EFFECTIVE ELIGIBILITY DETERMINATION FOR THE CARE ACT AND OTHER SYSTEMS

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EFFECTIVE ELIGIBILITY DETERMINATION FOR THECARE
ACT AND OTHER SYSTEMS
Julia Hidalgo, ScD, MSW, MPHPositive
Outcomes, Inc.Harwood MDwww.positiveoutcomes.ne
tjulia.hidalgo_at_positiveoutcomes.net
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CARE Act Payer of Last Resort Policies

• The CARE Act is the payer of last resort
• Grantees must ensure that clients meet
  eligibility criteria for CARE Act services
• Including ADAP, insurance continuation, and
  direct services
• CARE Act grantees must ensure that alternate
  payment sources are pursued
• Grantees must establish and monitor procedures to
  ensure that their subgrantees verify and document
  client eligibility

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CARE Act Payer of Last Resort Policies

• Direct service grantees and subgrantees must
  document that their clients are screened for and
  enrolled in eligible programs and their benefits
  are coordinated after enrollment
• Medicare, Medicaid, VA health care benefits,
  private health insurance
• Other programs include public housing, drug or
  mental health treatment, or Food Stamps
• Income assistance, including disability income
  and Temporary Assistance to Needy Families (TANF)
• Grantees must coordinate with other funders to
  ensure that CARE Act funds are the payer of last
  resort
• These and other HAB requirements are subject to
  audit

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Eligibility Determination Pieces of the Puzzle

• There is a vast array of entitlement and
  discretionary programs that HIV clients may be
  eligible for today and tomorrow
• Eligibility criteria (the short list)

• Geographic residency, US citizenship, legal
  residency status, age, gender, previous financial
  contributions by client, employment status, type
  of employer, preexisting medical condition,
  disability, employability, income, assets, HIV
  serostatus, CD4 count, annual or lifetime
  utilization of benefits, criminal convictions

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Medicaid Eligibility For HIV/AIDS Beneficiaries
Assistance Category Eligibility Criteria Mandatory/Optional
Supplemental Security Income (SSI) Severely disabled, unemployable, low-income Mandatory
Parents, pregnant women, children Low income, with income and asset criteria vary by assistance category and State Mandatory, States may offer higher income threshold
Medically needy Severely disabled and low income (median56 of FPL) after subtracting medical expenses Optional, 35 States use this option for disabled individuals
Workers with disabilities Severely disabled, low-income, for persons returning to the workforce Optional
Poverty level expansion Allows for income above SSI levels up to the FPL Optional, 19 States use this option
State Supplemental Payment (SSP) Allows for coverage of beneficiaries receiving SSP Optional, 21 States use this option
Adapted from Kaiser Family Foundation HAB
presentation
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Medicaid and HIV/AIDS

• Social Security Administration (SSA) delegates
  the review of SSI applications to States
• Substantial variability in the acceptance rates
  of SSI applications from HIV individuals
• Initial denial rates tend to be very high
• Significant changes are being made to State
  Medicaid programs due to the Deficit Reduction
  Act (DRA)
• Example beneficiaries and applicants must
  document their US citizenship
• Disability claims are taking longer than ever to
  process
• Many State and federal entitlement programs have
  had layoffs or are working with inexperienced
  staff

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Medicare Eligibility For HIV/AIDS Beneficiaries
Assistance Category Eligibility Criteria
Individuals age 65 years or older Sufficient number of work credits to quality for Social Security payments
Individuals under 65 years of age Sufficient number of work credits to quality for Social Security Disability Income (SSDI) payments due to disability also includes spouses and adults disabled since childhood Have been receiving SSDI payments for at least 24 months
Individuals with end-stage renal disease, any age Sufficient number of work credits to qualify for Social Security payments
Adapted from Kaiser Family Foundation HAB
presentation
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Commercial Insurance

• Coverage is primarily through group benefits via
  employers or association membership
• Individual coverage can be purchased through
  carriers
• Some states fund health insurance pools in which
  individuals and families can purchase premiums
• Benefits vary substantially among carriers
• ED must address
• Waiting periods for pre-existing medical
  conditions
• Annual or lifetime caps
• Service utilization limits for specific services
  (e.g., number of prescriptions, home health
  visits)
• HIV beneficiaries of these plans may receive
  CARE Act benefits during waiting periods or while
  services caps are exceeded
• Some eligible HIV individuals do not seek
  insurance or drop their coverage due to
• Concern about HIV disclosure and discrimination
• Growing premiums, co-payments, and deductibles
• Important to counsel clients
• To retain or seek coverage during open season
• Seek improved coverage if they have limited
  benefits or high premiums, co-payments, or
  deductibles

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What is HABs policy regarding veterans?

• In 2004, HAB clarified their policy about
  providing CARE Act services to HIV veterans who
  also are eligible for VA benefits
  http//hab.hrsa.gov/law/0401.htm
• CARE Act providers
• Should inquire if a client is a veteran and
  enrolled in the VA
• May not deny services, including medications, to
  veterans who are otherwise eligible for the CARE
  Act
• Should be knowledgeable about VA medical
  benefits, including medications
• Must coordinate health care benefits for veterans
• Make HIV veterans aware of VA services available
  procedures for getting VA care and helping them
  navigate care systems to secure HIV care
• Even if enrolled in the VA, a veteran does not
  have to use the VA as their exclusive health care
  provider

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What are the eligibility criteria for veterans to
receive services from the VA?

• Eligibility information is available at
  http//www.va.gov/healtheligibility/HECHome.htm
• Eligibility for most veterans health care
  benefits is based on active military service in
  the Army, Navy, Air Force, Marines, or Coast
  Guard, and other criteria
• VA health care benefits are not just for veterans
  who served in combat or have a service-connected
  injury or medical condition
• Not all veterans are eligible for VA benefits
• In recent years, VA eligibility requirements
• have become increasingly strict

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Partners In Eligibility Determination (ED)

• Grantees
• Direct service agency managers
• Case managers or other ED staff
• Physicians documenting disability
• Reception staff
• Other payers and other systems

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Adoption of System-wide ED Processes

• Some grantees use unified, coordinated ED
  processes
• Fund trained ED workers
• Set clear eligibility criteria and apply them for
  all clients
• Centralized intake on behalf of all HIV providers
  in the system
• Use standardized forms and train personnel to use
  them
• Ensure forms are linguistically appropriate to
  the subpopulations served
• Require tax returns or credit checks to document
  income, assets, and employment
• Use contractual language regarding ED
  requirements that is auditable and enforceable
• Determine how client-level data will be
  transmitted effectively between agencies, with
  HIPAA requirements addressed for data transfer

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Adoption of System-wide ED Processes

• ADAPs that delegate ED to case managers, should
  determine if they screen effectively for
  eligibility for other programs
• Particularly critical in jurisdictions with
  waiting lists
• Collaborate with other care systems to identify
  resources and coordinate referrals
• Other systems include substance abuse and mental
  health treatment, affordable housing,
  pantry/nutrition programs, transportation, etc.
• Legal services must be available (through CARE
  Act-funded programs or referral) to pursue
  administrative procedures following rejected
  disability or other claims and to assist clients
  in employment discrimination cases
• Establish processes with SSA to fast track
  applications and to train public and commercial
  claim assessment staff regarding HIV disease

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Adoption of System-wide ED Processes

• Ensure that culturally and linguistically
  competent ED processes are in place to address
  the needs of subpopulations (e.g., undocumented
  residents)
• Systematically assess the ED processes of HIV
  subgrantees by applying performance standards
  and auditing charts
• In systems with multiple agencies conducting ED,
  benchmark data can be used to compare the
  performance of subgrantees
• Subgrantees failing to document ED processes
  might be subject to progressive discipline,
  including withholding payments or other penalties
• Effective coordination with Medicaid and other
  payers to expand eligibility is critical
• Changes to major payers in your community should
  be rapidly communicated to subgrantees and their
  ED workers

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Strategies For HIV Programs

• Do not assume another agency will take care of ED
  unless that explicit role is assigned to another
  agency in your community
• Coordinate with community partners if another
  agency is responsible for ED
• Determine how client-level will be transmitted
  effectively between agencies, with HIPAA
  requirements addressed for data transfer
• Do not assume that your programs case managers
  are handling it
• Many case managers report that their case loads
  are too high and that they are not trained to
  handle ED
• Assess if case managers are the most
  cost-effective personnel model for ED

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Strategies For HIV Programs

• Receptionists should ask ALL clients at EACH
  visit if their health insurance status has
  changed since their last appointment
• It is important that receptionists not assume
  that no change has occurred
• At the beginning of each calendar year, it is
  important to confirm insurance status
• Have them confirm through the online Medicaid
  system that the client is newly or still enrolled
• Copies of new health insurance cards should be
  made and filed
• Intake and re-determination forms should be
  tailored to screen for the unique set of health
  and other programs in your community
• It is not enough to ask a client if he/she is
  enrolled but assess eligibility based on the
  criteria used for relevant programs

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Strategies For HIV Programs

• Review your policies and procedures with your ED
  staff to determine what is actually being done
• Talk to your staff, assess data, and conduct your
  own audits
• Develop CQI to improve ED
• Some agencies find electronic case management
  software helpful in ED screening
• It is important that the software be updated
  regularly to reflect new programs or changes in
  existing programs
• Train and retrain ED staff and test their
  knowledge periodically
• Use trained and experienced supervisors
• Use benchmark data to compare ED workers
  performance
• Identify entitlement and discretionary programs
  for which there are barriers to enrollment
• Document the problem and establish ongoing
  processes for resolution an important advocacy
  role
• Communicate with other HIV programs to document
  system-wide barriers
• Routinely monitor changes in entitlement and
  discretionary programs that impact eligibility
  and adjust accordingly

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Effective Strategies Used By ED Staff

• Knowing how to complete the paperwork, document
  claims, and making sure clients follow through
  are the keys to success
• Provide ED in England and other languages spoken
  by your target population
• Do not front-loaded ED at entry in care
• Screen for eligibility on a routine basis (e.g.,
  every six to twelve months)
• Use rolling re-determination to normalize
  required staffing
• Medical providers must communicate with ED staff
  about eligibility triggers
• Loss of employment due to disability, inability
  to be employed due to the side efforts of HAART,
  inpatient admissions, changes in clinical
  condition
• Do not assume that clients disability claims
  should only be HIV-related, they may have other
  chronic conditions

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Effective Strategies Used By ED Staff

• Encourage clients with health insurance, income,
  or assets to disclose honestly relevant
  information
• Coordinate applications for benefits
• Avoid flooding the system with completed forms to
  see what sticks
• Do not advise clients to get a Medicaid
  rejection letter so they can access CARE
  Act-funded services
• Rather, work with the client to prepare valid,
  accurate applications for benefits
• Partner with legal aid staff to prepare well
  documented applications and address
  discrimination issues

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Effective Strategies In Working With Clients

• Communicate with clients that to continue to
  operate, your program must have revenue
• Avoid the attitude dont ask, dont tell,
  giving the clients the impression that there is a
  free lunch
• Providers are often unaware that clients are
  already enrolled or eligible for care
• Concerns about discrimination and stigma are real
  and may result in lack of complete disclosure
• Do not assume that clients can navigate the
  system, read, or complete forms
• Conversely, do not assume that clients cannot
  navigate the system when some can
• ED processes that rely heavily on clients are
  commonly doomed
• Paperwork is not the highest priority when you
  are trying to survive
• Ensure that clients receive the maximum benefit
  to which they are legally entitled