EFFECTIVE ELIGIBILITY DETERMINATION FOR THE

CARE ACT AND OTHER SYSTEMS

EFFECTIVE ELIGIBILITY DETERMINATION FOR THE

CARE ACT AND OTHER SYSTEMS

Julia Hidalgo, ScD, MSW, MPH

Positive Outcomes, Inc.Harwood MD

www.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net

The CARE Act is the payer of last resortGrantees 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

CARE Act Payer of Last Resort PoliciesCARE 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

CARE Act Payer of Last Resort PoliciesCARE Act Payer of Last Resort Policies

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

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 (median=56% 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

Medicaid and HIV/AIDSSocial 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 citizenshipDisability claims are taking longer than ever to

process Many State and federal entitlement programs have

had layoffs or are working with inexperienced staff

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

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

What is HAB’s 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

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 benefitsIn recent years, VA eligibility requirements

have become increasingly strict

Partners In Eligibility Determination (ED)

GranteesDirect service agency managersCase managers or other ED staffPhysicians documenting disabilityReception staff Other payers and other systems

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

Adoption of System-wide ED ProcessesAdoption 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

Adoption of System-wide ED ProcessesAdoption 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

Adoption of System-wide ED ProcessesAdoption of System-wide ED Processes

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 program’s 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

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

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

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

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

Effective Strategies Used By ED Staff

Effective Strategies In Working With Clients Communicate with clients that to continue to operate,

your program must have revenue Avoid the attitude “don’t ask, don’t 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