june 2015 julia hidalgo, scd, msw, mph research professor, george washington university and ceo,...
Post on 11-Jan-2016
216 Views
Preview:
TRANSCRIPT
June 2015
Julia Hidalgo, ScD, MSW, MPHResearch Professor, George Washington University and CEO, Positive Outcomes, Inc.Julia.hidalgo@positiveoutcomes.net
HIV Care Under the Affordable Care ActAddressing the Needs of HIV Clinics and Clinicians in Washington
Today We Will Address
• Key provisions of the Patient Protection and Affordable Care Act (ACA)
• provider participation and covered benefit provisions
• Federal and State Medicaid policies • Eligibility, service delivery, and payment systems
• Focus on challenges and opportunities for Washington HIV clinical, social support, and prevention providers
• Maximizing third party reimbursement for HIV prevention, care, and support services through collaborative strategies
ACA Marketplace
From: Hidalgo J and Edelbrock E. Commercial Health Insurance Basics for HIV Prevention Programs Webinar. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-3-commercial-health-insurance-basics-for-hiv-prevention-programs/
ACA Requirements: Essential Health Benefits (EHBs)
• Ambulatory patient services• Hospitalization • Emergency services• Pregnancy, maternity, newborn care, and pediatric services (oral
and vision care)• Mental health and substance abuse disorder services (i.e.,
behavioral health treatment)• Prescription drugs• Rehab and habilitative services and devices• Laboratory services• Preventive and wellness services and chronic disease management
ACA Requirements: Essential Community Providers (ECPs)
ECP Category ECP provider Type
Federally Qualified Health Centers (FQHCs)
FQHCs and other community health centers, and healthcare facilities operated by Indian tribes and other Indian organizations
RWHAP provider Ryan White HIV/AIDS Program-funded providers
Family Planning provider
Title X family planning clinics and look alike family planning clinics
Indian Health provider Indian Health Service (IHS) providers, Indian tribes organizations, and urban organizations
Hospital Disproportionate share hospitals (DSH) and eligible hospitals, children’s hospitals, sole community hospitals, and other similar facilities
Other ECP providers STD clinics, TB clinics, and other entities that serve predominantly low-income, medically underserved individuals
CMS issued a letter to Federally-Facilitated Marketplaces in December 2014 QHPs must contract with at least 30% of ECPs in each QHP’s service area Offer contracts in good faith to all available Indian health providers in the service
area Offer contracts in good faith to at least one ECP in each ECP category in each
county in the service area Where an ECP in that category is available and provides medical or dental services
that are covered by the issuer plan type (i.e., Individual or SHOP)
To be in “good faith,” a contract should offer terms that a willing, similarly-situated, non-ECP provider would accept or has accepted Issuers must be able to provide verification of such offers if CMS chooses to review
the offers for compliance
ACA Requirements: ECPs
ACA Requirements: Preventive Services DHHS US Preventive Services Task Force (USPSTF) recommends “A” grade for HIV infection screening
Adolescents and adults ages 15 - 65 years Younger adolescents and older adults at increased risk All pregnant women, including those presenting in labor who are untested and
whose HIV status is unknown
“A” grade for syphilis for all pregnant women and other persons at increased risk for infection
“B” grade for chlamydia screening for sexually active women age 24 or younger and in older women at increased risk for infection
“B” grade for STD counseling for sexually active adolescents and for adults at increased risk for STDs
ACA QHPs Offering Coverage on the WA Health Benefits Exchange
Issurer Plan Type Counties
BridgeSpan Individual Benton, Clark, Franklin, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Yakima
Columbia United Providers
Individual Clark
Community Health Plan of WA
Individual Adams, Benton, Chelan, Clark, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, King, Kitsap, Lewis, Okanogan, Pacific, Pend Oreille, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Yakima
Coordinated Care Individual Adams, Benton, Chelan, Douglas, Franklin, Grant, Jefferson, King, Lewis, Lincoln, Snohomish, Spokane, Stevens, Thurston, Walla Walla, Yakima
Group Health Cooperative
Individual Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, Yakima
Kaiser Foundation Health Plan
Individual and SHOP
Clark and Cowlitz
LifeWise Health Plan
Individual All 39 counties
Moda Health Plan Individual and SHOP
All 39 counties
Molina Health Care Individual Chelan, Douglas, Grant, King, Okanogan, Pierce, Spokane
Premera Blue Cross Individual All counties except Clark
Impact of the ACA on State Medicaid Programs
From: Hidalgo J and Edelbrock E. Medicaid Basics for HIV Prevention Program. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-2-medicaid-basics-for-hiv-prevention-programs/
Medicaid Overview Federal and state entitlement program Medical assistance for people with limited income and resources Covers 60 million adults and children Enrollment in “traditional” Medicaid is commonly via TANF, Aged,
Blind, Disabled or other Categorical Programs Supplements Medicare benefits for 9 million low income aged and/or
disabled individuals Disability continues to be a common pathway to Medicaid and Medicare for HIV+ adults
Beginning in 2014, the ACA permitted states to expand Medicaid optionally to non-disabled individuals Anyone who is poor (include < $16,104 or 138% of the FPL) 4.8 million Americans enrolled in expanded Medicaid
Until ACA Medicaid expansion implementation, WA HIV+ adults commonly enrolled in Medicaid through enrollment in Social Security Administration (SSA) disability or TANF benefits. In WA, applications for SSA disability benefits are determined by the WA State Department of Social and Health Services Disability Determination Services (DDS)
Average Monthly SSA Initial SSI Allowance Rates in GA, LA, PA, TX, WA, By Year, 2001 to 2014
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
10.0
20.0
30.0
40.0
50.0
60.0
GA LA PA TX WA Linear (WA)
ACA-Related Medicaid BenefitsEXPANSION STATES ACA requires adults enrolling through Medicaid expansion must
receive “alternative benefit plans” (ABPs) Must include the ten “essential health benefits” (EHBs) required for
Marketplace QHPs Must provide the full range of prevention services, including
preventive services rated “A” or “B” by the USPSTF at no cost to beneficiaries
Must cover family planning services and supplies (e.g., condoms), parity between physical health and behavioral health services, non-emergency transportation, and FQHC and Rural Health Center services
New Opportunities for Medicaid Payment for Preventive Services
CMS published a final rule effective in January 2014 Before the rule change: preventive services could only be
provided by a physician or other licensed practitioner (OLPs) of the healing arts to be paid by Medicaid
After the rule change: other practitioners, not just physicians and OLPs, can be paid to provide preventive services recommended by a physician or OLP
Assigns authority to State Medicaid Programs to Define practitioner qualifications Ensure appropriate services are provided by qualified practitioners Define the preventive services to be provided Design the reimbursement methods
Does not define the type of personnel to be covered
WA Apple Health Managed Care Organizations (MCOs)
Apple Health MCOs• Amerigroup (AMG)• Community Health Plan
(CHP)• Coordinated Care (CCC)• Molina Healthcare (MHC)• UnitedHealthcare (UHC)
WA Apple Health Eligible Populations
Clients receiving Medicaid under SSA provisions for coverage of families receiving AH Family
Clients who are ineligible for cash assistance who remain eligible for medical services under Medicaid
Clients receiving Medicaid under the ACA effective January 1, 2014 Children, from birth - 18 years of age, eligible for Medicaid under
expanded SSA pediatric coverage provisions Pregnant women, eligible for Medicaid under expanded SSA maternity
coverage Children eligible for the Children’s Health Insurance Program (CHIP) Categorically Needy - Blind and Disabled Children and Adults who are
ineligible for Medicare
WA Apple Health MCO Contract Preventive Services SpecificationsPREVENTIVE SERVICES When possible, the MCO shall develop guidelines based on the USPSTF as the primary source MCOs may adopt guidelines developed by recognized sources that develop or promote evidence-
based clinical practice guidelines such as voluntary health organizations or NIH If the MCO does not adopt guidelines from recognized sources, board-certified practitioners must
participate in the development of the guidelines MCOs shall develop health promotion and preventive care educational materials for enrollees using
both print and electronic media
FORMULARY The MCO shall maintain an HCA-approved formulary that includes
All therapeutic classes in the HCA’s FFS drug file and a variety of drugs in each therapeutic class determined by HCA to be sufficient to meet enrollees’ medically necessary health care needs
A number of drugs in each US Pharmacopeia (USP) category and class equal to or greater than the number included in Washington State’s selected EHB benchmark plan
At least 1 drug in any USP category and class for which the EHB benchmark plan has no covered drugs
Additional drugs as determined necessary by HCA to meet enrollees’ medically necessary health care needs
WA Apple Health MCO Contract HIV and Related Specifications
Included Specifications Enrollee Self-Referral: STD screening and follow-up, HIV screening through and if
provided by a local health department Prescription and OTC Drug Products: according to the HCA-approved formulary Covered Drug Products: include all OTC contraceptives without a prescription
including but not limited to condoms
Missing Specifications USPSTF HIV recommendations not reflected Coverage of HIV prevention, screening, and clinical services are not explicitly
addressed Enhanced HIV/AIDS capitation rates Requirement for MCOs to coordinate with the RWHAP grantees or providers Infectious disease clinician network adequacy HIV quality measures (e.g., HIV screening and undetectable viral load rates)
WA Apple Health MCO Contract Local Health Department (LHDs) and Community Health Worker (CHW) Specifications
MCOs shall make a reasonable and fair effort to subcontract with all LHDs If MCOs subcontracts with LHDs as participating providers or refers enrollees
to them to receive services, MCOs shall pay for services provided up to the limits described in this Contract
Care Coordinator is a health care professional or group of professionals, licensed in WA, who is responsible for providing care coordination services to enrollees
Care Coordinators may be a RN or Social Worker employed by the Contractor or primary care provider and/or Individuals or groups of licensed professionals, or individuals working under their
licenses, subcontracted by the primary care provider/clinic Allied health care staff, such as CHWs and others, to facilitate the work of the care
coordinator
WA Apple Health Targeted HIV/AIDS Medical Case Management (MCM)
DOH screens applicants for eligibility Recipients cannot receive concurrent MCM from another program Applicants must require help obtaining and effectively using necessary medical, social, and
education services, or need 90 days of continued monitoring Have a benefit service package that covered Clients enrolled in MCOs may receive MCM services, without MCO referral
Proc Code
Modifier Dx Code Unit Payment Rate
Description
T2022 U8 Limited to diagnosis
042 or V08
CM, per month
$173.72 Full Month. A full-month rate applies when:• Criteria in WAC 182-539-0300 have been met; and• Individual service plan (ISP) in place > 20 days in that month
T2022 U9 CM, per month
$86.86 Partial Month. A partial-month rate applies when:• Criteria in WAC 182-539-0300 have been met• Individual service plan (ISP) has been in place < 20 days in that
month
T1023 Program intake
assess-ment
$139.12 Full Month. A full-month rate applies when:• Criteria in 182-539-0300 have been met.• An ISP has been in place > 20 days in that month.
Opportunities for HIV Core Medical, Support, and Prevention providers in the ACA and Medicaid Reform
Addressing Health Insurers’ Interests Via Services Offered by HIV providers
Health Insurers’ Interests Services That HIV providers Might Offer
Identify enrolled members that do not obtain preventive or other services
Outreach, linkage, patient navigation
Essential covered benefits RWHAP core medical providers
Address members’ healthcare and health insurance literacy needs
Non-MCM, patient navigation, health education
Prevent communicable diseases including HIV, STDs, TB, and HCV
nPEP and PrEP support, HIV/STD CTS, behavioral prevention, condom distribution and education, HERR
Address members’ linguistic and numeracy needs to ensure that they can participate actively in health promotion, prevention, and care
Translation and health education
Culturally competent care coordination, disease management, treatment education
Culturally competent workers with expertise in serving racial, ethnic, and sexual minority populations
Addressing Health Insurers’ Interests Via Services Offered by HIV providers
Health Insurers’ Interests Services That HIV providers Might Offer
Ensure access to physical, behavioral, and other outpatient services to promote health, and prevent and treat disease
MCM, navigation, behavioral health tx support, medical transportation
Ensure HIV+ clients receive and optimally benefit from ARVs and other medications
MCM, navigation, tx education and adherence counseling, MCM
Coordinate services provided by the care team with the client, his/her family, and community resources
MCM
Disease management MCMDischarge planning and readmission prevention interventions for hospitalized patients
MCM
Align With Your Organization Before Seeking New Opportunities
Before moving forward, it is critical to Ensure your HIV program’s efforts are aligned with your
organization’s overarching readiness efforts An important step for HIV practices in large integrated health systems,
hospital-based or university-affiliated health systems, LHDs, large FQHCs Contracts may have been negotiated or are being negotiated QHP and Medicaid MCO contracts have probably been finalized for the
current year
Engage organizational leadership, including corporate board support
Identify organizational resources that can be applied to your contracting and collaboration activities
Resources for Contracting for HIV Prevention and Care ServicesHealthHIV. Health Insurance Contracting for HIV Prevention and Wrap-around Service providers. 2015. Available at: http://wwwhealthhiv.org
HIV Medicine Association. Strategies for HIV Medical providers Contracting With Health Insurers. 2013. Available at: http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/Strategies%20for%20HIV%20Medical%20providers.pdf
On Our Own
• Chart your own organizational course• Enhance your TPR capacity, join insurers’ FFS programs and networks • Crush the competition
Virtual Integration
• Adopt a “trade association” model • Collaborate in information gathering, purchasing, and marketing• ASOs seek out and create formal relationships with HIV clinics, community health
centers, or other core providers
Physica
l Integration
• Co-locate services but remain independent organizations• Share infrastructure costs
Acquisitions & Mergers
• Identify agencies with services strengthening your capacity and “buy them”• Identify similar agencies but different service areas or populations and merge • Transfer clients to a fiscally solvent, culturally competent, and high quality agency
close HIV program
Strategies for Strengthening the HIV Care Continuum
Collaborative Integration StrategiesContract for services using “grant” type budget, FFS, sub-capitated arrangements
Augment care management services provided by the insurer through contract
Contract with provider networks to provide HIV and HIV services
Provide subcontracted essential and other covered services
Coordinate and collaborate to serve HIV+ and non-HIV+ clients
Subcontract with CBOs and handle their billing
Provide subcontracted essential and other covered services
Coordinate and collaborate to serve HIV+ and non-HIV+ clients
Subcontract with CBOs and handle their billing
Provide subcontracted outreach, HIV and STD testing, linkage, home visits, MCM, preventive services
QHP or
MCO
Hospital Systems
FQHCs & HIV Clinics
CBOs
How to Learn More About ACA and Medicaid-Related Health Insurers in My State
top related