EFFECTIVE ELIGIBILITY DETERMINATION IN THE CARE ACT AND OTHER SYSTEMS A Workshop Funded by the Suburban Maryland Title I Program

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EFFECTIVE ELIGIBILITY DETERMINATION IN THECARE
ACT AND OTHER SYSTEMSA Workshop Funded by the
Suburban Maryland Title I Program
Julia Hidalgo, ScD, MSW, MPHPositive
Outcomes, Inc. Harwood MDwww.positiveoutcomes.ne
tjulia.hidalgo_at_positiveoutcomes.net
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Ground Rules

• I do not represent DHMH, HAB, or CMS
• 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!

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Why conduct eligibility determination (ED) for
HIV clients?

• Ensure clients receive the optimal benefits that
  they are legally eligible
• Ensure access to health care and medications
  through enrollment in MADAP, MAIAP, or other
  public programs
• Through enrollment in commercial insurance,
  ensure access to a full range of health care
  benefits not commonly covered by the CARE Act
• Ensure income maintenance through disability
  income and other income maintenance programs
• Ensure that HIV clinics and other health care
  providers are compensated for their services
• Adhere to federal Ryan White CARE Act
  requirements
• Now referred to as the Ryan White HIV/AIDS
  Treatment Modernization Act of 2006

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CARE Act Payer of Last Resort Policies

• The CARE Act is the payer of last resort (PLR)
• Grantees and subgrantees (i.e., contractors) must
  ensure that clients meet eligibility criteria for
  CARE Act services
• Including MADAP, MAIAP, and direct services
• CARE Act grantees and subgrantees must ensure
  that alternate payment sources are pursued before
  providing CARE Act-funded services
• Grantees must establish and monitor procedures to
  ensure that their subgrantees verify and document
  client eligibility

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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, 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 PLR
• Including coordination with the VA
• These and other HAB requirements are subject to
  audit

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DC Metro Area Title I Eligibility Criteria

• Be a resident of the jurisdiction funding the
  services to be provided
• Be HIV or have been diagnosed for AIDS or
  HIV-related illness by a primary medical
  practitioner
• A completed Medicaid application and documented
  submission date for all clients with incomes
  below the federal poverty level (FPL) and T-cell
  below 200 is required when providing Medicaid
  reimbursable services
• What does this mean?

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Which DC Metro Area Title I agencies are
responsible for eligibility determination (ED)?

• The Title I Request for Proposals (RFP) states
  that Title I case management agencies are
  responsible for ED
• Care coordination is that element of case
  management that is focused on arranging and
  scheduling coordination for the various service
  elements a client may require, and for
  eligibility determination, including
  determination of income eligibility and last
  resort requirements

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Which DC Metro Area Title I agencies are
responsible for eligibility determination (ED)?

• Title I-funded case management agencies must
  ensure case managers or care coordination staff
• Provide counseling and assistance to ensure
  eligible clients receive entitlements
• Screen clients for all third party payer sources
  including, but not limited to, Medicaid,
  Medicare, MADAP, and private insurance
• Complete and submit Medicaid applications for
  eligible clients, follow up on the application,
  and initiate third-party retroactive collections
  for the cost of care paid by Title I while
  awaiting Medicaid determination
• Re-determine eligibility every six months
• Document the status of Medicaid, Medicare, and
  MADAP applications for all Title I-eligible
  clients

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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

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Medicaid Eligibility For HIV/AIDS Beneficiaries
Assistance Category Eligibility Criteria Mandatory/Optional
Supplemental Security Income (SSI) Severely disabled, unemployable, low-income Mandatory
Parents, pregnant women, children Low income, with income and asset criteria vary by assistance category and State Mandatory, States may offer higher income threshold
Medically needy Severely disabled and low income (median56 of FPL) after subtracting medical expenses Optional, 35 States use this option for disabled individuals
Workers with disabilities Severely disabled, low-income, for persons returning to the workforce Optional
Poverty level expansion Allows for income above SSI levels up to the FPL Optional, 19 States use this option
State Supplemental Payment (SSP) Allows for coverage of beneficiaries receiving SSP Optional, 21 States use this option
Adapted from Kaiser Family Foundation HAB
presentation
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Medicaid and HIV/AIDS

• Substantial state variability in the acceptance
  rates of SSI applications from HIV individuals
• Initial denial rates tend to be very high in most
  states
• Social Security Administration (SSA) delegates
  the review of SSI applications to the MD State
  Department of Education Division of
  Rehabilitation Services, Disability Determination
  Services (DDS)
• 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
• What has been your HIV clients experience
  applying and enrolling in Maryland Medicaid?

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Medicare Eligibility For HIV/AIDS Beneficiaries
Assistance Category Eligibility Criteria
Individuals age 65 years or older Sufficient number of work credits to quality for Social Security payments
Individuals under 65 years of age Sufficient number of work credits to quality for Social Security Disability Income (SSDI) payments due to disability also includes spouses and adults disabled since childhood Have been receiving SSDI payments for at least 24 months
Individuals with end-stage renal disease, any age Sufficient number of work credits to qualify for Social Security payments

• Medicare Part D Enrollment
• Year 1 implementation was challenging
• HIV Medicare beneficiaries continue to express
  challenges in comparing plans
• What has been your HIV clients experience with
  Medicare Part D?

Adapted from Kaiser Family Foundation HAB
presentation
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Commercial Insurance

• Coverage is primarily through group benefits via
  employers or association membership
• Individual coverage can be purchased through
  carriers
• 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

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Commercial Insurance

• 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
• Case managers should not facilitate dual
  enrollment in CARE Act-funded programs to address
  these concerns
• It is 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

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What is HABs 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
  help them to navigate HIV care
• Even if enrolled in the VA, a veteran does not
  have to use the VA as their exclusive health care
  provider

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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

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QUICK QUIZ1. Identify Maryland-funded programs
in which HIV indigent clients obtain coverage
for HIVmedical care and medications2. Identify
three publicly-funded programs in which HIV
indigent clients obtain income support3.
Identify two publicly-funded housing assistance
programs
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MD HIV Program Eligibility Criteria
House-hold Size Federal Poverty Level (As of 01/01/07) MD Primary Adult Care (PAC) Program (As of 07/01/06) MADAP and MADAP Plus (As of 02/07) MAIAP (As of 02/01/07) Title II CARE Act (As of 01/01/07)
1 10,210 11,376 51,050 30,630 40,840
2 13,690 13,200 68,450 41,070 54,760
3 17,170 16,600 85,850 51,510 68,680
4 20,650 20,000 103,250 61,950 82,600
5 24,130 23,400 120,650 72,390 96,520
6 27,610 26,800 138,050 82,830 110,440
7 31,090 30,200 155,450 93,270 124,360
8 34,570 33,600 172,850 103,710 138,260
Asset   4,000 per person 4,000 per person 10,000 per person 10,000 per person
Limits   6,000 per couple 6,000 per couple or couple or couple
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MD HIV Program Eligibility Criteria
MD PAC Program MADAP and MADAP Plus MAIAP Title II CARE Act HOPWA
HIV HIV MD resident Meet income guidelines HIV MD resident Be enrolled in a health insurance plan Meet income and asset guidelines Be unable to work due to HIV infection HIV MD resident Uninsured / underinsured HIV Resident of HOPWA service area Income at or below 80 of average income in county of residence
What challenges have your HIV clients
experienced enrolling in these programs?
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HOPWA MD County-Specific Income Criteria
County Median Income 80 of Median Income
Charles 62,199 49,759
Frederick 60,276 48,220
Montgomery 71,551 57,241
Prince George's 55,256 44,205
St. Mary's 54,706 43,765
Based on average family size of approximately two. Based on average family size of approximately two. Based on average family size of approximately two.
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Eligibility for Other Publicly Funded Services

• Under the CARE Act PLR policy, if a client is
  eligible for services through other publicly
  funded services they should be referred to those
  services before CARE Act-funded services should
  be provided
• Examples include
• Substance abuse treatment services
• Mental health services
• Food/pantry services
• Transportation
• Utilities assistance
• What challenges have your HIV clients
  experienced enrolling in these programs?

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QUICK QUIZ TRUE OR FALSE1. Physicians and
other clinicians can help HIV patients to enroll
in Medicaid2. The reception staff at HIV clinics
can assist in periodic re-determination of health
insurance coverage3. Re-determination should
only be done once per year4. I am very familiar
with eligibility requirements for MD Medicaid,
MADAP, and MAIAP
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Partners In Eligibility Determination (ED)

• Direct service agency managers and HIV program
  directors

• Case managers or other ED staff
• Physicians documenting disability
• Reception staff
• Other payers and other systems
• Legal advocacy programs

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Role of HIV Program Directors and Case
Management Supervisors

• Link with HIV clinics to obtaining documentation
  of clients HIV serostatus documentation
• Case managers working in clinics must document
  HIV serostatus in your clients case management
  charts
• Use standardized forms and train personnel to use
  them
• Ensure forms are linguistically appropriate to
  the subpopulations served
• Address the varied literacy level of clients
• Clearly identify expectations to case managers
  regarding chart documentation
• Require tax returns or credit checks to document
  income, assets, and employment

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Role of HIV Program Directors and Case
Management Supervisors

• 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
• Reflect the availability of state and local
  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 continuous quality improvement (CQI) to
  improve ED
• Train and retrain ED staff and test their
  knowledge periodically
• Use trained and experienced supervisors

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Role of HIV Program Directors and Case
Management Supervisors

• Systematically assess the ED processes by
  applying performance standards and auditing
  charts
• Use benchmark data to compare the performance of
  ED staff
• Do not assume that your programs 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
• 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
• How do supervisors in your agency monitor ED
  functions of your HIV case managers?

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Role of HIV Program Directors and Case
Management Supervisors

• Routinely monitor changes in entitlement and
  discretionary programs that impact eligibility
  and adjust accordingly
• Changes to major payers in your community should
  be rapidly communicated to ED workers
• Meet with county DSS staff to become familiar
  with their processes, get on the list for program
  announcements, and ask if your staff can
  participate in training
• Do not assume another agency will take care of ED
  unless that explicit role is assigned to them
• 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

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Role of HIV Program Directors and Case
Management Supervisors

• 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 may 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 disability
  determination staff regarding HIV disease
• Are there other actions your HIV program director
  or supervisor can do to help you do ED?

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Strategies For HIV Programs

• Receptionists should ask ALL clients at EACH
  visit for a copy of their health insurance card,
  including Medicare Part D enrollment card
• Any changes should be reported to the case
  management staff
• 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
• Scheduling staff should confirm through the
  online Medicaid system that the client is newly
  or still enrolled
• Confirm Medicaid enrollment the day before the
  clients appointment
• What if our agency is not a Medicaid provider?
• Copies of new health insurance cards should be
  made and filed in the clients chart

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Effective Strategies Used By ED Staff

• 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
• 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
• Knowing how to complete the paperwork, document
  claims, and making sure clients follow through
  are the keys to success

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Effective Strategies Used By ED Staff

• 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
• 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 clients to prepare valid,
  accurate applications for benefits
• Partner with legal aid staff to prepare well
  documented applications and address
  discrimination issues
• What other strategies do you use?

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Effective Strategies In Working With Clients

• Communicate with clients that to continue to
  operate, your program must have revenue
• Avoid the attitude dont ask, dont 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
• What other strategies do you use?