherine R. Gaulke, PhD, MHA

Katherine R. Gaulke PhD, MHA

WAFCC Executive Directorkatherinegaulke@hotmail.com

262-949-2971

� Doctorate in Public Service Leadership from Capella University. Graduate of University of Florida with a Master of Health Administration and Saint Leo

University with a Bachelors in Business Administration (Accounting).

� Executive Director - Wisconsin Free & Charitable

Clinic Association (WAFCC) � Active volunteer at Open Arms Free Clinic, Inc. in Elkhorn

� Chairwoman – Walworth County Affordable Care Act Awareness Steering Committee

� Area Chair College of Natural Science, Health

Science, and Nursing University of Phoenix, Madison

� Member of the American College of Health Care

Executives (ACHE), FC3, & WPHCA� Previous careers include:

� Payment Resolution Manager, Financial Analyst

and Accountant for HCA Patient Account Services (managed BCBS, Humana & Medicare HMO inventory for 25 for-profit hospitals)

� Medical Office Property Manager for Cogdell Spencer Erdman, Inc.

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What are the benefits of membership?

� Semi-annual meetings (June/Nov),

� Opportunities for funding (state appropriations, BCBS, or grants to association to disperse to members),

� Contact point for agencies & stakeholders,

� Potential receipt of settlements from Office of State Attorney General,

� Research and advocacy, “Insurance Literacy/Case Management Study" and/or "Bring Your Legislator to Work" week,

� Periodic webinars on topics of critical interest,

� Statewide data tracking,

� Communication of roll in statewide health outcome initiatives (Healthiest Wisconsin 2020),

� Directories of clinics, periodic newsletters and/or other correspondence with clinics,

� Continuous telling of the free and charitable clinic story & need in the post-ACA environment,

� Fostering collaboration within clinics and in Wisconsin.

� As an association WAFCC participates in the NAFC Association Steering conference calls.

Membership/Supporter dues are $100 annuallyPlease make checks payable to WAFCCMail to WAFCC, PO Box 678, Elkhorn, WI 53121

WAFCC Committees Forming

Committee Committee Chair

Executive CommitteeTerry Ladwig414-588-2885

tladwig629@charter.net

Governance (Board Development) Committee

Jessica Osenbrügge262-323-9069

josenbrugge@gmail.com

Finance & Sustainability Committee

Mary Reich262-569-4990

maryreich@lakeareafreeclinic.org

Membership Services Committee

Linda Smith262-257-3394

Linda.Smith@froedert.com

Marketing & Public Relations Committee

Molly Zuehlke608-930-2232

mol.zuehlke@gmail.com

Strategic Planning Committee

Terry Ladwig414-588-2885

tladwig629@charter.net

Resource Development & Fundraising Committee

Jessica Osenbrügge262-323-9069

josenbrugge@gmail.com

Kerri Zergoski & Stephen FrewLiability & Compliance Hotspots

for Free & Charitable Clinics

Presentation & Open Discussion

Avoiding The Traps That Lead To Liability

Stephen A. Frew JD

Johnson Insurance Services, LLC

Tips for Free Clinics

Legal Disclaimer

The following presentation is a general discussion of risk management and risk financing considerations. It does not constitute legal or insurance advice. For specific legal advice consult your attorney. For insurance advice, consult your own insurance agent or Kerri Zergoski (Johnson Insurance).

What We Will Cover Today

Intro to liability

protection approaches

Risk Management

Tips

Your Questions

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Liability protection approaches WISCONSINVOLUNTEER PROGRAM

STAFF ONLY

MALPRACTICE ONLY

GAPS IN COVERAGE

MUST APPLY ANNUALLY

$250,000 LIMIT TO LIABILITY

STAT LIMIT $250K

STATE CLAIMS CT

STATE ATTNY GEN

$0.00 COST

FEDERAL FREE CLINIC FTCA

STAFF ONLY

MALPRACTICEONLY

GAPS IN COVERAGE

MUST APPLY ANNUALLY

$ UNLIMITED

FOLLOWS WISC MEDMAL CAPS

FTCA COURTS

US JUSTICE DEPT

$0.00 COST

COMMERCIALINSURANCE

STAFF AND CLINIC

BUSINESS AND PROFESSIONAL

FULL STANDARD COVERAGE

ANNUAL RENEWAL

$1 MIL – 3 MIL

$UNLIMITED PCF MALPRACTICE

FOLLOWS WISCMEDMAL CAPS

PRIVATEATTORNEYS

$ PREMIUMS

Wisconsin volunteer healthcare program

WHO IS ELIGIBLE:

� Physician

� RN

� LPN

� Marriage counselor

� Family Therapist

� Professional counselor

� PAC

� Nurse Midwife

� Psychologist

� Social worker

� Nurse practitioner

� Physical therapist

� Podiatrist

� Chiropractor

� Dietitian

� Dentist

� Dental Hygienist

� Pharmacy tech

� Optometrist

QUESTION: What if a volunteer gets hurt?

�“True” volunteers are not covered by worker’s compensation

�Volunteers not covered by compensation could potentially sue the clinic or fellow employees

�Requires GL insurance

QUESTION: What if a malpractice claim goes over $250 K

� The amount recoverable by

any person or entity for any damages, injuries or death in

any civil action or civil

proceeding against a state officer, employee or agent…

shall not exceed $250,000. No punitive damages may be allowed or recoverable in any such action.

� 893.82(6)

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Risk Basics

Policies

Procedures

Training

Q/R Plan

Credential

Technical

RECORDS

Nature of medmal losses…

Issues Involved… False Myths About Malpractice

� Most doctors get sued every 3 years

� Doctors get sued due to greedy patients

� Doctors get sued due to greedy lawyers

� Doctors get sued because they take hard cases

� Doctors get sued because they practice in bad areas

� Doctors get sued because they are poor clinicians

� Nurses are never sued

� People in rural areas don’t sue

Risk Realties

�People don’t need to be RIGHT to sue you, they just have to be ANGRY

� Even if you WIN the suit, you still LOSE

� No clinic can survive by offending patients

� The “Patient” includes family and friends

Best Administrative Practices

� Be on time

� Keep patients advised if the physician is running behind and offer to reschedule

� Allow enough time

Rate doctors and staff on customer

service commitmentDon’t hire people who don’t smile

Don’t let people answer phones without special

trainingMonitor your answering service performance

Return calls

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Little staff tricks that boost patient approval

� Always apologize for being late – even if you

are not

� Always introduce yourself by title and last

name

� Always identify and greet each person in the

room

� Always sit down when talking to the patient

unless necessary for procedure or exam, then sit down

� Always look at the patient, not the computer

� NO MULTI-TASKING

� Get it done in one visit

It’s ALL about COMMUNICATION…

�Always ask about medical care, injuries, or hospitalizations since last visit

�Always let the patient finish what they have to say

�Always repeat back to clarify before anything else

�Assume that the patient has no medical vocabulary or knowledge

MORE TIPS…

�Answer the patient’s questions graciously and with solid information

�Don’t give them the “Doctor knows best” type answer�Always have the patient repeat back your instructions�Give written (printed) instructions whenever possible�Give information materials and online resources�Always ask the patient if there is anything else before they

leave

Risk Management Rule 3

�Avoiding lawsuits depends less on how you cared FOR the patient than on how much the patient or relative believes you cared ABOUT them

The sharks are circling…

�Involvement with illegal drug rx’s

�Allegations of sexual impropriety

�Lack of informed consent

�Privacy Issues

HIPAA – Rapidly growing threat…

�It’s more than a HIPAA violation – it is malpractice for breach of confidentiality� Avoid unnecessary discussions,

comments, snide comments, medical humor around patients

� Know who is in the room

� Know who is authorized for information

� Don’t take records off-premise

� Don’t access files with home computers or with wireless connects that are not encrypted

� Don’t take photos without consents – Ban cellphones

� Don’t run copies on the fly

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What you need to remember…

� Remember – the more interesting, the more private

� Remember – your job depends on confidentiality

� Know the rules for proper discussion of patient information

� Insist on proper authorization for any disclosure

� Keep your nose out of other people’s files� Do not take patient information out of the

office unless absolutely necessary� Do not access patient information from

home computers or over wireless networks that are not secure

� Act promptly to discipline for violations� Mandated notification and self-reporting

Records Security in the office…

� All records should be returned to a locked security area when the office is closed.

� Do not allow records to be stacked around the office

� Require all computers to revert to screensaver mode automatically

� Require strong passwords for all computer access

� Do not store backup records on premises

� Put someone in control of records access

Breaches

Staff

Theft or loss

Hacking

Other

Telephone triage� General rule: Don’t give

medical advice over the phone

� If you have to:

� Follow formal written protocol system approved for each doctor

� RN’s only

� Generate written standard phone record on each contact and must go into record

� Assure the physician sees the phone advice

� When in doubt consider it an emergency

Questions and

AnswersBREAK1:50pm – 2pm

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Volunteer Liability Provider Coverage Updates, Reporting Requirements, and Discussion

Traici Brockman from WI DHS and

Kim E. Whitmore, Policy Section Chief State Health Plan Officer from Office of Policy and Practice Alignment Wisconsin Division of Public Health,

ACA / Website UpdatesKathleen Falk – Regional DHS Director

Katherine Gaulke – WAFCC Executive Director

How many Wisconsinites have enrolled?

� The 2014 ACA open enrollment period ended in April, but enrollment in the Wisconsin exchange has continued throughout the summer thanks to qualifying events that trigger special enrollment periods. HHS will issue an updated enrollment total in November.

� 139,815 people had purchased private plans in the Wisconsin exchange by April 19 – nearly a 96 percent increase over the number who had done so by March 1.

� In addition to the private plan ACA enrollments, Wisconsin’s exchange has also enrolled 97,509 residents in the state’s BadgerCare Medicaid program by the end of June.

� According to a Gallup poll, 11.6 percent of Wisconsin’s population lacked health insurance in 2013. The poll found that the rate had dropped to 9.6 percent by the middle of 2014. Should be noted that Waukesha County’s insurance rate was below this even before ACA.

Open Enrollment vs. Tax SeasonWill People Enroll In-time?

There are those that will realize they need insurance after they file their taxes and open enrollment is closed-

NO SEP for this

Immigrant Eligibility for Medicaid and Marketplace Coverage in 2014

Medicaid Exchange Coverage

U.S.-born &NaturalizedCitizens

Expands to adults without dependents with incomes up to 100% of FPL.

Persons 101%-133% of FPL

losing Medicaid and moving to Marketplace (eligible for hardship waiver)

Individuals without affordable employer coverage can buy coverage through the Marketplaces.

Tax credits available to individuals with

incomes between 100%-400% of poverty who are not eligible for Medicaid.

Lawfully Present Immigrants

Many remain subject to a five-year wait before they may enroll or are excluded from eligibility.

May purchase exchange coverage and receive tax credits on the same basis as citizens. Persons with incomes below 100% of poverty who are ineligible for Medicaid based on immigration status

may purchase exchange coverage and receive tax credits.

Undocumented Immigrants

Remain ineligible for Medicaid.

Prohibited from purchasing exchange coverage and receiving tax credits.

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WI Marketplace Companies Filed

Individual Market CompaniesSmall Employer Group Market Insurance Companies (SHOP)

� All Savers Insurance Company (United)

� Arise (WPS Health Plan, Inc.)

� Common Ground Healthcare Cooperative

� Compcare Health Services Insurance Corporation (A BCBS plan)

� Dean Health Plan, Inc.

� Group Health Cooperative of South Central Wisconsin

� Gundersen Health Plan, Inc.

� Health Tradition Health Plan

� Managed Health Services Insurance

Corporation

� Medica Health Plans of Wisconsin

� MercyCare HMO, Inc.

� Molina Healthcare of Wisconsin, Inc.

� Physicians Plus

� Security Health Plan of Wisconsin, Inc.

� Unity Health Plans Insurance Corporation

� All Savers Insurance Company

� Arise (WPS Health Plan, Inc.)

� Common Ground Healthcare Cooperative

� Group Health Cooperative of South Central Wisconsin

� Gundersen Health Plan, Inc.

� Health Tradition Health Plan

� Medica Insurance Company

� MercyCare HMO, Inc.

� MercyCare Insurance Company

� Security Health Plan of Wisconsin, Inc.

CONCERN: Patients seeking assistance in the Open Market – very few consumer protections in place and lack of resources to assist in Wisconsin!

The Wisconsin’s uninsured rate has stabilized at 9.6%, showing a leveling off of the uninsured

compared with the month-by-month declines seen previously. Clearly, free and charitable clinics

(FCC) are still needed.

Who remains uninsured in Wisconsin?

Persons…

� With Affordability Waivers, Hardship Waivers, Incarceration, or Religious Waivers

� Waiting for Insurance to kick-in (90 day wait for new employees or Special Enrollment Period wait)

� Not eligible for subsidies due to employer individual premium viewed as “affordable” however Family Coverage is not

� Married filing separately not eligible for subsidies (waiting for divorce)*

� Dropped their COBRA coverage, no SEP triggered

� Cannot afford premiums, deductibles, co-pays, and co-insurance even with subsidies

� Cannot afford Medicare Part B/Advantage premiums

� Over 65 not eligible for subsidies or cost-sharing

� Lack of Insurance due to Inconsistencies in income figuring - - BadgerCare = monthly income; Marketplace = annual income

� Churning (season workers back and forth between Badgercare, uninsured, and the Marketplace)

� Missed Enrollment

� Legal resident 5-year wait for BadgerCare

� Undocumented residents

COBRA: Example of Expensive Insurance and potential future uninsured person

MAGI Annual Salary (250% FPL Single) $29,000

Less Expenses:

Income Tax 20% (federal & state) ($5,800)

401K /Savings Account (3%) ($870)

Rent/Home/Car Insurance premiums ($1,200)

Life Insurance Premium ($300)

Gas including To/From Work ($2,880)

Car payment and/or Maintenance ($1,200)

Food & Household Items ($6,000)

Rent or Mortgage ($8,400)

Energy, Water, & Trash ($2,400)

Cell Phone with Internet (looking forwork and work related emails/calls)

($1,200)

Yearly Entertainment/Netflix/Hulu ($120)

Funds Available for Health Care ($1,370)

Less Health Care Expenses

Health Insurance Premium (6.8% of income = “affordable”)

($2,000)

Deductible(no cost-sharing as above 250% of

FPL)

($2,500)

Medications (2 per month @ $30 each) ($720)

Dental Insurance Premium ($1,200)

Debt with Health Care Coverage ($7,790)

Despite Wisconsin’s best efforts to give residents access to affordable health

insurance – the subsidies offered by the ACA are not enough or the rules prevent those who need subsidies most from being able to receive them;

leaving many uninsured Wisconsinites who need affordable health care.

This budget is for a single person who does not

qualify for cost sharing at

the Marketplace, the FoodShare program, and many other government

income-based programs. This working

Wisconsinite has a negative cash flow available for health

care!

*NOTE – does not take into consideration deductibles, copays, or coinsurance!*

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Insurance Agents/Brokers volunteering at ClinicsKatherine Gaulke – WAFCC Executive Director

Dustin Schlesner – Clear Choice Insurance

David Liethen – Molina Healthcare of Wisconsin

Rodney Brown – The Brownig Insurance

Insurance Agent & Assister Model

� Uninsured individuals/families meet with a volunteer “assister” or “mobilizer” and complete their BadgerCare or Marketplace (healthcare.gov) application

� Have taxes or pay stubs and SSN/document numbers for family

�Go through “assister” training with Katherine or Clinic Program Coordinator

� Once insurance subsidy results obtained, meet with the volunteer insurance agent to understand what subsidies and cost sharing are and to make an informed choice on insurance selection

Using Insurance/Assister Model1st Enrollment Lessons Learned

Lesson One: There is limited understanding about how insurance works and what the next steps are once receiving insurance within the target population. There is low health insurance literacy, often even worse than general health literacy

Solutions Lesson 1:

� Coverage 2 Care materials marketplace.cms.gov/c2c

� These can be ordered for FREE through the CMS POW

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Using Insurance/Assister Model1st Enrollment Lessons Learned

Lesson Two: There is limited understanding about how insurance agents are paid and how that might impact the plans they are advising seekers to take. Many in the target population believe that ALL insurance agents/brokers can (and want to) help them pick the best plan and are the same; however some agents steer away from the Marketplace or to only one plan on the Marketplace, thus reinforcing beliefs on costs and the attainability of insurance .

Solutions Lesson 2:

� Require all agents assisting FCC patients to:

� Be contracted with ALL the payers in county Marketplace (healthcare.gov),

� Have FFM certification and completed the OCI BadgerCare training,

� Have a background check (no financial crimes or crimes against children as we work with families),

� Sign clinic HIPAA/privacy policy,

� give their business card & a Marketplace contact card to all visitors, complete a Marketplace summary sheet for all persons they assist,

� be familiar with the local premium assistance program, and

� Review and give all visitors the “Road Map” C2C booklet and explain insurance cards, and emergency vs. primary care situations

Insurance Literacy / Insurance Case Management Pilot StudyKatherine Gaulke – WAFCC Executive Director

Mary Reich – Lake Area Free Clinic Executive Director

Allison Espeseth – Covering Kids and Families

What is “Insurance Case Management”?

� Staying in contact with a patient who just obtained insurance for 6-12 months after you discharge them from your clinic

� Contacting the person to make sure they have found a PCP, made their first appointment, transferred their medications, and are taking their medications

� Understanding the hurdles the person is experience obtain care and medications (health literacy, health insurance literacy, finances, transpiration, wait lists, generic vs. name brand, etc)

� Advising and assisting to overcome the hurdles (contacting the provider, contacting the insurance company, financial assistance, financial counseling, health/health insurance terms classes, meeting with person to help understand EOB/insurance card, reviewing in-network providers, etc)

� Goal – Help patients move from being uninsured to successfully insured

The Pilot Study

� Implement the “insurance case management” model to at least the first 40 patients who notify your clinic that they are now insured.

� Track data and have the patients complete questionnaires.

� Communicate with WAFCC and ask for assistance whenever needed

� WAFCC will compile the results and report

� Potential for capacity funding grants next enrollment.

� If interested, contact Katherine

� Key Outcomes to be Measured:

� Insurance literacy beginning of intervention and end of intervention (Covering Kids & Families tool)

� Does the individual have a PCP?

� Is the individual taking the necessary prescribed medications?

� What expenses or debt has the individual incurred since obtaining insurance?

� What are the individual's struggles with insurance and the health system?

� How many visits to the ER/urgent care? Reasons?

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Virtual Tour – St. Vincent de Paul Free Clinic

Kathy Graham

St. Vincent de Paul Free Clinic

1004 E Main St, Merrill, WI 54452

(715) 539-9566 klgraham1212@frontier.com

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Drawing & Questions?

Thank you NAFC for donating a complimentary registration for the 2015 NAFC Summit in Palm Springs to be given away at the WAFCC Nov. Summit!

Thank you Henry Schein Medical for donating a Schein PPE (Personal Protective Equipment) Kit to be given away at the WAFCC Nov. Summit!

Thank you to YOU for attending the Nov. WAFCC Summit!

2014 Poverty Guidelines

Family

100% 133% 150% 200% 250% 300% 350% 400%

Size

1 $11,670 $15,521 $17,505 $23,340 $29,175 $35,010 $40,845 $46,680

2 $15,730 $20,921 $23,595 $31,460 $39,325 $47,190 $55,055 $62,920

3 $19,790 $26,321 $29,685 $39,580 $49,475 $59,370 $69,265 $79,160

4 $23,850 $31,721 $35,775 $47,700 $59,625 $71,550 $83,475 $95,400

5 $27,910 $37,120 $41,865 $55,820 $69,775 $83,730 $97,685 $111,640

6 $31,970 $42,520 $47,955 $63,940 $79,925 $95,910 $111,895 $127,880