Expanded Access
Coalition Meeting
February 24,
2004, 9:50-11:40 a.m., OHP Central Processing
MINUTES
Attending:
Linda Herman (Clackamas County Health Dept)
Sandra Callahan (OHAP)
Marcy Sugarman (Multnomah County Health Dept)
Rick Bennett (AARP)
Laura Brennan (DHS)
Kristi
Jamison (Central City Concern)
Rhonda Walker (OHAP/LC-CKF Coalition)
Laura Chenet Leopard
(Central City Concern)
Katie Gauthier (Oregonians for Health Security)
Joy Soares (CareOregon)
LoriAnn Sheridan (OHAP-CKF)
Gloria Rosales (VGMHC)
Ellen Pinney (OHAP-CKF)
Jennie Hamilton (OPCA)
Michele Wallace (OHP Processing Center)
Wendy Lear (Multnomah County)
Kelly Harms (IPGB)
Kristi Johnson (CKF-HNRS)
Carol Simila (OR Insurance Division)
Erica Hetfeld (Providence/PacificCare)
Glenna Awbrey (CKF-HNRS)
Julie Massa (Oregon Food Bank)
Karen Berkowitz (OR Legal Aid)
Carolyn Ross (DHS)
Ann Strada (Providence)
Kaye Stainbrock (WOSU/Chemawa Clinic)
Kara Pattinson (NAMI/OPA)
Wanda Schindler (OHAP)
Linda Peckron (OHAC)
Kevin McAndrews (PeaceHealth)
Lisa Hendricks (Community Health Center)
Peg Crowley (Community Health Center)
Elena Gainey (Virginia Garcia)
Maria Lopez (Virginia Garcia)
Yuleni Rodriguez (OHAC)
Kay Stainbrook (OPCA)
Kevls Earls (OAHHS)
Bonnie Luther (OHAP)
I. Call To
Order & Introductions: Jennie
called the meeting to order at 9:50 a.m., giving an update on the 9:45 am
scheduled start time for the meeting since the Committee for Outreach,
Enrollment & Retention will be meeting at Noon.
She reminded the EAC members that future meetings will be from
10:00am-12:00 p.m. Introductions followed.
II.
Reinstatement of OHP coverage for adults whose cognitive disabilities
impair their ability to make timely premium payments: Karen Berkowitz of Oregon Legal Services (OLS) addressed the
EAC, explaining how she and others can use the Americans With Disabilities Act
(ADA) to assist clients in seeking forgiveness for late premium payments.
She handed out samples of the letter she sent to Lynn Read and a provider
letter, pointing out one must have a genuine disability, an ongoing condition
that affects daily activities, such as severe depression, mental illness,
cognitive impairment which is related to failure to pay premiums in a timely
manner. She explained the client
also must request a reasonable accommodation or modification of program rules in
order to participate. She added the
client needs a letter from a provider attesting to their disability and
requesting reasonable accommodation. She explained the clients will still owe overdue premiums,
but may pay late once they receive reasonable accommodation.
Basically, due to OLS intervention,
for clients approved under this special accommodation, OHP Standard
enrollment will be reinstated for
the full six months of the client’s eligibility.
In addition, the state will reimburse medical expenses incurred during
the time of disenrollment. In order
to re-enroll in Standard at the six month re-enrollment, clients with past due
premiums accepted as needing ADA reasonable accommodation need to pay past due
premiums in full.
Carolyn
Ross of DHS explained they are trying to get a draft policy through the right
channels at this time. She confirmed Karen’s statements, indicating she hopes the
policy is completed in the next couple weeks.
She added in regards to processing requests for forgiveness, they are
dealing with these on a case-by-case basis, and the client remains covered for a
six-month period. She explained
that this process is usually set off when a client is disenrolled, and the
doctor / provider requests reasonable accommodation for
a disabled client.
Kristi
Jamison of Central City Concern shared her experience, representing clients who
request hearings because of OHP disenrollment for failure to pay premiums before
the judge, finding the judge almost always rules in favor of the client.
The primary question from the judges is why the client is not on OHP Plus
if they are severely disabled. She
questioned the fine line between Standard and Plus relative to disabled
individuals. Karen said the
criteria and rules differ with Social Security and SSI and there’s confusion.
Carolyn added the clients might very well qualify for OHP Plus.
Karen pointed out if OMAP is not responsive to a
request to reinstate coverage and the needs of someone whose disability impacts
activities of daily living and thus to pay premiums in a timely manner nd one
has a legitimate claim, there are legal remedies available as well as the HHS
Office of Civil Rights, which deals with ADA violations.
Karen
pointed out it is the obligation of DHS to pursue additional information and
have a dialogue relative to each case brought to them.
Peg Crowley of Community Health Center suggested having a
preauthorization process and including guidance to expedite appeals.
It was pointed out that many clients do not know where to go for help. Ellen pointed out that many of the 40,000 individuals who
were dropped last year due to failure to pay premiums may qualify for OHP Plus
or forgiveness, suggesting it was incumbent on EAC members to get clients
enrolled now that many of them are eligible to re-enroll after their six-month
disenrollment and to help clients who need reasonable accommodation get
reinstated for their full six months of coverage.
Carolyn Ross said letters requesting reasonable accommodation may be sent
to her, sharing her fax number, 503-373-7200.
She explained she has a policy person check on eligibility and they
process the request. Marcy Sugarman
of Multnomah County Health Department pointed out the hearings form asks if the
client wishes to continue benefits during the appeal process.
Karen suggested the first thing that should take place is requesting a
hearing as one only has a right to benefits if a hearings request is submitted
the first of the month, using the DHS hearings request form.
Karen addressed a few other issues relative to the Oregon Health Plan
that concern her. One is the notice
problem in which the notices go out on the 16th of the month when the
premium payments are not due until the 20th, and the notice says the
client is disqualified. Another
issue is that the law requires that notices be mailed out by certified,
registered mail or personal service and this has not taken place.
Ellen said she will create template letters for EAC to use to help
clients. She asked how OMAP knows
when someone has requested a hearing and wishes benefits to continue.
Carolyn said there’s no mechanism in place right now, but the
caseworker at the local office, who receives the hearings request, sends it on
and notification is sent out to client. Karen
stressed the need to submit the DHS hearings request form to the local office.
Carolyn explained that medical billings will be covered retroactively
during the period of disqualification due to inability to pay premiums.
Karen provided her contact information, which she asked not be shared
with clients: 503-471-1132 and
email at Karen.Berkowitz@lasoregon.org.
III.
Handouts and Information – Ellen Pinney reviewed the handouts
distributed at the meeting. She
briefly addressed OHP application checklists, which are useful in avoiding
pended applications. She explained
the primary reasons for pends identified by OHP Central Processing, which
included failure to complete the addendum, failure to sign the application and
lack of clarity by the applicant in regards to explaining how they can live when
they indicate little or no income. If, in fact, the applicant has little or no income,
applications are facilitated if the application
can include a written signed statement from someone who knows the
applicant. That letter or not could
say: “Mark is my friend / son. Is
sleeping on my couch. I know that
Mark lives by collecting cans and bottles.”
Or some language that clarifies how the applicant can live with little or
no income from someone that knows the applicant.
IV.
Ballot Measure 30 pending and potential impact on OHP – Ellen
told the EAC members the Governor wants to keep existing benefits for
categoricals and maintain SCHIP for kids to 185% FPL, however, it would take $60
million new dollars to do this. She
addressed the letter Jean Thorne sent to Theresa McHugh, providing options for
funding. She added there is a
question of whether constituents that would be impacted would be receptive to
moving dollars from their programs. Also,
the provider tax and managed care tax hinges on CMS approval of the waiver and
what conditions they may impose, if approved.
Kevin Earls of the Oregon Association of Hospitals and Health Systems
pointed out the application for the provider tax was sent to CMS in October.
He explained the review process used to be done regionally, however, a
year ago, CMS centralized their review process.
At this time, New Hampshire just received their waiver and Oregon is
fourth place in the queue. There is also tension in the Bush administration to pull back
due to concerns of using provider taxes primarily in the nursing home area, but
also some hospitals, to backfill revenue shortfalls states are experiencing that
impact their Medicaid programs. He
added there are policy and political issues at the state level. He explained the
three taxes, nursing home tax, managed care tax and provider tax, were bundled
together and sent to CMS for review. The nursing home tax seems to be holding
things up at the national level, so there’s a question of whether the taxes
should be unbundled. He expressed
his concern that since Oregon is already operating under a waiver, an expansion
plan, and OHP Standard is marked for elimination; the question is whether the
state can continue to operate under the current waiver.
He added if the waiver has to be refashioned, the attractive terms and
conditions will be lost.
Kevin explained the provider tax and managed care tax were part of a
revenue package created to fund the restoration of the hospital benefit for OHP
Standard. That deal was struck in
the context of a budget last year that provided all the rest of the funding for
OHP Standard (physician, lab, x-ray, diagnostics, etc) except for
hospitalization. In light of the
failure of Measure 30, all that funding is lost, but there is a revenue package
with the managed care and provider tax that can conceivably fund an emergency
benefit for the OHP Standard population. He
pointed out there is discussion on how the taxes should be used, such as managed
care tax for restoration of mental health services or other funding goals.
He stressed that if the hospital tax was executed on its own, it creates
an impossible situation in that hospitals cannot get money back relative to
their tax payments in the aggregate sufficient to cover the tax payments.
Essentially, it takes the managed care piece to make the provider tax
work so if the managed care piece is pulled off, the hospital association has
made it clear they will withdraw, scuttling the hospital tax.
Joy Soares of Care Oregon stressed the need to look at what’s going to
happen to Oregon if the Standard population coverage goes away – everyone is
going to lose. She suggested
looking at how to get a reasonable benefit package for the Standard population,
and encourage the State to first take care of the OHP Plus population. She explained there are available resources within the State
to take care of them so we need to encourage the State to take care of them.
She added the next focus should be on how to take care of the Standard
population. She suggested looking
at how many people are really receiving services and how much it costs, adding
the numbers vary. She added they should look at the DHS budget when they come
out with new numbers in a couple weeks.
Ellen asked Kevin how long it took New Hampshire to get their waiver
approved. Kevin said the story is
that the Governor camped out in Washington D.C. until it got approved, but he
did not know how long it took. Ellen
questioned if the legislation that authorizes the provider tax in Oregon statute
dedicate the resources to hospitalization specifically in statute or if it was a
gentle person’s agreement. Kevin
explained it is in statute, but there’s some room for interpretation, adding
it is clear in the memorandum of understanding with the Governor what the money
is to be used for. He pointed out
there is some savings in a rebalance, addressing the highly inflated caseload
DHS projected in last year’s budget – based on an average monthly enrollment
of 82,000, which did not happen. Currently,
the state is in the 40,000 range and it’s been dropping every month as a
result of premium payment requirements, loss of some benefits and the result of
an economic recession. He pointed
out there is some funds available from this drop in numbers covered, however,
there’s not enough money to restore OHP Standard.
He stressed the need to salvage some part of the Standard benefit package
to build upon in the future rather than totally eliminate it.
Jennie stressed the importance of primary care to circumvent needed
emergency services. She asked Kevin
if there’s hope for hospitals supporting primary care services. Kevin said the hospital association has met with the safety
net clinics and they don’t want to see the emergency rooms used as outpatient
clinics. He explained they need the
funding scenario because if not, the hospitals will have massive cost-shifting
and lose a significant portion of the insured base. The first priority is to restore the hospital benefit, and to
the degree they go from having a hospital benefit geared with both managed care
and provider tax working together, they were only paying for an 80% hospital
benefit – they were not fully restoring the OHP Standard hospital benefit.
He added once they have a working agreement reached, they will look at
primary care support.
Laura addressed a study done by a safety net group that worked on rates
with OMAP a few years ago. They looked at what $100 per member per month could
buy. Kevin said the large majority
of hospital services were coming from the emergency rooms for OHP Standard.
Laura asked if the hospitals have worked with the safety net as triage,
adding she has information on what other states are doing.
Ellen questioned if all agree that the managed care and provider tax are
going to work, the question remains whether or not CMS will approve it.
Peg suggested that the closer the agreement of all Oregon stakeholders is
on how to use it, the more likely CMS will approve it.
She further suggested working with DHS to figure out what it takes to
save OHP and still maintain a balance. Kevin
said the hospital association has not pulled in the whole delegation of
hospitals to-date and need the pieces they started with to move forward. Joy stressed the need to maintain OHP Plus delivery system
and maintain the infrastructure built around standard so the safety net clinics
don’t go under. Kevin pointed out
the amount of infrastructure for OHP Standard has shrunk to 40% now and managed
care would not contract with limited benefits.
Ellen asked if the managed care and provider tax will dedicate dollars to
maintaining OHP Plus and SCHIP for kids. Kevin
stated the hospital association has already told the governor they are
supportive of this. Michele pointed
out OHP Central Processing has lost 60 positions due to the rebalance @ $50
million and it was rolled into the disappropriation.
Joy recommended contacting E-Board members. Jennie said the list of E-Board members will be sent out to
EAC members. Peg suggested looking
at FHIAP, which is an option to keep people insured.
V.
OHP Standard – Carolyn said she is the point person with CAF on
OHP Standard, and is currently creating a plan as if OHP Standard is going away.
Issues involve how applications will be processed, legal and policy
issues, and how many staff and clients are affected.
She added she is seeking input on what to do.
Michele said they will not be doing anything until after the E-Board
meets on April 8 & 9. Carolyn
added they are currently doing information gathering at this point.
Michele explained it
currently takes 25 days before OHP Central looks at applications.
Addressing the upcoming changes with OHP Standard, she explained it’s a
legislative process, and recommendations will go to CMS after the E-Board meets.
She added there is a disconnect between Jean Thorne’s letter and the
Governor on where the money is coming from.
Kelly pointed out FHIAP was not part of the disappropriation bill. They receive $15 million general fund dollars and $47-48 million with federal match. By the end of the biennium, 14,000 people are anticipated to be covered under FHIAP. The current mix is 40.5% group market and 59.5% individual with a 12 month waiting time for individual market. It takes 10 days to process an application for group coverage. Ellen asked about the possibility of moving OHP Standard to FHIAP. Kelly explained that cannot happen as FHIAP does not work for all, but 30% of clients earn less than the Federal Poverty Level. Peg suggested not closing the door on FHIAP. Linda pointed out that OHP applicants are referred to FHIAP if the applicant’s employer has group coverage.
VI. Announcements & Adjournment
A. Next
meeting: March 23, 10:00-12:00
p.m., DHS Parkway Bldg., Upstairs, Room 6
Note:
Limited parking; overflow at Fred Meyer across the street
B. Adjournment:
11:40 a.m.
Handouts:
OMAP Medically Eligibles Data (January 2004) Application Assistance Checklists
OMAP Medically Eligibles Data Sheet (Dec. 2002-Jan. 2004) OHP Standard Medically Eligibles Data
Ballot Measure 30 & the Oregon Health Plan 2004 Federal Poverty Level chart
EAC Priorities established Jan. 27, 2004 OHS Flyer on Oregon’s Cigarette Tax
Sample Premium Forgiveness Letters 2004 FLP – DHS charts for TANF & Food Stamps
January 2004 EAC minutes
EAC
Minutes-022404-E.doc
Recorded by LoriAnn Sheridan, OHAP