Medi-Cal Reimbursement for Prisons and Jails California/Nevada Chapter of the American Correctional Health Services Association: Multidisciplinary Correctional Conference

1
Medi-Cal Reimbursement for Prisons and
JailsCalifornia/Nevada Chapter of the American
Correctional Health Services Association
Multidisciplinary Correctional Conference

• November 3, 2011
• Brenda G. Klütz
• Senior Consultant
• Health Management Associates

2
Learning Objectives

• Understand current Medi-Cal reimbursement
  opportunities for inmate inpatient stays
• Understand the how the key elements of healthcare
  reform effect payment for inmate, parolee and
  probationers health now in 2014

3
Health Management Associates

• Public health policy and management consulting
  firm, 12 offices
• Focus on Medicaid, uninsured, public health care
  programs and systems, health care reform, access
  and quality
• Clients
• County health systems and jails, prison systems
• Medicaid agencies, managed care, county
  governments, professional associations, hospitals
  and health systems, insurers, foundations

4
Todays Medicaid The Basics
5
Medicaid Eligibility

• Eligibility is based largely on
• Income
• Assets
• Age (under 21 and over 64)
• Families with children
• Disability

6
Medicaid Eligibility

• Low-income, childless adults between the ages of
  21 through 64 are generally not eligible for
  Medicaid, unless they have a disability.

7
Advantages of Medicaid Funding

• State Medicaid expenditures are matched by
  Federal funds amount of match is the Federal
  Medical Assistance Percentage (FMAP)

8
Advantages of Medicaid Funding

• The FMAP formula is a states per capita income
  relative to U.S. per capita income higher match
  to states with lower incomes (with a maximum of
  83) lower match to states with higher incomes
  (minimum of 50).

9
Advantage of Medicaid Funding

• Californias FMAP is 50
• Nevadas FMAP is 51.63 (2011)

10
Medicaid and Inmate Health Care What will
Medicaid Pay for?
11
Medicaid and Inmates The Facts

• Medicaid does not provide matching funds for
  services provided to incarcerated persons
• However, an inmate who spends 24 hours or more in
  a medical institution is not considered to be
  incarcerated during that time, even though still
  in custody

12
Medicaid and Inmates The Facts

• Medical institution hospital or skilled
  nursing facility not operated by the corrections
  organization, serves the general public
• (See Appendix A B of Handout)

13
Medicaid and Inmates The Facts

• CMS will provide matching funds for inpatient
  services provided in a hospital that has a locked
  correctional unit, as long as the overall
  hospital serves the general public. (See Appendix
  C)

14
Medicaid and Inmates The Facts

• Federal Medicaid rules allow payment for certain
  inpatient services provided to inmates who are
  eligible enrolled in Medicaid.
• CMS has made clear, that federal law does not
  require states to dis-enroll inmates from
  Medicaid, but the state may only claim federal
  matching funds for certain services. (See
  Appendix B)

15
Medicaid and Inmates The Facts

• Many states dis-enroll Medicaid beneficiaries
  upon incarceration.
• States may not have a process to enroll inmates
  in Medicaid if they become eligible while in
  prison or jail
• State laws, regulations or policies may prohibit
  continued enrollment

16
Advantages of Medicaid Eligibility and Enrollment

• If state laws permit, prisons and jails can claim
  federal matching funds for some health care
  services provided to eligible inmates that are
  now paid for by 100 state general fund
• Ensuring eligibility prior to release can ensure
  more seamless health care

17
What Other States are Doing

• At least nine other states have been claiming
  federal matching funds for the cost of inpatient
  stays for eligible inmates
• Some started in the late 1990s
• At least 5 other states have new laws or are
  proposing laws to permit

18
Health Care Reform How might it affect inmates?
19
Key Provisions of the Patient Protection and
Affordable Care Act

• Insurance Market Reforms in All States
• Delivery System Redesign
• Payment models
• Primary care workforce initiatives
• Coverage Expansions
• Health Insurance Exchanges
• Medicaid Expansions

20
Health Care Reform

• Effective 1/1/2014
• Asset, age and disability criteria for Medicaid
  eligibility will be eliminated
• Individuals with incomes of up to 133 FPL will
  be eligible for Medi-Cal

21
Health Care Reform

• Individuals with income from 134 up to 200 FPL
  will be eligible for coverage through CA Health
  Benefit Exchange
• Low income (up to 133 FPL), childless adults
  between the ages of 21 through 64 will be
  eligible for some Medicaid coverage. (majority of
  prison and jail population)

22
Health Care Reform

• In 2014, federal match for new enrollees will be
  100
• Year Two the match will be 90 federal funds

23
Planning for 2014 Californias Approach
24
Californias Bridge to Reform

• By 1/1/2014, approximately 851,000
  currently-uninsured Californians will be eligible
  for Medi-Cal.

25
Californias Bridge to Reform

• Created a Medicaid waiver option for counties to
  participate in a Medicaid expansion program Low
  Income Health Program (LIHP)
• Covers childless adults age 21 through 64, with
  income levels of up to 133 FPL and 200 FPL

26
Californias Bridge to Reform

• Starts to provide Medi-Cal-like coverage for
  low-income childless adults prior to health care
  reforms full implementation
• Builds the provider network capacity to prepare
  for 1/1/2014

27
California Law Change in 2010

• California regulations previously required
  counties to dis-enroll Medi-Cal beneficiaries
  upon incarceration

28
California Law Change in 2010

• California law now mandates counties to enroll
  state prison inmates in LIHP
• Gives counties the option to enroll inmates
  county jails to enroll in the LIHP or in the
  Medi-Cal program
• Law is silent about city jails.
• (See Appendix D of Handout)

29
Which Inmates TODAY are eligible (CA)?

• State Medicaid income asset guidelines AND
• Categorical Eligibility
• Pregnant women
• Inmateslt age 21
• Inmates age 65gt
• Disabled for at least 12 months
• Most relevant to prisons, but jails often have
  isolated very costly cases

30
Will it Last?

• According the Centers for Medicare and Medicaid,
  Medicaid Disabled and Elderly Programs
• There is no plan to rescind FFP for inmate
  inpatient care
• Medicaid eligibility for inmates offers important
  opportunities for continuity of care for chronic
  conditions, mental illness

31
Challenges and Opportunities
32
Medicaid as Payment in Full

• Federal rule prohibit providers participating in
  Medicaid to balance-bill patients or providers
• For some prisons and jails, provider payment
  levels are in statute and exceed Medicaid rates
• Some prisons and jails have negotiated contract
  rates with providers that exceed Medicaid rates

33
Medicaid as Payer of Last Resort

• Hospitals may challenge Medicaid payment because
  they perceive prison, jail, or vendor as
  insurance coverage.
• Key distinction between insurance and a
  correctional organizations constitutional
  obligation as custodian to avoid deliberate
  indifference and cruel or unusual treatment.

34
Alternatives

• Hospital bills Medicaid for admission, accepts
  payment prison/jail makes periodic patch
  payment to provider
• Prison/jail consolidates admissions to specific
  hospitals to gain volume and cooperation

35
Implementation Issues Hospitals

• Is Medicaid payment acceptable?
• Enrollment/eligibility process who does it? (In
  California, it is the counties)
• Does hospital bill Medicaid?
• Is payment significantly delayed?

36
Implementation Issues Inmates

• Freedom of Choice issue
• Inmate doesnt want to enroll/sign Medicaid
  application
• Documents not available
• Birth certificate
• Tax statements
• Bank statements

37
Implementation Issues Jails

• Difficult to change state law individually
• May require additional resources, or
  administrative systems changes
• In California, county jails should be working
  with the county health or social services
  department

38
Prisons

• May require new resources
• May require tracking system for claims, high-cost
  inmates, eligibility status, redetermination
  dates

39
Implementation Issues Medicaid

• Suspended eligibility
• Requires new resources (but 50 federal match)
• How is federal match tracked and traded?
• Many other competing priorities related to health
  care reform

40
Implementation

• Extremely complex and varies enormously by state
  Medicaid program
• May begin with workgroup that includes Medicaid
  and the agency that decides eligibility
• May work on jails and prisons simultaneously
• Most programs start by manually processing a few
  high-cost cases

41
Other Opportunities

• Create information for inmates under age 26 about
  coverage on parents insurance plan
• Assist eligible inmates with serious health needs
  to enroll prior to release

42
Get Moving Toward 2014

• Work with community stakeholders to develop
• Streamlined discharge planning
• Common prescription drug formulary
• Continuity of care
• Targeted Case Management Programs
• Develop inmate education materials

43
Discussion
44
For more information contact

• Brenda Klutz, Senior Consultant
• Health Management Associates916.446.4601, ext.
  424bklutz_at_healthmanagement.com