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Published byAlannah Nichols
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What Role Will Your Organization Play: Healthcare Reform Readiness Educate | Navigate | Connect
What will we cover today… Understanding Reform & Expansion How do we get ready and reduce the risk of caring for the uninsured During this presentation the presenter may discuss information provided by and gained as a result of this organizations having received federal funding to act as a Navigator as part the of the Federal Health Insurance Exchange. The following are required disclosure statements: “The project described was supported by Funding Opportunity Number CA- NAV-13-001 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services.” “The contents provided herein are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.” © 2012 Advanced Patient Advocacy Disclosure/Disclaimer Statement
Who has the most to lose if consumers are not enrolled in the healthcare coverage that best meets their needs? Federal Government State Government Insurance Carriers Providers (need not just coverage but the coverage that delivers the best reimbursement) 3 Accountability © 2012 Advanced Patient Advocacy
Choosing the Provider Role What are my choices? 1.Let the State & Federal Governments handle enrollment 2.Continue to provide enrollment assistance at my current level of involvement 3.Become the patients resource for all enrollment avenues © 2012 Advanced Patient Advocacy
Sources: KFF: The Uninsured: A Primer (2012); Advisory Board Company: Where the States StandKFF: The Uninsured: A Primer (2012)Advisory Board Company: Where the States Stand Red = not expanding Where the States Stand: May 24, 2013 26 Governors Support Medicaid Expansion © 2012 Advanced Patient Advocacy
6 Insurance Exchange Operational Model © 2012 Advanced Patient Advocacy
Knowledge of Insurance Exchange(s) Premium and Cost Sharing Limits for Individuals up to 400% of Poverty Under Health Reform © 2012 Advanced Patient Advocacy
QHP Enrollment Opportunity data.cms.gov © 2012 Advanced Patient Advocacy
Presumptive Eligibility How will Presumptive Eligibility Work? The patient provides basic information—to an intake worker at the hospital who then assesses "on the spot" whether the person has an income at or below Medicaid income eligibility guidelines for the state. If so, the intake worker determines the individual to be presumptively eligible for Medicaid for a temporary period An individual's temporary eligibility period lasts until the end of the month following the month in which the presumptive eligibility determination was made. During this time, hospitals will be paid—at regular Medicaid rates—for the services they provide, regardless of a person's ultimate Medicaid eligibility determination. During the temporary eligibility period, the patient will also be able to receive treatment from other Medicaid providers after he or she leaves the hospital © 2012 Advanced Patient Advocacy
Can Hospitals Pay QHP Premiums? 45 CFR §155.240 Payment of Premiums (a) Payment by individuals. The Exchange must allow a qualified individual to pay any applicable premium owed by such individual directly to the QHP issuer. (b) Payment by tribes, tribal organizations, and urban Indian organizations. The Exchange may permit Indian tribes, tribal organizations and urban Indian organizations to pay aggregated QHP premiums on behalf of qualified individuals, including aggregated payment, subject to terms and conditions determined by the Exchange. (c) Payment facilitation. The Exchange may establish a process to facilitate through electronic means the collection and payment of premiums to QHP issuers. (d) Required standards. In conducting an electronic transaction with a QHP issuer that involves the payment of premiums or an electronic funds transfer, the Exchange must comply with the privacy and security standards adopted in accordance with § 155.260 and use the standards and operating rules referenced in § 155.270.155.260155.270 © 2012 Advanced Patient Advocacy
In-Person Assistance Navigators – help consumers prepare electronic and paper applications; provide outreach and education to raise awareness about the Marketplace; refer consumers to health insurance ombudsman and consumer assistance programs when necessary. Navigators play a role in all types of Marketplaces, are funded through state and federal grant programs, and must complete comprehensive training. Certified Application Counselors – perform many of the same functions as Navigators and non-Navigator assistance personnel—including educating consumers and helping them complete an application for coverage. Agents and Brokers – brokers will play an important role in educating consumers about Marketplaces and insurance affordability programs, and in helping consumers receive eligibility determinations, apply for premium tax credits and cost-sharing reductions, compare plans, and enroll in coverage. In particular, CMS anticipates that agents and brokers will play a critical role in helping qualified employers and employees enroll in coverage through the Small Business Health Options Programs (SHOPs). © 2012 Advanced Patient Advocacy
APA Navigator Strategy Patients are most motivated to enroll in coverage at the time they need acute care. By building on the enrollment processes providers have already established more patients will have access to QHP enrollment services: Catch the applicant at the point in time where they are receptive to considering healthcare coverage Provide access outside the “normal” business hours Provide services in an environment where the applicant is comfortable Speak to the individual in their language of choice © 2012 Advanced Patient Advocacy
Enrollment Decision Tree © 2012 Advanced Patient Advocacy
Navigator Strategy Limited Funding and Limited Scope Focus on accessing the uninsured at the time and place they receive medical care Community outreach centered around the host provider organization and limited to 10 hours per month APA Navigator Partnerships Thomas Health System Thomas Memorial Hospital South Charleston, WV St. Francis Hospital Charleston, WV LifePoint Hospitals Raleigh General Hospital Beckley, WV Princeton Community Hospital PCH and the Pavilion Princeton, WV What are the possibilities of expansion? Not at this time Maybe next funding cycle? © 2012 Advanced Patient Advocacy
The To Do List… What Role? ENROLLMENT STRATEGY Streamline Update Policies & Procedures © 2012 Advanced Patient Advocacy
Build an Enrollment Strategy Policies & Procedures Target & Segment Broaden & Maximize Reimbursement Streamline © 2012 Advanced Patient Advocacy
Understand your State’s decisions And the position of other States Charity policy updates How will exchanges affect current charity write-offs? Adjust policies to be in line with NEW Medicaid guidelines. What changes are needed in the registration process? New verification procedures (New Technologies) Are you asking THE RIGHT questions? Assistance strategies for those uninsured or with life changes? Policies & Procedures © 2012 Advanced Patient Advocacy
Target & Segment Categorical Patient Mix Inpatient Outpatient/ED Do you know the categorical breakdown of your patient population? Understand your patient mix then you can target the populations most likely to qualify for assistance programs Focus resources and customize the enrollment strategy Develop an outpatient strategy that delivers enrollment assistance at the time and place eligible patients access services © 2012 Advanced Patient Advocacy
Are You Getting the Maximum Return on Your Enrollment Solution Investment? A Broad Enrollment Solution will reduce your level of Uncompensated Care An effective enrollment program must be more than just Medicaid! Social Security Disability Insurance Supplemental Security Income COBRA Pre-existing condition coverage New Minor & Adult groups for Medicaid Total Charges Resolved by Payer Payments resulting from enrollment by Payer Veterans Benefits Indian Health SCHIP Immigrant programs Liability (MVA & WC) Insurance Exchange Opportunities © 2012 Advanced Patient Advocacy
StreamlineStreamline Processes - Eliminate redundancies Within in your enrollment process Between the facility and the state/county With the patient and your process Communication Make sure everyone who needs to know has access to the information Create system-wide communication strategies Partnerships - Look beyond the hospital walls Leverage the resources others in the community have available for patients © 2012 Advanced Patient Advocacy
Action Items Make Decisions Decide what role your organization is able/willing to play Review and update policies Segment Customized enrollment programs for different patient groups Use technology to expand opportunities and leverage the registration process to expedite decision making Partner & Expand Build community relationships to improve access & eliminate redundancies Take a broad approach beyond traditional Medicaid & SSI Expand communication and share information system wide Educate, Navigate & Connect Be the resource and ensure your patients are knowledgeable of all options Mitigate financial risk by connecting patients to programs with better reimbursement © 2012 Advanced Patient Advocacy
Thank You Laura Adkins email@example.com (304) 575-0398 www.aparesults.com
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