Ryan White Providers and Medicaid: Preparing for 2014

June 25, 20132:30 – 4:00 pm EST

Visit Healthcare.gov• The Department of Health and

Human Services just re-launched this website on June 24, 2013.

• It contains many new tools and resources for you and your clients to understand their health care coverage options.

• Please direct your Ryan White Program colleagues and your clients to visit the site and learn more!

• Also available in Spanish at CuidadoDeSalud.gov.

• Consumers can also contact the Health Insurance Marketplace call center at 1-800-318-2596 (TTY: 1-855-889-4925)

HAB Technical Assistance Activities Focused on ACA Implementation and Ryan White

Grantees • Launched new ACA section of HAB website -

Ryan White and the Affordable Care Act: What You Need to Know - routinely update tools, policies and resources. To stay up-to-date please visit http://hab.hrsa.gov/affordablecareact/

• Launched new ACA section of HAB-funded TARGET Center TA site to link to many resources and tools developed by HHS, Ryan White grantees and stakeholders. To stay up-to date please visit https://careacttarget.org/category/topics/ health-care-reform

• Planning webinar for July to review recently issued or updated Ryan White Program policies

• Presented three Ryan White Program and ACA focused webinars to date and planning more with CMS and other partners - this one along with other two will be archived on our HAB website

• Developing a series of ACA tip sheets for Ryan White providers, grantees and clients to be issued this summer

• Working with the National Academy for State Health Policy (NASHP) to develop webinar and resources for Ryan White state based grantees

• Developing new and updating current Ryan White program policy notices to clarify issues for grantees pertaining to ACA implementation

• Drafting CAREAction newsletter on ACA for grantees and stakeholders

• HAB’s ACA webpage will soon include Frequently Asked Questions and Answers to serve as helpful TA tools and HAB will continue to update these as we approach 2014

Agenda for Today’s Webcast• Welcome and Overview – Laura Cheever, Acting Associate Administrator,

HIV/AIDS Bureau, HRSA• Welcome from CMS – Stephen Cha, Medical Director for Center for Medicaid

and CHIP Services• The Changing Landscape of the Health Care Delivery System

– Jessica Newman, Senior Program Officer, Center for Health Care Strategies (CHCS) Inc.

• Question and Answer Session• What Should Ryan White Providers Do Next?

– Maria Courogen, Director, Office of Infectious Disease, Washington State Department of Health

– Kasey Harding-Wheeler, Director of Integrated Care for Special Populations, Community Health Center Inc.

• Question and Answer Session• Concluding Remarks

www.chcs.org

The Changing Landscape of the Health Care Delivery System: Ryan White Providers and

Medicaid Managed CareHRSA/CMS Ryan White Providers and Medicaid:

Preparing for 2014 WebinarJune 25, 2013

Jessica Newman, Senior Program Officer

A non-profit health policy resource center dedicated to improving services for Americans receiving publicly financed care

► Priorities: (1) enhancing access to coverage and services; (2) advancing quality and delivery system reform; (3) integrating care for people with complex needs; and (4) building Medicaid leadership and capacity.

► Provides: technical assistance for stakeholders of publicly financed care, including states, health plans, providers, and consumer groups; and informs federal and state policymakers regarding payment and delivery system improvement.

► Funding: philanthropy and the U.S. Department of Health and Human Services.

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Setting the Stage

• In 2014, people living with HIV/AIDS (PLWH) will become eligible for insurance in significant numbers

• You are critical to keeping this vulnerable and complex population healthy with both medical and social services

• While many providers have experience working with Medicaid and health plans, many have not

• Goal for today: provide an introduction to participating in Medicaid managed care

I. Overview of the ACAII. Understanding MedicaidIII. Enrolling as a Provider in a Medicaid Health Plan

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Today’s Agenda

Federal Reform Basics: Coverage Expansions Under Health Reform• ACA provides two key vehicles for health insurance

coverage expansion:► Health insurance marketplaces, combined with premium and

cost sharing subsidies for those with income between 100-400% FPL

► Medicaid expansion for individuals under age 65 with incomes up to 138% FPL

What do the new coverage options mean for Ryan White Providers?

1. Many PLWH will be eligible for new health insurance options

2. Many PLWH will receive coverage through a health plan, either through the Marketplace or Medicaid

3. Timing is key -- Open enrollment begins October 1st

► Medicaid enrollment is ongoing

4. Your relationships with patients are critical to serving this population

5. Medicaid programs need your experience in serving this new, vulnerable population

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How will PLWH receive insurance?

Medicaid Medicare

Cover comprehensive HIV medical and support services not covered by public programs or private insurance

Cover comprehensive HIV medical and support services not covered by public programs or private insurancePLWH who remain uninsured

Employer-Based

Insurance

Health Insurance

MarketplaceOther Public

Other Private

Ryan White

Program

PLWH eligible for health coverage

Source: Adapted from The Affordable Care Act and the Ryan White HIV/AIDS Program: New Opportunities for People Living with HIV/AIDS, Presentation by: Health Resources and Services Administration and Centers for Medicare and Medicaid Services, April 5, 2013. 11

I. Overview of the ACAII. Understanding MedicaidIII. Enrolling as a Provider in a Medicaid Health Plan

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Today’s Agenda

How are Medicaid services delivered to enrollees?

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FEE-FOR-SERVICE (FFS)• The state is responsible for

provider reimbursement and rate development

• Enrollees choose doctors, hospitals, and other providers who are enrolled in the state’s Medicaid program and agree to accept the Medicaid reimbursement

• Providers are typically reimbursed for each service provided

MANAGED CARE

• The state contracts with a managed care organization (MCO) which is typically paid an amount per member per month to cover Medicaid services

• MCOs are financially “at risk” for the health care costs of their enrollees

• MCOs subcontract with doctors, hospitals, and other providers

• MCO reimburses for Medicaid services, not the state

• Creates a provider network

• Enrollees almost always are limited to receiving services from network providers

What does a managed care arrangement offer providers?

• A way to continue to serve your patients

• Payment for covered services that is generally at least as much as the State’s FFS payment

• Published provider network directory and enrollee services team to help members locate providers (because enrollees must choose from within the network, you will become a “go-to” provider)

• Provider services staff and/or hotline to answer questions and resolve billing and other problems

• Training on claims submission, medical record keeping, medical management, and other key policies and systems

• Help with enrollee patient care coordination through PCP and the plan’s care management and outreach staff

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What does a managed care arrangement offer enrollees?

• Improved access to care through a guaranteed provider network for all Medicaid services

► Enrolled services staff and a provider directory to help enrollees identify providers

• A primary care provider to coordinate and manage care

• Additional care management activities to coordinate improved care

• Enrollee rights to grievances, appeals, and fair hearings to complaints and service authorizations

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I. Overview of the ACAII. Understanding MedicaidIII. Enrolling as a Provider in a Medicaid Health Plan

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Today’s Agenda

Enrolling in a Medicaid Health Plan

1. Identify and contact Medicaid health plans2. Understand the contract3. Prepare for provider credentialing4. Understand provider networks5. Learn how to submit claims on standard insurance

forms (CMS 1500)6. Understand medical management7. Understand member benefits and eligibility

For each of these steps, you will need to (1) prepare for associated IT/systems requirements, staffing and training needs and (2) familiarize yourself with the associated health plan resources.

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For each of these steps, you will need to (1) prepare for associated IT/systems requirements, staffing and training needs and (2) familiarize yourself with the

associated health plan resources

Identify and contact Medicaid health plans

►Your state will contract with at least one Medicaid health plan on a statewide or regional basis

►Your state Medicaid website or staff can help you identify the Medicaid health plans: www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

►

Who are the Medicaid health plans in my state?

Who should I contact at the Medicaid health plan?►Each plan will have a provider contracting or provider services

department that can help you prepare to participate in the provider network►In anticipation of the changes in 2014, plans likely will offer orientation

and training for providers►Health plan staff, structure, and requirements will vary by health plan;

prepare to learn about and interface with multiple plans

Provider credentialing

►Valid license to practice medicine or provide services, when applicable; ►Valid Drug Enforcement Administration (DEA) and state prescriber’s

license/certificate, when applicable, by specialty; ►Complete and accurate work history; ►Other education or training, as applicable, by specialty; and►Malpractice, loss of license, or limitations of privileges, when applicable.

What will I need to meet provider credentialing requirements?

How do I prepare?►Understand credentialing requirements; allow time for approval – the

credentialing process can take several months►Most health plan websites have their provider applications and

instructions available►Contact health plan provider services staff

Provider networks

►Enrollees select a primary care physician (PCP)►The PCP coordinates care for enrollees, establish and maintains medical

records, ensures access to care, provides referrals for specialty care►Some plans may allow you to be a PCP for PLWH; others may classify

you as a specialist►In some health plan networks, enrollees must receive a referral from

their PCP to see a specialist. In other networks, enrollees can self-refer. You must understand the protocols for each plan; rendering services as a specialists without a PCP referral will result in non-payment of your claim

►Specialists are expected to send status reports back to the PCP to enable the PCP to properly coordinate and monitor the enrollee’s care

What are the responsibilities of PCPs and specialists?

Provider networks, cont

How do I prepare?

►Review existing IT capabilities: medical records system►Assign, train, or hire staff: Prepare staff to maintain medical

records, coordinate reports back to PCP as needed►Health plan resources: Provider services staff

Health plan billing and reimbursement

►Plans reimburse providers based on the terms of the contract

Some pay a fee for each covered services (known as fee-for-service reimbursement), others pay a fee for a bundle of services

The exact payment structure and rates must be clearly spelled out in the contract so that all parties understand them

► You will need to submit a claim (likely electronically) with required fields

Many providers use billing services or clearing houses to do this►Claims must be submitted in a timely fashion and will be

approved by the health planThe time limit will be spelled out in the contractFailure to submit within this timeframe will result in denial of the claim

How will I be paid for services?

Health plan billing and reimbursement, cont

How do I prepare?

►Review existing IT capabilities: internal billing system; ability to transmit claims securely; ability to receive payment

►Many health plans pay claims using electronic funds transfer (EFT). EFT is safer and much faster than paper checks. Review your accounting practices to ensure readiness.

►Assign, train, or hire staff: Billing staff; accounting staff; IT systems staff or contractor

►Health plan resources: Test claims submission; provider services representative; health plan training opportunities; provider manual

Medical management: prior authorization

►For some services, providers must request prior authorization to ensure that care is provided in the most appropriate care setting for enrollees

►Each health plan will provide more information on which services require prior authorization, as well as the process for making the request and timeline for getting responses

►If required, prior authorization must be obtained before services are rendered except in emergencies

Check the provider manual and/or contract for emergency services notification protocol

►PA must be received for reimbursement; failure to obtain prior authorization will result in an automatic denial of the claim

What is prior authorization?

Medical management: prior authorization, cont

How do I prepare?►Assign, train, or hire staff: Train clinicians to educate

enrollees; implement practice policy to ensure that PA guidelines from the plans you are contracted with are followed

►Health plan resources: Medical management staff; provider manual/contract

Medical management: care management

►Care management coordinates enrollee’s care, including physical, behavioral, and often supportive services

Care management can assist in navigating the health care system and identifying needed services; removing barriers to seeking care (e.g., transportation, interpretive services); education around specific diseases

►Providers can refer enrollees that would benefit from additional care management services to the health plan; enrollees are also identified by claims data and other sources

What is care management?

How do I prepare?►Assign, train, or hire staff: Train staff to understand the needs of your

enrollees; learn the process for referring enrollees to care management ►Health plan resources: Understand care management and coordination

resources; medical management staff

Enrollee services

►Enrollees may be enrolled in more than one Medicaid health plan, depending on how the state covers services

It is common to have one health plan for physical and acute services and another for behavioral health services

Other services or benefits (e.g., prescription drugs) may be paid for directly by the state

►Enrollees are eligible for certain covered services under Medicaid Some health plans provide additional services to their enrollees that would not

otherwise be covered by Medicaid►Some services may require PA or may be limited, such as prescription

drugs ►Providers should verify that services are covered to ensure that a

submitted claim will be paid

What services can I provide?

Enrollee services, cont

How do I prepare?►Assign, train, or hire staff: Train staff to verify covered

services on a regular basis; understand whether physical and behavioral health services are covered by different health plans and how you can coordinate

►Health plan resources: Online coverage summary; medical management staff

Enrollee eligibility

►Enrollees must be enrolled in the health plan in order for the plan to pay for services

►Providers should verify eligibility at each visit to ensure the enrollee is eligible and enrolled with the same health plan

►If you are enrolled as a PCP, check that the enrollee is assigned to you►Some patients may be required to pay a small co-pay

Who can I provide services to?

How do I prepare?►Review existing IT capabilities: Electronic health record; billing system ►Assign, train, or hire staff: Front office staff to verify eligibility/collect co-

pay (if applicable) ►Know the process for verifying eligibility with both the State and the plan

►Health plan resources: Online or telephonic member eligibility verification

Next steps

Connect with your Medicaid health plans

Identify areas for IT systems changes or upgrades that will need to be made

Review existing staffing structure to determine training and hiring opportunities; consider where contractors may be beneficial

Investigate resources for claims clearinghouses, billing management services, as appropriate

Look for training, technical assistance, or other educational opportunities from your state, provider associations, and health plans; learn from your peers

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Questions

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Questions?

The Affordable Care Act - Planning for 2014

Preparing the Ryan White Care System for Affordable Care Act Implementation

in Washington State

HRSA/CMS WebinarJune 25, 2013

Maria Courogen, MPHWashington State Department of Health

The Affordable Care Act - Planning for 2014

Every State Is Different…

• Generous state funding for people with HIV• Early Intervention Program has history of buying insurance• Medicaid located in a different state agency• Medicaid Expansion = yes• State-operated Health Benefits Exchange• Successful partnerships

Countdown to 2014 Task List

Countdown to 2014 Task List

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Understanding the client mix

MedicaidExpansion

Health BenefitsExchange Medicare Undocumented

33% 26% 36% 5%

Countdown to 2014 Task List

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Eligibility alignment

• Asset limitation• Income determination• Definition of family• Mandatory Marketplace application for clients

in first two buckets

Countdown to 2014 Task List

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Continuity of operations

• Role of Targeted Case Management• Medical Case Management standards for

health homes• Data sharing• Payment of client premiums in the Exchange• Review and selection of insurance policies

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Preparing providers

• Program formulary and list of primary providers sent to Health Care Authority for comparison

• Work with AIDS Education and Training Center• Follow up with current program providers• ACA information in quarterly update• Webinars

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Preparing case managers

• Incorporation of ACA information in training• Addition of funds to contracts for outreach,

non-medical case management• Navigator training• Lists of clients and expected “buckets”• Review of ACA in fall field visits• Webinars

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Preparing clients

• Provide general information about ACA (include importance of filing taxes)

• Add information about program-specific impacts to Web, client correspondence

• Send client-specific correspondence about expected “bucket”

• Town hall meetings (with HIV Prevention)• Webinars

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Goal

• By March 31, 2014, all program clients will have applied for benefits through the Exchange portal.

MedicaidExpansion

Health Benefit Exchange

Medicare Undocumented people

Contact Info

Maria Courogen, MPHWashington State Department of Health

360-236-3458Maria.Courogen@DOH.WA.GOV

Preparing for January 2014

Kasey Harding-Wheeler, Director of Integrated Care for Special Populations,Community Health Center, Inc.

• RW Consumers who were previously not eligible for Medicaid may be able to reapply with the new guidelines for eligibility.• RW Consumers who were previously not eligible for private insurance because of a pre-existing condition are now eligible.• Insurance premiums are federally regulated to avoid prohibitively high costs to consumers.• The CT Insurance Exchange provides consumers with an opportunity to shop for private insurance plans at reasonable costs. • ACA navigators and other special resources are available at FQHC’s and other agencies to assist consumers who need help in acquiring the appropriate level of coverage. • Federal tax credits may be available for consumers who qualify.• Federal tax penalties will be imposed to uninsured individuals.

What does the Affordable Care Act have to do with Ryan White Consumers?

ACA Implementation Plan for Ryan White Part C

ACA Implementation PlanObjective Key Action Steps Staff

ResponsibleTimeline Tools/Comments

Staff Education 1. Provide staff trainings via videoconferencing 2. Provide resources for staff to obtain independent

education about ACA and the effects on RW patients.3. Review level of staff education and understanding at

weekly staff meetings4. Review Access Health CT application, process and

paperwork requirements for familiarity5. Review RW specific ACA implementation during Project

ECHO weekly sessions as needed.

Director of RW March 2013 – on-going

List of websites

Marketing Tools 1. Develop marketing tools in top three languages at literacy level of 4th grade

2. Develop FAQ sheets which will explain the basic talking points for RW consumers.

3. Prepare flyers, pamphlets and other resources for exam rooms.

4. Post hotline information in exam and waiting rooms.

RW QI TeamCHC Public Relations Dept.CHC IT Dept.

March 2013July 2013

HRSA websiteKF resourcesAccess Health CT

Implementation Plan ContinuedConsumer Participation

1. Meet with RW CAB in open meeting (all consumers invited)

2. Provide CAB with focus group questions designed to request suggestions for direction of implementation of ACA for RW consumers

3. Provide opportunities for CAB to participate in consumer education

4. Request CAB assistance in word of mouth positive campaign regarding implementation and the services available to RW consumers at CHC

RW Director, MCM to facilitate

Feb, March, April CAB meetings

Questionnaire sampleTranscript of feedback

Consumer Education

1. Provide 2 education sessions for consumers to allow for face to face Q&A

2. Utilize Marketing tools in mailings which will occur twice before October 2013.

3. Staff RW ACA hotline4. Utilize suggestions from CAB about keeping messages

positive, reducing fears about paperwork, and assuring patients of active participation from RW staff.

RW DirectorCAB

May 2013, July 2013Open on 9/1/13

Provide staff with resources to answer hotline

Implementation Plan ContinuedApplications 1. Review applications pending at weekly staff

meetings2. Review consumers not complying with

updated information and application process3. Include case review of uninsured patients in

weekly provider meetings. 4. Utilize CHC Access to Care department for

assistance.5. Update CAB on patient response on a

monthly basis.

RW staffRW ProvidersRW Project ECHO participants

October 2013

Data 1. Review data on a monthly basis to ensure that all RW patients are being reached.

2. Review data monthly on specific two groups – uninsured and newly eligible for Medicaid based on new guidelines.

3. Record number of calls coming into hotline.

RW DirectorRW staffCHC data

October 2013Monthly

Provide data to RW QI Committee and RW CAB.

Community 1. Review data and concerns with Community Care teams including Interdisciplinary meetings on a monthly basis.

RW DirectorRW MCM

October 2013Monthly

Agenda item

Understanding changes in State Medicaid System

• It is critical that you join the state conversation about Medicaid including; applications, eligibility, accountability, documentation.

• Apply for federal and state grants and funding that will allow you to put support staff in place (patient navigators, case managers) to manage changes in Medicaid eligibility and enrollment of new Medicaid participants.

• Become familiar with the technology used by your state to file Medicaid applications and enroll new clients without delay.

• Be involved in discussions around timelines for enrollment of new clients.

Understanding changes in State Medicaid System

• Attend state, regional and local trainings on changes to Medicaid – if you can’t send all of your integral staff than send one person who is responsible for reporting back.

• Keep an updated list of community resources as they are announced:– libraries that are going to have dedicated computers for Insurance Exchange – community service providers who receive grant funding specific to Medicaid/ACA– state hotlines, new satellite offices opening, DSS office changes

• You will be inundated with information later so start keeping up with important resources now.

• Put yourself on email lists for DSS, DPH and other state and local municipalities to ensure timely updates and dates for meetings and education.

• Be sure that you are on the Essential Community Provider Listing in your state and make sure that all information is correct and updated.

Essential Community Providers• Changes in Medicaid eligibility are an important part of consumer and staff education.

Have all staff become very familiar with Eligibility Screening tools on the Insurance Exchange Website.

• If you are not in the database for Essential Community Providers you may need to work with your state to ensure that the “write in" option is fully implemented.

• Start changing all RW paperwork now to include updated Medicaid eligibility information, proof of income documentation requirements, new services you provide and community resources.

• Change policies and procedures around outreach to include provisions for education and enrollment in Medicaid and Insurance wherever possible.

• Take advantage of on line opportunities to educate staff – HRSA/RW webinars, videos etc.

• Check your state insurance exchange on a daily basis for updates.

Hints from the CAB

Answer

questions

honestly!

Don’t be afraid to say “I don’t know”.

Be patient with consumers!

Be Patient with staff!

Keep it SimpleHIV patients experience fear and stigma all the time – new

forms and policies can be scary. Don’t make us feel crazy

because of our feelings!

Try resources yourself

before telling us they

are easy!

Getting StartedGet help from your Consumer Advisory Board or plan a consumer focus group.

Provide Education

Ask about fears, concerns, and

questions

Ask for suggestions for

raising awareness, educating patients

and moving forward.

Make Consumer Education and Input on-going

Things to consider in developing marketing strategies

Do Don’t

Create useful marketing tools for consumers.

Reinvent the wheel – utilize tools that have already been developed and tailor them to your own population.

Pay close attention to literacy level and cultural sensitivity of marketing tools.

Assume public service announcements and radio ads are reaching consumers – start from zero!

Use the easiest and most recognizable names for things. ACA – VS – Healthcare Reform Bill

Use lots of acronyms, political terms or confusing language.

Give resources for questions/concerns. Give resources that you have not vetted yourself.

Send a positive message with your language and demeanor.

Encourage fear, frustration or confusion and DON’T let your personal views interfere with disseminating accurate and unbiased information.

What do you know about the Affordable Care Act? What have you heard from family and friends about the ACA? How do you think the ACA will affect you and other people with HIV/AIDS? What are some of your concerns about the ACA? What resources do you wish were available to help you better understand the ACA? Are there resources already in place that you have found helpful? What can you tell me about the CT Insurance Exchange? After looking over the Access CT Application for insurance what are your thoughts about it? What kind of assistance do you think people will need in getting applications done? Did you have any questions about the website or the application? Now that you know a little bit more about the ACA and the resources available do you have additional concerns?

Example of helpful consumer focus group queries

A reasonably formal letter with deadlines A fact sheet Graphics Brochures from government agencies Voice Messages Replicas of the website for the Insurance Exchange Sample of documentation need for applications. Videos – very popular with CAB Incentives for attending education sessions Accountability for leadership with other consumers Peer Education opportunities Drop in periods for Q&A about ACA Phone hotlines Community Resource Sheets Frequently Asked Questions

Different methods of educating consumers

Useful Resources

• www.HealthCare.gov

• www.acscan.org/content/affordable-care-actanimation/

• www.accesshealthct.com

Contact Info

Kasey Harding-Wheeler, Director of Integrated Care for Special

Populations, Community Health Center, Inc.860-347-6971 (x3914)HardinK@chc1.com

Questions

Questions?