EFFECTIVE ELIGIBILITY DETERMINATION FOR THE CARE ACT AND OTHER SYSTEMS

1. EFFECTIVE ELIGIBILITY DETERMINATION FOR THECARE ACT AND OTHER SYSTEMS Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc.Harwood MDwww.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net

2. 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

3. 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

4. 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

5. Medicaid Eligibility For HIV/AIDS Beneficiaries Adapted from Kaiser Family Foundation HAB presentation

6. 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

7. Medicare Eligibility For HIV/AIDS Beneficiaries Adapted from Kaiser Family Foundation HAB presentation

8. 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, 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, co-payments, or deductibles

9. 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

10. 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

11. 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

12. 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

13. 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 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 public and commercial claim assessment staff regarding HIV disease

14. 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

15. 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

16. 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

17. Strategies For HIV 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 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 system-wide barriers • Routinely monitor changes in entitlement and discretionary programs that impact eligibility and adjust accordingly

18. 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

19. 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

20. 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