November 3, 2011 Brenda G. Klütz Senior Consultant Health Management Associates

Medi-Cal Reimbursement for Prisons and JailsCalifornia/Nevada Chapter of the American Correctional Health Services Association: Multidisciplinary Correctional Conference November 3, 2011 Brenda G. Klütz Senior Consultant Health Management Associates

Learning Objectives • Understand current Medi-Cal & reimbursement opportunities for inmate inpatient stays • Understand the how the key elements of healthcare reform effect payment for inmate, parolee and probationers health now & in 2014

Health Management Associates • Public health policy and management consulting firm, 12 offices • Focus on Medicaid, uninsured, public health care programs and systems, health care reform, access and quality • Clients: • County health systems and jails, prison systems • Medicaid agencies, managed care, county governments, professional associations, hospitals and health systems, insurers, foundations

Today’s Medicaid The Basics

Medicaid Eligibility • Eligibility is based largely on: • Income • Assets • Age (under 21 and over 64) • Families with children • Disability

Medicaid Eligibility • Low-income, childless adults between the ages of 21 through 64 are generally not eligible for Medicaid, unless they have a disability.

Advantages of Medicaid Funding • State Medicaid expenditures are matched by Federal funds: amount of match is the Federal Medical Assistance Percentage (FMAP)

Advantages of Medicaid Funding • The FMAP formula is a state’s per capita income relative to U.S. per capita income: higher match to states with lower incomes (with a maximum of 83%) lower match to states with higher incomes (minimum of 50%).

Advantage of Medicaid Funding • California’s FMAP is 50% • Nevada’s FMAP is 51.63% (2011)

Medicaid and Inmate Health Care What will Medicaid Pay for?

Medicaid and Inmates: The Facts • Medicaid does not provide matching funds for services provided to incarcerated persons • However, an inmate who spends 24 hours or more in a medical institution is not considered to be incarcerated during that time, even though still in custody

Medicaid and Inmates: The Facts • “Medical institution” = hospital or skilled nursing facility not operated by the corrections organization, serves the general public • (See Appendix A & B of Handout)

Medicaid and Inmates: The Facts • CMS will provide matching funds for inpatient services provided in a hospital that has a locked correctional unit, as long as the overall hospital serves the general public. (See Appendix C)

Medicaid and Inmates: The Facts • Federal Medicaid rules allow payment for certain inpatient services provided to inmates who are eligible & enrolled in Medicaid. • CMS has made clear, that federal law does not require states to dis-enroll inmates from Medicaid, but the state may only claim federal matching funds for certain services. (See Appendix B)

Medicaid and Inmates: The Facts • Many states dis-enroll Medicaid beneficiaries upon incarceration. • States may not have a process to enroll inmates in Medicaid if they become eligible while in prison or jail • State laws, regulations or policies may prohibit continued enrollment

Advantages of Medicaid Eligibility and Enrollment • If state laws permit, prisons and jails can claim federal matching funds for some health care services provided to eligible inmates that are now paid for by 100% state general fund • Ensuring eligibility prior to release can ensure more seamless health care

What Other States are Doing • At least nine other states have been claiming federal matching funds for the cost of inpatient stays for eligible inmates • Some started in the late 1990’s • At least 5 other states have new laws or are proposing laws to permit

Health Care Reform How might it affect inmates?

Key Provisions of the Patient Protection and Affordable Care Act • Insurance Market Reforms in All States • Delivery System Redesign • Payment models • Primary care workforce initiatives • Coverage Expansions • Health Insurance Exchanges • Medicaid Expansions

Health Care Reform • Effective 1/1/2014: • Asset, age and disability criteria for Medicaid eligibility will be eliminated • Individuals with incomes of up to 133% FPL will be eligible for Medi-Cal

Health Care Reform • Individuals with income from 134% up to 200% FPL will be eligible for coverage through CA Health Benefit Exchange • Low income (up to 133% FPL), childless adults between the ages of 21 through 64 will be eligible for some Medicaid coverage. (majority of prison and jail population)

Health Care Reform • In 2014, federal match for new enrollees will be 100% • Year Two the match will be 90% federal funds

Planning for 2014 California’s Approach

California’s Bridge to Reform • By 1/1/2014, approximately 851,000 currently-uninsured Californians will be eligible for Medi-Cal.

California’s Bridge to Reform • Created a Medicaid waiver option for counties to participate in a Medicaid expansion program: Low Income Health Program (LIHP) • Covers childless adults age 21 through 64, with income levels of up to 133% FPL and 200% FPL

California’s Bridge to Reform • Starts to provide Medi-Cal-like coverage for low-income childless adults prior to health care reform’s full implementation • Builds the provider network capacity to prepare for 1/1/2014

California Law Change in 2010 • California regulations previously required counties to dis-enroll Medi-Cal beneficiaries upon incarceration

California Law Change in 2010 • California law now mandates counties to enroll state prison inmates in LIHP • Gives counties the option to enroll inmates county jails to enroll in the LIHP or in the Medi-Cal program • Law is silent about city jails. (See Appendix D of Handout)

Which Inmates TODAY are eligible (CA)? • State Medicaid income & asset guidelines AND • Categorical Eligibility • Pregnant women • Inmates< age 21 • Inmates age 65> • Disabled for at least 12 months • Most relevant to prisons, but jails often have isolated very costly cases

Will it Last? • According the Centers for Medicare and Medicaid, Medicaid Disabled and Elderly Programs: • There is no plan to rescind FFP for inmate inpatient care • Medicaid eligibility for inmates offers important opportunities for continuity of care for chronic conditions, mental illness

Challenges and Opportunities

Medicaid as Payment in Full • Federal rule prohibit providers participating in Medicaid to balance-bill patients or providers • For some prisons and jails, provider payment levels are in statute and exceed Medicaid rates • Some prisons and jails have negotiated contract rates with providers that exceed Medicaid rates

Medicaid as Payer of Last Resort • Hospitals may challenge Medicaid payment because they perceive prison, jail, or vendor as insurance coverage. • Key distinction between insurance and a correctional organization’s constitutional obligation as custodian to avoid deliberate indifference and cruel or unusual treatment.

Alternatives • Hospital bills Medicaid for admission, accepts payment; prison/jail makes periodic “patch payment” to provider • Prison/jail consolidates admissions to specific hospitals to gain volume and cooperation

Implementation Issues: Hospitals • Is Medicaid payment acceptable? • Enrollment/eligibility process – who does it? (In California, it is the counties) • Does hospital bill Medicaid? • Is payment significantly delayed?

Implementation Issues: Inmates • Freedom of Choice issue • Inmate doesn’t want to enroll/sign Medicaid application • Documents not available • Birth certificate • Tax statements • Bank statements

Implementation Issues: Jails • Difficult to change state law individually • May require additional resources, or administrative systems changes • In California, county jails should be working with the county health or social services department

Prisons • May require new resources • May require tracking system for claims, high-cost inmates, eligibility status, redetermination dates

Implementation Issues: Medicaid • Suspended eligibility • Requires new resources (but 50% federal match) • How is federal match tracked and traded? • Many other competing priorities related to health care reform

Implementation • Extremely complex and varies enormously by state Medicaid program • May begin with workgroup that includes Medicaid and the agency that decides eligibility • May work on jails and prisons simultaneously • Most programs start by manually processing a few high-cost cases

Other Opportunities • Create information for inmates under age 26 about coverage on parent’s insurance plan • Assist eligible inmates with serious health needs to enroll prior to release

Get Moving Toward 2014 • Work with community stakeholders to develop • Streamlined discharge planning • Common prescription drug formulary • Continuity of care • Targeted Case Management Programs • Develop inmate education materials

Discussion

Brenda Klutz, Senior Consultant Health Management Associates916.446.4601, ext. 424bklutz@healthmanagement.com For more information contact

November 3, 2011 Brenda G. Klütz Senior Consultant Health Management Associates