1. Medi-Cal Reimbursement for Prisons and Jails California/Nevada Chapter of the American Correctional Health Services Association: Multidisciplinary Correctional Conference
November 3, 2011
Brenda G. Klütz
Senior Consultant
Health Management Associates

2. Learning Objectives
Understand current Medi-Cal & reimbursement opportunities for inmate inpatient stays
Understand the how the key elements of healthcare reform effect payment for inmate, parolee and probationers health now & in 2014

3. Health Management Associates
Public health policy and management consulting firm, 12 offices
Focus on Medicaid, uninsured, public health care programs and systems, health care reform, access and quality
Clients:
County health systems and jails, prison systems
Medicaid agencies, managed care, county governments, professional associations, hospitals and health systems, insurers, foundations
Establish my credibility – not just making this up
Employ at least 10 ex-Medicaid directors and many high –level Medicaid administrators
CMS director of Medicaid eligibility = Ohio Medicaid director and HMA principal
Conduct Kaiser Medicaid survey every year, relationships with almost all Medicaid agencies
Current engagements with CA Prison Health Care Services, Michigan DOC addressing this issue
Several engagements under development with county health systems and jails
Recently surveyed 12 state DOCs:
CA Colorado Louisiana Mass MI Mississippi
Missouri Nebraska NY NC OK Washington Wisconsin
How many in audience are prisons? How many jails?
How many are billing Medicaid now?
How many tried and stopped?
How many working on starting now?
How many not but should be?

4. Today’s Medicaid
The Basics

5. Medicaid Eligibility Eligibility is based largely on: Income Assets
Age (under 21 and over 64)
Families with children
Disability

6. Medicaid Eligibility
Low-income, childless adults between the ages of 21 through 64 are generally not eligible for Medicaid, unless they have a disability.

7. Advantages of Medicaid Funding
State Medicaid expenditures are matched by Federal funds: amount of match is the Federal Medical Assistance Percentage (FMAP)
Now prisons and jails using state general fund or county/city $ for inmate hospital care
Using Medicaid where possible reduces cost to state/county/city by providing federal money
Any FFP not collected is money left on the table in Washington.

8. Advantages of Medicaid Funding
The FMAP formula is a state’s per capita income relative to U.S. per capita income: higher match to states with lower incomes (with a maximum of 83%) lower match to states with higher incomes (minimum of 50%).

9. Advantage of Medicaid Funding
California’s FMAP is 50%
Nevada’s FMAP is 51.63% (2011)

10. Medicaid and Inmate Health Care
What will Medicaid Pay for?

11. Medicaid and Inmates: The Facts
Medicaid does not provide matching funds for services provided to incarcerated persons
However, an inmate who spends 24 hours or more in a medical institution is not considered to be incarcerated during that time, even though still in custody
“Medical institutions” definition has huge implications for corrections systems contemplating building won hospitals or LTC facilities – extremely important
Cannot be inside the walls of a prison system
Cannot be owned or operated by corrections
Eligible services CAN be a distinct locked unit of a community hospital dedicated to inmates, per recent interpretation

12. Medicaid and Inmates: The Facts
“Medical institution” = hospital or skilled nursing facility not operated by the corrections organization, serves the general public
(See Appendix A & B of Handout)

13. Medicaid and Inmates: The Facts
CMS will provide matching funds for inpatient services provided in a hospital that has a locked correctional unit, as long as the overall hospital serves the general public. (See Appendix C)

14. Medicaid and Inmates: The Facts
Federal Medicaid rules allow payment for certain inpatient services provided to inmates who are eligible & enrolled in Medicaid.
CMS has made clear, that federal law does not require states to dis-enroll inmates from Medicaid, but the state may only claim federal matching funds for certain services. (See Appendix B)

15. Medicaid and Inmates: The Facts
Many states dis-enroll Medicaid beneficiaries upon incarceration.
States may not have a process to enroll inmates in Medicaid if they become eligible while in prison or jail
State laws, regulations or policies may prohibit continued enrollment
Now back to the REAL agenda
There is a great deal of mis-information across corrections and Medicaid agencies
Many confusing elements that seem to relate but don’t
These are the FACTS
Dear Medicaid Director letter: Medicaid allows Medicaid coverage for eligible inmates who stay overnight in a medical institution
How many in audience are prisons?

16. Advantages of Medicaid Eligibility and Enrollment
If state laws permit, prisons and jails can claim federal matching funds for some health care services provided to eligible inmates that are now paid for by 100% state general fund
Ensuring eligibility prior to release can ensure more seamless health care

17. What Other States are Doing
At least nine other states have been claiming federal matching funds for the cost of inpatient stays for eligible inmates
Some started in the late 1990’s
At least 5 other states have new laws or are proposing laws to permit

18. How might it affect inmates?
Health Care Reform
How might it affect inmates?

19. Key Provisions of the Patient Protection and Affordable Care Act
Insurance Market Reforms in All States
Delivery System Redesign
Payment models
Primary care workforce initiatives
Coverage Expansions
Health Insurance Exchanges
Medicaid Expansions
Market reforms are obligatory by 2014, some for children already in effect
Extremely important in leveling the playing field and stopping skimming and dumping
Medical Loss Ratio important – Medicare 2-3% admin fees, commercial insurance held to 15%
Delivery system redesign extremely important – incentivizing effective care delivery, patient-centered. Corrections has a lot to learn here. Another topic = primary care medical home in corrections, esp for chronic illness. Integration of BH too

20. Health Care Reform Effective 1/1/2014:
Asset, age and disability criteria for Medicaid eligibility will be eliminated
Individuals with incomes of up to 133% FPL will be eligible for Medi-Cal

21. Health Care Reform
Individuals with income from 134% up to 200% FPL will be eligible for coverage through CA Health Benefit Exchange
Low income (up to 133% FPL), childless adults between the ages of 21 through 64 will be eligible for some Medicaid coverage. (majority of prison and jail population)

22. Health Care Reform
In 2014, federal match for new enrollees will be 100%
Year Two the match will be 90% federal funds

23. California’s Approach
Planning for 2014
California’s Approach

24. California’s Bridge to Reform
By 1/1/2014, approximately 851,000 currently-uninsured Californians will be eligible for Medi-Cal.

25. California’s Bridge to Reform
Created a Medicaid waiver option for counties to participate in a Medicaid expansion program: Low Income Health Program (LIHP)
Covers childless adults age 21 through 64, with income levels of up to 133% FPL and 200% FPL

26. California’s Bridge to Reform
Starts to provide Medi-Cal-like coverage for low-income childless adults prior to health care reform’s full implementation
Builds the provider network capacity to prepare for 1/1/2014

27. California Law Change in 2010
California regulations previously required counties to dis-enroll Medi-Cal beneficiaries upon incarceration

28. California Law Change in 2010
California law now mandates counties to enroll state prison inmates in LIHP
Gives counties the option to enroll inmates county jails to enroll in the LIHP or in the Medi-Cal program
Law is silent about city jails.
(See Appendix D of Handout)

29. Which Inmates TODAY are eligible (CA)?
State Medicaid income & asset guidelines AND
Categorical Eligibility
Pregnant women
Inmates< age 21
Inmates age 65>
Disabled for at least 12 months
Most relevant to prisons, but jails often have isolated very costly cases

30. Will it Last?
According the Centers for Medicare and Medicaid, Medicaid Disabled and Elderly Programs:
There is no plan to rescind FFP for inmate inpatient care
Medicaid eligibility for inmates offers important opportunities for continuity of care for chronic conditions, mental illness

31. Challenges and Opportunities

32. Medicaid as Payment in Full
Federal rule prohibit providers participating in Medicaid to balance-bill patients or providers
For some prisons and jails, provider payment levels are in statute and exceed Medicaid rates
Some prisons and jails have negotiated contract rates with providers that exceed Medicaid rates

33. Medicaid as Payer of Last Resort
Hospitals may challenge Medicaid payment because they perceive prison, jail, or vendor as insurance coverage.
Key distinction between insurance and a correctional organization’s constitutional obligation as custodian to avoid deliberate indifference and cruel or unusual treatment.

34. Alternatives
Hospital bills Medicaid for admission, accepts payment; prison/jail makes periodic “patch payment” to provider
Prison/jail consolidates admissions to specific hospitals to gain volume and cooperation

35. Implementation Issues: Hospitals
Is Medicaid payment acceptable?
Enrollment/eligibility process – who does it? (In California, it is the counties)
Does hospital bill Medicaid?
Is payment significantly delayed?
Some jails/prisons fund out-stationed eligibility worker at hospitals

36. Implementation Issues: Inmates
Freedom of Choice issue
Inmate doesn’t want to enroll/sign Medicaid application
Documents not available
Birth certificate
Tax statements
Bank statements

37. Implementation Issues: Jails
Difficult to change state law individually
May require additional resources, or administrative systems changes
In California, county jails should be working with the county health or social services department

38. Prisons May require new resources
May require tracking system for claims, high-cost inmates, eligibility status, redetermination dates

39. Implementation Issues: Medicaid
Suspended eligibility
Requires new resources (but 50% federal match)
How is federal match tracked and traded?
Many other competing priorities related to health care reform
Michigan DOC pays 50% of salary for eligibility worker outstationed to prison, manages medicaid apps fand re-enrollment for whole system
Federal match is 50% for enrollment work
Really need CENTRALIZED eligibility because of movem3ent across county lines, may need legislation or regulation

40. Implementation
Extremely complex and varies enormously by state Medicaid program
May begin with workgroup that includes Medicaid and the agency that decides eligibility
May work on jails and prisons simultaneously
Most programs start by manually processing a few high-cost cases

41. Other Opportunities
Create information for inmates under age 26 about coverage on parent’s insurance plan
Assist eligible inmates with serious health needs to enroll prior to release

42. Get Moving Toward 2014 Work with community stakeholders to develop
Streamlined discharge planning
Common prescription drug formulary
Continuity of care
Targeted Case Management Programs
Develop inmate education materials

43. Discussion

44. For more information contact
Brenda Klutz, Senior Consultant
Health Management Associates , ext. 424