Presentation on theme: "Medi-Cal Reimbursement for Prisons and Jails California/Nevada Chapter of the American Correctional Health Services Association: Multidisciplinary Correctional."— Presentation transcript:
1Medi-Cal Reimbursement for Prisons and Jails California/Nevada Chapter of the American Correctional Health Services Association: Multidisciplinary Correctional ConferenceNovember 3, 2011Brenda G. KlützSenior ConsultantHealth Management Associates
2Learning ObjectivesUnderstand current Medi-Cal & reimbursement opportunities for inmate inpatient staysUnderstand the how the key elements of healthcare reform effect payment for inmate, parolee and probationers health now & in 2014
3Health Management Associates Public health policy and management consulting firm, 12 officesFocus on Medicaid, uninsured, public health care programs and systems, health care reform, access and qualityClients:County health systems and jails, prison systemsMedicaid agencies, managed care, county governments, professional associations, hospitals and health systems, insurers, foundationsEstablish my credibility – not just making this upEmploy at least 10 ex-Medicaid directors and many high –level Medicaid administratorsCMS director of Medicaid eligibility = Ohio Medicaid director and HMA principalConduct Kaiser Medicaid survey every year, relationships with almost all Medicaid agenciesCurrent engagements with CA Prison Health Care Services, Michigan DOC addressing this issueSeveral engagements under development with county health systems and jailsRecently surveyed 12 state DOCs:CA Colorado Louisiana Mass MI MississippiMissouri Nebraska NY NC OK Washington WisconsinHow many in audience are prisons? How many jails?How many are billing Medicaid now?How many tried and stopped?How many working on starting now?How many not but should be?
5Medicaid Eligibility Eligibility is based largely on: Income Assets Age (under 21 and over 64)Families with childrenDisability
6Medicaid EligibilityLow-income, childless adults between the ages of 21 through 64 are generally not eligible for Medicaid, unless they have a disability.
7Advantages of Medicaid Funding State Medicaid expenditures are matched by Federal funds: amount of match is the Federal Medical Assistance Percentage (FMAP)Now prisons and jails using state general fund or county/city $ for inmate hospital careUsing Medicaid where possible reduces cost to state/county/city by providing federal moneyAny FFP not collected is money left on the table in Washington.
8Advantages 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%).
9Advantage of Medicaid Funding California’s FMAP is 50%Nevada’s FMAP is 51.63% (2011)
10Medicaid and Inmate Health Care What will Medicaid Pay for?
11Medicaid and Inmates: The Facts Medicaid does not provide matching funds for services provided to incarcerated personsHowever, 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“Medical institutions” definition has huge implications for corrections systems contemplating building won hospitals or LTC facilities – extremely importantCannot be inside the walls of a prison systemCannot be owned or operated by correctionsEligible services CAN be a distinct locked unit of a community hospital dedicated to inmates, per recent interpretation
12Medicaid 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)
13Medicaid 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)
14Medicaid 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)
15Medicaid 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 jailState laws, regulations or policies may prohibit continued enrollmentNow back to the REAL agendaThere is a great deal of mis-information across corrections and Medicaid agenciesMany confusing elements that seem to relate but don’tThese are the FACTSDear Medicaid Director letter: Medicaid allows Medicaid coverage for eligible inmates who stay overnight in a medical institutionHow many in audience are prisons?
16Advantages 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 fundEnsuring eligibility prior to release can ensure more seamless health care
17What Other States are Doing At least nine other states have been claiming federal matching funds for the cost of inpatient stays for eligible inmatesSome started in the late 1990’sAt least 5 other states have new laws or are proposing laws to permit
18How might it affect inmates? Health Care ReformHow might it affect inmates?
19Key Provisions of the Patient Protection and Affordable Care Act Insurance Market Reforms in All StatesDelivery System RedesignPayment modelsPrimary care workforce initiativesCoverage ExpansionsHealth Insurance ExchangesMedicaid ExpansionsMarket reforms are obligatory by 2014, some for children already in effectExtremely important in leveling the playing field and stopping skimming and dumpingMedical Loss Ratio important – Medicare 2-3% admin fees, commercial insurance held to 15%Delivery system redesign extremely important – incentivizing effective care delivery, patient-centered. Corrections has a lot to learn here. Another topic = primary care medical home in corrections, esp for chronic illness. Integration of BH too
20Health Care Reform Effective 1/1/2014: Asset, age and disability criteria for Medicaid eligibility will be eliminatedIndividuals with incomes of up to 133% FPL will be eligible for Medi-Cal
21Health Care ReformIndividuals with income from 134% up to 200% FPL will be eligible for coverage through CA Health Benefit ExchangeLow 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)
22Health Care ReformIn 2014, federal match for new enrollees will be 100%Year Two the match will be 90% federal funds
23California’s Approach Planning for 2014California’s Approach
24California’s Bridge to Reform By 1/1/2014, approximately 851,000 currently-uninsured Californians will be eligible for Medi-Cal.
25California’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
26California’s Bridge to Reform Starts to provide Medi-Cal-like coverage for low-income childless adults prior to health care reform’s full implementationBuilds the provider network capacity to prepare for 1/1/2014
27California Law Change in 2010 California regulations previously required counties to dis-enroll Medi-Cal beneficiaries upon incarceration
28California Law Change in 2010 California law now mandates counties to enroll state prison inmates in LIHPGives counties the option to enroll inmates county jails to enroll in the LIHP or in the Medi-Cal programLaw is silent about city jails.(See Appendix D of Handout)
29Which Inmates TODAY are eligible (CA)? State Medicaid income & asset guidelines ANDCategorical EligibilityPregnant womenInmates< age 21Inmates age 65>Disabled for at least 12 monthsMost relevant to prisons, but jails often have isolated very costly cases
30Will it Last?According the Centers for Medicare and Medicaid, Medicaid Disabled and Elderly Programs:There is no plan to rescind FFP for inmate inpatient careMedicaid eligibility for inmates offers important opportunities for continuity of care for chronic conditions, mental illness
32Medicaid as Payment in Full Federal rule prohibit providers participating in Medicaid to balance-bill patients or providersFor some prisons and jails, provider payment levels are in statute and exceed Medicaid ratesSome prisons and jails have negotiated contract rates with providers that exceed Medicaid rates
33Medicaid 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.
34AlternativesHospital bills Medicaid for admission, accepts payment; prison/jail makes periodic “patch payment” to providerPrison/jail consolidates admissions to specific hospitals to gain volume and cooperation
35Implementation 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?Some jails/prisons fund out-stationed eligibility worker at hospitals
36Implementation Issues: Inmates Freedom of Choice issueInmate doesn’t want to enroll/sign Medicaid applicationDocuments not availableBirth certificateTax statementsBank statements
37Implementation Issues: Jails Difficult to change state law individuallyMay require additional resources, or administrative systems changesIn California, county jails should be working with the county health or social services department
38Prisons May require new resources May require tracking system for claims, high-cost inmates, eligibility status, redetermination dates
39Implementation Issues: Medicaid Suspended eligibilityRequires new resources (but 50% federal match)How is federal match tracked and traded?Many other competing priorities related to health care reformMichigan DOC pays 50% of salary for eligibility worker outstationed to prison, manages medicaid apps fand re-enrollment for whole systemFederal match is 50% for enrollment workReally need CENTRALIZED eligibility because of movem3ent across county lines, may need legislation or regulation
40ImplementationExtremely complex and varies enormously by state Medicaid programMay begin with workgroup that includes Medicaid and the agency that decides eligibilityMay work on jails and prisons simultaneouslyMost programs start by manually processing a few high-cost cases
41Other OpportunitiesCreate information for inmates under age 26 about coverage on parent’s insurance planAssist eligible inmates with serious health needs to enroll prior to release
42Get Moving Toward 2014 Work with community stakeholders to develop Streamlined discharge planningCommon prescription drug formularyContinuity of careTargeted Case Management ProgramsDevelop inmate education materials