KDP Annual Conference

1
KDP Annual Conference

• May 13, 2008
• Presenters Cathy Fisher, Maureen Guzman, Nicole
  Nguyen Lauren Kreiger

2
Agenda

• 900 Introductions and Welcome Lauren
  Kreiger
• 910 KDP Overview Lauren Kreiger
• 935 AEM Maureen Guzman and Cathy Fisher
• 1000 Break
• 1015 Spenddown Overview Cathy Fisher
• 1115 Drug List Nicole Nguyen
• 1130 No-host Lunch
• 1230 Manual Lauren Kreiger
• 125 Cost Report/Payments Lauren Kreiger
• 145 Break
• 200 Other Updates/Remaining
  Questions/Discussion

3
Introduction

• Lauren Kreiger Program Manager
• Melissa Usitalo Program Back-up
• Scott Palafox Unit Manager
• Maureen Guzman KDP Clinician
• Cathy Fisher Eligibility Representative
• Nicole Nguyen Pharmacist

4
KDP Overview

• KDP Vision Paper KDP is the payor of last
  resort
• Other programs available
• Medicare/Medicaid must be applied for before
  KDP
• AEM medical assistance for immigrants
• Insurance Premera, Blue Shield, Regence,
  etc.
• WSHIP Washington State Health Insurance Pool
• Managed Care Group Health, etc.
• Basic Health premium-based low-cost
  insurance program (under age of 65).

5
AEM Program

• Required, federally funded program for
  non-citizens with emergency medical conditions
• Medical benefits necessary to treat the emergency
  condition only
• Eligibility for program three parts
• Must be SSI-related, parent of a dependent child,
  or a dependent child.
• Must meet income and resource criteria for
  program.
• Must have qualifying emergency medical condition.

6
Potential AEM Clients

• Undocumented Aliens Persons who either
• 1)  Entered the US without inspection at the
  border, or
• 2)  Were lawfully admitted but have lost their
  status.
• Qualified Aliens Subject to a 5-year bar.
  Examples are
• 1)  Lawful permanent residents.
• 2)  Paroled into the US under Section 212(d)(5)
  of the INA.
• 3)  Battered aliens.

7

• PROCUL Aliens (Permanently Reside Under Color
  of Law)1)  Are not Qualified Aliens.2)  They
  intend to reside indefinitely in the
  US.3)  USCIS know they are here and are not
  enforcing departure.
• Non-Immigrants Admitted to the US for a
  specific purpose and time limit. Can be
  AEM-eligible as long as they reside in WA and
  intend to remain.1)  Business visitors.
• 2)  Students.
• 3)  Tourists.

8
AEM Program

• Emergency Medical Condition
• WAC 388-500-0005
• Sudden onset of medical condition
• Acute symptoms of sufficient severity
• Absence of immediate medical attention
• Place patients health in serious jeopardy
• Serious impairment to bodily functions
• Serious dysfunction of any organ or part

9
AEM Program

• Services not normally necessary to treat
  emergency require Prior Authorization
• Related to the emergency condition
• Medically necessary
• Prior authorization services - examples
• Hospice
• Skilled Nursing Facility
• Nursing Home
• Inpatient Physical Medicine and Rehabilitation
• Durable Medical Equipment

10
AEM Program

• Non-covered services
• Chronic medical conditions
• Transplants
• School-based
• Prenatal
• Exceptions to Chronic Medical Conditions
• Cancer requiring
• Surgery
• Chemotherapy
• Radiation
• Insulin-dependent diabetes mellitus
• Diseases that impact public health, e.g. TB

11
Maureens Contact Info

• Maureen Guzman
• Clinical Program Manger
• Health Recovery Services Administration
• PO Box 45506
• Olympia, WA 98504
• (360-725-2033)
• Guzmam_at_dshs.wa.gov

12
Medically Needy and Spenddown

• Optional Program
• For persons related to a categorically needy (CN)
  medical program such as SSI, childrens medical,
  pregnancy medical, etc.
• Must meet all requirements other than income of
  the related CN program.

13
Medically Needy

• Who Is Eligible?
• SSI-related (age 65 or older persons with
  disabilities or blind)
• Children with family income above 250 of Federal
  Poverty Level (FPL)
• Pregnant women with income above 185 of FPL
• Hospice clients with income over 300 of FPL
• Note No MN for TANF-related adults

14
Medically Needy

• Income budgeting
• SSI-related clients use a prospective income
  estimate.
• Determine income using expected wages and pay
  dates.
• If seasonal or migrant worker and client is not
  working, budget no income.
• Client must report if income changes.
• See WAC 388-450-0215 http//www1.dshs.wa.gov/manua
  ls/eaz/sections/INCMFbudgeting.shtml388-450-0215

15
Medically Needy How do we determine what is
countable income?

• Standard Income Deductions
• 20 unearned income
• 65 and ½ of the balance earned income
• Child care for a disabled client to work
• Each dependent child is allowed half the federal
  benefit rate (FBR) minus any income
• This is currently 318.50.
• The non-applying spouse is allowed the MNIL
• Chapter 388-475 WAC
• MNIL for 2008 is 637 for one person. This goes
  up annually in January.
• This is for SSI-related clients over 65, blind
  or disabled.

16
Medically Needy Calculating Income over the
Standard

• Countable income the remaining income after
  income disregards and family deeming
• Countable income is then compared to the MNIL
  standard.
• If countable income is below the MNIL, the client
  is eligible for MN coverage for 12 months and no
  spenddown.

17
Medically Needy Example

• So, how does this work?
• Bill is 67 and has been diagnosed with end stage
  renal disease. He gets social security benefits
  of 800 per month. His wife Laura is 62 and gets
  350 per month in social security benefits. They
  have no other income and are paying rent of 400
  per month. Bill qualifies for Medicare, but they
  need some extra help. He is paying copayments for
  his prescription drugs and he takes a lot of them
  each month! They apply for Medicaid for Bill.
• Can we help Bill with his medical costs?

18
Medically Needy - Example

• Bills income is 800 - 20 disregard 780.
• We allocate some money to Laura to bring her
  income up to the MNIL of 637. She has 350
  income so we can give her another 287 from
  Bills income.
• Bills income of 780 - 287 493.
• This is Bills countable income. It is less
  than the MNIL of 637 so he is eligible for MN
  coverage with no spenddown.
• He will get 12 months of MN medical. But wait
  theres more

19
Medically Needy - Example

• Bill also has Medicare and pays his Part B
  premium of 96.40 per month. He has free Part A,
  but he pays 38 per month for Part D coverage.
• We can look at the QMB (Qualified Medicare
  Beneficiary) program for Bill.
• The standard is 100 of the federal poverty level
  which is 867 for one person.
• After deeming of income, Bill is found eligible
  for QMB. We will pay his Part B premium,
  coinsurance deductibles.
• SSA will stop deducting the 96.40 from his
  check.

20
Medically Needy - Example

• . And still more..
• Bill now has Medicaid and Medicare so he is a
  deemed a dual-eligible client. He is
  automatically eligible for the low-income subsidy
  for his Part D premium. CMS will pick up this
  cost for him and pay the premium for the rest of
  the year.
• Medicaid will now pay his drug
• copayments up to 3.10 per
• prescription.
• Bill is very happy!!!

21
Medically Needy - Spenddown

• What if the countable income is over the MNIL?
• Income in excess of the monthly standard
  spenddown.

22
Medically Needy - Spenddown

• What is Spenddown?
• Spenddown is the process of spending down
  income above the standard.
• Spenddown is like an insurance deductible.
• Not eligible for Medicaid until spenddown is met
  by incurring medical expenses.
• Spenddown is set up for either three or six
  months this is the clients choice.

23
Spenddown - Setting a Base Period

• Once established, the client can change it if
  medical has not been opened.
• Base period begins the first of the month of
  application.
• Base period may be three months prior to an
  application.

24
How much is Spenddown?

• Excess income multiplied by the number of months
  in base period total spenddown amount.
• Client must show evidence of medical expenses
  before Medicaid approval.
• Medical card is issued once spenddown has been
  met.
• Expenses used to meet spenddown are the clients
  responsibility to pay.

25
Spenddown - Example

• So, back to Bill
• Bill was doing just fine until Laura left him and
  moved in with her sister. Bills Medicaid
  calculation looks a little different now. We
  cannot allocate income to Laura so we have to
  look at all of Bills income.
• 800 20 780. Compare this to the MNIL of
  637, and he now has 143 per month of excess
  income.
• Bill has a spenddown of 858 for
• 6 months and he is not
• happy.

26
Medically Needy Spenddown

• What can be used to help Bill meet his spenddown?
  
• Prior unpaid medical expenses he still owes
  (regardless of age).
• Medical expenses he incurs during the base period
  (minus any 3rd party liability) whether he has
  paid for the expense or not and even if they
  exceed HRSA allowed amounts, duration or scope.
• Other medical expenses not covered by Medicaid
  such as hearing aids, or in some cases, expenses
  for other family members ineligible for Medicaid
  coverage for their own bills.

27
Medically Needy Spenddown

• What can be used to help Bill meet his spenddown?
  
• Transportation expenses to medical appointments.
• Bill should keep a log of his trips for medical
  purposes. This will be adequate verification for
  the CSO.
• Costs of public transportation, such as taxi
  fares, rail tickets, bus tickets, etc.
• Parking expenses. Medicare premiums, copayments,
  co-insurance and deductibles.

28
Medically Needy - Spenddown

• What about health insurance premiums?
• Health insurance premiums are an income
  deduction, not a spenddown expense this may
  make a big difference for your client.
• If KDP pays for insurance premiums on behalf of a
  client, ask the CSO to re-determine the clients
  eligibility for Medicaid.

29
Medically Needy - Spenddown

• Luckily, Bill has been working with his local
  kidney center who has helped him find affordable
  health insurance. KDP can pay the 190 premium.
  They verify the 190 insurance premium to DSHS.
• Bills new calculation looks different again..

30
Medically Needy - Spenddown

• Bills monthly income is 800 - 20 780 - 190
  HP 590.
• 590 is now less than the MNIL of 637 so Bill is
  eligible again for MN with no spenddown amount.
• KDP will need to pay the premium, but all other
  charges potentially can be payable by Medicaid.

31
Medically Needy - Spenddown

• Bill is very happy.
• KDP is happy Bill has
• Medicaid coverage and
• eventually HRSA may help
• with the costs of the
• insurance premium.
• Cathy is happy everyone
• understands spenddown
• and no-one calls her anymore!!!!

32
But just in case you do still need to contact
her..

• Catherine Fisher
• Regional Medical Eligibility Representative
• Health Recovery Services Administration
• PO Box 45534
• Olympia, WA 98504
• (360-725-1357)
• Fishecl_at_dshs.wa.gov
• Medically needy and spenddown policy questions

33
KDP Drug List Changes

• Deletions
• Altace (Ramipril)
• Coreg (Carvedilol)
• Toprol XL (Metoprolol Succinate)
• generic is added to list
• generic remains on list

• Additions
• Azithromycin
• Bupropion XL
• Carvedilol
• Omeprazole
• Ramipril
• Simvastatin

34
Manual

• Retroactive Period
• Three calendar months prior to the month of
  Medicaid
• application.
• Home Helper Rates/Training
• Flat fee per session training to be paid as
  well as dialysis.
• Seasonal Workers
• Use current income (if currently working)
  along with previous
• bank statements in order to come up with
  educated guess in
• finding income. Then reassess/correct income
  when renewal time comes by using W-2s.

35
Manual Contd

• Dialysis Sessions per person per month
• To mirror that of Medicaid 14 Hemodialysis
  sessions a
• month authorization needed for extensions
  through clinical
• support.
• Transportation
• Mileage can be used towards deductibles/spenddo
  wn. Currently at 0.50 a mile.

36
A-19/Payments

• Going back to A-19 submittal
• No more cost reports providers fill out the
  provided
• A-19 form and submit back-up documentation
  for
• payment.
• Payments determined by actual costs
• A-19 submitted with actual costs
• Payments made according to A-19

37
A-19/Payments Contd

• Documentation
• Each provider to submit a line-by-line
  spreadsheet that keeps track of individual
  patient expenditures for every month. For an
  example, click here.

38
Payments Contd

• Four Quarterly Payments
• To be paid three months after end of quarter
  (to
• account for adjustments). First payment to
  cover
• submitted costs, or contract maximum,
  whichever is less. Amendment amounts to be
  paid after
• reconciliation. For an example, click here.

39
Laurens Contact Info

• Lauren Kreiger
• Kidney Disease Program Manager
• Health Recovery Services Administration
• PO Box 45510
• Olympia, WA 98504
• (360-725-1152)
• Kreigl_at_dshs.wa.gov