is disability a “leaky ucket” in your eligibility program?

Is Disability A “Leaky Bucket” In Your Eligibility Program?

Florida HFMA WebinarJuly 24, 2019

Outline

1. Discussion of Uncompensated Care2. Eligibility Programs3. Medicaid Eligibility How “Disability” is

Different4. SSI vs. SSDI5. Reasons Why Disability is Problematic6. Roadblocks to Disability Awards7. What Hospitals Can Do To Plug the “Leaky

Bucket”

A discussion of uncompensated care

Uncompensated Care =Bad Debt + Financial Assistance

First, a discussion of uncompensated care

Uncompensated Care:Bad Debt + Financial Assistance Services for which hospital anticipated but did NOT receive payment (insured)______________________Deductible, Co-Pay, Out-of-Network, Payer Denials_______________________Can afford insurance

_______________________Solution: Collections, Payer Contract Administration

First, a discussion of uncompensated care

Uncompensated Care:Bad Debt + Financial AssistanceServices for which hospital Services hospital neither received anticipated but did NOT nor expected to receive paymentreceive payment (insured) (self pay)______________________ ___________________________Deductible, Co-Pay, Out-Of- No payment or partial paymentNetwork, Payer Denials_______________________ ___________________________Can afford insurance Can’t afford insurance or don’t

Know they qualify for insurance _______________________ ___________________________ Solution: Collections, Payer Solution: Eligibility Program Contract Administration

Eligibility Programs

Objective: • Get uninsured patients signed-up for Medicaid

Process:• Interview every self pay patient prior to discharge• Identify potential Medicaid candidates and assist

with the applications process

Financial Criteria for Medicaid Eligibility

Medicaid eligibility has certain financial criteria• In 33 states (including Florida) the income

methodology is called Modified Adjusted Gross Income (MAGI)• Considers taxable income and tax filing

relationships

Financial Criteria for Medicaid Eligibility

Medicaid eligibility has certain financial criteria• In 33 states (including Florida) the income

methodology is called Modified Adjusted Gross Income (MAGI)• Considers taxable income and tax filing

relationships• 7 states make their own Medicaid eligibility

decisions (using SSI criteria)

Financial Criteria for Medicaid Eligibility

Medicaid eligibility has certain financial criteria• In 33 states (including Florida) the income

methodology is called Modified Adjusted Gross Income (MAGI)• Considers taxable income and tax filing

relationships• 7 states make their own Medicaid eligibility

decisions (using SSI criteria)• 10 states have elected to use eligibility

requirements that are more restrictive than SSI –209(b) states

Application For Disability Diverges

Examples of Medicaid Groups Non Disability Medicaid Groups Disability Groups

Low Income

Pregnant Women

FPL Related Infants

Low Income Families

FPL Related Children Ages 1-5

Deemed Newborn

Blind or Disabled Eligible in

1973

Disabled Adult

Children

Medically Needy

Disabled

Working Disabled

under 1619(b)

Qualified Disabled &

Working

Disability Is Different

Disability is a “grey” area and often hard to prove…very resource intensive• Must prove that a disability prohibits the

individual from “substantial, gainful employment expected to last at least 1 year or result in death

Disability Is Different

are exempt from MAGI-based income rules

• Medicaid eligibility for these groups, generally determined using the income methodologies of the SSI program

• SSI income requirements • For individual: about $2,000 in assets; $682/mo. income• For couple: about $3,000 in assets; $1,157/mo. income

Blind, Aged (65+) and/or

Disabled

Disability Is Different

are exempt from MAGI-based income rules

• Medicaid eligibility for these groups, generally determined using the income methodologies of the SSI program

• SSI income requirements:• For individual: about $2,000 in assets; $682/mo. income• For couple: about $3,000 in assets; $1,157/mo. income

• Florida has a single point application process• If apply for SSI, automatically apply for Medicaid

• Once awarded SSI, the individual automatically receives Medicaid coverage

Blind, Aged (65+) and/or

Disabled

Disability Is Different

are exempt from MAGI-based income rules

• Medicaid eligibility for these groups, generally determined using the income methodologies of the SSI program

• SSI income requirements:• For individual: about $2,000 in assets; $682/mo. income• For couple: about $3,000 in assets; $1,157/mo. income

• Florida has a single point application process• If apply for SSI, automatically apply for Medicaid

• Once awarded SSI, the individual automatically receives Medicaid coverage

• Plus monthly cash payments

Blind, Aged (65+) and/or

Disabled

SSI vs. SSDI

Title XVI (SSI) Title II (SSDI)Supplemental Security Income Social Security Disability Ins.

Needs Based – Poor No Income/Resources Restrictions

Candidates Earn Work Credits

Paying Into FICA

SSI Award = Medicaid SSDI Award = Medicare

$771 (FL) Max. Individual Monthly Benefit $1,234 (FL) Max. Mo. Benefit

Retroactive Benefits To Protected Filing Medicare Coverage 29 Mo. From

Onset

Blind, Aged (65+) and/or

Disabled

Making A Case For Disability

Disability applicant must prove that the onset of a disability prohibits the individual from “substantial gainful employment” To prove this you must:• Often, dig back into patient’s health records• Identify onset of disability• Document diagnosis from Health Record• Interview physicians• Get statements for the record• Overlay a work history timeline• Interview supervisors• Get statements for the record

The Disability Challenge

Two reasons disability is problematic1. Difficulty identifying disability candidates2. Extensive resources needed to secure a disability

award

Disability Is Often Hard To Identify

Some DisabilitiesAre Apparent

The “Disability ” component may be difficult to identify in an interview

Aged Blind Hospice

Care

Mental/Emotional

Issues

Lack of Medical Evidence

Onset of Disability In

Past

Application Challenges

✓ Applications are complicated,

long delays in Process

✓ Applicants are discouraged by

the local SSA office

✓ Homelessness and poverty

✓ Low Self Esteem/Unable to

advocate for themselves

✓ Unaware of programs and

criteria to apply

Navigating The Disability Award Process

✓ Successful Disability Applicants May Begin Receiving Payments Within 6-8 Months

✓ Full Federal Benefit $750✓ Medicaid/Medicare Healthcare Coverage✓ Individual Is NOT Charged For HRS Services

Qualifying For Disability is a Complicated Process

Claims Up: Staff Going Down

✓ SSA’s operating budget has shrunk 9% from 2010 to 2017*

✓ Staff is down 12% over same period*✓ While disability beneficiaries have

increased 2%*✓ Plus retirement and survivors insurance

beneficiaries have increased 20%✓ Since 2016, SSA has lost over 1,000 field

office staff bringing total loss at 3,500 since 2010*

*SSA Statistical Report, 2017

Results at ALJ Appeal Level

✓ If SSA denies an application –candidate may appeal

✓ After the second appeal, the only recourse is a “Hearing”

✓ Hearing is presided by an Administrative Law Judge

✓ Hearing appeals jumped from 700,000 in 2010 to about 1.1 million in 2017*

✓ Average wait for a hearing decision has reached an all-time high of 21 months in 2017

* SSA Statistical Report, 2017

Success Is Earned

Disability Awards

Title XVI (SSI) Title II (SSDI)Supplemental Security Income Social Security Disability

28.5%* 33.3%*

*Most recent SSA Statistical Report, Disability Rate 2017

Disability Opportunity

Opportunities For Hospital To Convert DisabilityCharity Care Into Cash Payments

Dual Eligible (SSI + SSDI)

SSDI Not Qualified For SSI

SSI Not Qualified For Medicaid

Medicaid

The “Leaky Bucket”

Qualified Pregnant

Aged BlindedFoster Care Adolescents

Individuals with TB

Challenges unique to disability: (1) difficulty identifying candidates; (2) demand on resources to qualify

The “Leaky Bucket”

Qualified Pregnant

Aged BlindedFoster Care Adolescents

Individuals with TB

Solution requires a different way of handling Disability Cases

Must Manage Disability Cases Cost-Efficiently

(1) The Disability Team

SSA

Disability Team

Hospital

Patient

(2) Establish Disability Metrics

Track Filings vs. Cases Pending/Awarded 1 Yr.

80%-100%

60%-80%

Less Than 60%

Cherry Picking

Optimum Wheelhouse

Underworking Cases

(3) Prioritize Work Flow

ApplicationsSelf Pay Population

Interview Process

Software

Protected Filing & F/U

(4) Advocate Throughout Process

✓ Filing Assistance✓ Proxy Contact✓Answer Questions✓Challenge

Rejections✓Write Hearing

Briefs✓ Personally

Represent At Hearings

(5) Always File for SSDI When Filing for SSI

✓ If filing for SSI also file for SSDI

✓Awards for both yield dual eligibility

✓Greater Payments for the hospital

Provider Impact

✓ Convert uncompensated care/charity

care to cash payments

✓ Increase SSI days and DPP percentage

✓ Incremental “Eligible Days” Count

Toward 340B Threshold

✓ Reduce Re-Admissions, Lowering ACA

Penalties

✓ Recognized Community Service

Patient Impact

✓ Successful SSI Applicants May Begin

Receiving Payments Within 6-8 Months

✓ Max. Individual SSI Monthly Benefit $771*

✓ Max. Individual SSDI Monthly Benefit $1,234*

✓ Medicaid/Medicare Healthcare Coverage

✓ Life Changing

Questions?

Mike VanaAssociate

Quality Reimbursement Services(917) 592-5802

mvana@qualityreimbursement.com

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