Oregon Health Plan Medicaid Demonstration

1
Oregon Health Plan Medicaid Demonstration
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Session Overview

• Definitions
• Background
• Eligibility Criteria
• Benefit Packages
• Client Issues

• Premiums
• Copayments
• OHP Plus Benefit Package
• OHP Standard Benefit Package
• Contacts

3
What are the definitions of terms used in these
slides?

• Categorical Clients (These slides only.)
• Clients who are

• - Getting services under the Home Community
  Based or Developmental Disability waivers
• - An inpatient of Hospital, Nursing Facility, or
  Intermediate Care Facility for the Mentally
  Retarded
• - Getting medical assistance under Temporary
  Assistance to Needy Families

- Blind or disabled getting SSI or waivered
services - Age 65 or older getting SSI or
waivered services - Pregnant - Under the age
of 19 - Getting medical assistance under
General Assistance
4
What are the definitions of terms used in these
slides?

• Non-Categorical Clients
• Adult clients who do not meet the definition for
  Categorical Clients (see previous slide).

5
What are the definitions of terms used in these
slides?

• Employer-Sponsored Insurance (ESI)
• Health insurance available through the work
  place. An employer typically makes a
  contribution toward the premium charged for
  employee coverage. In some cases, an employer
  may also make a contribution toward the premium
  charged for dependent (spouse and/or
  spouse/children) coverage.

6
What are the definitions of terms used in these
slides?

• Family Health Insurance Assistance Program
  (FHIAP)
• A state program that helps pay health premiums
  for employer-sponsored insurance individual
  insurance for low-income clients who have been
  without health insurance for at least six months
  and who meet other eligibility criteria.
• The amount paid by FHIAP depends on family income
  and the amount paid by an employer.

7
What are the definitions of terms used in these
slides?

• Oregon Health Plan (OHP)
• Although the Oregon Health Plan (OHP) is a series
  of programs aimed at reducing the number of
  Oregonians without health insurance, in these
  slides it refers to the Medicaid Demonstration in
  effect from 02-01-94 through 01-31-03.
• Oregon Health Plan 2 (OHP 2)
• Changes made to the Medicaid Demonstration based
  on Oregons federally-approved waiver
  application. These modifications go into effect
  beginning 02-01-03.

8
What are the definitions of terms used in these
slides?

• OHP Plus
• A benefit package that replaces the former Basic
  Benefit Package. It goes into effect on 02-01-03
  as part of OHP 2.
• OHP Standard
• A new benefit package that looks like commercial
  insurance. It has premiums, copayments, benefit
  exclusions, and benefit limits. It provides less
  coverage than OHP Plus. It goes into effect on
  02-01-03 as part of OHP 2.

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Background
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Why change the Medicaid program?

• Could Not Sustain Existing Program
• Needed the ability to adjust benefits to match
  available revenues.
• The federal government did not allow Oregon to
  reduce coverage for the Basic Benefit Package.
• Health care costs continue to rise.
• Demand on General Fund constrains expansion.
• Increase Number of Oregonians With Health
  Insurance

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What features changed?

• Eligibility Criteria
• Benefits
• Premiums
• Copayments

12
Who is affected by copayments enacted by the
Legislature?

• Current OHP clients getting the Basic Benefit
  Package on a fee-for-service basis.
• These copayments take effect on 01-01-03.

13
Who is affected by changes included in the OHP 2
waiver application?

• Non-categorical clients as defined in this slide
  show.
• Households in which clients get varied medical
  coverage such as OHP Plus and OHP Standard.
• These changes take effect 02-01-03.

14
How many Oregonians will gain coverage in 2003-05?
15
Eligibility Criteria
16
What are the new income limits?
17
What new criteria apply to non-categorical
clients?
18
What new policies apply to premiums?
19
What new policies apply to premiums?
20
What new policies apply to premiums?
21
Can you give an example of the new premium
policies?
22
Benefit Packages
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Which benefit package will current clients get on
02-01-03?
Non-Categorical Clients
Categorical Clients
OHP Plus
OHP Standard
Non-Categorical Clients w/ESI (If FHIAP
enrollment is open.)
FHIAP Group
24
What benefits does OHP Standard exclude?

• As of 02-01-03, it excludes
• Non-Emergency Transportation
• Routine Vision Services Supplies (eye
  examinations, frames and contacts)
• Audiological Services related to Hearing Aids
  (hearing aid examinations, selection, dispensing,
  hearing aids, ear molds repair or modification
  of a hearing aid)
• As of 03-01-03, it will also exclude
• Alcohol, Drug Mental Health Outpatient Services
• Dental Services
• Durable Medical Equipment Supplies

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What benefits does OHP Standard limit?

• As of 02-01-03, it limits
• Dental benefits to 500 per person
• Durable Medical Equipment Supplies
• As of 03-01-03, OHP Standard will exclude the
  services listed above.

26
What if the client receives services that are not
covered?

• Similar to coverage through a private health
  insurance plan, the client must pay for excluded
  services such as
• Non-Emergency Transportation
• Routine Vision Services Supplies
• Audiological Services Related to Hearing Aids
• Dental Services
• Durable Medical Equipment Supplies.

27
When might a clients benefit package change?

• A clients benefit package may change when the
  client moves between categorical
  non-categorical eligibility.
• Effective Date
• For a client moving from OHP Standard to OHP
  Plus, the benefits change after verification of
  the new eligibility status.
• For a client moving from OHP Plus to OHP
  Standard, the benefits change the 1st of the
  month after the date reported to the worker.

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Are there factors that influence these changes?

• Yes.
• OHP Plus OHP Standard
• All past due premiums for OHP Standard must be
  paid in full.
• OHP Standard OHP Plus
• Past due premiums for OHP Standard do not
  influence the clients ability to enroll in OHP
  Plus.

29
How will clients/providers know which package?

• The OMAP Medical Care Identification will
  identify the benefit package for each member of
  the household.
• It will also identify the copayment applicable to
  each client listed.

30
What does the new OMAP Medical Care ID look like?

• Top Part of the Medical Care ID

31
What does the new OMAP Medical Care ID look like?

• Middle Part of Medical Care ID

32
What does the new OMAP Medical Care ID look like?

• Bottom Part of Medical Care ID

33
Which benefit package do CAWEM clients receive?

• Benefits have not changed for clients qualifying
  under the Citizen/Alien Waived Emergency Medical
  (CAWEM) program. These clients are not eligible
  for OHP Plus or OHP Standard.

34
Client Issues
35
Must a family cover all family members?

• No. The family can choose to not cover one or
  more non-categorical family members.
• This decision must be made at the time of
  application.

36
How does ESI influence a clients coverage
choices?

• Clients meeting criteria for OHP Standard who
  have access to employer-sponsored insurance (ESI)
  must seek coverage through that source via FHIAP.
• Medicaid may cover these clients when FHIAP finds
  that
• Its enrollment or ESI enrollment is closed or
• ESI coverage does not meet its coverage
  benchmarks.

37
How does the client access services?
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What are the clients eligibility enrollment
appeal rights?

• Topics Subject To Appeal
• An eligibility decision including
• Whether the client was approved as eligible for
  the correct program or benefit package
• The termination of benefits
• The disqualification from receiving benefits.
• The amount of copayment charged.
• Disenrollment from a managed care plan.

39
What are the clients eligibility enrollment
appeal rights?

• Topics Not Subject To Appeal
• Conversion to OHP Standard.
• End of Prior Authorizations for services not
  covered by OHP Standard.
• Imposition of copayments.
• Physician refusal to see patient who does not pay
  OHP Standard copayments.
• Expiration of the Certification Period.

40
Premiums
41
Who is subject to exempt from premiums?

• Premiums apply to clients enrolled in OHP
  Standard.
• Only American Indians or Alaskan Natives who are
  members of federally recognized Indian tribes are
  exempt from the OHP Standard premium requirement.

42
How are premiums billed?

• Premiums are charged for each client enrolled in
  OHP Standard who is not exempt.
• No premium discounts for couples.
• Must pay the full premium or all household
  members in OHP Standard, who are subject to
  premiums, are disqualified are ineligible for
  six months.
• Premiums are billed once per month for all OHP
  Standard household members.

43
Will the premium change? If so, when does it
change?

• The household premium may change when the client
  moves between categorical non-categorical
  eligibility.
• Premium adjustments, if any, occur after a change
  is reported to the worker.

44
How much are premiums?
45
How many current clients fall into each premium
group?
20 per person
6 per person
18 per person
15 per person
9 per person
46
When are premiums due?

• The premium is billed on the 1st day, and is due
  on the 20th day, of each month.
• It is possible for the first billing to include
  premiums for more than one month and/or for a
  partial month of coverage.

47
What happens if all or part of the premium is
late?

• All household members getting OHP Standard, who
  are subject to the premium, are
• Disqualified as of the first of the month after
  the grace period ends and
• Ineligible for OHP Standard for six months.
• The grace period ends 35 days after the premium
  due date.

48
Can a client be found eligible for OHP Standard
when there is premium debt?

• No. The premium debt must be paid in full before
  OHP Standard eligibility can be re-established.
• All household members disqualified for
  non-payment of premium are ineligible for OHP
  Standard for 6-months.

49
How long will the premium debt be carried?

• Unless paid, the premium debt is carried for
  three years.
• The premium debt will be attached to every
  household member enrolled in OHP Standard who was
  subject to the premium.

50
Can the eligibility worker waive premium debt?

• No. Workers are no longer allowed to waive past
  due premiums, which were billed on or after
  02-01-03.
• For premiums billed before 02-01-03, workers may
  waive cancel premiums as under current policy.

51
Copayments OHP Plus
52
Were copayments applied to the Basic Benefit
Package?

• On 01-01-03, copayments apply to the Basic
  Benefit Package.
• On 02-01-03, the OHP Plus benefit package
  replaces the Basic Benefit Package.
• The next group of slides apply to the OHP Plus
  benefit package.

53
Who is subject to OHP Plus copayments?

• All clients covered by OHP Plus who do not
  receive the service through a managed care plan.
  Exceptions include
• American Indians and Alaska Natives, children
  under 19 years of age, pregnant women, clients in
  a nursing or inpatient facility, clients
  getting waivered services.

54
Which services are exempt from OHP Plus
copayments?

• Alcohol, Drug Mental Health - Dosing,
  Dispensing Case Management
• Dental Services - Diagnostic Preventative
• Durable Medical Equipment Supplies
• Emergency Services (OAR 410-120-0000)

• Family Planning Services Supplies
• Hearing Aids
• Prescription Drugs Ordered through OMAPs Mail
  Order Pharmacy Program
• Vision Frames Contact Corrective Devices

55
Which services are subject to OHP Plus copayments?

• Ambulatory Surgical Centers
• Dental Services -- Restorative
• Hospital
• Outpatient Facility
• Emergency Room Visit (Non-Emergent)

• Optometrist Ophthalmologist Exams
• Prescription Drugs
• Visits -- Home
• Home Health Agency
• Private Duty Nursing
• Enteral/Parenteral

56
Which services are subject to OHP Plus copayments?

• Visits -- Practitioner
• Acupuncturist, Chiropractor Naturopath
• Alcohol, Drug Mental Health Services
• Dentist, Denturist

• Visits -- Practitioner
• Nurse Practitioner
• Occupational, Physical Speech Therapy
• Physician Physician Assistant
• Podiatrist

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What are the OHP Plus copayments?

• The copayment amount is 3 except for generic
  prescription drugs.
• The copayment amount for generic prescription
  drugs is 2.

58
How are fee-based providers paid?

• The OMAP claims processing system
• Determines the allowable amount payable
• Calculates the copayment applicable to the claim,
  if any
• Subtracts that copayment amount from the
  allowable amount payable and
• Issues a check for the balance due.

59
Copayments OHP Standard
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Who is subject to OHP Standard copayments?

• All clients covered by OHP Standard, except
• American Indians and Alaska Natives who are
  members of a federally recognized Indian tribe or
  Tribal Organization.
• These copayments go into effect on 02-01-03.

61
What happens when an OHP Standard client does not
pay the copayment?

• The client should tell the provider billing clerk
  set a repayment schedule.
• If the client does not pay the debt when due, the
  provider may turn the account over to collections.

• The provider may refuse to see a client with
  unpaid copayments.
• The plan must find another provider for this
  client.
• The plan may request that a client be disenrolled
  for not making copayments under certain
  conditions.

62
Which providers services are exempt from OHP
Standard copayments?

• Providers
• Family Planning
• Hospice
• Indian Health Providers
• Practitioners Making Hospital Visits

• Services
• Admin. Medical Exams
• Certain Diagnostic Preventive Services
• Dosing, Dispensing Case Management for Alcohol,
  Drug Mental Health
• Family Planning, HIV Testing, Hospice Services
• Some Specialty Services

63
Which services are subject to OHP Standard
copayments?

• Hospital Surgical Services
• Practitioner Visits Home Visits
• Alcohol, Drug Mental Health Services
• Dental Services

• Durable Medical Equipment
• Emergency Medical Transportation
• Laboratory Services
• Prescription Drugs

These services will not be covered as of
03-01-03.
64
Who collects copayments when does that occur?

• Providers collect the copayments.
• Providers may collect copayments at the time that
  best fits with their practice
• Before rendering services
• After rendering service
• With the billing cycle

65
Do health clinics also charge copayments?

• Yes. Federally Qualified Health Centers Rural
  Health Clinics must collect copayments from OHP
  Standard clients seeking their services.

66
What are the copayments for hospital surgery?
67
What are the copayments for laboratory services?
68
What are the copayments for prescription drugs?
69
What are the copayments for home visits?
70
What are the copayments for practitioner visits?
71
What are the copayments for dental services?
72
What are the copayments for miscellaneous
services?
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Contacts
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Who can answer my questions?

• Client Issues
• Client Advocate Services
• 1-800-273-0557
• 1-800-375-2863 TTY
• OHP Application Center
• 1-800-359-9517
• Premium Billing Office
• 1-800-922-7592
• FHIAP
• 1-888-564-9669
• 1-800-735-2900 (Relay Service)

• Provider Issues
• Automated Information System
• 1-800-522-2508
• OHP Benefit/RN Hotline
• 1-800-393-9855
• Provider Enrollment
• 1-800-422-5047
• Provider Services
• 1-800-336-6016

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Thank You
Everyone needs basic health care. These changes
to the Oregon Health Plan help expand basic
coverage to uninsured, low-income families. OHP
is good for Oregon -- its protection, its
prevention, its good health.