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TRANSCRIPT
The Source for
Housing Solutions
Medicaid 101: The Basics
for Homeless Advocates
July 29, 2014
Peggy Bailey
CSH
Senior Policy Advisor
Getting Started
Things to Remember:
Medicaid Agency
1. Medicaid is not a social service program – it is an insurance
program
2. Medicaid agencies have goals – put supportive housing in their
terms
- Cost savings
- Lead with service component of supportive housing
3. Come with suggestions
4. Medicaid isn’t the only piece of the puzzle and may not work for all
supportive housing providers
Things to Remember:
Managed Care
1. Not unlimited flexibility
2. Must operate within construct of state contract arrangement
3. Only serve those in their network
4. Serving more and more high need members
5. Open to non-traditional partners
6. Cost savings and member HEALTH outcomes must be
measured
Medicaid Basics
Medicaid Basics
Authorized under Section XIX of the Social Security Act of 1965
Began As Health Insurance for:
Low-Income Pregnant Women and Children
Disabled
Counterpart for Medicare
Over the years – populations have expanded
Federal/State Partnership
Federal Oversight and Structure
Significant State Flexibility
Federal Payment Contribution is called Federal Medical Assistance Percentages (FMAP)
FMAP differs by state
Based on per capita income
No lower than 50%, highest is Mississippi at 73%
Territories rate - 55%
Admin is reimbursed at 50% for all
FMAP can also differ by benefit, mostly per ACA
Medicaid Fundamentals
Eligibility
• Traditional
• Low-Income Kids and Pregnant Women
• Disabled
• Elderly
• For Expansion States: Newly
Eligible those with incomes below 138% of FPL
Benefits
• Traditional
• Mandatory
• Optional
• Medicaid Waivers and State Plan Amendments – expanded benefits
• New Essential Benefits Package
Provider Billing
• State Requirements vary
• Further variation based on benefit/population
• Can be Extensive
• States exploring ways to expand provider ability to bill
• ACA does not directly address
Eligibility
Eligibility
Traditional Medicaid
Pregnant Women
Children
Disabled
Based on Supplemental Security Income Determination
(SSI/SSDI)
Does not include substance use population
Those who need Home and Community-Based Care
Low-income Seniors
Low-income Parents (in some states)
Expansion Medicaid
Those with incomes below 138% of federal poverty level
No longer based on disability or subpopulation
Brings in childless adults and substance use populations
Benefits
Mandatory Benefits
Inpatient Hospital Services Outpatient Hospital Services
Prenatal Care Vaccines for Children
Physician Services Nursing facility services for those
over 21
Family planning Rural health clinic services
Home health care for persons
eligible for skilled-nursing services
Laboratory and X-Ray Services
Pediatric and family nurse
practitioner services
Nurse-midwife services
FQHC services Early and Periodic Screening,
Diagnostic, and Treatment
(EPSDT) for children
Optional Benefits
Diagnostic services Clinic Services
Intermediate care facilities for
those with Developmental
Disabilities
Prescribed drugs and prosthetic
devices
Eye exams and glasses Nursing facility services for
children under 21
Transportation Case Management
Rehab and physical therapy
services
Home and Community-Based
Services
Newly Eligible Benefits
Affordable Care Act establishes 10 benefit categories
Ambulatory patient services;
Emergency services;
Hospitalization;
Maternity and newborn care;
Behavioral health services and treatment;
Prescription drugs;
Rehabilitative and habilitative services and devices;
Laboratory services;
Preventive and wellness services and chronic disease management; and
Pediatric services, including oral and vision care.
States determine specifics but must be equivalent to
benchmark private plans
People with Disabilities can qualify for traditional Medicaid
and receive benefits needed for their conditions
Comparison of Medicaid Authorities
for Supportive Housing
1115 Waiver 1915c and 1915b
HCBS Waiver
1915i HCBS State
Plan Option
Health Homes State
Plan Option
Medicaid Rehab
Option
Targeted Case
Management
What is it? Flexible waiver for
demonstration
programs that enable
States to pilot
innovative care
delivery models and
coverage expansion
that differ from federal
rules
Medicaid waiver to
provide Home and
Community-Based
Services to
populations leaving or
at-risk of
institutionalization;
‘c’ is for state Medicaid
depts and ‘b’ is for
MCOs
State plan option to
extend Home and
Community Based
Services to people
with disabilities but
who are not
necessarily at-risk of
institutionalization and
without cost neutrality
requirement
CMS program
enabling states to
create highly
integrated,
coordinated, and
flexible health/social
services networks for
people w/chronic
conditions; enhanced
federal match for 1st 8
quarters
Authority traditionally
used to cover range of
recovery and
rehabilitative services
for people with serious
mental illness and/or
developmental
disabilities
Authority to make
case management
available to specific
populations, including
in specific geographic
locations to better
access and coordinate
medical, social, and
other care
Eligible/
Covered
Populations
Any Medicaid eligible
Can also be used to
expand Medicaid
coverage beyond
federal eligibility (e.g.
to low-income singles
pre-2014)
Beneficiaries leaving
or at-risk of
institutionalization
including seniors,
people with SMI,
development disabled,
PLWAs, or people with
TBI
Beneficiaries with
disabilities requiring
HCBS who meet
approved “needs-
based criteria”
Beneficiaries with
serious mental illness
or two or more other
chronic conditions
No specific guidelines,
but typically states use
for beneficiaries with
serious mental illness
or development
disabilities
States can define and
limit coverage to
certain beneficiaries,
can include PWAs,
seniors, parolees,
children in foster care,
people with disabilities
inc. substance use
Potential
Coverage of SH
Services
High (gives States
highest degree of
flexibility)
Medium (due to cost
neutrality requirement)
High (due to no cost
neutrality standard)
High (highly tailored
services including
intensive care
management)
Medium to low Medium to low (must
be fee-for-service,
limits coverage to one
case manager per
client)
Considerations States must meet high
standards for research
methods that will
demonstrate better
outcomes, lower costs
Limited to people
leaving or at-risk of
entering institutions
Subject to cost-
neutrality
States adopting 1915i
must extend coverage
statewide; cannot
restrict targeting by
geography
A hybrid between a
payment system and a
care model, Health
Homes is very new
with only a few states
adopted
Services tend to be
more treatment or
rehabilitative as
opposed to care
management focused
Coverage limited for
certain activities such
as client transport.
Cap on federal match
at 50% makes less
attractive to states.
Medicaid 101: The Basics
for Homeless Advocates
The National Alliance to End Homelessness
July 29, 2014
Marti Knisley
The Technical Assistance Collaborative
www.tacinc.org
18
Medicaid Basics
Are Important
1. Most people you serve are eligible for Medicaid benefits
covered by this insurance program;
2. It’s complex, but knowing the basics helps you help people
you serve;
3. Understanding the basics helps your agency make
decisions about role you can play—eligibility, enrollment,
provider, network member, advocate……;
4. Medicaid policy and programs are changing rapidly,
knowing the basics helps understand the changes; and
5. Access to health (and behavioral health) care (covered by
Medicaid) is a stabilizing force in everyone’s life—it’s part
of a person’s recovery.
19
The Why
Services and supports for people to live in their own home
C
os
ts o
f c
are
Community Services and supports are in
the state Medicaid Plan
Service arrangements in the state
Medicaid Plan to help promote people
living in their own home
Healt
h O
utc
om
es
20
The Basics: What and How
The What:
• Benefits, eligibility, program and provider
requirements;
• Questions you need answered for people
you serve and for your agency (system);
The How:
• What is the best way to get your questions
answered and help people you serve and
your agency at the same time?
21
Understanding Medicaid
Experts: HH, MC, HCBS, MFP, ACOs, Dual Eligibles, payment models, etc; tracks and analyzes data (cost and
program) and performance, manages services across multiple programs
Staff and consumers: Understand basics of enrollment, eligibility, benefits by
major program types/ and billing requirements
Agency Directors, Managers, Key Leaders: Manage, deliver and advocate for services
in Medicaid programs
22
The Basics
• Eligibility;
• Enrollment;
• Services/ Benefits----by program;
• Provider requirements;
• Billing, reporting, tracking processes; and
• Business options
23
The How
• What are some ways to learn and use
basic (and beyond) information to help
persons and families who are homeless?
• What are options for your community, your
agency (as a whole) and your staff: to
ensure Medicaid benefits are available,
accessible, comprehensive and targeted to
assure better outcomes?
24
The How
• Take steps to learn the processes,
approaches, benefits:
– Sponsor or attend workshops/ training:
• Eligibility experts are available, Medicaid provider
training, associations events, etc.
– Join a healthcare coalition;
– Check the web for materials and background
papers; and/or
– Sponsor a coalition among your providers.
25
Options for Providers
• Establish a business plan;
• Become an Enrollment Center;
• Become a provider or join a Network;
• Help create opportunities to learn.
• Examples:
– The Connecticut MISHA Institute;
– The SHRP Training Program in New Jersey;
– PSH Certification Program in Louisiana;
– Others ???
26
The Source for
Housing Solutions
Medicaid Billing Quandary
Do you need a national accreditation
or state certification
Agency Support
Is the Board “on board” What about Senior
Management
There is a cost
Policies and procedures
What is the state of agency policies and practices
Things to consider
w
Who do you serve
Services you provide
Clinical paperwork
Staffing
Billing capability
QI plan for ongoing compliance
Target Population
Service Delivery
What services are currently being delivered
Type
Volume
Frequency
Location
Can the services be certified
Paperwork
Current state of client charts
Location and security of client charts
Revisions needed for forms
Diagnostic assessment
Progress notes
Individualized service plans
Staff
Expertise and skill level
Licensure
Caseload size
Supervisors
Training
Billing Capability
Type of current billing
Keeping track of units
Who should do the billing
Can Medicaid billing be incorporated
Should Medicaid billing be contracted to external
vendor
Ongoing compliance
QI Plan
All levels of staff must be part of the ongoing process
Process for reviewing policies and procedures
Ongoing staff training
Staying in compliance with standards
Client chart review
Audits and recertifications
Is it worth it
COST VS REVENUE
National accreditation Type of services
you will provide
Medicaid billing process
Higher level staff Estimating
number of units
QI process
Training Estimating
revenue
Medicaid 101: The Basics for Homeless Advocates ~ A
Provider Perspective
Karen Batia, Ph.D.
National Alliance to End Homelessness
July 29, 2014
HHO Mission
Heartland Health Outreach’s mission is to
transform healthcare for the most vulnerable –
particularly people experiencing homelessness,
mental illness or addictions, or struggling with
multiple chronic illnesses – improving health for
all and the well-being of our community.
Heartland Health Outreach
Heartland Health Outreach
Specialty FQHC – Healthcare for the Homeless provider in
Cook County, IL (medical encounters)
Specialty Mental Health provider (MRO Rule 132)
– Assertive Community Treatment
– Community Support Teams
– Outpatient Services
Specialty Alcohol and Substance Abuse Services (Rule
2060/2090)
Continuum of housing options
Training and Technical Assistance
Heartland Health Outreach
Heartland Health Outreach
HCH Program Vision
Decrease health disparities and increase the
lifespan of people experiencing homelessness.
The average life expectancy of an adult
experiencing homelessness is 30 years less
than a housed adult.
-Boston HCH Program
Heartland Health Outreach
Heartland Health Outreach HCH Integrated Program Structure
Primary Care Services – Health Center(s)
– Outreach
Oral Health Care
HIV Care
Mental Health and Substance Abuse
Nutrition and Grocery Centers (for people with HIV/AIDS)
Supported Housing Options (for people with chronic health issues)
Permanent Supported Housing with Medical and Mental Health Services
TB / Direct Observational Therapy
Housing Subsidies
Heartland Alliance for Human Needs & Human Rights
Heartland Health Center – Uptown and James West Clinics
Modified Open Access Scheduling – Same day and future appointments
Integrated Electronic Health Record System
Lab Services
Prescription Assistance – 340b
– PAP
Heartland Health Outreach
Heartland Health Outreach HCH Outreach
Delivery of services to people experiencing
homelessness where they reside
Provide transportation to follow-up services
Render services regardless of ability to pay
Collaborate with community partners to provide
comprehensive care
Heartland Health Outreach Services Offered
Heartland Clinics Chronic disease management
Preventative care (screenings)
Immunizations
Acute care
Lab services
Prescription services
Psychiatric and counseling services
Urgent and preventative dental care
Smoking cessation
Case Management Supportive Services
Care Coordination
Heartland HCH - Outreach Chronic disease management
Preventative care (screenings)
Immunizations
Acute care
Prescription services
Urgent and preventative dental care
Smoking cessation
Case Management Supportive Services
Care Coordination
Heartland Health Outreach
Outreach locations
Approximately 100 outreach sites
– Emergency shelters
– Permanent Supportive Housing
– Transitional Housing Programs
– Single Room Occupancies
– Street
– Meal Programs
Outreach Models
Street outreach (PATH and HCH)
– Small integrated team (typically not billable to Medicaid)
– Focus on engagement
Shelters and Housing
– Integrated team including medical assistant (FQHC
Medicaid)
– Urgent care (return to medical home and engagement)
– Ongoing medical care
Electronic health record follows participant
Most services can be provided at outreach sites
Heartland Health Outreach
Outreach Models
HHO Supported Housing
– Provide on-site Mental Health services (MRO) if eligible
– Provide medical care
– Case management staff collaboration with housing
property managers
Non-HHO Supported or Subsidized Housing
– HHO teams work with property managers with limited
ability to share information
– Continuity of care if participant evicted or struggling with
tenancy more challenging for medical care Heartland Health Outreach
Lessons Learned
It’s all about building relationships with both
participants, landlords and property management
Engagement, identify mutual goals and be
consistent
Medicaid billing will depend on which service
taxonomy, license and site regulations and
“medical necessity”
Integrated electronic record is critical
Data, data and data
Heartland Health Outreach