Tribal Readiness Jennifer DuPuis, M.B.A. Associate Director of Human Services Fond du Lac Band of Lake Superior Chippewa Tribal Self-Governance Consultation Conference Arlington, VA May 7, 2014 Key Opportunities Plan Approach to Target Activities Where are your biggest opportunities? Study Populations Fond du Lac Human Services Population by Insurance Type 2013 Uninsured 18% Commercial 37% Medicare 8% Medicaid 37% Study Populations Fond du Lac Uninsured Population by Income Level 2010 251 - 300% 6% over 400% 15% 201 - 250% 6% 151 - 200% 9% 134 - 150% 5% 301 - 400% 10% 0 -133% 49% Tribal Sponsorship Tribes, tribal organizations, and urban Indian organizations are permitted to pay premiums on behalf of eligible individuals. Medicare Part B (Reimbursement) Medicare Part C Medicare Part D Qualified Health Plans Target your low hanging fruit. Where is the easiest place to start? Tribal Sponsorship Medicare Part D Successful sponsorship program informed us how worth while sponsorship is. In 2013, every $1 Fond du Lac spent on Medicare Part D premiums, there was over a $6 return. Implementation Policy & Procedures You must establish and operate under policies that have been approved by Tribal Council. Contract Health Policy & Procedures Registration Policy & Procedures Patient Advocate Policy & Procedures Tribal Sponsorship Policy & Procedures Implementation 1. Develop gates to access services that include enrollment activities. 2. Educate staff and establish uniformity of application of the policy. 3. Gather, assess, and troubleshoot specific real-life examples during team meetings. Enrollment Process Patient Flow Patient Arrives Patient Registers Demographics are updated Uninsured individuals referred to Patient Advocate Patient Meets With Patient Advocate Patient Sees Provider Eligibility for Medicaid, MNCare (BHP), Medicare, and QHP’s is checked All uninsured patients are referred to a Patient Advocate for insurance eligibility check. Enrollment Process Contract Health Services Because CHS is a payer of last resort, clients must apply for other alternative resources available to them. Process to get through the “gate” for CHS coverage: 1. All CHS eligible individuals who are uninsured must complete the MNsure application process to determine eligibility for Medicaid, MNCare, or Tribal Sponsorship. 2. Eligible individuals must accept Tribal Sponsorship, which is of no cost to them or their family. 3. Descendents must complete the MNsure application process during the open enrollment period. Enrollment Process Contract Health Services Waiver “By declining premium sponsorship by FDLTC, which is of no cost to me or my family, I understand that I am denying an alternative resource and will be waiving my rights to CHS funds until I have secured another form of health care coverage.” Evaluate & Redesign Monitor Progress 1. Be prepared to adjust your focus. 2. Target your enrollment processes and adjust rules for payer groups. 3. Enforce flexibility with staff assignments. Marketing Literature Make literature your own. Use your own photos and information. Marketing Patient Advocates Educate clients and evaluate eligibility for Medicare, Medicaid, MinnesotaCare, MNsure and other employer/private insurance programs. 1. Staff Expertise: 1. Familiar with all rules. 2. Relationally Rich Environment: 1. 2. 3. 4. One-on-one counseling. Community member staff. Plenty of time to talk. Familiar with cultural sentiments 5. Explains community benefits. Marketing Educating Clients Why should IHS eligible individuals have health insurance? Although IHS makes a substantial contribution to the overall health of American Indians and Alaska Natives, in most Indian communities, the level of funding does not meet the need. Tribes must generate other sources of income. Marketing Patient Advocate Referrals Electronic Health Records Reports Medical Department Referrals Dental Department Referrals Patient Advocate Pharmacy Department Referrals Registration Referrals Contract Health Referrals Building Business Office Capacity Third Party Billing Experience Competence Measures of Competence Administration Budgeting Monitoring Managing Contracts Credentialing Contract Health Savings Medicare Like Rates Third Party Administrator Comprehensive Care Services (CCStpa) Blue Cross Blue Shield Discounts of 20-40% CHS pays discounted amount plus 22% of savings. Example: $1,000 bill – 40% discount = $600 CHS pays CCStpa $600 + 22% of savings = $688 Contract Health Savings Medicare Like Rates Third Party Administrator Comprehensive Care Services (CCStpa) Medicare Like Rate Discounts of 30-40% CHS pays discounted amount plus per claim fee of $9.50. Example: $1,000 bill – 40% discount = $600 CHS pays CCStpa $600 + $9.50 fee = $609.50 Contract Health Savings Medicare Like Rates Savings 2012 BCBS Discounts $375,488 Billed to CHS $248,853 Paid by CHS Savings of $126,635 MLR Discounts $563,369 Billed to CHS $172,221 Paid by CHS Savings of $391,148 Total Savings of $517,783 Tribal Readiness Checklist Key Opportunities Plan approaches to target activities, and ask yourself “where are your biggest opportunities?” Study Populations Use data from your electronic health record and the U.S. Census. Tribal Sponsorship Medicare and/or Qualified Health Plans. Implementation Establish policy and procedures, develop gates to access services, educate staff, and troubleshoot examples. Evaluate and Redesign Monitor progress, target enrollment processes, and enforce flexibility with staff assignments. Marketing Hire Patient Advocates, create a referral process, use your own literature for materials, and educate patients. Building Business Office Capacity Have an experienced and competent billing department, and have processes in place for Administration to monitor. Contract Health Services Create policy and procedures, and take advantage of Medicare Like Rates Questions? Thank You!