Post on 11-Jan-2016
+
March 5, 2014
Session 2:Public
Insurance
+ Objectives
Provide foundational background for learning Public Insurance
Introduce key types of Public Insurance and their components related to Part C
Display public insurance information from the 2012 ITCA Financial Survey and what forms of Public Insurance state Part C systems are accessing
Highlight developments and directions in State Public Insurance programs and opportunities they may offer Part C systems
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+ Overview
Medicaid Background Eligibility and Benefits Medicaid Waivers Early Periodic Screening Detection Treatment (EPSDT)
Children’s Health Insurance Program (CHIP)
Delivery systems and sources of State share
National Part C uses of Medicaid and CHIP
Recent Developments, future directions, and opportunities
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+ Medicaid Background
State and Federal FinancingFederal Medical Assistance Percentage (FMAP)*
50% - 76% 2014 ACA – 100% Federal
50% Administrative Claiming
No Cap on Federal DollarsWaiver exception
Entitlement ProgramStateEligible Individual
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+ Medicaid Background (continued)
Covers nearly 1/3 of all children in the United States
State administered program Eligibility standards Payment rates Benefits Packages Administration policies
Medicaid State Plan serves as the contract between the State and CMS
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+ Medicaid Background (continued)
Medicaid/CHIP Program Information http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html
State Plan Amendments http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Plan-Amendments/Medicaid-State-Plan-Amendments.html
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+ Medicaid Eligibility
General Eligibility Children in Foster Care Low Income Families with Children People receiving SSI due to disability People over 65
Optional Eligibility Higher Income
Medically needy Other Groups
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+ Medicaid Background Eligibility and FMAP Under ACA
Single Standard Under 65: income < 133% of federal poverty level
($25,390 for family of three)
FMAP 100% from 2014-2016 Gradual decline to 90% by 2020
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+ Medicaid Eligibility (continued)
Eligibility Criteria:Required for:
children birth to 5 with family incomes below 133% of FPL
children 6 through 18 with incomes below 100% of FPL
Optional for: Children at higher income levels Children with severe disabilities who live at home
but qualify for institutional care – Katie Beckett waiver
Children who meet SSI disability criteria with income less that 300% - buy-in
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+ Medicaid BenefitsMandatory Benefits:
Inpatient and Outpatient Hospital Services Physician Services Early Periodic Screening, Diagnosis and Treatment (EPSDT) Family Planning services and supplies Nursing Facilities Certified Pediatric and Family Nurse Practitioner services Laboratory and X-ray Services Tobacco cessation for pregnant women Transportation for non-emergency medical services Home Health services Rural health clinic services Federally qualified health center services Nurse Midwife services Freestanding Birth Center services (licensed or otherwise recognized by state)
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+ Medicaid Benefits (continued)
Optional Benefits include: Prescription Drugs
OT, PT and Speech Therapy Optometry
Targeted case management Skilled Nursing Facilities for children under 21
Rehabilitative services Personal Care services Private Duty Nursing services Dental services Hospice services Inpatient psychiatric services for children under 21 Medical and remedial care from other licensed providers includes psychologists
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+ Medicaid Cost Participation
In some situations states may require cost sharing.
Children are exempt from : Copayments Deductibles Co-insurance Cost-sharing
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+ Medicaid Waivers
Request to CMS to “waive” certain requirements Statewide availability Freedom of choice of providers Universal access to all benefits
Must have cost neutrality Cannot cost the federal government no more than the amount
projected if there was no waiver Caps for numbers served
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+Medicaid Waivers
1115 Research and Demonstration
1915 (b) - Managed Care
1915 © Home and Community-based Services
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Waivers.htmlervices
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+ EPSDT
“The EPSDT program consists of two mutually supportive, operational components: assuring the availability and accessibility of required health care resources; and helping Medicaid recipients and their parents or guardians effectively use them.”
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+ EPSDT (continued)
Benefits for children are guaranteed and are required to prevent as well as treat conditions.
Treatment is defined as: Necessary health care diagnosis services, treatment,
and other measures classified as medical assistance to
correct or ameliorate defects and physical and mental health
conditions discovered by screening services, whether or not
such services are covered under the state medical
assistance plan
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+EPSDT (continued)
EPSDT also requires states to do more than
merely offer to cover services. States are
obligated to actively arrange for treatment,
either by providing the service itself or
through referral to appropriate agencies,
organizations or individual
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+ Early Periodic Screening Diagnosis Treatment (EPSDT) Benefits
Screening through Comprehensive Well-Child Exams: Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations Laboratory tests Health Education Vision, hearing and dental screening in primary care
Diagnosis
Treatment
Other Necessary Health Care
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+ Children’s Health Insurance Program (CHIP)Exclusively for Children
If a state chooses, for pregnant women
Also State/Federal Partnership
Higher match rate
Highest income level is 405% 14 states above 300% (5 additional with Medicaid) 10 states between 235-290% 20 states at 200 -235% 2 states < 200%
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+ 20
Notes: Eligibility levels are based on 2013 federal poverty levels. January 2014 income limits reflect MAGI converted income standards, and include a 5 percentage point of federal poverty level disregard. Eligibility standards include CHIP-funded Medicaid expansions. Eligibility levels are based on a family of three. Eligibility levels reflect state decisions on the Medicaid expansion as of September 30, 2013, available here. Per CMS guidance, there is no deadline for states to implement the Medicaid expansion. Eligibility limits for adults in Michigan, reflect levels effective April 2014, when the state plans to adopt the Medicaid expansion. This table does not include notations of states that have elected to provide CHIP coverage from conception to birth.
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CHIP
Medicaid Birth to 1 (no coverage > 1)
Medicaid to age 1, CHIP >1 to 5 yo
Medicaid
Medicaid/ CHIP Income Eligibility Limits Children Birth to 5, Effective January 1, 2014
Data from Kaiser Family Foundation: http://kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-children-at-application-effective-january-1-2014
+ CHIP (continued)
Capped federal funds
Increased flexibility Medicaid expansion Separate program Combination
Benefits
Link to the CMS Website with State by State and program wide information. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Childrens-Health-Insurance-Program-CHIP.htm
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+ CHIP Benefits
Expansion – same as Medicaid
Separate Program Benchmark Coverage
Federal Employee Benefits State Employee Coverage HMO with largest commercial enrollment
Benchmark Equivalent Coverage Coverage approved by HHS Comprehensive state-based coverage that existed
when CHIP was enacted (FL, NY, PA)
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+ How Are Public Insurance Services Delivered?
Managed Care Mandatory/Voluntary Prepaid/capitated (actuarially sound)
Risk adjustment Some services may be carved out
Fee for Service
Combination Primary Care Case Management
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+How do States fund their share of Medicaid ?
CMS approved Medicaid State Plans include the source of the state share of Medicaid expenditures.
CMS approved state plan amendments include the authorization of state funding sources as the federal financial participation (FFP) for the covered services.
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+How do States fund their share of Medicaid ?
Recognized sources of funding for the state share of Medicaid payments include:
Legislative appropriations to the single state agency
Inter-governmental transfers (IGTs)Certified public expenditures (CPEs)Permissible taxes and provider donations
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+
Part C Use of Public Insurance
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+Public Insurance in Part C Systems
FY 2012 ITCA Financial Survey
States reported Public Insurance funding:
$495,914,000 Federal Medicaid
$335,900,000 State Medicaid Match
$21,069,000 Managed Care (collected locally)
$3,480,000 CHIP
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+ National Part C System Funding 28
+Assessing Factors Influencing Funding from Public Insurance
What are the structures and relationships between your State’s Public Insurance and Part C systems? Are Part C services addressed in Medicaid State Plan? Under which
sections? What types of providers deliver Part C services and does your Part C
system, have a certification process? Has your state identified the sources for the state share?
What percent of children in Part C are eligible and enrolled in Medicaid or CHIP? How do your Part C demographics and Medicaid and CHIP eligibility
compare? Is the Part C system reaching families with Public Insurance eligible
children? Is service coordination assisting families eligible for Public Insurance
but not enrolled?
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+
FY 12 ITCA Finance Survey: 32 States and territories reported Medicaid as Part C system funding
Part C System FundingStates by Medicaid % of State Part C System Funding
+
FY 12 ITCA Finance Survey: 34 States and territories reported using at least one type of Medicaid for Part C system funding
Part C System Funding
+ Infrastructure Number of States Funding Function with Medicaid /CHIP by Type
Admin Gen EPSDT RehabManaged
CareWaivers CHIP
State Administration
4 3 3 1 3 0 2
Local Administration
8 0 3 1 2 1 1
Eligibility Determination
4 5 9 3 7 3 6
IFSP Development
2 5 9 2 5 2 3
32
+ Direct ServicesNumber of States Funding Service with Medicaid/ CHIP by Type
Admin Gen EPSDT RehabManaged
CareWaivers CHIP
Assistive Technology 1 11 13 2 9 3 6
Audiology 2 12 14 3 10 3 6
Family Train/ Counseling
2 5 10 3 5 2 5
Health 2 11 12 4 9 1 7
Medical 2 11 12 4 8 2 9
Nursing 2 11 14 4 10 3 7
Occupational Therapy 2 12 14 6 10 3 6
Physical Therapy 2 12 14 6 10 3 6
Psychology 2 9 13 3 7 3 5
Respite 1 3 1 1 1 0 1
Service Coordination 5 8 9 4 5 3 2
Special Instruction 2 4 10 4 4 3 2
Speech 2 12 13 6 10 3 6
Vision 2 10 11 4 9 3 5
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+
Developments and Directions in Public Insurance
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+ Developments and Directions
Nearly all states are developing and payment and delivery system reforms designed to: Improve quality Manage costs Better balance the delivery of long-term services and
supports across institutional and community based settings
Nearly all states developed at least one new policy to control Medicaid costs in the past two years. Most frequently states: Expanded Managed Care Initiated and Enhanced Care Coordination Strategies Increased Program Integrity Activities
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+ Directions: Managed Care
The majority of states have expanded Medicaid Managed Care in recent years
States are expanding both services (carved in) and populations covered
Objectives of expanding Managed Care include: improvement in health plan performance increased health care quality improvement in health care outcomes
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+ Directions: Care Coordination
All but six States reported new care coordination in FY 2012 and 2013
Care Coordination includes: Health Homes and Patient-Centered Medicaid
Homes that focus on coordinating and integrating care for persons with chronic conditions and disabilities. Health/Medicaid Homes coordinate primary, acute, mental and behavioral health, and long term services and supports.
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+ Directions: Program Integrity
Enhanced provider screening, use of various data bases for electronic verification, and advanced data analysis and predictive modeling
Detailed utilization review of paid claims, access to other data including provider ownership and death records, increased targeted field audits
Efforts to develop and increase collaborations across state agencies, private entities and CMS
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+ Medicaid Directors Top Issues and Challenges for FY 2014 and Beyond
Development of new strategies to improve care, quality and outcomes which include: new requirements for MCOs and Health Homes coordination and integration of physical and
behavioral health new quality improvement activities integrated with
reimbursement methodologies
Development of new systems of care for seniors and persons with disabilities including managed care and coordinated systems for dual eligibility beneficiaries
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+ Opportunities for Part C in changing public insurance systems
State Plan Amendments negotiations are opportunities for the addition of Part C system services in State Plans
Managed Care Contracts and Part C Systems State level system requirements for Part C providers and
MCO relationships MCO facilitation of local level public awareness and child
find activities including Physician / Health care referrals
New waivers Part C systems accessing payments for services Waivers facilitating payment for populations and services
within Part C systems
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Thank you for your attention!This is the second of four webinars in a series on Part C Finance presented in 2014. Resources related to this call and other calls in the series are available at the following URL:
http://ectacenter.org/~calls/2014/financepartc/financepartc.asp