Ryan White Providers and Medicaid: Preparing for 2014

1. Ryan White Providers and Medicaid: Preparing for 2014 June 25, 2013 2:30 – 4:00 pm EST

2. Visit Healthcare.gov • The Department of Health and Human Services just re-launched this website on June 24, 2013. • It contains many new tools and resources for you and your clients to understand their health care coverage options. • Please direct your Ryan White Program colleagues and your clients to visit the site and learn more! • Also available in Spanish at CuidadoDeSalud.gov. • Consumers can also contact the Health Insurance Marketplace call center at 1-800-318-2596 (TTY: 1-855-889-4925)

3. HAB Technical Assistance Activities Focused on ACA Implementation and Ryan White Grantees • Launched new ACA section of HAB website - Ryan White and the Affordable Care Act: What You Need to Know - routinely update tools, policies and resources. To stay up-to-date please visit http://hab.hrsa.gov/affordablecareact/ • Launched new ACA section of HAB-funded TARGET Center TA site to link to many resources and tools developed by HHS, Ryan White grantees and stakeholders. To stay up-to date please visit https://careacttarget.org/category/topics/ health-care-reform • Planning webinar for July to review recently issued or updated Ryan White Program policies • Presented three Ryan White Program and ACA focused webinars to date and planning more with CMS and other partners - this one along with other two will be archived on our HAB website • Developing a series of ACA tip sheets for Ryan White providers, grantees and clients to be issued this summer • Working with the National Academy for State Health Policy (NASHP) to develop webinar and resources for Ryan White state based grantees • Developing new and updating current Ryan White program policy notices to clarify issues for grantees pertaining to ACA implementation • Drafting CAREAction newsletter on ACA for grantees and stakeholders • HAB’s ACA webpage will soon include Frequently Asked Questions and Answers to serve as helpful TA tools and HAB will continue to update these as we approach 2014

4. Agenda for Today’s Webcast • Welcome and Overview – Laura Cheever, Acting Associate Administrator, HIV/AIDS Bureau, HRSA • Welcome from CMS – Stephen Cha, Medical Director for Center for Medicaid and CHIP Services • The Changing Landscape of the Health Care Delivery System • Jessica Newman, Senior Program Officer, Center for Health Care Strategies (CHCS) Inc. • Question and Answer Session • What Should Ryan White Providers Do Next? • Maria Courogen, Director, Office of Infectious Disease, Washington State Department of Health • Kasey Harding-Wheeler, Director of Integrated Care for Special Populations, Community Health Center Inc. • Question and Answer Session • Concluding Remarks

5. The Changing Landscape of the Health Care Delivery System: Ryan White Providers and Medicaid Managed Care HRSA/CMS Ryan White Providers and Medicaid: Preparing for 2014 Webinar June 25, 2013 Jessica Newman, Senior Program Officer

6. A non-profit health policy resource center dedicated to improving services for Americans receiving publicly financed care Priorities: (1) enhancing access to coverage and services; (2) advancing quality and delivery system reform; (3) integrating care for people with complex needs; and (4) building Medicaid leadership and capacity. Provides: technical assistance for stakeholders of publicly financed care, including states, health plans, providers, and consumer groups; and informs federal and state policymakers regarding payment and delivery system improvement. Funding: philanthropy and the U.S. Department of Health and Human Services. 6

7. Setting the Stage • In 2014, people living with HIV/AIDS (PLWH) will become eligible for insurance in significant numbers • You are critical to keeping this vulnerable and complex population healthy with both medical and social services • While many providers have experience working with Medicaid and health plans, many have not • Goal for today: provide an introduction to participating in Medicaid managed care

8. Today’s Agenda

9. Federal Reform Basics: Coverage Expansions Under Health Reform • ACA provides two key vehicles for health insurance coverage expansion: • Health insurance marketplaces, combined with premium and cost sharing subsidies for those with income between 100-400% FPL • Medicaid expansion for individuals under age 65 with incomes up to 138% FPL

10. What do the new coverage options mean for Ryan White Providers? • Many PLWH will be eligible for new health insurance options • Many PLWH will receive coverage through a health plan, either through the Marketplace or Medicaid • Timing is key -- Open enrollment begins October 1st • Medicaid enrollment is ongoing • Your relationships with patients are critical to serving this population • Medicaid programs need your experience in serving this new, vulnerable population

11. How will PLWH receive insurance? PLWH eligible for health coverage Employer-Based Insurance Health Insurance Marketplace Other Private Other Public Ryan White Program Cover comprehensive HIV medical and support services not covered by public programs or private insurance Cover comprehensive HIV medical and support services not covered by public programs or private insurance PLWH who remain uninsured Source: Adapted from The Affordable Care Act and the Ryan White HIV/AIDS Program: New Opportunities for People Living with HIV/AIDS, Presentation by: Health Resources and Services Administration and Centers for Medicare and Medicaid Services, April 5, 2013.

12. Today’s Agenda

13. How are Medicaid services delivered to enrollees? • FEE-FOR-SERVICE (FFS) • The state is responsible for provider reimbursement and rate development • Enrollees choose doctors, hospitals, and other providers who are enrolled in the state’s Medicaid program and agree to accept the Medicaid reimbursement • Providers are typically reimbursed for each service provided Managed care • The state contracts with a managed care organization (MCO) which is typically paid an amount per member per month to cover Medicaid services • MCOs are financially “at risk” for the health care costs of their enrollees • MCOs subcontract with doctors, hospitals, and other providers • MCO reimburses for Medicaid services, not the state • Creates a provider network • Enrollees almost always are limited to receiving services from network providers

14. What does a managed care arrangement offer providers? A way to continue to serve your patients Payment for covered services that is generally at least as much as the State’s FFS payment Published provider network directory and enrollee services team to help members locate providers (because enrollees must choose from within the network, you will become a “go-to” provider) Provider services staff and/or hotline to answer questions and resolve billing and other problems Training on claims submission, medical record keeping, medical management, and other key policies and systems Help with enrollee patient care coordination through PCP and the plan’s care management and outreach staff

15. What does a managed care arrangement offer enrollees? • Improved access to care through a guaranteed provider network for all Medicaid services • Enrolled services staff and a provider directory to help enrollees identify providers • A primary care provider to coordinate and manage care • Additional care management activities to coordinate improved care • Enrollee rights to grievances, appeals, and fair hearings to complaints and service authorizations

16. Today’s Agenda

17. Enrolling in a Medicaid Health Plan For each of these steps, you will need to (1) prepare for associated IT/systems requirements, staffing and training needs and (2) familiarize yourself with the associated health plan resources • Identify and contact Medicaid health plans • Understand the contract • Prepare for provider credentialing • Understand provider networks • Learn how to submit claims on standard insurance forms (CMS 1500) • Understand medical management • Understand member benefits and eligibility For each of these steps, you will need to (1) prepare for associated IT/systems requirements, staffing and training needs and (2) familiarize yourself with the associated health plan resources.

18. Identify and contact Medicaid health plans Who are the Medicaid health plans in my state? Who should I contact at the Medicaid health plan? • Each plan will have a provider contracting or provider services department that can help you prepare to participate in the provider network • In anticipation of the changes in 2014, plans likely will offer orientation and training for providers • Health plan staff, structure, and requirements will vary by health plan; prepare to learn about and interface with multiple plans • Your state will contract with at least one Medicaid health plan on a statewide or regional basis • Your state Medicaid website or staff can help you identify the Medicaid health plans: www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

19. Provider credentialing What will I need to meet provider credentialing requirements? How do I prepare? • Understand credentialing requirements; allow time for approval – the credentialing process can take several months • Most health plan websites have their provider applications and instructions available • Contact health plan provider services staff • Valid license to practice medicine or provide services, when applicable; • Valid Drug Enforcement Administration (DEA) and state prescriber’s license/certificate, when applicable, by specialty; • Complete and accurate work history; • Other education or training, as applicable, by specialty; and • Malpractice, loss of license, or limitations of privileges, when applicable.

20. Provider networks What are the responsibilities of PCPs and specialists? • Enrollees select a primary care physician (PCP) • The PCP coordinates care for enrollees, establish and maintains medical records, ensures access to care, provides referrals for specialty care • Some plans may allow you to be a PCP for PLWH; others may classify you as a specialist • In some health plan networks, enrollees must receive a referral from their PCP to see a specialist. In other networks, enrollees can self-refer. You must understand the protocols for each plan; rendering services as a specialists without a PCP referral will result in non-payment of your claim • Specialists are expected to send status reports back to the PCP to enable the PCP to properly coordinate and monitor the enrollee’s care

21. Provider networks, cont How do I prepare? • Review existing IT capabilities: medical records system • Assign, train, or hire staff: Prepare staff to maintain medical records, coordinate reports back to PCP as needed • Health plan resources: Provider services staff

22. Health plan billing and reimbursement How will I be paid for services? • Plans reimburse providers based on the terms of the contract • Some pay a fee for each covered services (known as fee-for-service reimbursement), others pay a fee for a bundle of services • The exact payment structure and rates must be clearly spelled out in the contract so that all parties understand them • You will need to submit a claim (likely electronically) with required fields • Many providers use billing services or clearing houses to do this • Claims must be submitted in a timely fashion and will be approved by the health plan • The time limit will be spelled out in the contract • Failure to submit within this timeframe will result in denial of the claim

23. Health plan billing and reimbursement, cont How do I prepare? • Review existing IT capabilities: internal billing system; ability to transmit claims securely; ability to receive payment • Many health plans pay claims using electronic funds transfer (EFT). EFT is safer and much faster than paper checks. Review your accounting practices to ensure readiness. • Assign, train, or hire staff: Billing staff; accounting staff; IT systems staff or contractor • Health plan resources: Test claims submission; provider services representative; health plan training opportunities; provider manual

24. Medical management: prior authorization What is prior authorization? • For some services, providers must request prior authorization to ensure that care is provided in the most appropriate care setting for enrollees • Each health plan will provide more information on which services require prior authorization, as well as the process for making the request and timeline for getting responses • If required, prior authorization must be obtained before services are rendered except in emergencies • Check the provider manual and/or contract for emergency services notification protocol • PA must be received for reimbursement; failure to obtain prior authorization will result in an automatic denial of the claim

25. Medical management: prior authorization, cont How do I prepare? • Assign, train, or hire staff: Train clinicians to educate enrollees; implement practice policy to ensure that PA guidelines from the plans you are contracted with are followed • Health plan resources: Medical management staff; provider manual/contract

26. Medical management: care management What is care management? How do I prepare? • Assign, train, or hire staff: Train staff to understand the needs of your enrollees; learn the process for referring enrollees to care management • Health plan resources: Understand care management and coordination resources; medical management staff • Care management coordinates enrollee’s care, including physical, behavioral, and often supportive services • Care management can assist in navigating the health care system and identifying needed services; removing barriers to seeking care (e.g., transportation, interpretive services); education around specific diseases • Providers can refer enrollees that would benefit from additional care management services to the health plan; enrollees are also identified by claims data and other sources

27. Enrollee services What services can I provide? • Enrollees may be enrolled in more than one Medicaid health plan, depending on how the state covers services • It is common to have one health plan for physical and acute services and another for behavioral health services • Other services or benefits (e.g., prescription drugs) may be paid for directly by the state • Enrollees are eligible for certain covered services under Medicaid • Some health plans provide additional services to their enrollees that would not otherwise be covered by Medicaid • Some services may require PA or may be limited, such as prescription drugs • Providers should verify that services are covered to ensure that a submitted claim will be paid

28. Enrollee services, cont How do I prepare? • Assign, train, or hire staff: Train staff to verify covered services on a regular basis; understand whether physical and behavioral health services are covered by different health plans and how you can coordinate • Health plan resources: Online coverage summary; medical management staff

29. Enrollee eligibility Who can I provide services to? How do I prepare? • Review existing IT capabilities: Electronic health record; billing system • Assign, train, or hire staff: Front office staff to verify eligibility/collect co-pay (if applicable) • Know the process for verifying eligibility with both the State and the plan • Health plan resources: Online or telephonic member eligibility verification • Enrollees must be enrolled in the health plan in order for the plan to pay for services • Providers should verify eligibility at each visit to ensure the enrollee is eligible and enrolled with the same health plan • If you are enrolled as a PCP, check that the enrollee is assigned to you • Some patients may be required to pay a small co-pay

30. Next steps • Connect with your Medicaid health plans • Identify areas for IT systems changes or upgrades that will need to be made • Review existing staffing structure to determine training and hiring opportunities; consider where contractors may be beneficial • Investigate resources for claims clearinghouses, billing management services, as appropriate • Look for training, technical assistance, or other educational opportunities from your state, provider associations, and health plans; learn from your peers

31. Questions Questions?

32. Preparing the Ryan White Care System for Affordable Care Act Implementation in Washington State HRSA/CMS Webinar June 25, 2013 Maria Courogen, MPH Washington State Department of Health The Affordable Care Act - Planning for 2014

33. Every State Is Different… • Generous state funding for people with HIV • Early Intervention Program has history of buying insurance • Medicaid located in a different state agency • Medicaid Expansion = yes • State-operated Health Benefits Exchange • Successful partnerships The Affordable Care Act - Planning for 2014

34. Countdown to 2014 Task List

35. Countdown to 2014 Task List

36. Understanding the client mix Health Benefits Exchange Medicaid Expansion Medicare Undocumented Health Benefit Exchange Undocumented people Medicaid Expansion Medicare 5% 33% 36% 26%

37. Countdown to 2014 Task List

38. Eligibility alignment • Asset limitation • Income determination • Definition of family • Mandatory Marketplace application for clients in first two buckets Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

39. Countdown to 2014 Task List

40. Continuity of operations • Role of Targeted Case Management • Medical Case Management standards for health homes • Data sharing • Payment of client premiums in the Exchange • Review and selection of insurance policies Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

41. Preparing providers • Program formulary and list of primary providers sent to Health Care Authority for comparison • Work with AIDS Education and Training Center • Follow up with current program providers • ACA information in quarterly update • Webinars Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

42. Preparing case managers • Incorporation of ACA information in training • Addition of funds to contracts for outreach, non-medical case management • Navigator training • Lists of clients and expected “buckets” • Review of ACA in fall field visits • Webinars Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

43. Preparing clients • Provide general information about ACA (include importance of filing taxes) • Add information about program-specific impacts to Web, client correspondence • Send client-specific correspondence about expected “bucket” • Town hall meetings (with HIV Prevention) • Webinars Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

44. Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

45. Goal • By March 31, 2014, all program clients will have applied for benefits through the Exchange portal. Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

46. Contact Info Maria Courogen, MPH Washington State Department of Health 360-236-3458 Maria.Courogen@DOH.WA.GOV Health Benefit Exchange Undocumented people Medicaid Expansion Medicare

47. Preparing for January 2014 Kasey Harding-Wheeler, Director of Integrated Care for Special Populations, Community Health Center, Inc.

48. What does the Affordable Care Act have to do with Ryan White Consumers? • RW Consumers who were previously not eligible for Medicaid may be able to reapply with the new guidelines for eligibility. • RW Consumers who were previously not eligible for private insurance because of a pre-existing condition are now eligible. • Insurance premiums are federally regulated to avoid prohibitively high costs to consumers. • The CT Insurance Exchange provides consumers with an opportunity to shop for private insurance plans at reasonable costs. • ACA navigators and other special resources are available at FQHC’s and other agencies to assist consumers who need help in acquiring the appropriate level of coverage. • Federal tax credits may be available for consumers who qualify. • Federal tax penalties will be imposed to uninsured individuals.

49. ACA Implementation Plan for Ryan White Part C

50. Implementation Plan Continued