sustainability: medicaid and other health insurance

SUSTAINABILITY: MEDICAID SUSTAINABILITY: MEDICAID AND OTHER HEALTH AND OTHER HEALTH

INSURANCEINSURANCE

MARY B. TIERNEY, M.D.MARY B. TIERNEY, M.D.

August 21, 2003August 21, 2003

Technical Assistance Partnership

Discussion PointsDiscussion Points

• Relevant Medicaid legislative Relevant Medicaid legislative mandates and optionsmandates and options

• Waiver optionsWaiver options


MEDICAIDMEDICAIDREVELANT PROGRAMSREVELANT PROGRAMS

• EPSDTEPSDT

• TEFRA OPTIONTEFRA OPTION

• 1915 B WAIVERS1915 B WAIVERS

• 1915 C WAIVERS1915 C WAIVERS

• 1115 WAIVERS1115 WAIVERS


EPSDTEPSDT

• A Benefit Under MedicaidA Benefit Under Medicaid• Mandates a Set of Benefits Including Mandates a Set of Benefits Including

Preventive, Diagnostic, and Treatment Preventive, Diagnostic, and Treatment Services, Such as Health Histories; Services, Such as Health Histories; Physical Examinations; Developmental Physical Examinations; Developmental Assessments;Vision, Hearing and Dental Assessments;Vision, Hearing and Dental Services; ImmunizationsServices; Immunizations

• Mandates Screening for Both Physical Mandates Screening for Both Physical and Mental Health Issuesand Mental Health Issues


EPSDT EPSDT SCREENING SERVICESSCREENING SERVICES

Type and frequency of services must be Type and frequency of services must be based on nationally recognized standards based on nationally recognized standards of medical and dental care. They also of medical and dental care. They also must be developed in consultation with must be developed in consultation with recognized medical and dental recognized medical and dental organizations in the state with expertise organizations in the state with expertise in child health. in child health.

Periodicity schedule must ensure that a Periodicity schedule must ensure that a MINIMUM number of health examinations MINIMUM number of health examinations occur at critical points in a child’s life.occur at critical points in a child’s life.


EPSDT EPSDT Diagnosis and TreatmentDiagnosis and Treatment

When screening examinations so When screening examinations so indicateindicate

What services – all services covered What services – all services covered under the state plan and any under the state plan and any additional services (diagnostic or additional services (diagnostic or therapeutic) that are found therapeutic) that are found necessary to diagnose and treat necessary to diagnose and treat conditions found as a result of a conditions found as a result of a screen regardless of any limitations screen regardless of any limitations under the state planunder the state plan


EPSDT EPSDT UTILIZATION OF PROVIDERS AND UTILIZATION OF PROVIDERS AND

COORDINATION WITH RELATED PROGRAMSCOORDINATION WITH RELATED PROGRAMS

• States must use all categories of States must use all categories of providers, including private providers, including private practitioners and group practices, practitioners and group practices, and encourage developments of a and encourage developments of a permanent relationship with a permanent relationship with a provider to have continuity of care. provider to have continuity of care. They must also coordinate with other They must also coordinate with other human services, including Education, human services, including Education, Early Intervention, Maternal and Early Intervention, Maternal and Child Health, and Behavioral Health.Child Health, and Behavioral Health.


Tax Equity and Fiscal Tax Equity and Fiscal Responsibility Act Responsibility Act

• Known as TEFRA or Katie BeckettKnown as TEFRA or Katie Beckett• States are allowed at their option States are allowed at their option

to make Medicaid benefits to make Medicaid benefits available to children age 18 or available to children age 18 or under even though they would not under even though they would not be eligible because of parental be eligible because of parental incomeincome


TEFRATEFRA

• Found under 1902 (e) of the Social Found under 1902 (e) of the Social Security ActSecurity Act

• States do not need to have a Home States do not need to have a Home and Community-Based Waiverand Community-Based Waiver

• Home and Community-Based Home and Community-Based Waivers allow for more flexibility in Waivers allow for more flexibility in providing services providing services


ELIGIBILITY FOR TEFRAELIGIBILITY FOR TEFRA

• Child would be Child would be eligible if he/she was eligible if he/she was in an institutionin an institution

• Child requires a level Child requires a level of care provided in a of care provided in a hospital, skilled hospital, skilled nursing or nursing or intermediate care intermediate care facilityfacility

• It is appropriate to It is appropriate to provide the care provide the care in the homein the home

• The cost of caring The cost of caring for the child in the for the child in the home cannot home cannot exceed that of the exceed that of the institution institution


1915 B WAIVERS1915 B WAIVERS

• State permitted to waive State permitted to waive statewideness, comparability statewideness, comparability of services, and freedom of of services, and freedom of choice,choice,

• Limited in that they apply to Limited in that they apply to existing groups of individuals who existing groups of individuals who are or would be eligible for are or would be eligible for MedicaidMedicaid



• Have four types of waiversHave four types of waivers• Mandate enrollment into Managed Mandate enrollment into Managed

CareCare• Use a Central BrokerUse a Central Broker• Use cost savings to provide Use cost savings to provide

additional servicesadditional services• Limit the number of providers for Limit the number of providers for

servicesservices



• Can create a carve-out delivery system Can create a carve-out delivery system for specialty care such as Managed for specialty care such as Managed Behavioral Health Care PlanBehavioral Health Care Plan

• Can create programs that are not Can create programs that are not available statewideavailable statewide

• Can provide an enhanced service Can provide an enhanced service package allowing States to provide package allowing States to provide additional services from savings from additional services from savings from managed caremanaged care


1915 C WAIVERS1915 C WAIVERS

– Afford States opportunity to develop and Afford States opportunity to develop and implement creative alternatives to placing implement creative alternatives to placing Medicaid-eligible individuals in institutional Medicaid-eligible individuals in institutional settings and rather place them in their settings and rather place them in their homes and communitieshomes and communities

– Allow States to request waivers of Allow States to request waivers of statewideness, comparability of statewideness, comparability of services, and community income and services, and community income and resource rulesresource rules

•Home and Community-BasedHome and Community-BasedServices WaiverServices Waiver



– Case ManagementCase Management– HomemakerHomemaker– Home Health ServicesHome Health Services– Personal Care ServicesPersonal Care Services– Adult day healthAdult day health– Habilitation and Habilitation and – Respite ServicesRespite Services

•The law lists seven services The law lists seven services allowed in these programsallowed in these programs



– Non-Medical TransportationNon-Medical Transportation– In-Home Support ServicesIn-Home Support Services– Minor Home ModificationsMinor Home Modifications– Adult Day CareAdult Day Care– Day TreatmentDay Treatment– Partial HospitalizationPartial Hospitalization

• Optional ServicesOptional Services



– ElderlyElderly– Persons with Physical DisabilitiesPersons with Physical Disabilities– Technology Dependent ChildrenTechnology Dependent Children– Persons with Mental RetardationPersons with Mental Retardation– Persons with Chronic Mental Illness and Behavioral Persons with Chronic Mental Illness and Behavioral

Health Issues, Including Substance AbuseHealth Issues, Including Substance Abuse– Persons with AIDSPersons with AIDS– Individuals who would qualify only if they were served Individuals who would qualify only if they were served

in an institutional settingin an institutional setting

• Who Is Targeted to Be ServedWho Is Targeted to Be Served


1915 B & C WAIVERS1915 B & C WAIVERS

• Both are approved through the Both are approved through the Regional Office.Regional Office.

• Both must be cost neutral.Both must be cost neutral.

• Both are approved for an initial 2 Both are approved for an initial 2 years with subsequent renewal years with subsequent renewal every 5 years. every 5 years.


1115 WAIVERS1115 WAIVERS

• Provide the Secretary of Health and Provide the Secretary of Health and Human Services with broad authority to Human Services with broad authority to authorize experimental, pilot, or authorize experimental, pilot, or demonstration projects that are “likely demonstration projects that are “likely to assist in promoting the objective of to assist in promoting the objective of the Medicaid Statute.”the Medicaid Statute.”

• Allow States to test substantially new Allow States to test substantially new ideas and demonstrate something that ideas and demonstrate something that has not been widespread and has a has not been widespread and has a specific research design.specific research design.



• Allow expansion of eligibility – unlike the Allow expansion of eligibility – unlike the 1915 Waivers1915 Waivers

• Allow expansion of services over and Allow expansion of services over and above those listed in the 1915 Waiversabove those listed in the 1915 Waivers

• CMS must evaluate the project including CMS must evaluate the project including state-specific and cross-state analysis on state-specific and cross-state analysis on utilization, insurance coverage, public utilization, insurance coverage, public and private expenditures, quality, and private expenditures, quality, access and satisfaction.access and satisfaction.



• Approved through the Central Office of Approved through the Central Office of CMSCMS

• Are subject to CMS, OMB, and HHS Are subject to CMS, OMB, and HHS Secretarial approvalSecretarial approval

• Must be cost neutralMust be cost neutral• Are approved for an initial 5 years, Are approved for an initial 5 years,

usuallyusually• May be renewed at the discretion of the May be renewed at the discretion of the

HHS SecretaryHHS Secretary


PRIVATE INSURANCEPRIVATE INSURANCE

• Parity of services for behavioral healthParity of services for behavioral health• Institute of Medicine Report on the Institute of Medicine Report on the

Consequences of Uninsurance–Care Without Consequences of Uninsurance–Care Without CoverageCoverage

• Surgeon General Reports: Surgeon General Reports: Mental Health: A Mental Health: A Report of the Surgeon GeneralReport of the Surgeon General

• Report to CongressReport to Congress on the Prevention and on the Prevention and Treatment of Co-Occuring Substance Abuse Treatment of Co-Occuring Substance Abuse Disorders and Mental DisordersDisorders and Mental Disorders


EXAMPLES OF STATE EXAMPLES OF STATE PROGRAMSPROGRAMS

• Pennsylvania – EPSDTPennsylvania – EPSDT

• Colorado – 1915 BColorado – 1915 B

• Minnesota – 1915 CMinnesota – 1915 C

• Washington, DC – 1115Washington, DC – 1115


NEXT STEPSNEXT STEPS

IT’S UP TO YOUIT’S UP TO YOU

sustainability: medicaid and other health insurance

Documents

frequency of services

indicatewhat services

treatment services

child health

comparability of services

services eligibility

human services

additional services