overview on medicaid and the deficit reduction act of 2005 (dra) presentation by kay johnson...
TRANSCRIPT
Overview on Medicaid and the Deficit Reduction
Act of 2005 (DRA)Presentation by Kay Johnson
Director, Project THRIVE at NCCPBuilding Systems for Babies Conference
November 16, 2006
Established at the National Center for Children in Poverty,
Project THRIVE provides public policy analysis and
education to promote healthy child development. THRIVE
work informs State Early Childhood Comprehensive System
(ECCS) initiatives and others in the field.
This work is supported by the Maternal and Child Health Bureau, HRSA-DHHS.
MEDICAID
ELIGIBILITY
Eligibility
Federal law mandates:
Infants and children to age 6 up to
133% of poverty
Children ages 6-18 up to 100% of
poverty
State options to cover:
Children in Medicaid at any income
level
SCHIP > 200% of poverty
Children with disabilities and
special needs > 300% of poverty Birth to 6 Ages 6 -18
Mandated up to 100% of poverty
Mandated up to 133% of poverty
Optional Medicaid and/or SCHIP up to or above 200% of poverty
Optional Medicaid for children with disabilities up to or above 300% of poverty
Post DRA: Family Opportunity Act (Effective 1/1/2007)
New State option allows families of children with severe disabilities to “buy-into” Medicaid Age:
Target group children birth to age 19 (qualified for SSI) Phased-in, starting with younger children under age 6
Income: Up to 300% FPL; At higher income levels with state funds only
Premium caps: 5% cap <200% FPL, 7.5% cap 200-300% FPL
Employer-sponsored family coverage: If eligible must enroll + 50% of premium paid by employer Premium subsidy at option of state
Parent-to-Parent Information Centers (Title V)
Post-DRA: Citizenship Documentation (Effective 7/1/2006)
Citizens: No self-declaration of U.S. citizenship Must present:
1. U.S. passport, certificate of naturalization, certificate of U.S. citizenship, valid driver’s license, or other ID document deemed valid, or
2. birth certificate or other ID document deemed appropriate (e.g., school id, medical record)
3. Other documents by special exception
Special challenges for babies born to non-citizens
MEDICAID FINANCING:
FAMILY CONTRIBUTIONS
Post DRA: Premiums & Cost SharingEffective January 1, 2007
For mandatory groups of children and pregnant
women no premiums and cost sharing
For child/family income below 150% FPL
No premiums
Cost sharing limited to 5% of income
Co-insurance to 10% of cost for service
For child/family income above 150% FPL
Premiums and cost sharing limited to 5% of
income
Co-insurance to 20% of cost for service
For new disability optional group
For child family income 150-200% FPL, premiums
and cost sharing limited to 5% of income
For child family income 200-300% FPL, premiums
and cost sharing limited to 7.5% of income
Birth to 6 Ages 6 -18
Mandated up to 100% of poverty
Optional Medicaid and/or SCHIP up to or above 200% of poverty
Optional Medicaid for children with disabilities up to or above 300% of poverty
Mandated up to 133% of poverty
Optional group to 150% has special cost sharing rules
Above 300% FPL no federal participation; family buy in at full cost anticipated
Post-DRA: Premiums & Cost-Sharing (Effective 3/31/06, except ER 1/1/07)
State may impose premiums, cost-sharing, or both
Protections for certain groups
Providers may require payment or waive at time of service (case-by-case)
States may terminate coverage for failure to pay premiums >60 days; may waive if “undue hardship”
MEDICAID
BENEFITS
Post-DRA: Medicaid Benefits
Benefits required for children:Guarantee is not the same. States may change benefit package based on
“benchmark” plans.EPSDT benefits are required for “mandatory”
children under age 19 But will not be offered in same manner “wrap-around” concept to be tested in
implementation.
Post-DRA: Coverage Rules (Effective 3/31/2006)
States have the option to use a “benchmark” benefit package and require enrollment for certain groups. No waiver; State Plan Amendment suffices This is similar to what is used for State (non-
Medicaid) SCHIP programs.
“Benchmark” Plans: State Options
FEHBP standard Blue Cross/Blue Shield PPO option
State employee benefit planCoverage by HMO with largest insured,
commercial, non-Medicaid enrollment in the state
Another benefit package designed by the state and approved by HHS
Post-DRA: Coverage Wrap-around(Effective 3/31/2006)
For children, states must supplement with “wrap-around” EPSDT coverage Benefits as defined since 1989 in Sec. 1905(r) of
Medicaid law Obligation to provide comprehensive children’s
services appears to be maintained. Further CMS guidance expected
MEDICAID
CASE MANAGEMENT
Post DRA: Case Management (Effective 1/1/2006)
Definition clarified Assessment Development of care plan Referrals Monitoring and follow-up
Excludes from the definition Direct delivery of referred medical, educational, social,
or other services Foster care administrative supports
Potentially related to Part C, home visiting, mental health, child development, etc.
Spending Smarter Using Federal Programs and Policies to Promote Healthy Social and Emotional
Development Among Our Most Vulnerable Young Children
Kay Johnson and Jane KnitzerNational Center for Children in Poverty, 2005.
Spending Smarter means:
Paying for appropriate services.
Capturing existing dollars from federal funding streams.
Blending and braiding funds.
Using flexible funds to fill gaps.
Leveraging both smaller grant funds and entitlement dollars.
Creating efficiencies through systems approach.
Promising practices: Medicaid/EPSDT
Use uniform billing, blended funds
Maximize federal matching
Expand list of professionals who may bill
Pay for “family” therapy
Permit payment for services delivered
outside of physicians’ offices.
Promising practices : EPSDT
Early and Periodic Screening, Diagnosis, and Treatment
Clarify distinction between EPSDT
developmental screening and diagnostic
assessment
Specify benefit definitions
Use age-appropriate billing codes
Apply EPSDT medical necessity standard
Lessons from ABCD II Projects
Payment not greatest barrier
Providers willing to use recommended screening tools
Parents and providers appreciate information
Referral resources must be available
Billing codes are available
Serving “at-risk” without “diagnosis” toughest
646-284-9644 ext. 6456
Kay Johnson, MPH, MEdTHRIVE Project Director
Jane Knitzer, EdDExecutive Director,National Center for Children in Poverty
Suzanne Theberge, MPH THRIVE Project Coordinator
Leslie Davidson, MDSenior Health Advisor
For more information or questions, contact us at Project THRIVE
More Resources www.hrsa.gov/epsdt
For general use www.cms.gov https://www.cms.hhs.gov/medicaid/
epsdt/default.asp www.cms.hhs.gov/
EPSDTDentalCoverage http://www.hrsa.gov/medicaidprimer/
maternal_child_part3only.htm www.kff.org www.gwumc.edu/sphhs/healthpolicy/c
hsrp/newsps www.cmwf.org www.nashp.org www.mchlibrary.info/KnowledgePaths www.chcs.org www.mchpolicy.org
For families www.family-networks.org www.partoparvt.org www.healthconsumer.org/
cs009epsdt.pdf www.familyvoices.org www.wpas-rights.org
For providers www.aap.org www.brightfutures.org/
mchepsdt.html www.medicalhomeinfo.org
/tools/screening.html