CMSP Training Webinar. Counties & Stakeholders

Transcription

1 CMSP Training Webinar Counties & Stakeholders MARCH 10, 2016

2 Agenda Introduction of Speakers Additional Training Opportunities History & Background of CMSP Governing Board s Strategic Planning Effort CMSP Eligibility Administration CMSP Standard Benefits Two-Year Pilot Project: Eligibility Enhancements Primary Care Benefit (PCB) Questions & Answers

3 Key Abbreviations ACA = Affordable Care Act ACL = All County Letter AEVS = Medi-Cal s Automated Eligibility Verification System AMM = Advanced Medical Management, Inc. BIC = Beneficiary Identification Card CFBU = CMSP Family Budget Unit CMSP = County Medical Services Program NOA = Notice of Action PCB = Primary Care Benefit SOC = Share of Cost TPA = Third Party Administrator

4 Additional Training Opportunities Provider Trainings Hosted by AMM Tuesday, March 15th at 10:00 AM 11:00 AM Thursday, March 17th at 1:30 PM 2:30 PM Visit the CMSP website at the following link for information:

5 Background on CMSP

6 Background on CMSP & Governing Board Key Historical Events In 1982 California law eliminated Medi-Cal eligibility for medically indigent adults (MIA) MIA population became county responsibility under WIC Section (county aid to medically indigent) CMSP created in 1983 to address needs of smaller counties: A pooled risk program Eligible counties have populations of 300,000 or less (in base year 1980) 35 participating counties (Yolo County joined 7/1/12) In April 1995 CMSP Governing Board established by California law: Charged with overall policy and fiscal responsibility for CMSP Ten county officials elected by CMSP counties Ex-officio, non-voting State representative (CA HHS Agency Secretary) CMSP was originally administered by CA Department of Health Services CMSP today is administered through contracts with: Advanced Medical Management (AMM) for CMSP medical and dental benefit administration MedImpact Health Systems for CMSP pharmacy benefit administration California DHCS provides eligibility data file transfers Other consultants and contractors provide various services

7 35 Participating Counties

8 CMSP Mission The mission of the County Medical Services Program (CMSP) Governing Board is to partner with participating CMSP counties in meeting their indigent health care responsibilities by delivering cost-effective, high quality health care services through the CMSP benefit program; and, to develop pilot projects and alternative products that support improved delivery of health care services in participating counties to CMSP members and populations potentially eligible for CMSP and other public programs. The Governing Board s ability to fulfill its mission is dependent on maintaining the fiscal soundness of the CMSP benefit program and the overall CMSP Budget.

9 Role of CMSP Governing Board CMSP Governing Board is defined as a separate local agency formed and operated pursuant to its enabling statutes (WIC Section et. seq.) and also under the provisions of the Government Claims Act and Brown Act Governing Board s Authorities: Broadly defined in statute to take any actions necessary to operate CMSP Statute includes express authority to: o o o o o Determine CMSP eligibility and benefit levels Establish reserves and participation fees Establish procedures for county entry into and disenrollment from CMSP Apportion jurisdictional risk to each county Adopt rules and regulations governing CMSP

10 Role of CMSP Governing Board (cont.) Governing Board s Authorities: Statute also includes express authority of the Board to: o o Establish and maintain pilot projects to identify or test alternative approaches for determining eligibility or for providing or paying for services Develop and implement alternative products with varying levels of eligibility criteria and benefits outside of CMSP for counties contracting with the Governing Board for those products Any such products shall be funded separately from CMSP and shall not impair the financial stability of CMSP

11 Affordable Care Act (ACA) The Federal Affordable Care Act was enacted in March Two components of the ACA directly impact most members previously served by Path2Health & CMSP: 1) Medicaid Expansion In 2014, Medi-Cal was expanded to include all non-elderly lawfully present residents up to 138% of the poverty level, including adults without children at home, who were previously excluded 2) Insurance subsidies through the California s health insurance exchange, Covered California Those over 138% FPL up to 400% FPL have access to subsidies for private coverage through Covered California. Open enrollment for 2016 occurred between November 1, 2015 through January 31, 2016.

12 Current CMSP Program Context With ACA in place, CMSP enrollment and costs have sharply declined: CMSP/Path2Health enrollment for 12/2013: 83,600 members Unduplicated CMSP enrollment in CY 2015: ~ 700 members While the ACA is in place, adult populations that remain uncovered include: Adults with incomes above 138% FPL that do not join Covered California or have other health insurance and then have a health care need Undocumented low-income adults (for non-emergency services) Low-income adults with excess assets Adults who have a SOC for CMSP that exceeds their monthly ability to pay

13 Strategic Planning Efforts In June 2015, the CMSP Governing Board held a Strategic Planning Meeting CMSP s Eligibility and Planning & Benefits Committees met in the months leading up to the Strategic Planning meeting to develop concepts County representatives, provider and beneficiary stakeholders provided feedback, opinions and suggestions to the Board After the Strategic Planning Meeting, the Board took actions to: Create a Two-Year Pilot Project: Eligibility Enhancements Primary Care Benefit for Aid Code 50 and SOC members Waive the FY County Participation Fee Waive the FY County Participation Fee contingent upon excess revenue (to be determined at a future time)

14 CMSP Eligibility Administration

15 CMSP Eligibility Administration County social services departments conduct eligibility for CMSP using existing automated welfare systems (C-IV and CalWIN) CMSP Policy is documented in the CMSP Eligibility Manual and through CMSP All County Letters (ACL) CMSP is the payer of last resort. Refer to CMSP Eligibility Manual Section Applicants must a resident of one of the 35 CMSP counties and between the ages of years old

16 CMSP Eligibility Administration (cont.) Prior to evaluating eligibility for CMSP: All applicants shall be evaluated for all Medi-Cal programs, including: MAGI-based Medi-Cal Pregnancy and Emergency Services Only Medi-Cal

17 CMSP Eligibility Administration (cont.) Prior to evaluating eligibility for CMSP (cont.): CMSP applicants are required to avail themselves of coverage through Covered California during open enrollment periods or due to qualifying life events For applicants that are otherwise eligible for Covered California, the following rules apply: An application for CMSP shall be considered subject to the Covered California open enrollment period when the application is pending disposition action by the county between the first day of open enrollment to the 15 days prior to the close of open enrollment. Provide electronic or written evidence to the county that an application has been made to Covered California for health insurance coverage. Provide electronic or written evidence to the county that the applicant has paid the first month s premium for participation in Covered California, when required.

18 CMSP Eligibility Administration (cont.) CMSP Applications: Information collected on the CMSP Supplemental Application (CMSP 215 form) Designed to be a supplemental application and only asks applicants the missing questions that were not otherwise gathered from other aid applications Telephonic signature is allowed (CMSP 216 form) The beginning date of eligibility for persons applying for CMSP, and whose eligibility has not yet been determined, shall be either: The first day of the month of the Medi-Cal or Covered California Application, if all eligibility requirements are met. The first day of the month, subsequent to the month of the Medi- Cal or Covered California Application, during which the eligibility requirements of CMSP are met.

19 CMSP Eligibility Administration (cont.) Upon enrollment, CMSP members receive a CMSP ID Card from AMM & a State of California BIC

20 Standard CMSP Benefits

21 Summary of Standard CMSP Benefits* Acute inpatient hospital care Adult day health care services Audiology services Blood and blood derivatives Chronic hemodialysis services Specified dental services Durable medical equipment Emergency air and ground ambulance services Hearing aids Home health agency services Hospital outpatient services Laboratory and radiology services Medical supplies * Benefit restrictions & authorization requirements may apply Non-emergency medical transportation when medically necessary Occupational therapy services Outpatient clinic services Outpatient heroin detoxification services Pharmaceutical services provided by network pharmacies Physical therapy services Physician services Podiatry services Prosthetic and orthotic appliances Psychiatric services (inpatient & outpatient) provided by a licensed, innetwork psychiatrist Speech therapy services

22 Summary of Standard CMSP Benefits (cont.) CMSP does not cover the following services: Pregnancy-related services, infertility services, long-term care facility services, chiropractic services, acupuncture services, cosmetic services, sexual reassignment services, vision services, methadone maintenance, and services by a Psychologist, LCSW, MFT, or substance use disorder counselor All services provided outside of the State of California and designated border state areas Services provided by providers that do not participate in the CMSP network administered by Advanced Medical Management (excluding emergency services) and the MedImpact Healthcare Systems pharmacy network Organ transplants for persons who are eligible for CMSP emergency services only under aid code 50

23 Summary of Standard CMSP Benefits (cont.) The majority of persons eligible for CMSP including legal residents (Aid Code 89) and undocumented members (Aid Code 50) have a SOC obligation. They must pay, or agree to pay, part of their monthly income towards their medical expenses in the month of service before CMSP will pay for covered benefits. Additionally, coverage under CMSP Aid Code 50 (undocumented CMSP members) is limited to only for emergency services.

24 Two Year Pilot Project Eligibility Enhancements

25 Overview High-level Summary of Eligibility Enhancements Updated CMSP Resources: CMSP All County Letter Revised CMSP Manual (effective 5/16) CMSP Form Changes CalWIN & C-IV Systems Changes Details About Each Eligibility Change: Income Limit Share of Cost Asset Test Retroactive CMSP Coverage Enrollment Term Aid Code Changes

26 CMSP ELIGIBILITY CRITERIA Applications 4/30/16 & Prior Applications 5/1/16 End of Pilot Federal Poverty Level 200% FPL 300% FPL Asset Test Income 138% FPL Asset Test Income above 138% $2,000 single $3,000 couple $2,000 single $3,000 couple Waived, no asset test $20,000 single $30,000 couple Term (Aid Code 50) 2 months 6 months Term (Aid Codes 88, 89) Up to 3 months Up to 6 months Share of Cost Income 138% FPL Share of Cost Income above 138% Retroactive Eligibility Net nonexempt income less maintenance need Net nonexempt income less maintenance need 10-day Pre- Enrollment Policy thru April 2016 Waived, no SOC 75% reduction to prior formula 1 st month of retro CMSP is May 2016 for June applications

27 CMSP ACL, Manual & Form Changes In April 2016, CMSP will release ACL documenting the components of the Two-Year Pilot Project CMSP Eligibility Manual (effective May 2016) has been updated and will be released in April 2016 CMSP forms have been updated and will be released in May 2016

28 CMSP Form Changes Form Number Title Status CMSP 203 (05/16) Other Insurance Revised CMSP 215 (05/16) CMSP Supplemental Application Revised CMSP 239 B (05/16) Notice of Action Revised CMSP 239 P (05/16) NOA: Emergency Services Only Revised CMSP Info Notice 1 (05/16) Important Information About CMSP CMSP Info Notice 2 (05/16) CMSP Eligibility Summary CMSP 239 F (05/16) CMSP 239 G (05/16) Approval of One-Month Retroactive CMSP Benefits Denial of One-Month Retroactive CMSP Benefits Revised Revised New New Note: Several other CMSP forms have been deemed obsolete & will be removed from CMSP s website

29 C-IV Changes C-IV provides the eligibility system for 32 CMSP counties C-IV implementation timeline includes: Uses the standard C-IV change process C-IV change number 1126 C-IV communication: April 2016 C-IV release on May 23, 2016

30 CalWIN Changes CalWIN provides the eligibility system for 3 CMSP counties CalWIN implementation timeline includes: Uses the standard CalWIN change process CalWin change numbers & CalWIN County Information Transmittal (CIT): April 1, 2016 CalWIN release on May 7, 2016

31 Details About Eligibility Changes

32 Federal Poverty Level Income Test Prior to 2-Year Pilot Project, CMSP eligibility is capped at 200% FPL Beginning May 1, 2016, new CMSP income cap will be 300% FPL: 300% Federal Poverty Level Income Test means the net nonexempt income of the CFBU must be less than, or equal to, the 300% FPL limit for an applicant(s) to be eligible for CMSP benefits. Refer to revised CMSP Eligibility Manual Section (effective 5/16)

33 Asset Test/ Property Limit Prior to 2-Year Pilot Project, one asset test of $2,000 single and $3,000 couple for all CMSP applicants Beginning May 1, 2016: For applicants with incomes less than or equal to 138% of the Federal Poverty Level (FPL), as determined in accordance with Section 8-011, no property limits, as set forth in this section, shall apply for consideration of CMSP eligibility. Refer to revised CMSP Eligibility Manual Section (effective 5/16)

34 Asset Test/ Property Limit (cont.) Beginning May 1, 2016 (cont.): For applicants with incomes greater than 138% FPL up to 300% FPL, as determined in accordance with Section 8-011, the following limits shall apply: Number of Persons Whose Property is Considered Property Limit 1 person $20,000 2 persons $30,000 3 persons $31,500 4 persons $33,000 5 persons $34,500 6 persons $36,000 7 persons $37,500 8 persons $39,000 9 persons $40, persons $42,000

35 CMSP Enrollment Terms Prior to 2-Year Pilot Project, CMSP enrollment terms were limited to: Up to 3 months for Aid Code 85, 88, and 89 members 2 months for Aid Code 50 members Beginning May 1, 2016, CMSP enrollment terms will be modified: Up to 6 months for Aid Code 88 and 89 members 6 months for Aid Code 50 members Aid Code 85 will be eliminated and members moved to Aid Code 89 Refer to revised CMSP Eligibility Manual Section (effective 5/16)

36 Share of Cost (SOC) Prior to 2-Year Pilot Project, SOC was calculated by taking the net nonexempt income less maintenance need standard (i.e. $600 for 1 person, $1,100 for 4 persons) Beginning May 1, 2016, the following SOC changes apply: No Share of Cost shall be required for applicants with income less than or equal to 138% of the Federal Poverty Level (FPL), as determined in accordance with Section Refer to revised CMSP Eligibility Manual Section (effective 5/16)

37 Share of Cost (SOC) (cont.) Beginning May 1, 2016, the following SOC changes apply (cont.): For applicants with incomes greater than 138% FPL up to 300% FPL, as determined in accordance with Section 8-011, the Share of Cost for all CMSP CFBUs shall be determined as follows: 1) Determine the net nonexempt income available to the CFBU based on the most recent information available. 2) Round the total net nonexempt income for the month determined in (1) to the nearest dollar, with amounts ending in 50 cents or more rounded to the next higher dollar. 3) Determine the appropriate maintenance need for the CFBU for the month in accordance with Section Steps 4 & 5 continued on the next slide

38 Share of Cost (SOC) (cont.) Beginning May 1, 2016, the following SOC changes apply (cont.): For applicants with incomes greater than 138% FPL up to 300% FPL, as determined in accordance with Section 8-011, the Share of Cost for all CMSP CFBUs shall be determined as follows (cont.): 4) Subtract the maintenance need from the total rounded net nonexempt income for the month to determine the remainder. 5) If the remainder amount is greater than 0, multiply the remainder amount by.25. The value of this calculation is the Share of Cost. Refer to revised CMSP Eligibility Manual Section (effective 5/16)

39 Share of Cost (SOC) (cont.) Example of how the 75% SOC reduction works with a single adult with net nonexempt monthly income of $2,600 and application date of June 26, 2016: $2,600 - $600 = $2,000 $2,000 x 0.25 = $500 monthly SOC Pre-pilot, an applicant with similar circumstances would have had a SOC of $2,000 per month. Under the 2-Year Pilot Project, the applicant s SOC is reduced by 75% to $500 per month.

40 Retroactive CMSP Eligibility Prior to 2-Year Pilot Project, the only retroactive CMSP coverage was for the 10 prior days to the month of application through the paper CMSP Pre-Enrollment Claims Payment Authorization (PECPA) process For example, the beginning date of aid was March 2016 and the applicant had a medical emergency on February 25 th The CMSP PECPA process will still apply to any application dated May 31, 2016 or prior. Remember, the 2-Year Pilot project doesn t start until May 1 st. Therefore, the month of May 2016 will be the earliest possible retro CMSP month. The last 10 days in April 2016 will be the last days that the CMSP PECPA process applies to.

41 Retroactive CMSP Eligibility (cont.) Effective with Supplemental Applications taken on or after June 1, 2016, retroactive eligibility for a period of one month may be granted for CMSP cases. Retroactive eligibility may be requested at the following times: At the time the Supplemental Application is completed by requesting retroactive eligibility on the revised Supplemental Application (05/16). During the Medi-Cal application process. At any time during the applicant s term of CMSP enrollment by making a request for retroactive eligibility to the county worker and the request is documented in the case notes for the applicant. Refer to revised CMSP Eligibility Manual Section (effective 5/16)

42 Retroactive CMSP Eligibility (cont.) To determine retroactive CMSP eligibility for an applicant, the county shall utilize the same information and process utilized to determine retroactive Medi-Cal eligibility with the MC 210A Supplement to Statement of Facts for Retroactive Coverage/Restoration form. In its process, the county may use the MC 210A form to process retroactive CMSP eligibility or collect the information required on that form through telephonic or other communication with the applicant. In no instance shall retroactive CMSP eligibility be granted for more than one month. Refer to revised CMSP Eligibility Manual Section (effective 5/16)

43 Retroactive CMSP Eligibility (cont.) Two new CMSP Notice of Actions: CMSP 239F: Approval of Retroactive Benefits NOA CMSP 239G: Denial of Retroactive Benefits NOA If otherwise eligible, it is possible for an applicant to only be eligible for CMSP in the one retro month and not the month of application Please note: CMSP s retroactive coverage is only one-month unlike Medi-Cal which maybe up to three-months of retroactive coverage

44 Aid Code Changes CMSP Aid Code Eligibility Month April 2016 Prior 8F No Change No Change 50 No Share of Cost 50 With Share of Cost o Net nonexempt income less than /equal to $ o Asset test: $2,000 single, $3,000 couple o 2-month enrollment term o Net nonexempt income more than $ o Up to 200% FPL o Asset test: $2,000 single, $3,000 couple o 2-month enrollment term Eligibility Month May 2016 End of Pilot Category eliminated as applicants have access to coverage under ER only Medi- Cal o Income greater than 138% FPL & less than equal to 300% o 75% reduction to SOC amount o Asset test: $20,000 single, $30,000 couple o 6-month enrollment term*

45 CMSP Aid Code 85 With Share of Cost 88 No Share of Cost o Eligibility Month April 2016 Prior Net nonexempt income more than 100% FPL o Net nonexempt income less than /equal to $ o Asset test: $2,000 single, $3,000 couple o Up to 3-month enrollment term Eligibility Month May 2016 End of Pilot Category eliminated due to overlap with Aid Code 89 o o o Income less than/ equal to 138% FPL No asset test Up to 6-month enrollment term* 89 With Share of Cost o Net nonexempt income more than $ o Up to 200% FPL o Asset test: $2,000 single, $3,000 couple o Up to 3-month enrollment term o Income greater than 138% FPL and less than/ equal to 300% o 75% reduction to SOC amount o Asset test: $20,000 single, $30,000 couple o Up to 6-month enrollment term* * An additional one month of retroactive CMSP coverage may apply to applications dated on or after June 1, 2016

46 CMSP ELIGIBILITY CRITERIA Applications 4/30/16 & Prior Applications 5/1/16 End of Pilot Federal Poverty Level 200% FPL 300% FPL Asset Test Income 138% FPL Asset Test Income above 138% $2,000 single $3,000 couple $2,000 single $3,000 couple Waived, no asset test $20,000 single $30,000 couple Term (Aid Code 50) 2 months 6 months Term (Aid Codes 88, 89) Up to 3 months Up to 6 months Share of Cost Income 138% FPL Share of Cost Income above 138% Retroactive Eligibility Net nonexempt income less maintenance need Net nonexempt income less maintenance need 10-day Pre- Enrollment Policy thru April 2016 Waived, no SOC 75% reduction to prior formula 1 st month of retro CMSP is May 2016 for June applications

47 Two Year Pilot Project Primary Care Benefit

48 Primary Care Benefit (PCB) Purpose: Provide a new limited scope Basic Primary Care Benefit that provides coverage for three (3) Primary Care or Specialty Care visits, preventative services, specified lab & diagnostic tests, and prescription medications. Details: Covered medical services are based on Adult Preventative Health services covered under the ACA Services must be provided by contracted providers Pharmacy coverage is limited to $1,500 for benefit period $5 co-payments for PCB pharmacy services No copay for covered PCB medical services

49 Primary Care Benefit (PCB) (cont.) The Primary Care Benefit (PCB) is in addition to the standard CMSP benefit package covered earlier in today s presentation. However, there is no monthly Share of Cost (SOC) requirement for the PCB services. Aid Code 50 members, which only have access to coverage for emergency services under the standard CMSP benefit package, have access to primary and preventative healthcare services under the PCB.

50 Primary Care Benefit (PCB) (cont.) Persons enrolled in or eligible for Medi-Cal (Full Scope or Pregnancy/Emergency Services Only) are not eligible to receive CMSP or the new PCB Remember, CMSP is the payer of last resort An applicant cannot decline enrollment in Medi-Cal in order to obtain CMSP coverage Only CMSP Aid Code 50 & 89 members enrolled in PCB Pilot CMSP Aid Code 88 members are excluded from the PCB as they already have access to the covered services without a SOC

51 PCB Enrollment Process & Terms Counties need to process CMSP applications in accordance with standard process and don t need to do anything for the PCB enrollment CalWIN & C-IV are building weekly reports for CMSP on newly added cases which will be used by AMM to generate ID cards PCB benefit period is up to 6 months with defined start and stop months Ending PCB month will not be greater than member s CMSP enrollment term Once the member s PCB period has been established, changes in aid won t impact member s PCB benefit

52 PCB ID card will be in addition to the CMSP ID & BIC cards Member guide explaining the benefit will be sent with PCB ID card Member s PCB Member ID will be the Member s CIN with a PCB prefix For example: PCB A

53 Reservations & Customer Service Since the number of office visits is limited to 3 visits during the PCB benefit period, providers must contact AMM s PCB Information/Reservation Hotline at (888) to obtain a reservation for one of the three visits to ensure reimbursement MedImpact will handle member and pharmacy inquires through its customer service line, (800)

54 Contact Us Kari Brownstein, Administrative Officer (916) ext. 13 Chris Salmon, IT Systems Manager (916) ext. 15 Lee Kemper, Policy and Planning Consultant (916) ext. 14 Alison Kellen, Program Manager (contact prior to April 1 st ) akellen@cmspcounties.org (916) ext. 19

55 Other Important Numbers AMM Customer Service (877) AMM PCB Hotline/ Reservation Note: Number will staffed on May 2, 2016 (888) MedImpact Customer Service (800)

56 Final Reminders A link to the Webinar presentation and copies of the slides will be available on the CMSP website on 3/18. Provider Trainings Hosted by AMM Tuesday, March 15th at 10:00 AM 11:00 AM Thursday, March 17th at 1:30 PM 2:30 PM Visit the CMSP website at the following link for information:

57 Thank you for participating in today s webinar!