Health Insurance Contracting

Transcription

1 National Center for Health Care Capacity Building Syncing Innovative Approaches with Successful Outcomes Health Insurance Contracting for HIV Prevention and Wrap-around Service Providers

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3 Table of Contents 1 Introduction 2 Purpose of the Guide 3 Which Providers Can Benefit from this Guide? 4 Why Contract with Health Insurers? 5 Steps for Contracting with Insurance Plans and MCOs 6 1. Identify Opportunities in Private and Public Health Insurance 6 2. Check With Your Agency About Their Health Insurance 15 Contracting Plans and Policies 3. Gather Information About Insurers Assess Insurer s Track Record Understand How Insurers Will Pay for Services Evaluate Adequacy of Payment Based on Actual Costs Contract with Public and Private Insurers 24 References 25 1

4 INTRODUCTION Over 300,000 HIV positive (+) individuals in care in the US are enrolled in health insurance through their employers, their spouses or parents insurance coverage, or publicly funded insurance such as Medicaid, Medicare, Department of Veterans Affairs (VA), and TRICARE. i Beginning in 2014, an estimated 47,000 uninsured HIV+ adults can enroll in Medicaid if the states in which they reside expand Medicaid benefits covered by the Patient Protection and Affordable Care Act (ACA). Since the Supreme Court ruled that states do not have to expand Medicaid enrollment, some states have decided not to expand enrollment. An estimated 26,560 HIV+ adults in care live in states that have expanding Medicaid coverage under provisions of the ACA. An additional 20,350 HIV+ adults live in states that have not expanded Medicaid. The ACA also expands access to commercial health insurance through Marketplaces or Exchanges. An estimated 22,800 uninsured HIV+ adults could enroll in a Marketplace Qualified Health Plan (QHP) in The large and growing number of insured HIV+ individuals offers the opportunity for HIV prevention and wrap-around service providers to diversify their funding from exclusive reliance on grant funds to include third party reimbursement (TPR) from health plans. 2

5 PURPOSE OF THIS GUIDE This guide provides HIV prevention and wrap-around providers with basic information to help them successfully participate in and navigate the rapidly changing health insurance market. The guide identifies specific services that may be offered to health insurers serving individuals needing HIV screening, prevention services, or HIV health and supportive services. The guide offers specific steps for contracting with publicly funded health insurers, such as Medicaid and Medicare. These insurers commonly pay for services directly through fee-for-service (FFS) arrangements or indirectly through participation in managed care organizations (MCOs) who contract with the funder to serve large numbers of their enrollees. The guide also addresses steps for contracting with commercial health insurers, including MCOs. Learning how to contract with health insurers requires learning how to speak the language of insurers. HealthHIV offers a companion guide, Glossary of Useful Health Insurance Terms, which explains the terms used in this guide. 3

6 WHICH PROVIDERS CAN BENEFIT FROM THIS GUIDE? HIV prevention providers commonly offer services such as those funded by the Centers for Disease Control and Prevention (CDC). High impact prevention (HIP) services commonly include condom distribution, HIV counseling and testing services (CTS), and linkage to HIV medical care. ii Pre-exposure prophylaxis, or PrEP, also offers a biomedical prevention strategy that includes Truvada (a combination of tenofovir disoproxil fumarate and emtricitabine), HIV and STI testing, condoms, medication adherence counseling, behavioral risk reduction support, and symptom assessment. iii The Ryan White HIV/AIDS Program (RWHAP) funds early intervention services (EIS) that provide HIV testing and targeted counseling, referral services, linkage to care, and health education and literacy training that enable HIV+ individuals to navigate the HIV care continuum. iv The RWHAP also funds wrap-around services to help HIV+ individuals to link to and engage in HIV medical care, navigate healthcare and insurance systems, address barriers to care, and facilitate receipt of care from HIV experienced providers. Wrap-around services for HIV+ individuals are commonly funded as non-core medical services. 4 The guide also addresses contracting with health insurers for case management services. The RWHAP defines medical case management (MCM) services as including treatment adherence to ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, provided by trained professionals, including both medically credentialed and other healthcare staff who are part of the clinical care team. 4 Activities include initial assessment of service needs; developing a comprehensive, individualized care plan (ICP); coordinating services required to implement the ICP; and continuous client monitoring to assess the efficacy of the ICP. The RHWAP defines non-medical case management (non-mcm) as helping clients to obtain medical, social, community, legal, financial, and other needed services. 4 Non-MCM services do not involve coordinating and following-up on medical treatments. 4

7 WHY CONTRACT WITH HEALTH INSURERS? Contracting with health insurers and MCOs offers new financial opportunities. Diversifying income sources helps to reduce dependency on a single source of income. Prevention and wrap-around service providers are commonly heavily or exclusively dependent on federal or state grant funds. Government funding priorities are shifting, with some communities experiencing reduced HIV prevention funding. Prevention and wrap-around service funding has become heavily competitive in many communities, and may not be a long-term, dependable source of funds in the future. Diversified funding also helps to contribute to fiscal solvency by increasing cash flow. TPR generates income that can be used in ways that grant funds do not sufficiently cover for capital improvements, rent, or administrative costs. TPR may also make up to some extent for decreased charitable donations. Participation in health insurance systems also ensures that providers meet the RWHAP s payer of last resort requirements. v The federal HIV/AIDS Bureau (HAB), which operates the RWHAP, published Policy Clarification Notice (PCN) #13-03 that states that RWHAP funds may not be used: For any item or service to the extent that payment has been made, or can reasonably be expected to be made by another payment source. This means grantees must assure that funded providers make reasonable efforts to secure non-rwhap funds whenever possible for services to individual clients. Grantees and their contractors are expected to vigorously pursue enrollment into healthcare coverage for which their clients may be eligible (e.g., Medicaid, CHIP, Medicare, state-funded HIV/AIDS programs, employer-sponsored health insurance coverage, and/or other private health insurance) to extend finite RWHAP grant resources to new clients and/or needed services. vi Growing numbers of insured HIV+ or HIV at-risk populations also offers opportunities for providers to expand access to new populations that would benefit from experienced HIV prevention, counseling and testing, case management, and supportive services. Among currently insured clients, participation by their providers in health insurance also ensures that they can benefit from continuity of services. HIV providers may also consider expanding their focus to other populations that have similar prevention and wrap-around service needs, such as individuals infected with Hepatitis C. 5

8 STEPS FOR CONTRACTING WITH INSURANCE PLANS AND MCOS Step 1. Identify Opportunities to Participate in Private and Public Health Insurance The guide outlines seven steps for contracting with health insurance plans and MCOs: In workshops conducted by HealthHIV, HIV prevention and wrap-around service providers often state that they do not provide services that are covered by health insurers and MCOs. This statement is commonly based on an untimely understanding of the services and compelling interests of health insurers in which covered services are focused on treating existing medical conditions in inpatient and outpatient settings, as well as constraining access to services to 1. Identify Opportunities in Private and Public Health Insurance 2. Check With Your Agency About Their Health Insurance Contracting Plans and Policies 3. Gather Information About Insurers 4. Assess Insurer s Track Record 5. Understand How Insurers Will Pay for Services 6. Evaluate Adequacy of Payment Based on Actual Costs 7. Contract with Public and Private Insurers reduce costs. Some HIV prevention and wrap-around service providers have the misimpression health insurers are only interested in paying for services rendered by licensed healthcare providers or facilities. These reports are commonly not based on their efforts to market their services to insurers. In reality, health insurers operating in public and commercial markets have learned the value of: Preventive medical and behavioral services that avoid unnecessary costs resulting from chronic diseases; Screening for medical and behavioral health problems so that they can be treated on a timely and effective basis; Patient navigation that helps to educate individuals about the basics of the healthcare and insurance systems; Integrated physical, mental health, and substance abuse services; Avoidance of psychosocial crises, such as homelessness, that result in poor treatment adherence and contribute to poor health; Patient education, counseling, and support services that promote educated patients who take an active role in self-managing their wellness 6

9 and healthcare services; Low-cost assistive services that promote access to healthcare services, such as community health workers (CHWs), transportation, and translation services; Managing and promoting high quality rather than managing utilization; and Disease management strategies that integrate clinical and non-clinical providers, patients, and their family members in coordinated healthcare teams. The rapidly evolving healthcare and insurance system offers new and emerging opportunities for HIV prevention and wrap-around providers. It is important for providers to become educated about specific opportunities in their community, as health insurers and MCOs are evolving at different rates. For example, some State Medicaid programs are on the forefront of innovation in the US, while others continue to use relatively traditional delivery and payment systems. ACA provisions require that Medicaid programs covering optional diagnostic adult services must also cover prevention services and immunizations recommended by the US Prevention Services Task Force (USPSTF) and Advisory Committee on Immunization Practices. vii Medicaid law requires that preventive services be medical or remedial, involve direct patient care for the purpose of diagnosing, and treating or preventing illness, injury, or other impairments to an individual s physical or mental health. Non-medical preventive services that address broader social or environmental concerns are not covered by Medicaid. viii The Centers for Medicare and Medicaid Services (CMS) has further afforded opportunities for HIV preventive and wrap-around services by announcing in January 2014 new regulations designed to enhance home and communitybased services. Following approval by CMS of Medicaid State Plan Amendments (SPAs), Medicaid FFS programs will be allowed to reimburse for preventive services recommended by licensed providers and provided by nonlicensed providers. State Medicaid Programs are authorized to define the qualifications of workers undertaking preventive services, the scope of those services, and how their services will be paid. MCOs contracting with Medicaid already are allowed to reimburse for such services. 7

10 The January 2014 CMS ruling has launched collaborative actions across the US among Medicaid programs, healthcare advocates, and organizations employing CHWs that undertake an array of services that meet the CMS preventive services criteria. The scope of CHWs services must be defined at the state-level, as has already been undertaken in several key states with experience in deploying CHWs for prevention services. ix In the HIV care continuum, Medicaid payment for CHWs services might be sought for behavioral counseling to prevent HIV, PrEP treatment adherence counseling, linkage to care for HIV+ individuals, engagement and retention services, patient navigation, antiretroviral (ARV) treatment education and adherence, home visiting and assessment, lost-to-care services to re-engage HIV+ individuals that dropped out of care, and case management services. The ACA promotes preventive services by eliminating cost-sharing for many insured individuals. Medicare covers preventive services without cost sharing if the services are graded A or B by the USPSTF. Among commercial insurers, the ACA has had variable impact in expanding prevention services. While new Marketplace/Exchange plans offering group and individual QHPs must cover HIV screening and preventive services recommended with A or B grades assigned by the USPSTF without deductibles or co-insurance. x A grades are assigned to preventive service that the USPSTF recommends, has high certainty that the net benefit is substantial, and should be offered or provided. B grades are assigned by the USPSTF to services in which there is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. This requirement, however, does not apply to grandfathered health insurance plans that were in effect on the day in which the ACA was signed into law (March 23, 2010). xi Translating shifting national policy changes into a prevention or wrap-around service agency s contracting strategy may be challenging. Table 1 illustrates some of the common interests of public and commercial health insurers and how HIV prevention and wrap-around providers might help insurers to meet those needs. In considering the services your HIV program might offer to health insurers and MCOs, consider offering assistance in organizing HIV services and in training MCO disease management staff about HIV-related topics, including 8

11 ways to increase cultural competency in serving racial, ethnic, and sexual minority patients. Table 1. Addressing Health Insurers Interests Through Services Offered by HIV Prevention and Wrap-Around Providers Health Insurers Interests Identify enrolled members that do not obtain preventive or other services Address members healthcare and health insurance literacy needs Prevent communicable diseases including HIV, sexually transmitted diseases (STD), tuberculosis (TB), and Hepatitis C Address members linguistic and numeracy needs to ensure that they can participate actively in health promotion, prevention, and care Culturally competent care coordination, disease management, treatment education Ensure access to physical, behavioral, and other outpatient services to promote health, and prevent and treat disease Ensure HIV+ clients receive and optimally benefit from ARVs and other medications Coordinate services provided by the care team with the client, his/her family, and community resources Disease management Discharge planning and readmission prevention interventions for hospitalized patients Services That HIV Providers Might Offer Outreach, counseling, linkage to care, patient navigation Non-MCM, patient navigation, health education PrEP support services, HIV/STD counseling and testing, behavioral prevention interventions, condom distribution and education, risk reduction Translation and health education Services by culturally competent workers with expertise in serving racial, ethnic, and sexual minority populations MCM, non-mcm, patient navigation, behavioral health treatment support, medical transportation MCM, patient navigation, treatment education and adherence counseling MCM MCM MCM 9

12 Prevention and wrap-around providers can use several approaches to identify health insurers operating in their state or geographic service area. The American Academy of HIV Medicine (AAHIVM) maintains an interactive website that provides timely information about State Medicaid FFS Programs, Medicaid MCOs, and Marketplace QHPs. The website also offers basic information about healthcare reform in each state and the District of Columbia (DC), the status of ACA Medicaid expansion, and implementation of ACA Marketplaces/Exchanges. Some Medicaid programs continue to pay for some services through FFS. Providers must enroll in the FFS program in order to receive reimbursement for services provided by enrolled beneficiaries. The AAHIVM website provides information about how to enroll in Medicaid FFS programs. The website also provides the internet addresses for additional resources concerning how to enroll in MCOs and QHPs provider networks. If your agency serves a multi-state area, it is important to learn about private and public insurers in those states as well. For information, visit Check with the State Health Insurance Commissioner in your state to identify other health insurers licensed to operate in your state. The National Association of Insurance Commissioners maintains a state-level database that can direct you to the jurisdiction of interest: Information about the types of services that Medicaid MCOs must provide can be found using several key sources. State Medicaid Programs commonly maintain on their websites valuable provider resources summarizing the FFS Programs covered services. This information is commonly posted in a provider section of the website. Resources may include provider handbooks, transmittals summarizing policy changes regarding benefits and payments, detailed fee schedules that identify covered services and unit-based payment rates, prior authorization policies, and related materials. Fee schedules are commonly organized by the code set used to identify the type of service provided and claimed for payment. CMS has established which code sets may be used by State Medicaid Programs. The Current Procedural Terminology (CPT) codes are maintained by the American Medical Association (AMA) and describe medical, 10

13 surgical, and diagnostic services. xii CPT codes are used, for example, to describe HIV and other lab tests and counseling services. CMS maintains the Healthcare Common Procedure Coding System (HCPCS) to describe non-physician services and supplies not addressed in the CPT code set. xiii CPT and HCPCS code sets are also used by Medicare and commercial health insurers. Table 2 summarizes CPT and HCPCS codes for services or supplies that may be offered by HIV prevention and wrap-around service providers. Table 2. Common Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) Codes and Descriptions for HIV Testing, Counseling, and Other HIV Services or Supplies CPT Code Description Antibody: HTLV or HIV antibody, confirmatory test (e.g., Western Blot) Antibody: HIV * Antibody: HIV-1, rapid HIV 2, single result Antibody: HIV-1 and HIV-2, single assay * Antibody: HIV-1 and HIV-2, single assay, rapid Enzyme immunoassay (EIA) HIV 1 antibody with HIV 1 & HIV 2 antigens; qualitative or semi-quantitative; single step Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semi-qualitative, multiple step method; HIV Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV Infectious agent detection by nucleic acid (DNA or RNA): HIV-1, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA): HIV-1, amplified probe technique 11

14 87536 Infectious agent detection by nucleic acid (DNA or RNA): HIV- 1,quanitification Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique DNA/RNA; HIV 2 quantification HIV-1/2 antigen and antibodies, fourth generation, with reflexes HIV-1/2 antibody differentiation CPT Code CPT Counseling Codes Preventive medicine counseling, individual, approximately 15 minutes Preventive medicine counseling, individual, approximately 30 minutes Preventive medicine counseling, individual, approximately 45 minutes Preventive medicine counseling, individual, approximately 60 minutes HCPCS Code A4267 A4268 G0432 G0433 G0435 S3645 Description Contraceptive supply, condom, male, each Contraceptive supply, condom, female, each Infectious agent antibody detection by EIA technique, HIV-1 and/or HIV-2, screening Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening HIV-1 antibody testing of oral mucosal transudate Ù CPT codes with a -92 modifier should be used when lab testing is performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual lab procedure code (HIV testing and 86703) 12

15 CMS requires that State Medicaid Programs address specific requirements in contracting with MCOs. These requirements are summarized in model contracts that must be reviewed and approved by CMS before they are executed. Many State Medicaid Programs post these model contracts on their websites for viewing by the public. Detailed information about the types of services MCOs must cover the delivery and payment systems to be used, and types of providers or workers that must be employed or obtained through contract. For example, Medicaid programs operating in states with relatively large HIV epidemics commonly address requirements for HIV screening. If the state of interest does not post their model contract, it should be available through a request of the State Medicaid director. The National Association of State Medicaid Directors (NASMD) maintains a timely list of directors and their contact information at State Medicaid Programs must competitively contract for MCO services. Requests for proposals (RFPs) used to select MCOs also provide detailed information about covered benefits and other requirements. RFPs are commonly archived on the Medicaid or the State s general procurement websites. In some states disproportionately impacted by the HIV/AIDS epidemic, State Medicaid Programs have designed and provide enhanced payments for MCOs that operate HIV special needs plans (SNPs). Some of these SNPs are commercial MCOs, while others are AIDS service organizations (ASOs) that expanded their capacity to become licensed as an MCO. SNPs are paid additional funds to provide HIV clinical, therapeutic, and wrap-around services. The SNPs must organize a provider network that offers wrap-around services, including MCM. Currently, Florida, Maryland, and New York Medicaid Programs operate HIV SNPs. More information about these programs can be obtained from Medicaid programs websites. The ACA has not impeded State Medicaid Programs ability to design and operate home and community-based waiver programs. xiv Waivers are a mechanism that Medicaid programs can use to test new or modify existing ways to deliver and pay for services funded by Medicaid or the Children's Health Insurance Program (CHIP). Section 1115 Research and Demonstration Projects provide flexibility to test new or existing approaches to financing and delivering Medicaid and CHIP. Section 1915(b) managed care waivers allow states to 13

16 provide services through MCOs or otherwise limit enrollees choice of providers. Section 1915(b) home and community-based service waivers provide long-term care services at home or in community settings rather than in long term care or other institutions. States may simultaneously implement concurrent Section 1915(b) and 1915(c) waivers to provide a care continuum to elderly or disabled enrollees, as long as all Federal requirements for both programs are met. In some states, Medicaid Programs operate or are designing innovative waiver programs that offer prevention and wrap-around services. HIV providers may be specifically included in those waiver programs, or are eligible for offering services needed by participating enrollees, such as HIV counseling and testing for high risk populations. See the CMS website for information about waivers operating in your state: Information/By-Topics/Waivers/Waivers.html. If you are still unclear whether your agency s services might be of interest to State Medicaid FFS Programs or MCOs, you may want to contact the Medicaid Program. Begin by contacting the Medicaid director s office, whose staff can forward you to a staff expert who can research and report to you ways in which your agency might participate as a Medicaid provider. ACA Marketplaces or Exchanges vary in the detailed information available about covered benefits and the types of providers that must participate in a QHP s provider network. The AAHIVM website described earlier in this guide provides information regarding whether a state participates in an ACA state, partnership, or federally facilitated Marketplace. The Marketplace/Exchange website addresses are provided, which can be used as a source of information regarding the essential covered benefits and other services that must be provided. It is important to note, however, that these websites vary considerably in how much information is available. A follow-up telephone call to the Marketplace/Exchange staff may be needed to get additional information. The AAHIVM website also provides QHP website addresses with information about to join their provider networks, covered services, and member handbooks. It is important to keep in mind that your agency s HIV prevention and wraparound services may be of interest to large healthcare providers that participate in Medicaid MCO and QHP networks. Integrated healthcare systems, hospital systems, FQHCs, other community health centers (CHCs), and large group 14

17 medical practices may be interested in contracting directly with your agency for HIV prevention and wrap-around services for insured patients. Large healthcare providers commonly engage in capitated payment arrangements with insurers that incentivize prevention and low cost treatment alternatives and disincentivize inpatient admissions, emergency room (ER) visits, and rehospitalizations. Large providers may be interested in contracting for HIV prevention and wrap-around services to address insured patients participating in their ambulatory care panels, particularly if they reside in HIV epicenters or are perceived as being at high risk for HIV. Grant-type cost-based contracts might be sought by HIV providers. Some HIV prevention and wrap-around service providers operate in communities in which large numbers of HIV+ or at-risk populations are insured by TRICARE, the military insurance system for active duty and retired military members and their dependents. For more information about TRICARE see The Defense Health Agency contracts many of their services with community providers to supplement clinical and support services offered at military health centers. For more information about the military health system see The VA may also be interested in contracting for HIV prevention and wrap-around services for VA beneficiaries. For more information about contacting VA Medical Centers in your HIV program s service area see Step 2. Check with Your Agency about Their Health Insurance Contracting Plans and Policies Many HIV prevention and wrap-around programs are operated by communitybased non-profit agencies that have not previously contracted with health insurers. Before moving forward with plans for contracting, it is important that the agency s board of directors and senior managers are aware of and support participation in the health insurance system. For some agencies, such contracting may not be envisioned as consistent with the mission of the organization to provide free services to individuals at risk for or infected with HIV. They may feel for example that collecting co-payments, often a necessity for making whole the cost of providing services to commercially insured individuals, conflicts with the agency s mission. For other agencies, senior managers and board members may want to assess carefully the financial 15

18 investment, opportunities, and challenges involved in insurance participation before moving forward. HealthHIV can offer boards of directors and senior managers additional information to help them weigh the payoffs and pitfalls of health insurance contracting. In other organizations, plans for moving forward with health insurance contracting may be well underway. Some HIV programs operate in agencies that have individuals designated to negotiate contracts with health insurers. It is important to determine if your agency has entered into contracts, with which plans they have negotiated contracts, and if HIV services were taken into consideration in considering sufficiency of covered benefits (including HIVrelated procedures), the payment arrangements, and other considerations. In some instances, contracts may already have been signed and it is too late during the current contract year to influence the details of the agreement. In other cases, your agency may be currently negotiating contracts. If so, you may want to ask that the contract address (a) coverage of HIV procedures and supplies specified in Table 2; (b) limits on the frequency of the service (e.g., number of times an insured individual may receive an HIV test) or populations that can receive the service (e.g., only pregnant women may receive an HIV test); and (c) payment levels that cover the costs of your agency s HIV services. Step 3. Gather Basic Information about Insurers and Their Provider Networks It is vital to gather basic information about insurers before joining their networks. Most but not all insurers offer websites with basic information about covered benefits, geographic service areas, their existing primary care and specialty networks, medication formularies, and hospitals participating in their networks. It is important to understand who is operating the provider network you are considering joining. Due to the ACA and other economic forces in the healthcare sector, some insurance plans have recently merged with others. Some healthcare plans may continue to use their earlier names to do business, although their ownership has changed. If your agency plans to offer HIV primary prevention services, consider how your staff will gain access to insured members to undertake prevention activities. Does the insurer s provider network include federally qualified health centers (FQHCs), hospital outpatient departments, or large group practices that can be 16

19 venues for providing large scale prevention services? If not, how will your staff locate and provide services to members that receive healthcare in large, geographically dispersed areas? If your agency intends to provide HIV counseling, testing, and linkage services, has your program already negotiated a memorandum of agreement (MOA) with the physicians and clinics in the network? Have you established a positive working relationship with those providers? Is the healthcare provider willing for your staff to provide on-site counseling and testing services to ensure rapid linkage to medical care? Does the insurer pay for HIV rapid testing and counseling services during the testing session? If a commercial lab provides standard HIV testing, can your HIV program offer pre and post-testing counseling as an additional voluntary service? Does the insurer pay for fourthgeneration HIV testing? Does the contracting commercial lab offer fourthgeneration HIV testing? Ensuring the provision of high quality HIV wrap-around services commonly requires ready access to expert specialty and subspecialty physicians in an insurer s provider network. Not all insurers have adequate HIV clinical capacity, and some are still building their provider networks. Insurers commonly provide on their websites the list of clinical and other providers participating in their networks. It is important to review the insurer s provider network to identify whether the providers commonly serving your clients are available in the network. Are you familiar with the quality of services provided by the specialists and subspecialists listed? For HIV wrap-around providers planning to offer MCM, treatment adherence, and medication education services, it is important to understand how insured members will access ARVs and other medications. Easy access to ARVs and other HIV-related medication through conveniently located retail pharmacies is critical to ensure adherence to medication. What mechanism is used for retail pharmacy services? Are you familiar with the pharmacies participating in the insurer s network? Are they conveniently located for your clients? Do the pharmacies offer medication education services? Are they experienced with coordinating pharmacy services with MCMs? Is mail order delivery of medications available? How will your staff coordinate their activities with mail order staff, which may be located in another state? 17

20 Other questions that you may ask include: What are the insurer s credentialing requirements for HIV prevention and wrap-around services providers? Are HIV+ members commonly assigned to disease or care managers? How are HIV+ members identified by the insurer? What is the role of disease or care managers roles? What is their training requirements and expertise? Can your HIV program s staff meet those credentialing requirements? Does the insurer currently pay for CHW services? What types of services are covered and for what insured populations (e.g., pregnant women) or diseases (e.g., diabetes)? Can coverage be extended to include CHWs that serve HIV+ or at risk insured enrollees? Can your agency negotiate contract items with the plan or must your HIV program accept the standard contract? What payment mechanisms does the plan use to pay for the types of services that your HIV program is planning to offer? Some HIV prevention and wrap-around services may require prior authorization to determine if medical necessity or other criteria are met. Who determines medical necessity? Where are the criteria posted? What is the process for reconsideration of the determination that a service is not a medical necessity? What is the plan s policy for timely payment? What utilization management and review procedures does the insurer employ? What are the insurer s quality and performance measures? Do any of the measures relate specifically to the types of services your HIV program would provide? What are the insurer s reporting requirements for providers? Can your agency meet those reporting requirements with your existing client-level data systems? What access standards must your program meet? For example, does the insurer have requirements regarding required hours and days of operation, coverage during evening and weekend business hours, after-hour and on-call coverage, maximum waiting time for establishing 18

21 an appointment, caseload standards, required intervals for providing specific services, and maximum waiting-room times)? Health insurers commonly post important materials on their websites that should be reviewed carefully before moving forward as a contractor. These materials include provider policy and procedure manuals, utilization and authorization procedure guidelines, and model provider contracts. Insurers commonly offer toll-free helplines with provider representatives that can address other questions you may have that are not readily addressed by their websites. Step 4. Assess the Health Insurer s Track Record Many insurers have operated previously in your state or elsewhere. For example, many Medicaid MCOs operate in multiple jurisdictions or states. Some MCOs also offer commercial insurance products to employer-sponsored groups or to beneficiaries enrolled in Medicare Advantage, the Medicare managed care system. You might reach out to your colleagues in HIV clinics, infectious disease practices, and AIDS service organizations (ASOs) to gather information about: Their perceptions of the insurer; Extent to which the insurer is willing to be creative in integrating HIV prevention and wrap-around services in their delivery and payment system; Willingness to negotiate contracts with HIV prevention and wrap-around service providers, including payment arrangements; Adequacy of payments; Financial stability and timeliness of payment; Propensity to deny claims because the service was not a medical necessity; Coverage of HIV testing and counseling services; Use of disease managers to manage the care of HIV+ members. Step 5. Understand How Health Insurers Will Pay for Your Services It is important to understand the payment methods used by public and commercial insurers to purchase services, manage utilization, and predict costs. In this section, we review the most common payment methods used by insurers. It is important to note that payment for many of the services offered by HIV 19

22 prevention and wrap-around service providers may be undertaken through a cost-based budget contract, similar to that used by CDC, HAB, and their grantees. Such contracting arrangements may help HIV providers to avoid the short-term need to establish claims-based billing systems. Fee-For-Service: FFS continues to be commonly used by private and public insurers. FFS payment is made for each service provided to a patient. Each specific service provided is billed to the insurer after the service is provided (i.e., retrospective payment). Generally, the higher the charge and the higher the volume of services, the more payment the provider will be paid by the insurer. FFS payments are set through formulas, budgetary funding levels, or negotiated with providers. FFS does not vary based on the size or organizational structure of a physician s practice, geographic location where the service was provided, type of service provided, or setting in which the service was provided (e.g., hospital, physician s office, lab). Claims for FFS payments are commonly submitted using coding systems that define what can be billed and paid for. Such coding systems include CPT, HCPCS, and the International Classification of Diseases (ICD). xv Capitated Payment Systems: Many new payment systems adopt capitated payment arrangements. Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician or practice for the delivery of healthcare services. Commonly, the unit of time is a month. The actual amount paid is determined by the types of services provided, number of patients assigned to the physician, and period in which the services are provided. Capitation rates are commonly computed using historical local costs and average rate of service utilization. As a result, capitation rates commonly vary among the service areas. When the provider signs a capitation contract with an insurer, a list of specific services that must be provided to patients is identified in the contract. Commonly, insurers establish a risk pool in which a percentage of capitation payments are withheld from the physician or practice until the end of the contract period (e.g., fiscal year). If the insurer incurs a profit at the end of the contract period, payment is made to the provider. Alternatively, if the insurer does not break even in the contract period, the withheld funds are used to pay the deficit. Insurers commonly purchase stop loss health insurance policies that 20

23 take effect after a certain amount has been paid in claims in a specified period. Such insurance protects insurers from higher than projected claims or catastrophic claims for insured patients with significantly higher than average claims. Premiums are based on the number of insured patients, their age, and other information. Budget-Based Payment Systems: Most new payment models use budget-based payment systems to promote value rather than volume, and are designed to achieve cost targets and outcomes. Payments are tied to providers ability to successfully predict future utilization of insured patients based on the past utilization of patients with similar characteristics and costs associated with providing covered services. Providers must ensure that the costs of their covered patients do not exceed the budget offered by the insurer. Insurers use historical expenditure data to compute projected utilization based on the number of covered individuals (commonly referred to as lives), their health status, and the array of services to be provided by the contracting providers. These factors are used to compute actuarially sound per member per month (PMPM) capitated rates. The rates are commonly risk adjusted to account for age, gender, geographic area, clinical acuity, diagnoses, co-morbidities, or other patient characteristics. Pay for Performance: Pay for performance (PFP) supplements FFS payments with bonuses to provider to achieve defined and measurable goals for care processes, performance, clinical outcomes, patient experience, and resource utilization. The insurer bases its evaluation of performance by comparing performance criteria with claims quality and cost data from participating individual clinician, workers, or providers. Patient satisfaction data may also be taken into consideration in assessing performance. Insurers may also take into consideration use of electronic health records (EHRs), electronic prescribing systems, care management, and capacity to report quality data. Shared Savings: There are two types of shared saving systems. Shared savings occur when the cost of care received by the patients is lower than budgeted costs and the physician or practice receives a percentage of the difference between actual and budgeted costs. Alternatively, if actual costs exceed the budgeted amount, the physician or practice is responsible for a portion of the difference. This arrangement represents upside risk, as the physician or 21

24 practice is at risk for additional revenue and not the cost of providing the service. In the second arrangement, the risk may be downside risk, in which the physician practice receives a percentage of savings as in the first example, but if the actual costs exceed budgeted costs, the practice is responsible for a percentage of the difference. Shared savings models are used by private and public sector insurers, including the Medicare Shared Savings Program established by the ACA. Global Payments: The global payment model applies a single payment to cover all services provided to a defined population in a defined period. This model is similar to CDC or HAB grant-based contract arrangements. This model creates incentives for providers to deliver coordinated, high quality, low-cost, and population-based care to a defined population. The global payment model is similar to capitation in providing a PMPM payment for services. The global payment model builds on capitation by adjusting payments based on the results of performance measures and risk adjustment. The global payment model applies an estimated total budget calculated for a defined population of patients. It is assumed that providers will reduce the costs of each episode of care by reducing the number of services and changing the types of services used by patients. Although the global payment model pays a bonus based on documented savings, the provider receives a global payment assumes financial risk for higher-than-expected costs. Commonly, global payment programs reduce the impact of this financial risk by adopting PFP. Condition-Specific Capitation: In the condition-specific capitation model, a periodic comprehensive care payment is paid to a group of providers to cover all care management, prevention services, and minor acute services related to a patient s chronic illnesses. Comprehensive care payments vary based on the patient s clinical acuity and other characteristics. The provider receives payment bonuses or penalties based on patients health outcomes, satisfaction levels, and utilization of acute care services. Patients may receive incentives to use higher-quality and lower-cost providers and adhere to care regimens developed by the patient and their provider. The condition-specific capitation model has been used by several State Medicaid programs for HIV+ patients. Accountable Care Organizations (ACOs): The ACA adopted ACOs as a major reform model. ACOs are provider collaborations that integrate physicians, 22

25 hospitals, and other healthcare providers to receive additional payments by achieving quality targets and incurring reduced overall spending for a defined patient population. The ACA requires ACOs to be responsible for the continuum of care. ACO models may be organized in different ways, ranging from fully integrated delivery systems to networks of physicians in small practices who collaborate to improve quality, coordinate care, and reduce costs. ACOs may adopt different payment incentives from FFS payments to limited or fully capitated models with quality bonuses. Step 6. Evaluating the Adequacy of Payment Systems Based on Your Costs Before contracting with an insurer, it is important for HIV prevention and wraparound service providers to determine the actual cost of their covered services to ensure that they will at least break even. Cost projections should include a realistic accounting of likely personnel costs including supervisors and administrative personnel. For example, a clerk might be employed to conduct daily electronic verification of insurance enrollment to ensure that your agency does not charge for services provided to individuals whose insurance enrollment has lapsed. Other direct and indirect costs associated with providing contracted services should be accounted for. Shortfalls between the cost of a service and payments should be assessed and cost inputs assessed to identify ways to reduce costs. For example, can some services be undertaken by lower cost personnel? Can services be provided more efficiently through the use of an EHR system? HAB has funded the development of unit cost model that can be found at: An important consideration in estimating the adequacy of insurance payment is whether a current grant funder will allow your agency to balance bill grant funds for the shortfall between an insurer s payment and the actual cost of providing a service. RWHAP grantees and subgrantees are prohibited from balance billing. Additionally, RWHAP and CDC grantees and subgrantees should seek guidance from their project officer about whether lab or other supplies purchased by grant funds (e.g., lab test kits, condoms) may be in turn billed to an insurer. Costs that cannot be shifted to grant funds may make insurance contracting a poor financial option. 23

26 Step 7. Contracting With Private and Public Health Insurers Several critical activities are necessary in undertaking contracts with health insurers. It is important to engage legal counsel to help guide you through the contract negotiation process. It is important to understand fully the contract offered by the insurer. Some of the questions that should be addressed in evaluating a contract include: Does the contract clearly define the scope of services to be provided? Does the contract or its attachments clearly identify the covered services available to enrollees? What is the term (time period) in which the contract is in effect? Does it include automatic renewal provisions or annual rate negotiations? What are the procedures to be used by your agency to determine patient eligibility (e.g., electronic or telephone verification) for services? Does your agency have systems in place, including available staff, to undertake enrollment verification? Are policies, procedures, protocols and timelines regarding referrals clearly spelled out in the contract or attached and incorporated by reference? Does the contract specify any requirements that the provider must meet in order to charge enrollees for co-pays and deductibles? What is the time frame for submission of claims and payment of claims? Will the insurer pay interest on late payments? What is the insurer s policy for over or under payments? What is the process for claims dispute resolution? What fee schedule is being used? What access and appointment standards must your agency meet? Is payment adequate under the contract to cover all of the costs incurred in meeting the access and appointment standards? What is the termination clause, and how much notice must be given to the provider? What is the contract renewal procedure? Does the provider have the right to review and approve amendments to the contract? 24

27 REFERENCES i ii iii Kates J, Garfield R, Young K, Quinn K, Frazier E, Skarbinki J. Assessing the Impact of the Affordable Care Act Health Insurance Coverage of People With HIV. Kaiser Family Foundation. January Retrieved at: CDC, High-Impact HIV Prevention: CDC's Approach to Reducing HIV Infections in the United States. Retrieved at: CDC. Pre-Exposure Prophylaxis (PrEP). Retrieved at: iv HAB, Division of Metropolitan HIV/AIDS Programs, National Program Monitoring Standards for Ryan White Part A Grantees: Program Part A. Retrieved at: v HAB, Division of Metropolitan HIV/AIDS Programs, National Fiscal Monitoring Standards for Ryan White Part A Grantees: Program Part A. Retrieved at: vi HAB, Ryan White HIV/AIDS Program Client Eligibility Determinations: Considerations Post- Implementation of the Affordable Care Act. Policy Clarification Notice (PCN) #13-03 (Revised 9/13/2013). Retrieved at: vii Cassidy A. "Health Policy Brief: Preventive Services Without Cost Sharing," Health Affairs, December 28, Retrieved at: viii CMS. Medicaid Preventive Services: Regulatory Change. April Retrieved at: Topics/Benefits/Downloads/Preventive-Webinar-Presentation pdf ix Association of State and Territorial Health Officials. Community Health Workers. Retrieved from: x US Prevention Services Task Force. Recommendations. Retrieved at: xi Merlis M. Health Policy Brief: Grandfathered Health Plans, Health Affairs, October 29, Retrieved at: xii American Medical Association. CPT- Current Procedural Terminology. Retrieved at: xiii CMS. HCPCS- General Information. Retrieved at: o/ xiv CMS. Waivers. Retrieved at: Topics/Waivers/Waivers.html xv CMS. ICD 10. Retrieved at: 25

28 National Center for Health Care Capacity Building Syncing Innovative Approaches with Successful Outcomes Telephone: Fax: Website: