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Medicaid Expansion in the District of Columbia November 27, 2012

Medicaid Expansion in the District of Columbia November 27, 2012. Background. Unique Environment Grants. Multiple Federal Grants CARE Act Part A $31.2 Million CARE Act Part B $20.2 Million HOPWA $13.6 Million Multiple Federal Footprints. Unique Environment Geography. DC VA MD WVa

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Medicaid Expansion in the District of Columbia November 27, 2012

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  1. Medicaid Expansion in the District of ColumbiaNovember 27, 2012

  2. Background

  3. Unique Environment Grants • Multiple Federal Grants • CARE Act Part A $31.2 Million • CARE Act Part B $20.2 Million • HOPWA $13.6 Million • Multiple Federal Footprints

  4. Unique Environment Geography DCVA MD WVa • Part A X X X X • Part B X • HOPWA X X xx • CDC X

  5. Unique Environment DC • Department of Defense Drug Price • Available to all ADAP • Requires • Centralized Purchase • Centralized Delivery and Re-Distribution • Replenishment, not Reimbursement • Low Prices

  6. Unique Environment DC • Robust Medicaid • All FDA-Approved Medications • Wide Range of Specialty Benefits • 1115 Medicaid • Cost Neutrality by DOD Drug Prices • Applied to • HIV Anti-Retrovirals • Medicaid Fee-for-Service Clients with HIV

  7. Unique Environment Alliance • DC Locally Funded Health Insurance • Eligible Residents • Income Less than 200% FPL • Not Medicaid Eligible • “Carve Out” for HIV Anti-Retrovirals • Forty Percent of ADAP Beneficiaries were Alliance Enrollees

  8. Medicaid Expansion DC • Eligibility 133% FPL July 1, 2010 • End of 1115 Waiver Sept 30, 2010 • Eligibility 200% FPL Dec 1, 2010 • Alliance Enrollment Decreases • In the District of Columbia • Adults with Coverage 93% • Children with Coverage 96%

  9. Medicaid Expansion ADAP • ADAP Beneficiaries (Approx) • Before Medicaid Expansion 2,000 • Enrolled into Medicaid 1,235 • Served (Monthly Avg) • “Traditional” ADAP 700 • ADAP for Co-Paymentor Deductibles 275

  10. Medicaid Expansion ADAP • Implications • Substantial Cost-Shifting from ADAP to Medicaid • Cost to the District of Columbia • Increased for Drugs • Decreased Cost for Primary Care, Inpatient Care

  11. Medicaid Expansion ADAP • Implications for Pharmacy Points of Sale • Revitalized Pharmacy Network • Re-Framed Drug Assistance Program • Single Standard Regardless of Funding Source • Increased Efficiency • Reduced Costs

  12. Medicaid Expansion • Next Steps • Medicaid Managed Care Organizations • Provide Drugs through DOD Pricing • 3,200 Beneficiaries • Effective January 2013

  13. Medicaid Expansion • Implications for Primary Care • Little Disruption in Service Providers • HIV Primary Care Providers Supported by CARE Act, Medicaid and Alliance • Increased Emphasis on Health Care Financing

  14. Medicaid Expansion • Implications for Support Service Providers • Increases Emphasis on Demonstrating Health Outcomes • Enhances Need for Coordination, Collaboration and Partnership

  15. Medicaid Expansion • Financing Health Care

  16. Payorof Last Resort • Core Requirement of the CARE Act • Ensures All Other Payor Sources Used • Some Exceptions • Indian Health Service • Veterans • Competing “Payor of Last Resort” Provisions, e.g., FQHC

  17. Payorof Last Resort • Familiarity with Third Party Payor Systems and Benefits • Medicaid • Medicare • Indian Health Service • Alliance • Ensure Clients are • Screened • Enrolled if Eligible

  18. Payorof Last Resort • Ensure Claims are • Billed • Collected • Returned as Program Income

  19. Payorof Last Resort • Past Practices • Parallel Systems of Care • CARE Act Clients • Medicaid Clients • Fee for Service Reimbursement for CARE Services • Coding • Cost Recovery • Adoption of Medicaid Rates

  20. “Whole Program” • Allows a Single Standard of Care without Regard to Funding Source • Maximizes Flexibility of Funding to Support Whole Program • Requires Different Reimbursements • Third Party Fee-for-Service • CARE Act Cost Reimbursement • Results in Program Income

  21. Program Income • Income Generated by Funded Program • Third Party Payment • Client Fees or Client Contribution • Required • Demonstrated Benefit the HIV Program • Track and Report Monthly

  22. Program Income • Example • CARE Act Sub-Grant for Outpatient Ambulatory Care • Cost Reimbursement • Pays Salaries • Salaried Staff • Service Unit Paid by Medicaid • Medicaid Reimbursement is Program Income

  23. Program Income • May Be Used in Ways Not Permitted for CARE Act Funds • Occupancy Costs • Administrative Costs • Drug Costs for non-HIV Conditions • Competing Federal Guidance • Multiple Parts of CARE Act • Federally Qualified Health Centers

  24. Whole Program Medical Home • Program Income Can Support “Medical Home” Activities • Ensuring Linkage from Testing • Re-Engaging Lost-to-Care Clients • Targeted Support for High-Need Clients • Liaisons with Support Organizations

  25. Prospects • Single System of Services • Consistently High Standards of Care • Supported by Multiple Funding Sources • Organized around Client Need • Achieved through Dynamic Partnerships

  26. Questions and Discussion

  27. Gunther Freehill, Chief Care, Housing and Support Services Bureau HIV/AIDS, Hepatitis, STD and Tuberculosis Administration (HAHSTA) 899 North Capitol Fourth Floor Washington, DC 20002 Phone: 202/671-4900 Fax: 202/671-4860 E-mail: Gunther.Freehill@DC.Gov Contact Information

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