Impact of CMS and HRSA Policies on CARE Act Grantees and Subgrantees: A Florida Case Study

1. 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

2. 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

3. Background

4. 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

5. 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 FL TA and Training Initiative      

6. 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

7. 105 organizations participated in the Initiative

8. MEDC Evaluation Responses

9. TPR Evaluation Responses

10. Slide sets available at: www.positiveoutcomes.net

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Required for sufficiency Hospital outpatient services Durable medical equipment Home health care Prescription drugs Required to be offered, but amount, scope and duration are flexible Chiropractic care Podiatry Outpatient therapy New 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 Additional Required or New Benefits

19. Medicaid Reform Plans And Networks: Broward & Duval

20. How will impact of Medicaid reform on HIV+ enrollees? • 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

21. Proposed Per Member Per Month Capitated AIDS, HIV, TANF and SSI Rates: Duval and Broward * Rate for TANF female enrollees

22. 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

23. 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

24. 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