is disability a “leaky ucket” in your eligibility program?
TRANSCRIPT
Is Disability A “Leaky Bucket” In Your Eligibility Program?
Florida HFMA WebinarJuly 24, 2019
Outline
1. Discussion of Uncompensated Care2. Eligibility Programs3. Medicaid Eligibility How “Disability” is
Different4. SSI vs. SSDI5. Reasons Why Disability is Problematic6. Roadblocks to Disability Awards7. What Hospitals Can Do To Plug the “Leaky
Bucket”
A discussion of uncompensated care
Uncompensated Care =Bad Debt + Financial Assistance
First, a discussion of uncompensated care
Uncompensated Care:Bad Debt + Financial Assistance Services for which hospital anticipated but did NOT receive payment (insured)______________________Deductible, Co-Pay, Out-of-Network, Payer Denials_______________________Can afford insurance
_______________________Solution: Collections, Payer Contract Administration
First, a discussion of uncompensated care
Uncompensated Care:Bad Debt + Financial AssistanceServices for which hospital Services hospital neither received anticipated but did NOT nor expected to receive paymentreceive payment (insured) (self pay)______________________ ___________________________Deductible, Co-Pay, Out-Of- No payment or partial paymentNetwork, Payer Denials_______________________ ___________________________Can afford insurance Can’t afford insurance or don’t
Know they qualify for insurance _______________________ ___________________________ Solution: Collections, Payer Solution: Eligibility Program Contract Administration
Eligibility Programs
Objective: • Get uninsured patients signed-up for Medicaid
Process:• Interview every self pay patient prior to discharge• Identify potential Medicaid candidates and assist
with the applications process
Financial Criteria for Medicaid Eligibility
Medicaid eligibility has certain financial criteria• In 33 states (including Florida) the income
methodology is called Modified Adjusted Gross Income (MAGI)• Considers taxable income and tax filing
relationships
Financial Criteria for Medicaid Eligibility
Medicaid eligibility has certain financial criteria• In 33 states (including Florida) the income
methodology is called Modified Adjusted Gross Income (MAGI)• Considers taxable income and tax filing
relationships• 7 states make their own Medicaid eligibility
decisions (using SSI criteria)
Financial Criteria for Medicaid Eligibility
Medicaid eligibility has certain financial criteria• In 33 states (including Florida) the income
methodology is called Modified Adjusted Gross Income (MAGI)• Considers taxable income and tax filing
relationships• 7 states make their own Medicaid eligibility
decisions (using SSI criteria)• 10 states have elected to use eligibility
requirements that are more restrictive than SSI –209(b) states
Application For Disability Diverges
Examples of Medicaid Groups Non Disability Medicaid Groups Disability Groups
Low Income
Pregnant Women
FPL Related Infants
Low Income Families
FPL Related Children Ages 1-5
Deemed Newborn
Blind or Disabled Eligible in
1973
Disabled Adult
Children
Medically Needy
Disabled
Working Disabled
under 1619(b)
Qualified Disabled &
Working
Disability Is Different
Disability is a “grey” area and often hard to prove…very resource intensive• Must prove that a disability prohibits the
individual from “substantial, gainful employment expected to last at least 1 year or result in death
Disability Is Different
are exempt from MAGI-based income rules
• Medicaid eligibility for these groups, generally determined using the income methodologies of the SSI program
• SSI income requirements • For individual: about $2,000 in assets; $682/mo. income• For couple: about $3,000 in assets; $1,157/mo. income
Blind, Aged (65+) and/or
Disabled
Disability Is Different
are exempt from MAGI-based income rules
• Medicaid eligibility for these groups, generally determined using the income methodologies of the SSI program
• SSI income requirements:• For individual: about $2,000 in assets; $682/mo. income• For couple: about $3,000 in assets; $1,157/mo. income
• Florida has a single point application process• If apply for SSI, automatically apply for Medicaid
• Once awarded SSI, the individual automatically receives Medicaid coverage
Blind, Aged (65+) and/or
Disabled
Disability Is Different
are exempt from MAGI-based income rules
• Medicaid eligibility for these groups, generally determined using the income methodologies of the SSI program
• SSI income requirements:• For individual: about $2,000 in assets; $682/mo. income• For couple: about $3,000 in assets; $1,157/mo. income
• Florida has a single point application process• If apply for SSI, automatically apply for Medicaid
• Once awarded SSI, the individual automatically receives Medicaid coverage
• Plus monthly cash payments
Blind, Aged (65+) and/or
Disabled
SSI vs. SSDI
Title XVI (SSI) Title II (SSDI)Supplemental Security Income Social Security Disability Ins.
Needs Based – Poor No Income/Resources Restrictions
Candidates Earn Work Credits
Paying Into FICA
SSI Award = Medicaid SSDI Award = Medicare
$771 (FL) Max. Individual Monthly Benefit $1,234 (FL) Max. Mo. Benefit
Retroactive Benefits To Protected Filing Medicare Coverage 29 Mo. From
Onset
Blind, Aged (65+) and/or
Disabled
Making A Case For Disability
Disability applicant must prove that the onset of a disability prohibits the individual from “substantial gainful employment” To prove this you must:• Often, dig back into patient’s health records• Identify onset of disability• Document diagnosis from Health Record• Interview physicians• Get statements for the record• Overlay a work history timeline• Interview supervisors• Get statements for the record
The Disability Challenge
Two reasons disability is problematic1. Difficulty identifying disability candidates2. Extensive resources needed to secure a disability
award
Disability Is Often Hard To Identify
Some DisabilitiesAre Apparent
The “Disability ” component may be difficult to identify in an interview
Aged Blind Hospice
Care
Mental/Emotional
Issues
Lack of Medical Evidence
Onset of Disability In
Past
Application Challenges
✓ Applications are complicated,
long delays in Process
✓ Applicants are discouraged by
the local SSA office
✓ Homelessness and poverty
✓ Low Self Esteem/Unable to
advocate for themselves
✓ Unaware of programs and
criteria to apply
Navigating The Disability Award Process
✓ Successful Disability Applicants May Begin Receiving Payments Within 6-8 Months
✓ Full Federal Benefit $750✓ Medicaid/Medicare Healthcare Coverage✓ Individual Is NOT Charged For HRS Services
Qualifying For Disability is a Complicated Process
Claims Up: Staff Going Down
✓ SSA’s operating budget has shrunk 9% from 2010 to 2017*
✓ Staff is down 12% over same period*✓ While disability beneficiaries have
increased 2%*✓ Plus retirement and survivors insurance
beneficiaries have increased 20%✓ Since 2016, SSA has lost over 1,000 field
office staff bringing total loss at 3,500 since 2010*
*SSA Statistical Report, 2017
Results at ALJ Appeal Level
✓ If SSA denies an application –candidate may appeal
✓ After the second appeal, the only recourse is a “Hearing”
✓ Hearing is presided by an Administrative Law Judge
✓ Hearing appeals jumped from 700,000 in 2010 to about 1.1 million in 2017*
✓ Average wait for a hearing decision has reached an all-time high of 21 months in 2017
* SSA Statistical Report, 2017
Success Is Earned
Disability Awards
Title XVI (SSI) Title II (SSDI)Supplemental Security Income Social Security Disability
28.5%* 33.3%*
*Most recent SSA Statistical Report, Disability Rate 2017
Disability Opportunity
Opportunities For Hospital To Convert DisabilityCharity Care Into Cash Payments
Dual Eligible (SSI + SSDI)
SSDI Not Qualified For SSI
SSI Not Qualified For Medicaid
Medicaid
The “Leaky Bucket”
Qualified Pregnant
Aged BlindedFoster Care Adolescents
Individuals with TB
Challenges unique to disability: (1) difficulty identifying candidates; (2) demand on resources to qualify
The “Leaky Bucket”
Qualified Pregnant
Aged BlindedFoster Care Adolescents
Individuals with TB
Solution requires a different way of handling Disability Cases
Must Manage Disability Cases Cost-Efficiently
(1) The Disability Team
SSA
Disability Team
Hospital
Patient
(2) Establish Disability Metrics
Track Filings vs. Cases Pending/Awarded 1 Yr.
80%-100%
60%-80%
Less Than 60%
Cherry Picking
Optimum Wheelhouse
Underworking Cases
(3) Prioritize Work Flow
ApplicationsSelf Pay Population
Interview Process
Software
Protected Filing & F/U
(4) Advocate Throughout Process
✓ Filing Assistance✓ Proxy Contact✓Answer Questions✓Challenge
Rejections✓Write Hearing
Briefs✓ Personally
Represent At Hearings
(5) Always File for SSDI When Filing for SSI
✓ If filing for SSI also file for SSDI
✓Awards for both yield dual eligibility
✓Greater Payments for the hospital
Provider Impact
✓ Convert uncompensated care/charity
care to cash payments
✓ Increase SSI days and DPP percentage
✓ Incremental “Eligible Days” Count
Toward 340B Threshold
✓ Reduce Re-Admissions, Lowering ACA
Penalties
✓ Recognized Community Service
Patient Impact
✓ Successful SSI Applicants May Begin
Receiving Payments Within 6-8 Months
✓ Max. Individual SSI Monthly Benefit $771*
✓ Max. Individual SSDI Monthly Benefit $1,234*
✓ Medicaid/Medicare Healthcare Coverage
✓ Life Changing
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