SF PATH

Report
Ryan White Moving
Forward and ACA
Implementation
San Francisco Provides Access to Healthcare – SF PATH
Celinda Cantú
Data Administrator
San Francisco Department of Public Health
HIV Health Services
• San Francisco ‘s LIHP program is called SF PATH (“San Francisco
Provides Access To Healthcare”)
• San Francisco’s LIHP is under the Department of Public Health
• Provider network for SF PATH is Department of Public Health – same
network as Health Care Coverage Initiative under previous 1115
Waiver:
• 16 primary care clinics (all FQHcs)
• 12 community oriented primary care clinics, including Tom
Waddell, Castro Mission, Maxine Hall
• 4 hospital-based primary care clinics, including Ward
86:Positive Health Practice
• San Francisco General Hospital
• Community Behavioral Health Services
• Laguna Honda Hospital (short-term rehabilitation)
• SF PATH was approved by State and CMS, and implemented on July
1, 2011 – currently  10,000 enrollees in SF PATH
10/2/2014
Low Income Health Program (LIHP)
2
Eligibility Criteria
Ryan White
SF Resident
• Ryan White
• SF PATH
• RyanIncome:
White0% -133% FPL
• (formally RW clients)
SF Resident
Legal Residency not considered
Documented citizenship or
permanent legal resident (at least 5
years)
Government and other types of
identification accepted
Government issued identification
No insurance or limited coverage
Ineligible for Medi-Cal
HIV diagnosis
No medical condition needed
No age restrictions
Age: 19 – 64 years old
10/2/2014
Income: 0-400% FPL
SF PATH
(formally RW clients)
3
Entry into
Electronic
System (OeA)
Ryan White Provider
Completes SF PATH PreScreening Form with
Client at 6-Month Ryan
White Re-determination
Client Calls 415-2068558 to schedule a SF
PATH Eligibility
Determination
Appointment
Scheduled
Full Application
Determination in One-e-App
System Performed by
Assistor with Client
Completed SF
PATH PreScreening Form
Client Appears at
SFGH, Bldg 10, 5th
Floor with PreScreening Form
Ineligible for SF
PATH in One-e-App
Application Assistor Reviews
Client’s Documentation and
Pre-Screening Form to
Determine Preliminary
Eligibility
SF PATH Denial
Notice Completed
Ineligible
SF PATH
Denial Notice
Completed
Application Assistor Copies
Notice, Provides Original to
Applicant, Scans/Archives in
Files, and Faxes to Referring
Ryan White Program
10/2/2014
In-Person
Screening
Pre-Screening
SF PATH Eligibility Determination for Ryan White Clients
Preliminarily
Eligible
Application Assistor Copies Notice,
Provides Original to Applicant, Scans/
Archives in DPH Files, and Faxes to
Referring Ryan White Program
4
Client Enrolled in SF
PATH
ACA Services may include:
Enrollee may become ineligible for
these RW Core Service Categories:
Enrollee: Remains eligible for these RW
Service Categories:
•Ambulance Services
•Diagnostic and Laboratory
•Durable Medical Equipment
•Emergency & Post-Stabilization
Services
•Family Planning
•Home Health Care
•Hospital Care
•Mental Health Care (outpatient and
acute inpatient services)
•Non-Emergency Medical
Transportation
•Outpatient Alcohol and Drug
Treatment
•Podiatry Care
•Prescriptions (including ADAP/HIV
medications)*
•Preventive and Primary Care Services
•Radiology
•Short-term Rehabilitation
•Specialty Care
•Therapy (Occupational, Physical,
Speech)
•Urgent Care
Outpatient/Ambulatory
Medical Care
Ryan White Core Services:
Oral Health Care – (Dental
Services)***
Facility-based Care (not acute
hospital care)
Hospice
Ryan White Support Services:
Housing Services
Food Bank/Delivered Meals
Psychosocial Services
Legal Services
Case Management (Non-Medical):
Benefits Counseling
Money Management
Outreach Services
Emergency Financial Assistance
Residential Substance Abuse
Services
***Oral Health Care may be
reinstated as covered service with
level & frequency TBD by state of
CA
*Disenrollment from ADAP is
required for clients
Home Health Care
Medical Case Management
(including Treatment
Adherence)**
Outpatient Mental Health
Services**
Outpatient Substance Abuse
Services**
**Level of service provision
and frequency TBD by state of
CA
10/2/2014
HIV/AIDS Client Services Comparison for RW Eligible Clients Who
Become/Are SF PATH or ACA Enrollee
5
LIHP Transition Milestones
Milestone
Continue Stakeholder Engagement
June – July 2013
Initial SF PATH Transition Notice to
Enrollees
July 2013
Complete Data Transitions for Medi-Cal
Managed Care
October 2013
Transition Health Care Coverage Initiative
enrollee contact information to Covered
California for Outreach
October 2013
Medi-Cal Managed Care Initial Plan
Assignment Notice
November 2013
Administrative move of LIHP (SF PATH)
Medi-Cal Coverage Expansion to Medi-Cal
December 2013
Covered California Open Enrollment
Period Completed
December 2013
Medi-Cal Managed Care Plans & Covered
California Qualified Health Plans Initiate
Coverage
January 2014
10/2/2014
Topic
6
State ADAP Screening for LIHP
• New enrollment forms that include SF PATH-related questions have
been activated on the Ramsell ADAP enrollment website for San
Francisco
• These forms require the ADAP Enrollment Worker to determine if the
client may be eligible for SF PATH and track the client’s SF PATH
application process
10/2/2014
• On March 1, 2012, the ADAP enrollment/recertification process,
accomplished through Ramsell (the ADAP statewide pharmacy benefits
manager), began tracking client eligibility for SF PATH
• Any ADAP applicant who may qualify for LIHP must be referred to apply
to LIHP
• Access to the updated application can be obtained in the “Forms”
section of the Ramsell secure website at: www.publichealthrx.com
7
Post ACA Implementation populations that will
continue to receive medical services through
Ryan White Funding
• At high risk for falling out of care
• Often are 86-ed out of multiple programs
• At higher risk for depression, chaotic substance use, violence and suicide than
general population
• Have limited insight to modify behavior
• Don’t meet criteria for “mental disability”
• DSM5 Axis II “Personality Disorder” fixed traits or diagnosis
• Important to move beyond labels to see what is needed both for patient and
system
•
•
10/2/2014
• Residually ineligible individuals (undocumented and those
documented with resident status of less than five years)
• Other HIV populations at-risk to be under- served in capitated
care systems:
• Patients with significant behavioral health issues
Borderline is often over diagnosed and underdiagnosed
Often described as “low threshold patients”
• HIV elders
8
• Given uncertainty of RWPA funding in future years
• Focus on sustainability- if RWP does decrease
which services could be integrated into emerging
primary care system?
• Which services categories of service have funding
streams in addition to RWP?
• Use Gardner Cascade as a tool to assist in
determining service funding priorities
• Federal government is placing increased
importance on clinical health care outcomes
• what does the data show for what are considered
“support service categories”?
10/2/2014
Continuing Challenges
9
• CY 2014 is a unique opportunity to determine the best way for RWP
services and funding can wrap around ACA services
• HHS can help ensure successful payer transitions while maintaining
continuity of care both of which will be a more immediate and ongoing need
• HHS will focus on reviewing and potentially expanding services
within a given service category as well as expanded and new uses of
existing RW service categories
• HHSPC should sustain and improve the strength and coordination of
multiple partnerships :
• HIV Care and Prevention Services.
• Consumer, Provider, Council and SF DPH
10/2/2014
Conclusions and Opportunities
10

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