Medicaid Coverage in the District of Columbia

Medicaid Coverage in the District of Columbia
Jennifer Mezey, Supervising AttorneyAndrew Patterson, Senior Staff Attorneyjmezey@legalaiddc.organdapatterson@legalaiddc.orgJune 16, 2016
Presentation Overview
Overview of Medicaid in the DistrictEligibilityCoverage (including medical necessity)Home Health Services through MedicaidState plan covered servicesElderly and Physically Disabled (EPD) waiver covered servicesDental Services through MedicaidHearing Rules and Procedures
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Training on Home Health and Dental Cases
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Medicaid Eligibility
To be eligible, applicant must be:Low income(and, depending on eligibility category, low asset)Citizen or “qualified alien”+Eligibility category (see next slide) – MAGI or non-MAGI?
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Training on Home Health and Dental Cases
MedicaidEligibility Categories
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Training on Home Health and Dental Cases
Benefits & Coverage
What services are covered under each public insurance program and what is the cost?How are services delivered through each program?
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Training on Home Health and Dental Cases
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Medicare v. Medicaid v. Alliance2016 SummaryofBenefits, Services and Costs
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Training on Home Health and Dental Cases
Help for Low Income Medicare Beneficiaries
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Training on Home Health and Dental Cases
How are Services Delivered?Fee for Service versus Managed Care
What is Fee for Service (FFS)?Go to any doctor who accepts your insurance. No referrals, no networks.What is Managed Care?Third party contracts with doctors, hospitals, etc. to be in its network.If patient goes out of network, no coverage., with some very limited exceptions.Usually referral required for specialist.
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Training on Home Health and Dental Cases
Who is in FFS and who is in Managed Care in the District?
Fee for ServiceMostMedicarerecipients.Medicaidrecipients who get SSI or SSDI, are over 65 and some who are disabled but don’t get SSI or SSDI.Medicaidrecipients who are get Medicaid through the EPD Waiver.Managed CareMedicarerecipients who choose to enroll in a managed care plan.Most Medicaidrecipients(all children, and pregnantwomen, parents or caretakers and childlessadults who are not receiving SSI or SSDI).
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Training on Home Health and Dental Cases
Benefits vary among programs, but all beneficiaries must seek services:
from aprovider who participatesin:Health insurance program (Medicare or Medicaid)andManagedcareorganization (AmeriHealth,MedStar, Trusted (Medicaid and Alliance), Health Care Services for Children with Special Needs HSCSN (Children with Medicaid) and private plan through DC Health Link.that are“covered” servicesunder program.that are“medically necessary.”“Medical Necessity” is not defined in DC regulations.Contracts between DHCF and MCOs include definition of medical necessity.Case law also provides guidance for deference to treating physician under Medicaid Act.
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Training on Home Health and Dental Cases
COVERAGE OF HOME HEALTH AIDE SERVICES THROUGH STATE PLAN MEDICAID AND THE MEDICAID EPD WAIVER
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Training on Home Health and Dental Cases
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Eligibility for Medicaid State Plan PCA andEPD Waiver Services
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Training on Home Health and Dental Cases
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State Plan Personal Care Assistance (PCA) ServicesPart of DC’s package of benefits to all Medicaid enrolleesMust be enrolled in Medicaid (in one of the eligibility groups described earlier) before being able to access PCA services.Services must also be deemed “medically necessary” by independent contractor.Services are delivered by one of multiple Home Health Agencies that contract with DHCF to provide these services.Home Health Waiver for the Elderly and Physically Disabled (EPD Waiver)Waiver program is a different kind of category of Medicaid eligibilitySeparate application process and eligibility criteria from State Plan Medicaid.Like State Plan Medicaid – must meet DC residency and immigrant eligibility criteria.Income limit of 300% of monthly SSI payment amount ($733 x 3 = $2199 per month), and asset limit of $4,000 per month for individual, $6,000 per month for couple.Higher medical necessity standard than State Plan services – must need level-of-care equivalent to nursing home.
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Training on Home Health and Dental Cases
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Applying for State Plan Personal Care Assistance (PCA) Services and EPD Waiver services – Getting Started
State Plan PCA ServicesStart process by having Medicaid enrollee’s physician send Physician Order Form to Delmarva.Refer to State Plan PCA Services flow chart.Physician must certify that applicant is unableto perform one or more activities of daily living: bathing, toileting, mobility, getting dressed andeating.Limit of 8 hours per day, 7 days per week of PCA services. If need more, must get them through EPD waiver.EPD Waiver ServicesContactAging and Disability Resource Center (ADRC). Medicaid enrollment specialist will schedule home visit to begin application process. Refer to EPD flow chart.Physician must certify that the applicant requires:Extensiveor total assistance in 2 of 5 basic activities of daily living: bathing, toileting, mobility, getting dressed, and eating; or …More limited assistance in 2 of the 5 basic living activities,andsome level of assistance in 3 of 5 “instrumental” living activities: medication management, meal preparation, housekeeping, money management and telephone use.Cantheoretically receive up to 24 hoursper day of care. 16 hours per dayis typically the limit we see.
Renewing Home Health Services through State Plan and EPD Waiver
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State Plan PCA ServicesLevel-of-care needs be reassessed every 180 days.Delmarva (third party vendor) conducts home visit, conducts new level-of-care assessment and gets updated records from doctors (frequently need enrollee’s assistance), then issues a new approval or denial for hours per day and days per week of PCA services.EPD Waiver ServicesMust recertify for waiver coverage every year, which includes reassessment of level-of-care for home health servicesandfinancial eligibility determination.Enrollees receive 90 day recertification notice, and 30 day termination notice if recertification not completed.Recertification should be conducted by case manager, who is supposed to gather updated assessments and records from doctor. Case manager is also in charge of managing the recertification process and sending documents toQualis.Possible to be recertified for waiver coverage, but with reduced level-of-care assessment.BothState Plan and WaiverServicesAppeal any adverse decision to Office of Administrative Hearings.
Home Health Cases – Recertification Cases
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Recertification issues in Waiver casesCase manager is responsible for recertifying a client’s waiver eligibility each year.This is both a recertification of their level-of-care needs, as well as recertification of their entire Medicaid coverage.Requires case manager to gather updated eligibility information, including updated level-of-care assessments, and send them toQualis, Delmarva and the Economic Security Administration.If one part of process is not completed, can result in termination.Many cases of this type eventually settle, but still require intervention by an attorney to ensure the process gets done.Recertification issues in State Plan PCA casesThe amount of PCA services must be recertified every 180 days.If documentation (updated physician forms and medical records) or other parts of recertification have not been completed or sent to Delmarva, can result in termination of services.Many cases of this type are also resolved without full evidentiary hearing.
Home Health Cases – Medical Necessity Cases
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Training on Home Health and Dental Cases
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Medical necessity cases arise when:PCA or Waiver applications are denied because DHCF argues they are not medically necessary, orMore frequently, when existing services are reduced or terminated because DHCF argues the previous level-of-care is no longer medically necessary.Representing clients in medicalnecessity cases:Gather client’s medical records from treating physicians, and gather application or recertification materials from DHCF, Delmarva andQualis.Work with treating physicians to supplement medical recordsDHCF may ask for a new level-of-care assessment to be completed; ask doctor to submit letter explaining, in details, the client’s medical conditions, symptoms, limitations, and what services he or she needs.During hearing process, DHCF will frequently resubmit updated information for another assessment, and this frequently results in cases being settled.If the case is not settled – then prepare for evidentiary hearingPrepare client and other potential witnesses for testimony and cross examination; organize and introduce medical evidence; consider asking for permission to submit pre-hearing or post-hearing brief.
Coverage of dental benefits under dcMedicaid program
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Training on Home Health and Dental Cases
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Medicaid Dental Coverage
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All Medicaid enrollees in the District receive comprehensive dental coverage.More limited for adults than children.Dental benefits are described in the Medicaid State Plan.Further guidance on covered benefits and the prior authorization process (where it applies) is available in regulations and theQualisprovider manual (links to these materials are included in the training binder)Most basic services, cleanings, x-rays,etc… are generally available without prior authorization, though they may be subject to limits on frequency/quantity.Other services, such as orthodontics or implants, require prior approval before a Medicaid enrollee can receive them.
Denials of dental benefits under Medicaid
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Two primary reasons for dental (and most other) services under Medicaid to be denied:Not a “covered service,” (including quantity limits), orNot “medically necessary.”If not a covered service, may be little or nothing to do, unless …Early and Periodic Screening, Diagnoses and Treatment (EPSDT) generally allows children in Medicaid to receive any medically-necessary Medicaid-coverable service,regardless of whether that service is covered in the State Plan.Quantity limits – some support in case law for the argument that firm, inflexible quantity limits, with no exception for medical necessity, are not allowed under Medicaid Act, but not a settled matter.Check for discrepancies among DC regulations, state plan and contract in terms of coverage.
Dental Cases – Medical Necessity Cases
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Training on Home Health and Dental Cases
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Proving Medical Necessity in Dental CasesGet full records from dentist and other treating sources.Ask for dentist to testify, either in person or over the phone. Usually hard to arrange in-person or even phone testimony, but sometimes able to do so.Ifprovider is unable to testify, ask for written letter of support. Letter should discuss:Specific treatment sought,What functional deficits will treatment correct (trouble chewing, eating, pain, bleeding, etc.), to establish why procedure sought is not “cosmetic.”Have alternative treatments been applied? If so, explain why not successful. If not, explain why alternative treatments are not likely to succeed.Prepare client for testimony and cross examinationPrepare to cross-examine witnesses for DHCF (and their contractors)Consider asking to submit a pre-hearing or post-hearing legal brief
Appeal Rights
A decision to deny coverage under Medicaid can be appealed through a Fair Hearing request with the Office of Administrative Hearings (OAH) within 90 days of the date on the notice of denial, reduction or termination.If denial is by a Managed Care Organization (MCO), the client can also file a grievance with the MCO. Can be done simultaneously or can do this first and appeal the denial of the grievance to OAH.If applicant or recipient does not receive a notice, or the notice does not describe the appeal rights, then the applicant or recipient is not bound by the 90 day deadline.If arecipientrequests an appeal/fair hearingwithin 15 days of the notice date or before the termination or reduction occurs (whichever is later), recipient can getaid pending.Benefits cannot be reduced or terminated until the appeal is decided.Doesn’t help when trying to get the agency or Managed Care Organization to cover a service.
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Training on Home Health and Dental Cases
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Fair Hearing Process
Should request a fair hearing through (OAH)Can be made orally, but should follow-up in writing.OAH Resource Center for people without lawyers.Request for aid pending review should be explicit.If request already filed, must submit Notice of Appearance at OAH.Who is the proper respondent?Dental case – DC Department of Health Care Finance and MCO (if applicable).Home health aide case – DC Department of Health Care Finance and Home Health Agency.If Medicaid and QMB has been inappropriately terminated with EPD waiver termination, the DC Department of Human Services is also a party.Pre-Hearing ProceedingsDHCF cases will have status conference at OAH.DHS cases will have optional Administrative Review Conference at DHS.Hearingat OAH before Administrative Law JudgeDHCF, MCO (if applicable) and Home Health Agency will send attorneys.DHS (if involved)willsendanon-attorney representativePrepare a pre-hearing briefSubmit evidence and brief prior to hearingPrepare client testimony and be prepared to challenge evidence/cross examinewitnessesCases will often settle without a hearing
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OAH Information
District of ColumbiaOffice of Administrative Hearings441 4thSt. NW, Suite 540-SWashington, DC 20001-2714Phone: (202)442-9094Fax: (202)442-4789E-filing Address:oah.filing@dc.govOAH Resource Center hours:Mondays, Tuesdays, and Wednesdays from 10:00 am – 1:00 pmFridays from 10:00 am – 3:00 pmInstructions forOnline Filing:http://oah.dc.gov/webform/filing-documents-online-form
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