Accessing Care in Rural California Abbi Coursolle & Amy Arambula LAAC Traveling Training Fresno

Transcription

1 Accessing Care in Rural California Abbi Coursolle & Amy Arambula LAAC Traveling Training Fresno October 14, 2014

2 Your client You (the advocate) Needed health care service 2

3 The training will cover: Coverage basics What types of health care coverage are available for low-income people Common barriers to coverage and strategies for overcoming them Using coverage Who regulates health coverage? Important consumer protections: network adequacy, continuity of care Common barriers to getting care and strategies for overcoming them 3

4 How do cases arise? Getting coverage 1. Client doesn t know how to get coverage. 2. Client s case is stuck between Medi-Cal and Covered California. 3. Client s case is stuck in the Medi-Cal backlog. 4. Client is not eligible for Medi- Cal and didn t apply for coverage during open enrollment. 5. County or Covered California does not correctly apply eligibility rules. 6. Client is not enrolled in the most generous coverage. Using coverage 1. Coverage is expensive to use or client doesn t understand how to use it. 2. Coverage program claims it doesn t cover needed service. 3. Provider doesn t think client needs a particular service. 4. Provider thinks that client needs a particular service, but coverage program disagrees. 5. Client can t access a qualified provider. 6. Client accessed services outof-network and coverage program refuses to reimburse. 4

5 Issue Spotting & Choice of Procedure Does your client have health coverage? Is the insurance private or Medi-Cal? Is the insurance an HMO, PPO, POS, or fee-forservice (indemnity)? What does your client need? Coverage in general A particular service Who caused the problem? Covered California Medi-Cal Health Plan Provider Someone else 5

6 Issue Spotting & Choice of Procedure How much time has passed? Was there a notice? What steps (if any) has the client already taken to address the problem? Filed an appeal? Requested Independent Medical Review Which choices are available for this problem? What are the appropriate parties? What result(s) does the client seeks? 6

7 GETTING CLIENTS COVERED

8 What types of coverage can people get in California? Medi-Cal Fee-for-service Managed Care Medicare Fee-for-service Managed Care Veterans Health Administration Coverage County Programs Individual Market Plans Covered California Qualified Health Plans Other individual market plans Group Market Plans (small and large) Covered California SHOP plans Employer-sponsored coverage Union coverage TRICARE 8

9 Individual Mandate After January 1, 2014, most individuals must have health insurance that is minimum essential coverage or potentially pay a tax penalty Certain individuals are exempt from mandate (e.g., : 1) People who cannot afford coverage 2) Undocumented immigrants 3) People who are uninsured for less than three months 4) Individuals with incomes below the tax filing threshold Will have to apply for Certificate of Exemption from Covered California or HHS or directly to IRS 9

10 Minimum Essential Coverage (MEC) for Individual Mandate Covered California individual/shop coverage Full-scope Medi-Cal Medicare Part A coverage and Medicare Advantage plans Employer-sponsored coverage (including COBRA coverage and retiree coverage) TRICARE Certain types of veterans health coverage administered by the Veterans Administration Refugee Medical Assistance (RMA) supported by the Administration for Children and Families 10

11 Minimum Essential Coverage (MEC) MEC does not include: Coverage providing only limited benefits, such as coverage only for vision care or dental care. Enrollment in a County program. Medi-Cal covering only certain benefits such as pregnancy, family planning, workers' compensation, or disability policies. Medi-Cal w/soc (Medically Needy): Counts as MEC only in months where SOC is actually met 11

12 Income eligibility for subsidized coverage Adults ages 19-64: Income below 133% FPL Medi-Cal Income 133% 400% FPL Covered California (with subsidies) 12

13 Income Eligibility (cont d) Children: Ages 1-19: from 0-250% Medi-Cal Ages 1-19 from % Exchange with subsidies Infants Age 0-1 from 0-300% Medi-Cal Adults & children above 400% FPL Exchange, no subsidies 13

14 Income Eligibility (cont d) Pregnant Women 0-138% FPL* Full scope Medi-Cal % FPL Pregnancy Medi-Cal &/or Exchange subsidies (Pregnancy Wrap in 2016) % FPL AIM % FPL Exchange with subsidies Above 400% FPL Exchange without subsidies 14

15 Tax Penalty Flat rate or % of household income, whichever amount is greater. Year Flat Rate Share of Income 2014 $95 1% taxable income 2015 $325 2% taxable income 2016 $ % taxable income 15

16 Who are CA s remaining uninsured? 3-4 million Californians will remain uninsured, of which: 25% are undocumented immigrants 50% will be eligible, but not enrolled More likely to be Latino, LEP, and have incomes below 200% FPL More than 60% are from S. California (esp. LA) Most will be exempt from mandate for different reasons 16

17 17

18 Common issues: Client doesn t know how to get coverage (See previous slides) Note that to get a Covered California plan with subsidies, must show that other coverage options (like employer insurance) are unaffordable or do not have minimum value. 18

19 Common issues: case stuck between Medi-Cal and Covered California Clients with fluctuating income / seasonal employment Clients with unusual household composition especially multi-generational families Individuals with disabilities who might be eligible for Medi-Cal under the pre-aca rules 19

20 Common issues: case is stuck in the Medi-Cal backlog Clients who applied early, when IT was not functioning correctly Clients whose information could not be verified electronically (Note: NHeLP and CCLS, with other organizations, have filed a lawsuit against the state for failure to process applications timely and appropriately Rivera v. Douglas) 20

21 Common issues: not eligible for Medi-Cal and didn t apply for coverage during open enrollment As of 2014, people can only apply for individual market coverage (Covered California or otherwise) during open enrollment, unless they experience a qualifying event that entitles them to a special enrollment period. Medi-Cal is open year round. The next open enrollment period begins November 15, 2014, for coverage starting January 1,

22 Common issues: incorrect application of eligibility rules For example, county still using old, pre-aca rules, and denying clients due to assets. For example, Covered California failing to determine whether a client s employersponsored insurance meets the minimum value requirement. For example, county not counting the number of household members correctly. 22

23 Common issues: client not enrolled in the most generous coverage For example, client enrolled in Medi-Cal with a share-of-cost when she could be eligible for free Medi-Cal For example, pregnant woman enrolled in a Covered California plan when she could be eligible for enhanced services and lower costsharing in Medi-Cal 23

24 HELPING CLIENTS USE THEIR COVERAGE What Services Are Covered

25 Who regulates coverage? Federal Federal Department of Health & Human Services (HHS) All Covered California Plans Medicare: fee-for-service, Rx plans, Medigap plans, Medicare Advantage plans Medi-Cal: fee-for-service, managed care plans, plans for Medi- Cal/Medicare dual eligibles Office of Personnel Management: Anthem Blue Cross Multi-State Plan Department of Labor: Most self-funded plans (e.g. employer or union plans) Department of Defense: TRICARE Department of Veteran s Affairs Veterans Health Administration coverage 25

26 Who regulates coverage? State Department of Health Care Services (DHCS) Medi-Cal fee-for-service All Medi-Cal managed care plans Medi-Cal Access Program (formerly AIM) All plans for Medi-Cal/Medicare dual eligibles, e.g., Cal Medi- Connect & PACE plans Major Risk Medical Insurance Program (MRMIP) Covered California All Covered California Plans Department of Insurance (CDI) Medi-Cal: None Covered California: Health Net PPO Medicare: some Medigap plans Some MRMIP plans Private insurance: most EPOs, PPOs, and POS plans; no HMOs 26

27 Who regulates coverage? State (cont d) Department of Managed Health Care (DMHC) Medi-Cal: All GMC, Two-Plan, and Regional Model plans No COHS plans EXCEPT Health Plan of San Mateo Medicare: some Medigap plans Covered California: All plans EXCEPT Health Net PPO & Anthem Blue Cross Multi-State Plan Private insurance: All HMOs & some Blue Cross / Blue Shield EPOs & PPOs County Boards of Supervisors: County programs 27

28 What services are covered? Most health plans must cover the ten Essential Health Benefits, which include: Ambulatory / outpatient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services 28

29 What services are covered? To find out what is covered by a health plan, ask for the Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC). For other types of coverage, like Veteran s Health Administration Coverage, fee-for-service Medicare, feefor-service Medi-Cal, and County programs, you will likely need to consult statutes, regulations, and/or caselaw. Note: for enrollees in Medi-Cal managed care, certain services, like dental and specialty mental health, are carved out i.e. provided by an entity other than the health plan. 29

30 Accessing Services Health plans generally must provide covered services when they are medically necessary Medi-Cal: Most covered services for adults must be provided if necessary to protect life, to prevent a significant illness or disability, or to alleviate severe pain. For children, covered services must be provided if they are necessary to correct or ameliorate an illness or condition. This is part of the federal EPSDT requirement. Health plans and coverage programs may use prior authorization processes to determine when to provide services. 30

31 Consumer Protections for Access: Geographic Access DMHC and CDI plans: Primary care & hospitals available within 15 miles or 30 minutes of home or work. Additional DMHC standards: Ancillary services are a reasonable distance from primary care facilities. Additional CDI standards: Specialty care within 30 miles or 60 minutes. Mental health care within 15 miles or 30 minutes. Medi-Cal plans: Primary care within 10 miles or 30 minutes. 31

32 Consumer Protections for Access: Timely Access DMHC & Medi-Cal plans: Urgent care: 48 hours / 96 hours if prior authorization required Primary care: 10 business days Specialty care: 15 days Mental health: 10 business days Ancillary care: 15 business days Dental: urgent 72 hours, routine 36 days, preventive 40 days 24/7 Nurse hotline 24/7 emergency care 32

33 Consumer Protections for Access: Access out-of-network All plans must provide access to out-of-network services in cases of emergency. DMHC & Medi-Cal plans: When medically necessary services are unavailable in the plan s network, plan must provide access to services out-of-network at no additional cost to the enrollee. Medi-Cal plans: Must allow members of childbearing age to access family planning and reproductive health services out-of network. 33

34 34

35 Common issues: Coverage is expensive or client doesn t understand it. Plans may have high deductibles, co-pays, or coinsurance costs. Consumers do not understand the different features of health insurance and managed care type coverage such as limitations on which providers will be covered. 35

36 Common issues: Program claims it doesn t cover needed service. Client needs an unusual service and coverage program says: It s not covered It s experimental It s cosmetic 36

37 Common issues: Provider doesn t think client needs a particular service. Client wants a particular service, but provider won t give client a needed referral or prescription. Provider doesn t think the service is covered Provider doesn t think the service is medically necessary Provider refusal based on moral objection 37

38 Common issues: Provider refers client to service, but program says not needed. Coverage program s prior authorization process deems service unnecessary for client, even though provider recommended it. Coverage program requires client to try a less expensive alternative first. 38

39 Common issues: Client can t access a qualified provider. Client lives in remote area and there are no qualified providers nearby. Client s coverage program doesn t contract with any nearby providers and requires client to travel to providers some distance away. Client lives in remote area and there are only a few qualified providers; wait times for providers are very long. Client lacks adequate transportation to see qualified provider. 39

40 Common issues: Client got care out-ofnetwork and program won t reimburse. Client had an emergency and went to a hospital that isn t part of the coverage program s network. Client wasn t able to get an appointment for a needed service from an in-network provider so saw a provider out-of-network. Client s long-time provider is not part of the program s network but client wants to continue seeing that provider. 40

41 More Questions? Abbi Coursolle Staff Attorney, LA Office National Health Law Program D: (310) Amy Arambula Attorney, Health Team Central California Legal Services D: (559)

42 THANK YOU Washington DC Office Los Angeles Office North Carolina Office 1444 I Street NW, Suite 1105 Washington, DC ph: (202) fx: (202) nhelpdc@healthlaw.org 3701 Wilshire Blvd, Suite #750 Los Angeles, CA ph: (310) fx: (213) nhelp@healthlaw.org 101 East Weaver Street, Suite G-7 Carrboro, NC ph: (919) fx: (919) nhelpnc@healthlaw.org