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Patient Benefits Coodinators Suniga Buchanan
- 2. Winnebago Indian Health Service • Winnebago and Omaha Tribes of Nebraska • Over 10,000 members • Nebraska, Iowa, and South Dakota
- 4. Patient Benefits Coordinator • Enroll all eligible service unit population with alternate resources • Serve as a patient advocate for those who need assistance when applying for an alternate resource program • Provide education and training to staff about alternate resource programs and changes in the healthcare industry • Act as a liaison between federal, state, local, and tribal agencies
- 5. Contract Health Services • CHS funds are limited to the medical or dental services considered medically necessary and listed within the established Area IHS medical/dental priorities. • An individual must apply for and use all alternate resources that are available and accessible, • such as Medicare A and B, state Medicaid, state or other federal health program, private insurance, etc. • The IHS facility is also considered a resource, and the CHS funds may not be expended for services available at IHS facilities. • I H S is the "payor of last resort" of persons defined as eligible for CHS
- 6. Third Party Eligibility FY 2011 985 Medicare Part A Medicare Part B 2845 845 Medicare Part D Medicaid 367
- 8. 11 Benefits Medicare Part A - Hospital Coverage Part B - Medical Insurance Part C - Medicare Advantage Plans Part D - Prescription Drug Plans
- 9. Medicaid and CHIP Eligibility Requirements • Disabled Individuals • Pregnant Woman • Children • And some parents
- 10. Disability, Retirement, Wido w’s Benefits, and Survivor’s Benefits • Age • Education • Work Experience • Physical/Mental Conditions
- 11. Five Step Process • Work Activity • Medical severity of your impairment • Medical severity of your impairment meets the duration requirement and equals one of our listings through the SSA • Residual functional capacity and your past work • Age, education, and work experience
- 12. Hepatitis C • Chronic Liver Disease with Liver Cell Necrosis • Chronic Hepatitis and Alcoholic Liver Disease • Chronic Viral Hepatitis caused by Hep C virus • Gastrointestional Hemorrhaging from varices, requiring transfusions • Ascites of the hydrothorax • Spontaneous Bacterial peritonitis infection • Renal Failure associated with Chronic liver Disease • Hypoxemia associated with Chronic Liver Disease • Neuropsychiatric disorder characterized by abnormal behavior • End-Stage Liver Disease
- 13. Human Immunodeficiency Virus • Bacterial infections • Fungal infections • Protozoan or helminthic infections: • Viral infections • Malignant neoplasms • Hematologic abnormalities • Neurological abnormalities
- 14. Monthly Exception Report • Patients under 18 without third-party coverage who may be eligible for the Medicaid/CHIP Program • Patients over 65 without third-party coverage who may be eligible for Medicare A, B, and Part D
- 15. HOW CAN I/T/U PROVIDERS IMPROVE ON ACCESSING PUBLIC BENEFITS FOR THEIR COMMUNITIES • Implement an Action Plan • Keep statistics on your communities • Provide regular education and training to your communities • Be proactive rather than reactive • Hold regularly scheduled meetings with your service area • Report your progress with the local Tribal leadership • Assist the elders if they require assistance, e.g. home visits, application assistance, transportation, etc. • Resources – have promotional items made • Training – “your outreach effectiveness depends on your knowledge of programs and patience!”
- 16. Useful Tools • Exception Report • Page 5 • Appointment List • Trainings
- 17. References www.ihs.gov www.ssa.gov www.cms.gov www.Medicare.gov www.Healthcare.gov www.wikipedia.com www.allsup.com Flute music by Robert Mirabal and Rare Tribal Mob
Editor's Notes
- Intro: The Winnebago Hospital services the Winnebago and Omaha Tribes of Nebraska which consist of over 10,000 members as well as the tri-state area tribally enrolled members. As you can see by the number of potential patients, the need for adequate health care for Tribal Members in this area is critical.We also serve the tri-state area tribally enrolled members which includes Nebraska, Iowa, and South Dakota.
- The Winnebago SU created a program where workers known as Patient Benefits Coordinators proactively seek out patients and enroll them in various third party programs that help uninsured people receive the healthcare they need that is not offered in our facility. Types of programs that we enroll patients in are Medicare, Medicaid, CHIP, as well as applying and overseeing applications for disability through the state and federal programs. Our 3rd party collections help us fund other critical job positions, supplies, and building maintenance, that is not otherwise allocated through I H S funding.
- Explain CHS policy and how PBC’s play a role The IHS is considered the payor of last resort, and as such, the use of alternate resources is required when such resources are available and accessible to the individual. The Patient Benefits Coordinator (PBC) ensures compliance with the requirement for the use of alternate resources as required by CHS rules and regulations governing such procedures. Funds expended for medical cases later reimbursed by alternate resources must be returned to the facility program account. An individual must apply for and use all alternate resources that are available and accessible, such as: Medicare A and B, State Medicaid, State or other federal health program, Private insurance, etc. IHS or Tribal health facilities The IHS is the "payor of last resort" of persons defined as eligible for CHS, notwithstanding any state or local law or regulation to the contrary.
- Third party eligibility – We have 985 patients enrolled in Medicare Part A and 845 patients enrolled in Medicare Part B, 367 patients enrolled in Medicare Part D, and 2,845 patients enrolled in Medicaid. Medicaid is the largest 3P resource due to the large number of Children age 18 and under.
- This chart here shows a steady incline in enrollment numbers for Medicare parts A and B and a drastic incline in enrollment numbers for Medicaid. We are seeing a decline in Medicaid eligible patients due to employment of both parents making children ineligible due to share of cost.
- Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states.[1] People served by Medicaid are U.S. citizens or legal permanent residents, including low-income adults, their children, and people with certain disabilities. CHIP is Children’s Health Insurance Program that is part of the Medicaid program that provides medical assistance to children ages 18 and younger who meet certain income requirements.
- Social Security offers several types of monthly benefits for a disabled person, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI) as well as disability benefits for disabled widows, children, and adult children disabled since childhood. While each program has its own requirements for non-medical eligibility, they all use the same definition of total disability and the same method to determine if a person is “disabled enough” to be eligible for disability benefits. Under Social Security a person is considered disabled if: (1) Due to a medical condition he/she is unable to perform the tasks of a job for which he/she is suited, AND (2) That condition either has or will last for at least twelve months or is expected to result in death. Disability determination focuses on your symptoms and how they prevent you from working so it is a good idea to make sure your physicians enter your symptoms into the record with each visit, even if it is repetitive. Diabetes is a large contributing factor in qualifying our patients for Disability due to complications.
- The Social Security has a 5 step process to determine disability. SSA definition of working is earning more than $1010 a month.At the first step, we consider your work activity, if any. If you are doing substantial gainful activity, we will find that you are not disabled. (See paragraph (b) of this section.)(ii) At the second step, we consider the medical severity of your impairment(s). If you do not have a severe medically determinable physical or mental impairment that meets the duration requirement in § 404.1509, or a combination of impairments that is severe and meets the duration requirement, we will find that you are not disabled. (See paragraph (c) of this section.) (iii) At the third step, we also consider the medical severity of your impairment(s). If you have an impairment(s) that meets or equals one of our listings in appendix 1 of this subpart and meets the duration requirement, we will find that you are disabled. (See paragraph (d) of this section.)(iv) At the fourth step, we consider our assessment of your residual functional capacity and your past relevant work. If you can still do your past relevant work, we will find that you are not disabled. (See paragraph (f) of this section and § 404.1560(b).)(v) At the fifth and last step, we consider our assessment of your residual functional capacity and your age, education, and work experience to see if you can make an adjustment to other work. If you can make an adjustment to other work, we will find that you are not disabled. If you cannot make an adjustment to other work, we will find that you are disabled. (See paragraph (g) of this section and § 404.1560(c).)
- Hepatitis C is listed under the category of impairments known as the Digestive System – Medical Listing 5.05 (chronic liver disease). The following criteria has been established indicative and inability to engage in any substantial gainful activity (SGA). That is if one has a diagnosis of Hep C and one of the following, a finding of disabled under the Social Security Act is warranted.
- HIV infection is caused by a specific retrovirus and may be characterized by susceptibility to one or more opportunistic diseases cancers or other conditions as described in medical listing 14.08. Any individual with HIV infection, including one with a diagnosis of acquired immunodeficiency syndrome (AIDS), may be found disabled under this listing if his or her impairment meets any of the criteria in 14.08 or is of equivalent severity to any impairment in 14.08.Human Immunodeficiency Virus (HIV) documented by appropriate laboratory and clinical findings and one of the following:
- An Exception report is run monthly to identify patients who access our facility AND who are without third party coverage. This report is ran by identifying two separate eligibility groups, 18 and under and 65 and over. This report is reviewed each month by the Patient Benefits Coordinator.Page 8 is used to communicate with other staff regarding other 3rd party resources such as Medicare, Medicaid, and P.I.
- These tools will help increase revenue by identifying eligible populations.Provides a tool for mangers and CEOs to monitor Benefit Coordination productivity.