collaborating for success in medicaid transformation · success in medicaid transformation ....

Collaborating for Success in Medicaid Transformation

Jennifer Snow, Director of Public Policy, NAMI NAMI NC Conference October 12, 2018

Outline

• Medicaid Overview – Eligibility – Benefits – Service Delivery – Demonstration Waivers

• Integrated Care • North Carolina’s Demonstration Waiver

Medicaid Plays a Critical Role in our Health Care System

Health Insurance Coverage For 1 in 5 Americans

State Capacity to Address Health Challenges

MEDICAID

Support for Health Care System and Safety-Net

Assistance to 10 million Medicare Beneficiaries

> 50% Long-Term Care Financing

Source: KFF

Medicaid Flexibilities

• Effectively 56 different Medicaid programs (50 states, 5 territories and DC)

• States establish their own – Eligibility standards – Benefit packages – Service delivery – Administrative structures

• Demonstrations allow additional flexibilities

Medicaid Eligibility

• Populations – Children – Pregnant Women – People with Disabilities – People over age 65

• Financial Criteria • Medicaid expansion

North Carolina Medicaid Eligibility

210 196

133

73

44 44

24 0 0

50

100

150

200

250

Infants underage 5

Pregnantwomen

Children aged6-18

SSI Recipients Parents Young adults19-20

MedicallyNeedy Spend

Down

Other adults

Percentage of Poverty Level

Medicaid Eligibility

• Before ACA, only certain low-income people qualified for Medicaid

• ACA required states to expand coverage to those not previously eligible for Medicaid; Supreme court decision made expansion optional

Expansion

33 states + DC have adopted Medicaid expansion Over 15 million people became insured as a result

*Maine and Virginia have adopted the Medicaid expansion but it has not yet taken effect.

Expanded Medicaid

Medicaid expansion landscape

Expanded Medicaid Not expanded

17 states have not expanded Medicaid 1.9 million uninsured people with a mental health or substance use condition live in

states that has not yet expanded Medicaid

Medicaid expansion landscape

Expanded Medicaid Considering Expansion Not expanded

3 more states considering expansion through ballot initiative

Medicaid expansion landscape

Medicaid Benefits Mandatory • Inpatient hospital services • Outpatient hospital services • Nursing Facility Services • Home health services • Physician services • Rural health clinic services • Federally qualified health center services • Laboratory and X-ray services • Family planning services • Nurse Midwife services • Nurse Practitioner services • Freestanding Birth Center services • Transportation to medical care • Tobacco cessation counseling for

pregnant women

Optional • Personal care services • Physical therapy services • Prescription drugs • Primary care case management

services • Other diagnostic, screening,

preventive, and rehabilitative services • Home and community based services • Inpatient hospital and nursing facility

services for individuals age 65 or older in institutions for mental diseases

• Inpatient psychiatric services for individuals under age 21

• Targeted case management services • Occupational therapy services

Service Delivery

• Fee-For-Service (FFS) – the state pays providers directly for each covered

service received by a Medicaid beneficiary. • Managed care plans

– the state pays a fee to a managed care plan for each person enrolled in the plan. In turn, the plan pays providers.

• Comprehensive-risk based managed care • Primary care case management (PCCM) • Limited-benefit plans

Figure 13

SOURCE: Medicaid Managed Care Enrollment Report, Summary Statistics as of July 1, 2015, CMS, 2017.

Two-thirds of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs.

WY

WI

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH

NV NE

MT

MO

MS

MN

MI MA

MD

ME

LA

KY KS

IA IN IL

ID

HI

GA

FL

DC

DE

CT

CO

CA

AR AZ

AK

AL

U.S. Overall = 65%

Share of Medicaid beneficiaries enrolled in risk-based managed care plans

>0-50% (13 states) 0% (5 states)

51-80% (20 states, including DC) >80% (13 states)

Medicaid Demonstrations • Section 1115 demonstration waivers allow Secretary to

grant flexibility • “Likely to assist in promoting the objectives of the

Medicaid program” • Each Administration has some discretion over which

waivers to approve and encourage • Currently 44 waivers approved in 37 states • Many waivers expand services or coverage, like:

– ACA expansion waivers – Behavioral health services enhancements – Delivery system reform waivers – Managed long-term services and supports – Other targeted waivers (i.e., Flint, MI water crisis; HIV-AIDS, foster care children)

Benefits of Integrated Care

Triple Aim: • Improving the health of

populations, • Enhancing the

experience of care for individuals, and

• Reducing the per capita cost of health care

NC’s Medicaid Demonstration • Transition to Managed Care • Strengthening workforce • Telemedicine • Focus on those with behavioral health needs

– Tailored Plans (in Years 3-4) – Integrated physical, behavioral health and pharmacy

services to those with SMI, SED and SUD. – Intensive community-based care management – Specialized care managers – Specialized clinical supervisions

• IMD waiver request

Questions?

Thank you.

Jennifer Snow Director of Public Policy, NAMI

jsnow@nami.org 703-516-7981 www.nami.org