Ryan White Part A Quality Management

Transcription

1 Quality Management Health Insurance Continuation Program (HICP) Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant received by Broward County and sub-granted to Broward Regional Health Planning Council, Inc. Updated 3/23/17

2 Quality Management Health Insurance Continuation Program (HICP) Broward EMA Definition: Those services which provide financial assistance to a selection of Affordable Care Act Marketplace plans identified by the Ryan White Program. Financial assistance for eligible individuals living with HIV to maintain or obtain medical benefits through the HICP program is limited to insurance premiums payments, copays and deductibles for clients to maintain health insurance coverage. The goal is to ensure that the client s premium for a 12 month enrollment period is allocated prior to funding deductibles and copays. HRSA Definition: Health insurance premium and cost-sharing assistance, also referred to as Health Insurance Program (HIP), is the provision of financial assistance for eligible individuals living with HIV to maintain continuity of health insurance or to receive medical benefits under a health insurance program. This includes premium payments, risk pools, co-payments, and deductibles. Page 2 of 7

3 OUTCOMES, OUTCOME INDICATORS, INPUTS, STRATEGIES, DATA SOURCES Client Outcomes Outcome Indicators Inputs Strategies Data Source 1. Provide enrollment for clients eligible for HICP. Funding Staff % of clients requiring health insurance continuation program assistance will be assessed and enrolled in HICP prior to policy lapse. Clients Contact applicant within 48 hours of referral, provide pre-orientation and schedule intake. Conduct intake Electronic form Designated HIV MIS 2. Clients have monthly health insurance premium paid by due date % of clients eligible for HICP will have insurance premium paid by due date. Funding Staff Clients Make timely payments to insurance companies or employers Designated HIV MIS BRHPC ledger and invoices Page 3 of 7

4 STANDARDS FOR SERVICE DELIVERY Standard Indicator Data Source 1. Each HICP client s monthly insurance premium must be scanned into the designated HIV MIS. 2. Each client s copay and deductible will be paid upon receipt of documentation of a medical or pharmacy visit. Vendor must provide proof of payment (receipt, invoice, EOB, etc.). 3. Each client s proof of active insurance policy/card will be scanned into designated HIV MIS. 4. Each client s Explanation of Benefits (EOB) will be reviewed to ensure the client has attended a medical visit in the past six months. 5. Each client s Statement of Benefits will be documented into the designated HIV MIS. 6. Each client must accept 100% of the premium tax credit that they are eligible to receive. The credit shall be applied to the client s premium payment prior to providing premium assistance. 7. Viral load and CD4 count values for each client are collected % of client records will have documented monthly premiums in client record % of clients will have proof of payments documented in client record % of clients will active insurance policy/card scanned or keyed into the client record and filed under the appropriate tab % of medical visits will be documented in designated HIV MIS % of client s files will contain their Statement of Benefits for the plan covered by HICP % of client records will show documentation of accepted premium tax credit % of client viral loads and CD4 counts will be requested at least semiannually and recorded Insurance Premium Designated HIV MIS Copay and Deductible Medical, Lab or Pharmacy Visit Documentation Proof of Payment Designated HIV MIS Insurance Policy/Card Designated HIV MIS Client Record Designated HIV MIS Client Record Designated HIV MIS Client Record Designated HIV MIS Client Record Lab Reports Page 4 of 7

5 PROTOCOL Health Insurance Continuation Program (HICP) The HICP Protocol identifies the specific ways to implement HICP standards and processes inherent to this service category. The delivery of HICP services shall be conducted by culturally competent service providers. Providers are also expected to comply with applicable standards and guidelines that are relevant to individual service categories (i.e., HAB HIV Performance Measures, etc.). Eligibility Verification Agency staff shall verify client s eligibility by reviewing the certification in the designated HIV MIS. Stall shall perform an eligibility and financial assessment at each visit in addition to reviewing client s eligibility certification in the designated HIV MIS. Staff will review client s eligibility for all funding streams and services for which client may qualify. Staff will follow-up with referrals as appropriate. The purpose of this assessment is to ensure 1) client s access to all services client may be eligible for and 2) the status of Ryan White as payer of last resort. Target Population Individuals who are Broward County residents with HIV/AIDS who are privately insured through preapproved insurance plans and are unable to meet the costs of maintaining their private health insurance payments. Eligible clients must have an income between 100% and 400% of the Federal Poverty Guidelines and have barriers to economic stability. Client Intake HICP staff shall schedule a client intake within five (5) business days from the time the client is verified eligible to receive HICP services. Staff shall provide the client with an orientation to include: Client grievance process Client confidentiality Client Rights and Responsibilities Orientation shall be documented in the client file. Service Caps The provision of HICP services is limited to $6,500 per year per client towards their in-network deductible and copayments. The client s annual premium will be documented and subtracted from the $6,500 annual HICP allocation slotted for each client upon program enrollment. HICP funds shall be allocated for the client s annual premium payments and any remaining balance may be used to fund deductibles and copayments. Payment Verification HICP staff shall examine documentation to ensure copayments and deductibles are valid based on insurance plan benefits package and policies. All copayments and deductibles should be verified before payments are made. Access to Primary Medical Care HICP staff shall assess client participation in primary medical care. Staff shall ensure existing clients not in primary medical care, access primary medical care within six months from the beginning of the contract year for the client s continued participation in HICP services. Staff shall discuss with client the benefits of primary medical care and the referral process to access primary medical care through the case manager. Staff shall ensure referral of consenting client to their case manager to access primary medical care. Page 5 of 7

6 Retention in Primary Medical Care HICP staff shall assist the client to remain in primary medical care. Staff shall discuss with the client the need to remain in primary medical care as a condition to continue receiving HICP services. A referral to the case manager will be offered to assist client to remove any barriers to remain in primary medical care. Documentation Staff shall document all services provided to the client. Documentation shall be entered into the appropriate fields within the client record or upload scanned documentation. Continuous Quality Improvement HICP shall conduct chart reviews at least quarterly to ensure appropriate documentation of all services, including referrals, follow-up and re-certification. Payer of last resort An applicant may not be eligible for services from Program if the applicant is already receiving or is eligible for the same benefits/services from other programs. The services provided by Ryan White may be utilized for HIV related services only when no other source of payment exists. An applicant cannot be receiving services or be eligible to participate in local, state, or federal programs where the same type service is provided or available. This requirement does not preclude an individual from receiving allowable services not provided or available by other local, state, or federal programs, or pending determination of eligibility from other local, state or federal programs. services is the payer of last resort. All community resources should be explored with clients prior to obtaining and receiving services. Responsibilities of Staff Staff shall provide services to clients as indicated below: Prepare and summarize data for quarterly reports Prepare training, PowerPoint and other documents as needed and requested Create monthly data tracking through PE for the purpose of Quality Assurance and Crossreferencing of payments made on behalf of a HICP client. Prepare check request for payments made on behalf of clients in a timely manner Provide technical guidance and information to pharmacies, doctors, laboratories, etc. on HICP guidelines and as deemed appropriate. Professional Requirements and Training HICP/Eligibility Coordinator Education Requirements: Staff must have a minimum of a Bachelor s Degree or administrative staff must be under the supervision of staff having a minimum of a Master s Degree, and one year experience working with medical insurance claims and commercial insurance plans. Other Requirements: Knowledge of community resources Knowledge of target population Knowledge of HIV disease and treatment Cultural and linguistic competence Experience in care coordination Health and disability benefits policy experience Staff management and administration experience Page 6 of 7

7 Skills: Client assessment Written documentation Time management Training of the Eligibility Coordinator: HIV Basic Training Annual HIV Update Staff receives Part A case management training Page 7 of 7