Hurricane Katrina

CMS � Medicare

For seniors and persons with disabilities

CMS has temporarily modified its Medicare payment rules to provide payments for services provided to evacuees, by, for example: waiving usual documentation requirements to justify services, permitting services in extraordinary settings like shelters, and ensuring access to post-acute care. In addition to these waivers, Medicare will begin covering prescription drugs starting on January 1, 2006; until that time, lower-income Medicare beneficiaries can get coverage for their drugs through Medicaid (see below).

Medical care for seniors and persons with disabilities is being addressed.

CMS �Medicaid / SCHIP

For families and children, and individuals who are aged or disabled who have limited income and resources

CMS is working with both the directly-affected States and the States temporarily housing significant numbers of evacuees to provide expedited access to Medicaid coverage. CMS has issued a model waiver template that allows States hosting evacuees to enroll some evacuees in the host State�s Medicaid program, because of loss of income and resources. The template allows for the quick reenrollment of evacuees in Host States who were determined eligible for Medicaid in their Home States, as well as expedited enrollment of evacuees who may be newly eligible as a result of Hurricane Katrina. The Katrina demonstration programs build upon existing Medicaid/State Children�s Health Insurance Program (SCHIP) eligibility and other program rules, and provide immediate, comprehensive relief. Approved waivers allow for Host States to provide the Medicaid/SCHIP benefit package within their own State and provide comprehensive State Plan services to evacuees. Evacuees may receive coverage for up to 5 months. The duration of the program is from August 24, 2005 through June 30, 2006; however, the last possible date to submit an application is on January 1, 2006. CMS has approved Hurricane Katrina Multi-State Section 1115 Demonstrations for Alabama, Arkansas, District of Columbia, Florida, Georgia, Idaho, Mississippi, Puerto Rico, Tennessee, Texas, Indiana, and South Carolina. CMS is also arranging for reimbursement for some uncompensated care costs incurred by providers treating evacuees (see below).

Medical care for limited-income families and children is being addressed.

NDMS -Uncompensated Care Pools

For Katrina evacuees who do not have other coverage for medically-necessary services and supplies

CMS has provided that States with an approved uncompensated care pool (i.e., Texas, Mississippi, Alabama, Arkansas, Georgia, Tennessee, and South Carolina) can reimburse providers that incur otherwise uncompensated care costs for medically necessary services and supplies for Katrina evacuees who do not have other coverage for such services and supplies through insurance, or other relief options available including Title XIX and XXI. The uncompensated care pool may also be used to provide reimbursement for benefits not covered under Title XIX in the State. The uncompensated care pool excludes any supplemental payments and is without regard to the State�s DSH allotment. For those States that already have approval, the uncompensated care pool is available from August 24, 2005 to January 31, 2006. Examples of coverage that could be provided include mental health services, prescription drugs or any other medically necessary services needed by evacuees. For example, diabetics in need of insulin and neither insured nor covered by Medicaid could go to the pharmacy and the pharmacist would then bill the Host State�s Medicaid program. Uncompensated care pools address funding needs for those who are not Medicaid-eligible.

Uncompensated care pools also address funding needs for Medicaid eligibles who need services beyond those provided in the Host State's Title XIX State Plan.

CMS � HPSA Bonus Payments

Physicians in Health Professional Shortage Areas

Physicians providing services in areas designated as Health Professional Shortage Areas (HPSAs) qualify for bonus payments under Medicare. Many of the affected areas with significant low-income populations already have HPSA designation. HRSA has set up an expedited process for review and approval of additional HPSA designation applications for the affected area. For example, given the data limitations that exist relative to determining the number of people and physicians in the affected areas, HRSA could provide a time-limited HPSA designation based on best-available data, which would be validated at a later date.

Key assistance to encourage physicians to return to impacted areas.

HRSA

Health care providers, evacuees, and other medically underserved populations

Evacuees may receive comprehensive primary care services at Federally Qualified Health Centers (FQHCs) throughout the affected areas. Uninsured individuals may receive free or reduced cost services on a sliding fee scale if their income is at or below 200 percent of the Federal Poverty Level. Evacuees with low incomes may also be eligible for free or low cost HIV/AIDS treatment services or prenatal care.

People may locate a FQHC, HIV/AIDS Treatment Center or prenatal care program at a Healthy Start site through HRSA�s web site at http://ask.hrsa.gov/pc/ or by calling the HRSA information center at 1-888-Ask-HRSA.

With regard to the deployment of National Health Service Corps and Nurse Loan Repayment health care providers, priority will be given to the placement of these personnel in the impacted areas and States with significant evacuee populations. HRSA will also expedite applications for free clinics in affected areas and States with significant evacuee populations to provide liability coverage to volunteer providers practicing and providing services in these free clinics.

HRSA informed States that they may use State Hospital Preparedness Grants to address needs within affected areas and States with significant evacuee populations. These may include the purchase or upgrade of equipment, pharmaceuticals, and other priority countermeasures to enhance preparedness.

FEMA / SAMHSA Crisis Counseling Assistance and Training Program (CCP) grants

State mental health agencies and tribal authorities

In response to Hurricane Katrina, all 50 States as well as Puerto Rico and the District of Columbia have been identified as eligible to apply for Crisis Counseling Assistance and Training Program (CCP) Immediate Services Program grants. Through an interagency agreement with FEMA, SAMHSA monitors the CCP, which FEMA funds. Eligible entities (State mental health agencies and tribal authorities) receive grants for providing counseling outreach, and for training local crisis counselors to provide assistance after Federal relief workers leave the area.

Grants to provide outreach and crisis counseling.

SAMHSA Emergency Response Grants

Mental health and substance abuse services for priority populations in LA, AL, TX, and MS

When local resources are overwhelmed and other resources are unavailable, SAMHSA is authorized to provide grants for crisis mental health and substance abuse services. SAMHSA has provided $600,000 in Emergency Response Grants to Louisiana, Alabama, Texas, and Mississippi to ensure that mental health assessment and crisis counseling are available in areas impacted by Hurricane Katrina. Louisiana created a team of behavioral health specialists to provide counseling to disaster workers and first responders. Alabama created a pool of funding to support clinical assessments and immediate direct services. Texas supported existing methadone providers to allow for services to evacuees in shelters. Mississippi provided emergency support for populations in mental health treatment facilities.

Grants to provide crisis mental health and substance abuse services.

Private Insurance

Continuing insurance coverage to evacuees

To expand access to care, private health insurers have taken steps, such as waiving co-pays in September and vastly expanding access to out-of-network care.

Individuals who have lost their jobs as a result of Katrina have COBRA rights.

In addition, Medicare Advantage plans have been willing to work with the affected States and the States where evacuees have been sent, in order to identify opportunities for enrolling evacuees in private insurance.

This remains a main source of coverage particularly for people who are not low-income. However, to the extent that an employer ceases offering coverage to employees � for example, if the employer was destroyed as a result of Katrina � employees of that employer lose COBRA rights.

DHHS Office of Minority Health (OMH)

Support for organizations serving minority individuals, families and children affected by Hurricane Katrina

The Office of Mental Health (OMH), in partnership with the National Institute of Health�s (NIH�s) National Center on Minority Health and Health Disparities (NCMHD), has identified more than $12 M in grants to support minority-serving organizations. According to a recent DHHS press release, the grants will include support for NCMHD health disparities centers of excellence in the Gulf Coast, State Offices of Minority Health, professional associations, and community-based organizations to provide services and reduce cultural and linguistic barriers.

Efforts support key minority-serving organizations.

FEMA via State/ Local Governments

Medical care provided to evacuees

Emergency medical care provided at shelters may be reimbursed through State or local governments. Generally, referral care is not reimbursed. If through National Disaster Medical System (NDMS) transport, definitive medical care would be covered by NDMS.

Potential source of payment for certain costs incurred for evacuees treated at shelters.

FEMA/NDMS

Reimbursement to NDMS hospitals

Reimbursement to National Disaster Medical System (NDMS) hospitals for definitive medical care for patients to whom they deliver care who are uninsured or who have Medicaid coverage. NDMS hospitals receive 110 percent of the Medicare rate for care provided to patients in the NDMS system.

Additionally, a transportation program (the HHS Medical Travel Center) had been established to support the return of evacuees with medical needs from Texas, Mississippi and Louisiana, by arranging transportation for evacuees that require enroute medical care and/or medical transport (including a non-medical attendant) to an institution or to a private residence, as appropriate. If the evacuee�s originating medical facility is not available in his or her home State, or if his or her residence and community medical infrastructure is not suitable, then the evacuee will be allowed to travel to an interim location in the continental U.S. The HHS Medical Travel Center will then return the evacuee to his or her home of record when a medical facility there is available or he or she can return to a safe community/home environment.

So far, it is estimated that NDMS hospitals will be reimbursed for approximately 2,700 patients.

FEMA

Catch-all use for evacuees, including medical expenses

Evacuees may use some of the $26,200 they are potentially eligible for to cover medical care. This money also goes to pay for clothes, hotel expenses, housing repairs, and other disaster-related needs.

Broad use for all evacuees.

Veterans Health Administration

For veterans who are enrolled or otherwise eligible and for survivors and dependents of certain veterans through CHAMPVA.

VA is providing health care to enrolled veterans affected by hurricane Katrina. For those affected veterans not currently enrolled, instructions have been issued to facilitate such enrollment action and expedite consideration of special eligibility circumstances. Co-payments for affected veterans have been suspended.

Veterans who have previously applied for and were denied enrollment on the basis of income due to the enrollment restriction of 1/16/03 may request that VA reassess their eligibility status based upon their current financial status.

CMS - Medicare Extraordinary Circumstances Exception Provision

Hospitals

The Medicare inpatient prospective payment system includes payment for hospital inpatient capital costs, which is made on a per-discharge basis. The extraordinary circumstances exception provision provides an additional payment if a hospital incurs unanticipated capital expenditures in excess of $5 million (net of proceeds from other funding sources, including insurance, litigation, and government funding such as FEMA aid) due to extraordinary circumstances beyond the hospital�s control (e.g., a flood, fire, or earthquake). For most hospitals, the exception payments for extraordinary circumstances are based on 85 percent of Medicare's share of allowable capital costs (100 percent for sole-community hospitals) attributed to the extraordinary circumstance. The payments are made for the annualized portion of the extraordinary circumstance costs, over the useful lifetime of the assets, not in a lump sum.

A hospital must make an initial written request to its CMS Regional Office (RO) within 180 days after the occurrence of the extraordinary circumstance causing the unanticipated expenditures.

CMS � Stark Waiver

Would enable Hospitals and certain other health care entities in specified States to offer special arrangements to physicians who have been displaced by the hurricane

In response to the recent hurricane, CMS has received inquiries concerning whether hospitals can provide free office space, or low interest or no interest loans, or offer certain arrangements to physicians who have been displaced by the hurricane. The Secretary has given CMS authority to waive sanctions for violations of the physician self-referral (Stark) law (which prohibits physicians from referring Medicare patients to an entity with which the physician or a member of the physician's immediate family has a financial relationship, unless the arrangement meets the criteria of one of the statutory or regulatory exceptions). The States in which the Stark waiver would be available are limited to those States that have received a Section 1135 waiver.

CMS intends to consider Stark waiver requests on a case-by-case basis and/or through future guidance posted on the CMS website, and will waive Stark violations in such circumstances as CMS determines appropriate. The focus will be on ensuring access to care and assisting displaced physicians in the affected areas.

CMS intends to allow arrangements that otherwise would not meet the specific criteria for an exception, provided that such arrangements would not lead to program or patient abuse, and that other safeguards which may be applicable to the specific arrangement under consideration exist.

FEMA

Medical Facility Recovery, Community Health Centers and other public and non-profit entities

Under its Public Assistance program, FEMA reimburses public and private non-profit entities, including hospitals and community health centers, for the repair of non-insured infrastructure damages caused by the disaster. This includes clinics, rehabilitation and long-term care facilities.

The current Federal cost share is 75 percent, which can be increased in catastrophic disasters, and may be adjusted by the President.

FEMA

Temporary Housing for Health Care Workers

FEMA�s authority to provide emergency shelter is usually used to assist evacuees, but may be used to house medical personnel on the basis that medical care is an essential community service. The type of housing assistance given is determined by FEMA, based on the individual�s needs and what can be delivered most quickly and economically.

Currently, Transitional Housing Assistance is being provided to eligible applicants whose damaged dwellings are located in the following parishes and counties: Orleans, Jefferson, St. Bernard, St. Tammany and Plaquemines parishes in Louisiana; and Jackson, Harrison and Hancock counties in Mississippi.

The PHS Team in New Orleans is working on housing for health workers. In Louisiana, health care workers who had been living in the hospitals have been placed in housing, and requests by the hospitals for staffing of their remaining health care workers have been sent to FEMA, processed and given placement.

USDA-Rural Development Community Facilities Program

Not for profit (NFP), county or municipally owned organizations in municipalities with populations less than 20,000 or in unincorporated communities, as long as those communities are not in a MSA that is too large

Loans or grants are available from the USDA-Rural Development (RD) for building, repairing or acquiring public structures (such as court houses, libraries, health centers, etc.), including an interim temporary structure until the building is complete. Loans are issued at an interest rate set by RD (around 4.5 percent over the past 5 years) and can extend up to 40 years from approval if the entity is a NFP. There is no cap on how much USDA-RD may issue. The grant amount cannot exceed a maximum of 75 percent of the project cost (based on the median household income of the area), with no less than 25 percent of the cost being matched by a non-Federally funded source.

USDA-RD-approved grantees, as the owner of such structures, can arrange for services to be provided by others in order to allow the structure to meet its intended purpose. These arrangements (contractual or otherwise) may be made with entities who would not otherwise qualify as an eligible applicant (e.g., community physicians, or other for profit health care providers). As long as these arrangements allow the new or rebuilt structure to be used for the approved purpose (e.g., provide access to needed care), there are no further restriction by USDA applicable to these arrangements.

Contact your Local Area USDA Office to fill out an application packet and begin the approval process.

Note: This program pre-dates Hurricane Katrina, and continues to be evaluated in order to meet the needs of the affected areas.

USDA-RD Rural Business Enterprise Grant

Municipalities with no more than 50,000 population, on behalf of small or emergent businesses that sustained physical damage in a declared disaster county

The Rural Business Enterprise Grant Program provides grants to public bodies and non-profit organizations to finance development of small, emerging private business enterprises in rural areas or cities up to 50,000 in population with priority given to applications for projects in open country, rural communities and towns with populations of 25,000 and smaller in economically distressed communities. Such business may not exceed more than $1 million in net income in the 1st year of operations, and the number of employees may not exceed 50 in the first year.

Through this grant program, a municipal, county or NFP grantee could become the owner of a building (including an interim temporary structure until the building is complete) or equipment and then make arrangements to lease the building at a nominal amount (e.g., to physicians, health clinics, or other health care providers) so that the site could become a physician practice site, clinics, etc. The municipality must retain ownership of the building. Rural Business Enterprise Grants include grants made to third-party lenders to establish revolving loan programs.

Contact your Local Area USDA Office and ask for a Rural Business Enterprise Grant Application package.

Note: This program pre-dates Hurricane Katrina, and continues to be evaluated in order to meet the needs of the affected areas.

USDA-RD Business and Industry (B&I) Loan Program

Lenders in Communities that have no more than 50,000 population

The Business & Industry Guaranteed Loan Program is �lender-driven,� loans are made by eligible local lenders to businesses, including private for profit LLCs, individuals, etc. to benefit rural communities. USDA-RD guarantees up to 80% of the loan, rather than lending the money directly to an applicant. The amount of the guarantee, which is against loss to the lender, depends on the amount borrowed. This program frees up capital to go into small communities that may pose more risk than normal. Loans may not exceed $25 million. A commercial lender requests the B&I Guarantee, and if approved, the lender issues and services the loan. Does require the presence of a bank who will agree to make the loan.

Contact the USDA Rural Development State Office to receive a pre-application packet. www.rurdev.usda.gov/rd/disasters/katrina.html

Note: This program pre-dates Hurricane Katrina, and continues to be evaluated in order to meet the needs of the affected areas.

SBA

Homeowners and renters in a declared disaster county with damages to their primary residence.

www.sba.gov

For home and personal property losses, loans are available to homeowners for uninsured losses up to $200,000 to repair/replace their primary residence and up to $40,000 for personal property losses. Renters are also eligible for personal property loans. Interest rates are as low as 2.687 percent for renters and homeowners with terms up to 30 years. Loan amounts and terms are set by SBA and are based upon each applicant�s financial condition.

Victims with questions are encouraged to contact SBA�s customer service center at 800-659-2955 or disastercustomerservice@sba.gov. For a complete list of SBA office locations, visit: http://www.sba.gov/disaster_recov/disaster-office-locations.html

The first step in the application process for homeowners and renters is to register with FEMA at 800-621-3362 or online at www.fema.gov

SBA

Small and large businesses that sustained physical damage in a declared disaster county.

Small businesses that sustained physical damage or economic injury in a disaster-declared primary or contiguous county.

www.sba.gov

Business physical disaster loans are available for uninsured losses up to $1.5 million to repair/replace property to its pre-disaster condition. Loans can be used to repair/replace real estate damage, inventory and equipment. Economic injury disaster loans are limited-purpose working capital loans available to small businesses in a disaster area that sustained economic injury as a direct result of the disaster. Small businesses can borrow up to $1.5 million to pay ordinary and necessary operating expenses which would have been met had the disaster not occurred. The current maximum aggregate loan amount for any business and their affiliate is $1.5 million. Interest rates are as low as 4.000 percent for businesses with terms up to 30 years. Loan amounts and terms are set by SBA and are based upon each applicant�s financial condition.

Victims with questions are encouraged to contact SBA�s customer service center at 800-659-2955 or disastercustomerservice@sba.gov. For a complete list of SBA office locations, visit: http://www.sba.gov/disaster_recov/disaster-office-locations.html

Businesses are encouraged to register for assistance with FEMA at 800-621-3362 or online at www.fema.gov. Businesses may also request an application from SBA�s Customer Service Center at 800-659-2955 or download it from the SBA website at www.sba.gov/disaster

HUD

FHA/HUD Mortgage Insurance for Hospitals (Section 242):

This Federal Housing Administration (FHA) program will provide mortgage insurance for new construction financing, modernization, equipment, and expansion; funding is also available for refinancing.

In support of this HUD construction program, HRSA through an inter-agency agreement with HUD, provides architectural services, engineering services and financial services.

HRSA

Community Health Centers

A $100 million loan guarantee program provides up to 80 percent loan guarantees for construction of community health centers.

80 percent Loan Guarantee

Centers for Medicare & Medicaid Services (CMS)

• Medicare
• Medicaid / SCHIP
• NDMS Uncompensated Care Pools
• Medicare Extraordinary Circumstances Exception Provision
• Stark Waiver

• CMS main web site: http://www.cms.hhs.gov/default.asp
• CMS Hurricane Katrina Information, including Frequently Asked Questions (FAQs): http://www.cms.hhs.gov/katrina
• State Medicaid contacts: http://www.cms.hhs.gov/medicaid/allStateContacts.asp
• State Children�s Health Insurance Program (SCHIP) web site: http://www.cms.hhs.gov/schip/statemap.asp

Health Resources and Services Administration (HRSA)

• Health Professional Shortage Areas (HPSAs)
• Grant Programs

• HRSA main web site: http://www.hrsa.gov
• HRSA Hurricane Katrina Information: http://www.hrsa.gov
• HRSA Information Center: http://ask.hrsa.gov/

Substance Abuse and Mental Health Services Administration (SAMHSA)

• Crisis Counseling Assistance and Training Program (CCP) Grants
• SAMHSA Emergency Response Grants

• SAMHSA main web site: www.samhsa.gov
• SAMHSA Katrina and Rita Resources web site: http://www.samhsa.gov/hurricane/default.aspx

Private Insurance

• America�s Health Insurance Plans� Response to the Hurricane Disaster web site: http://www.ahip.org/HurricaneResponse/

Department of Health and Human Services Office of Minority Health (OMH)

• Support for organizations serving minority individuals, families and children affected by Hurricane Katrina

• DHHS/OMH main web site: http://www.omhrc.gov/
• DHHS press release about grants to support minority-serving organizations: http://www.hhs.gov/news/press/2005pres/20050930a.html

Federal Emergency Management Agency (FEMA)

• Reimbursement through State or local governments for emergency medical care provided to evacuees at shelters
• Reimbursement to National Disaster Medical System (NDMS) Hospitals
• Use of evacuees� allotment for medical expenses

• FEMA main web site: www.fema.gov
• FEMA Individual Assistance program web site: http://www.fema.gov/rrr/inassist.shtm
• FEMA Disaster Assistance Process for Individuals and families web site: http://www.fema.gov/about/process/index.shtm
• FEMA Housing Assistance web site: http://www.fema.gov/press/2005/katrinahousing.shtm
• FEMA Public Assistance program web site: http://www.fema.gov/rrr/pa/overview.shtm

Veterans Health Administration (VA)

• Veteran�s Health Administration main web site: http://www1.va.gov/health_benefits/

• U. S. Department of Veterans Affairs Hurricane Katrina Information web site: http://www1.va.gov/opa/katrina/

U. S. Department of Agriculture � Rural Development (USDA-RD)

• USDA-RD Hurricane Katrina Resources: http://www.rurdev.usda.gov/rd/disasters/katrina.html

Small Business Administration (SBA)

• Disaster Assistance Loans for Homeowners and Renters
• Disaster Business Loans

• SBA How to Apply for SBA Disaster Loan Assistance after a Declared Disaster web site: http://www.sba.gov/disaster_recov/loaninfo/dloanassit.html
• SBA List of Office Locations: http://www.sba.gov/disaster_recov/disaster-office-locations.html

U. S. Department of Housing and Urban Development (HUD)

• FHA Section 242 Mortgage Insurance for Hospitals

• FHA Section 242 Mortgage Insurance Program web site: http://www.hud.gov/offices/hsg/hosp/hsghospi.cfm