Making Every Dollar Count: Effective Strategies for Using Ryan White CARE Act Funds and Third Party Reimbursement in an

1. Making Every Dollar Count:Effective Strategies for Using Ryan White CARE Act Funds and Third Party Reimbursement in an Era of Diminished Resources

2. Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc.Harwood MDwww.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net(443) 203 - 0305

3. Planning Committee • Aubrey Arnold • Gayle Corso • John Eaton • Theresa Fiano • William Green • Deidre Kelly • Syd McCallister AHCA • Heidi Fox HRSA HAB Project Officers • Johanne Messore • Yukiko Tani TPR Trainers • Curt Degenfelder • Marilyn Massick • Michael Taylor

4. Ground Rules • I do not represent HRSA, CMS, or AHCA • 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!

5. Overview of Today’s Session • Overview of financing, third party reimbursement (TPR), and eligibility determination • Train the trainer approach • Materials on the POI website • Please follow-up by email with additional questions • Topics covered • HRSA’s payer of last resort (PLR) policies • Changes on the horizon that make it increasingly important for CARE Act grantees and subgrantees to address financing and eligibility determination issues • TPR • Participating in Florida Medicaid, commercial insurance, and managed care systems • Estimating your program’s costs • Marketing your program’s services • Eligibility determination

6. Patient 1st Party Provider 2nd Party services Insurer Medicaid Medicare 3rd Party $ $ What is third party reimbursement? TPR is receiving payment from a source other than the patient for services provided to patients by a provider. This other source is the “third party.”

7. CARE Act Payer of Last Resort Policies

8. CARE Act Has Three Principal Fiscal Requirements • Matching Funds • Title II Match • ADAP Match • ADAP Supplemental Match • Maintenance of Effort (MOE) • Payer of Last Resort (PLR)

9. Three CARE Act Fiscal Requirements By Title and Part F DRP = Dental Reimbursement Program

10. Title II Matching Fund Requirement • Introduced in the 1990 CARE Act authorization • State Title II programs must match a percentage of Federal funds received under the CARE Act with State funds or expenditures • Applies only to Title II grantees with > 1% of the US AIDS cases reported for the two most recent fiscal years • The match rate started at 16.66% in 1990 and increased to 33.33% in 1994 • The required matching fund rate has not been increased since the CARE Act 1990 authorization • Requirement cannot be waived if a State is unable to maintain its match rate

11. Maintenanceof Effort (MOE) Requirement • Introduced in the 1996 CARE Act reauthorization • Grantees are required to maintain a level of HIV expenditures for services at an amount that is equal to the levels of such expenditures for the preceding year • The MOE provision under Title I, II, III, states that the Secretary “shall not make a grant under this subsection if doing so would result in a reduction of State funding allocated for such purposes” • Federal funding can be decreased but not directly due to a reduction in other Federal funds, including reduction in CARE Act funds received by Title I, II, or AETC grantees

12. HAB PLR Policies • Are CARE Act grantees or sub-grantees required to bill? • If you provide services that are eligible for TPR and you charge anyone, you must have a system to bill and collect from third parties • You must identify potential TPR sources for each client, refer them for eligibility determination, set up billing systems, bill all available TPR sources, and negotiate the best reimbursement rates possible • While Medicaid eligibility is pending you may use grant dollars but you must bill retroactively • Pay and chase • Does HAB support the reduction of a grant award to their contractors due to increased TPR? • No, HRSA discourages this; preferring that you use the revenue to expand and/or enhance HIV services

13. Who is the payer of last resort (PLR)? • HAB considers the CARE Act to be the payer of last resort • Services that must be reimbursed by any private or public payers should be determined before CARE Act funds are used to pay for care • It is unclear which CARE Act Title should be considered the payer of last resort among CARE Act programs

14. HAB PLR Policies • Must an agency credit their HIV unit’s budget for TPR or can they retain the funds? • Your organization must report the amount of the reimbursements to the HIV/AIDS unit and to return or credit those funds to the HIV program • How can funds received from TPR be used? • The funds must be used to pay for HIV services to the populations • Since TP payment is typically less than submitted charges, should the grantee or contractor bill for their actual costs? • CARE Act funds cannot be used to “balance bill” • Try to negotiate the best possible rate with insurers

15. HAB PLR Policies • How can our program become a Medicaid provider? • Check the State Medicaid website or contact the State Medicaid Program directly • Help can also be obtained from CMS’s Regional Office: www.cms.gov/about/regions • Can CARE Act funds be used to pay to prepare to become a Medicaid provider? • Yes, capacity development funds may be used for this purpose • The Title I Planning Council must allocate capacity development funds

16. HAB PLR Policies • What must we do to meet the qualifications to be a provider if our employees do not meet Medicaid credential requirements and we provide Medicaid covered services? • If you do not charge for the covered service or seek TPR, there is a waiver provision • Otherwise, careful attention should be paid to staffing a program with quality of care and reimbursement implications in mind • Your program should evaluate the costs and benefits of adjusting your staff mix over time to assess if staffing changes would be beneficial in the long term to ensure quality of care

17. HAB PLR Policies • Can a grantee require a contractor to become a Medicaid provider even if the service provided is not covered by Medicaid? • No • If a client is enrolled in Medicaid, can CARE Act funds be used to pay for case management? • If your State Medicaid Plan covers the type of case management that you provide, Medicaid should pay for those services • To find out if case management is covered see: www.cms.gov/medicaid/tollfree.asp • To obtain information about your State’s State Medicaid Plan see: www.cms.gov/medicaid/stateplans/map/asp • If the case management services provided by your agency are not covered, then the services may be paid for using CARE Act funds

18. Sliding Fee Scale CARE ACT specifies the following sliding fee scale for clients with an income: • < 100% of FPL may not be charged for service provided under the grant • > 100% of FPL must be charged for services based on a schedule that is available to the public • > 100% and < 200% of FPL, the provider will not, for any calendar year, impose charges in an amount exceeding 5% of the client’s annual gross income • > 200% and < 300% of FPL, the provider will not, for any calendar year, impose charges in an amount exceeding 7% of the client’s annual gross income • > 300% of FPL, the provider will not, for any calendar year, impose charges in an amount exceeding 10% of the client’s annual gross income

19. Sliding Fee Scale • If a CARE ACT grantee or subgrantee charges for its services, it must do so on a sliding fee scale or a schedule available to the public • CARE ACT grantees or subgrantees may use their discretion, in the case of clients subject to a charge, to assess the amount of the charge, including imposing only a nominal charge for the provision of service • The grantee or subgrantee must take into consideration the medical expenses of clients in assessing the amount of the charge

20. Challenges to Applying a Sliding Fee Scale • The ceiling on out-of-pocket payments requires a high level of documentation of paid bills • Clients have difficulty maintaining records • Some providers do not have the ability to collect and account for cash • A problem in small and large institutions • In large organizations, out-of-pocket payments are often not applied to the budget of the HIV program nor does the accounting system separately identify out-of-pocket revenue generated by the HIV program

21. PLR Policies: An Example of Enforcement Challenges “This is a partial list of providers who receive Title III support from us. I'm sorry, but I don't feel that I can send you all our referral providers, as they may or may not know the funds paying their fees are from Ryan White. It is up to the patient to disclose to another provider, and often, that means the provider may chose not to provide services. This has happened on numerous occasions, so please understand it would not be in our patients' best interests to have you contact all the providers we use.” A Title III Grantee

22. PLR: Participation in TPR • Almost all CARE Act medical providers participate in Medicaid and other payers • Some are locked out of Medicaid managed care plans who will not contract with them • Some CARE Act providers funded for mental health and drug treatment services are not licensed and do not employ licensed supervisors or line staff • Not eligible for participation in Medicaid • May employ contractors that bill directly with no revenue returned to the program • Some Medicaid programs have a moratorium on new provider numbers for certain provider categories • Some CARE Act providers cannot afford credentialed personnel that would provide billable services

23. PLR: Participation in TPR Systems • Managed care plans have considerable requirements that CARE Act providers may not meet • 24/7 staffing, HIPAA compliance, staff credentialing, quality assurance, electronic claims submission, reporting, risk bearing • Considerable infrastructure investment is commonly required for HIV providers to become ready for participation in managed care • Case management and psychosocial support providers may not provide a billable service • Do provide a billable services but are not sufficiently credentialed • Some providers may not be aware that they provide a billable service • Becoming a participating provider is likely to represent some costs; often not covered by CARE Act capacity building funds

24. PLR: TPR Issues • Many CARE Act providers are unaware of their per unit of service cost • Tend to accept payments that are well below their actual costs • Commonly have little bargaining power with insurers • Personnel costs are reported to be rapidly rising • Unionized organizations are bound by collective bargaining • Grantee unit cost payments may be less than program costs • Visits to HIV care providers tend to be relatively long and labor-intensive • Volume is insufficient to generate increased marginal revenue • Insolvency is increasing among HIV clinics • In the past, parent institutions were willing to support administrative staff and related costs or absorb uncompensated costs • Many of HIV programs report their institutional support has eroded rapidly as broader financial pressures increase • An increasingly hostile environment is reported

25. PLR: Billing Systems • Many providers receiving CARE Act funds have inadequate billing systems • In large systems, their billing systems do not separately account for HIV program revenues or expenses • Some staff are not adequately trained, credentialed, or supervised • Newer or small providers often try to build rather than buy billing staff capacity • Evidence of coding insufficiency resulting in lower payments • Do not research and resubmit rejected claims • CARE Act providers are reluctant to require payment from self-pay patients • No collections process in place; even when patients have income • Billing systems are not set up to do “pay and chase” • Billing software, hardware, and training/re-training represent significant operating costs

26. PLR: Billing Systems • In some healthcare markets, CARE Act providers may potentially bill numerous payers • Payers vary in their mechanisms for provider networks, covered benefits, and the amount that they will pay • Prior authorization and standing order requirements must be addressed to ensure payment • Payments may be slow, with claims commonly rejected at first submission • This level of complexity is quickly outstripping the capacity of even relatively sophisticated providers • HIV clinics tend to offer non-covered services • Prevention, medication education, adherence counseling

27. Can veterans be required to receive services at a VA medical center? • In 2004, HAB clarified their policy about providing CARE Act services to HIV+ veterans who are also eligible for VA benefits: http://hab.hrsa.gov/law/0401.htm • CARE Act providers • May not deny services, including medications to veterans who are otherwise eligible for the CARE Act • Should inquire if an individual is a veteran and enrolled at the VA • Should be knowledgeable about VA medical benefits, including medications • Must coordinate health care benefits for veterans

28. Why do some veterans receive care outside the VA? • Concerns about quality in the VA system • Even if enrolled for VA health care, a veteran does not have to use the VA as their exclusive health care provider • The VA has limited resources and is funded each year by Congressional appropriations • The VA encourages veterans to retain existing health insurance • While veterans cannot be required to seek their care in the VA, CARE Act programs can provide a valuable service in making HIV+ veterans aware of VA services available procedures for getting VA care and helping them navigate care systems to secure HIV care

29. What are the eligibility criteria for veterans to receive services from the VA? • Eligibility for most veterans health care veterans is based on active military service in the Army, Navy, Air Force, Marines, or Coast Guard (or Merchant Marines during World War II), and other criteria • VA health care benefits are not just for those 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

30. Can CARE Act grantees or subgrantees contract to provide services to the VA? • Yes, individual VA facilities or any of the 21 regional Veterans Integrated Service Networks can contract with other agencies or groups to provide care to veterans • Usually, this occurs when a specific service is not available in the VA system or when providing the service through a contract is more economical for the VA • For clinical services, the VA must identify a need, develop a “scope of work,” and then obtain bids for the cost of providing the services

31. EFFECTIVE ELIGIBILITY DETERMINATION

32. Determination: Pieces of the Puzzle • Vast array of entitlement and discretionary programs that HIV+ clients might be eligible for today and tomorrow • Things change! • Eligibility criteria (the short list) • Geographic residency, US citizenship, legal residency status, age, race (Native Americans), gender, previous financial contributions by client, employment, employer, preexisting medical condition, disability, employability, income, assets, HIV serostatus, CD4 count, annual or lifetime utilization of benefits, criminal convictions • Knowing how to complete the paperwork, document claims, and making sure clients follow through

33. Determination: Pieces of the Puzzle • Disability claims are taking longer than ever to be processed • Many State and federal entitlement programs have had layoffs or working with inexperienced staff • SSA HIV policies are under review • Legal services must be available to pursue claims • Front-loaded intake and assessment at entry in care, without re-determination on a regular basis • There is ineffective communication between care providers about eligibility “triggers” • Loss of employment, inpatient admission, change in clinical condition

34. Challenges to Effective Determination The Entitlement, Discretionary, and Commercial System • State and local discretion in the implementation of federal policy • Lack of coordination of eligibility criteria and other federal, State, and local policies: payer of last resort • Whose client are you? • Varying opinions about application of policies: “HRSA said” • Significant contraction of public benefits due to the economy, erosion of the tax base, competing demands, shifts in priorities • Unwillingness of the commercial sector to take responsibility • Loss of personnel in local and State government to operate the system • Culture differences between HIV care systems and entitlement and discretionary systems

35. Challenges to Effective Determination AIDS Service Organizations and HIV Clinical Providers • Tend not to maximize resources available in other systems • Assume that case managers are “handling it” • Assume somebody else will take care of determination rather than coordinating efforts • Often take a passive approach to determination and do not make the system work for clients proactively • Take 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 • Do not coordinate applications for benefits • Flood the system with completed forms to “see what sticks”

36. Challenges to Effective Determination AIDS Service Organizations and HIV Clinical Providers • Front-load the intake and assessment at entry in care and do not effectively re-determine clients on a regular basis • There is ineffective communication between care providers about eligibility “triggers” • Loss of employment, inpatient admission, change in clinical condition • Assume that clients’ disability claims should only be HIV-related • Case managers are commonly used to conduct eligibility determination • Training and retraining of case managers regarding eligibility determination is often limited • There are competing demands for their time and turn-over is growing

37. Challenges to Effective Determination The Client or Patient • Many providers assume that the client will be able to navigate the system • Assume the ability to read and complete forms • Other providers assume that the client cannot navigate the system when they can • Determination processes that rely on clients are commonly doomed • Paperwork is not the highest priority when you are trying to survive • Clients are commonly not informed that providers rely on their ability to be paid for their work • Concerns about discrimination and stigma may result in lack of complete disclosure

38. Determination: “Best” Practices • Collaboration between policymakers to establish policies and procedures that coordinate benefits • Systematic assessment of the eligibility determination processes among HIV providers • Centralize intake in EMAs or other jurisdictions • Review organizational policies and procedures to determine what is actually being done in your program to determine clients • Talk to your staff, review insurance status data, and review client records • Develop continuous quality improvement (CQI) to improve determination • Identify entitlement and discretionary programs for which there are barriers to enrollment • Document the problem and establish ongoing processes for resolution

39. Determination: “Best” Practices • Establish processes to fast track applications and to train public and commercial claim assessment staff regarding HIV disease • Routinely monitor changes in entitlement and discretionary programs that impact eligibility and adjust accordingly • Fund and employ trained eligibility determination workers • Broker roles and responsibilities among medical providers, case managers, eligibility determination workers, and legal aid providers to reduce duplication of effort and maximize enrollment • Make sure that clients receive the maximum benefit to which they are legally entitled • Communicate with clients that to continue to operate, your program must have revenue

40. On the horizon… • Deficit Reduction Act • Proof of Medicaid beneficiaries claiming U.S. citizenship: http://www.cms.hhs.gov/MedicaidEligibility/05_ProofofCitizenship.asp • Further Medicaid reforms • Immigration legislation

41. On the horizon… CARE Act Reauthorization • Track using Thomas at http://thomas.loc.gov/ • Core service requirements • 75% of Titles I, II, and III funds must be allocated to core medical services • HHS shall waive this requirement if there is no ADAP wait list and core medical services are available to all HIV+ individuals • Severity of need adjustment • Moves to three-tiered Title I funding • Eliminates “double counting” by Title I and Title II • Moves to HIV name reporting as formula funding basis

42. What is the definition of primary medical care? Primary Medical Care (HR 5009 and S2339) • Medication, prescription drugs, diagnostic tests, visits with physicians and medically credentialed health care providers, oral health, treatment for psychiatric conditions, and treatment for other health care conditions directly related to HIV/AIDS infection, and health insurance premiums, co-payments, and deductibles • Does not include case management for non-medical services or short-term transitional housing

43. What is the definition of primary medical care? S2823 • Core Medical Services Outpatient and ambulatory health services, ADAP treatments, AIDS pharmaceutical assistance, oral health care, early intervention services, health insurance premium and cost sharing assistance for low-income individuals, home health care, hospice services, home and community-based health services (except homemaker services), mental health services, substance abuse outpatient care, medical case management (including treatment adherence services) • Support Services A grantee, subject to the approval of the HHS Secretary, may provide support services • Such as respite care for individuals with HIV/AIDS, outreach services, medical transportation, nutritional counseling, linguistic services, and referral for health care and support services for individuals with HIV/AIDS • Needed to achieve medical outcomes which are related to the medical outcomes for HIV+ individuals

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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 Customized Benefit Packages Required at Least to Current Limits