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Medica id
Syst em sw ide Adm inist rat ion
September 6, 2006
Charles Milligan, JD, MPH
Medicaid Commission Meeting
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Preview of Present a t ion
Matching rates Oversight
Workforce issues
Medicaid reform/global waivers
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Mat c h ing Rat es
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Medic a id is a p rogram jo in t l y
f inanc ed by s t a t es and t he federa l
governm ent . . .
Medicaid costs are shared:
For health services, a state’s federal medical assistance percentage(FMAP) relates to a complex formula that is not counter-cyclical , andthat includes a factor for per capita income. FMAP range: 50-80%.
For administrative services performed by states, the rates are the samefor all states. Most administrative services are50% (fed) /50% (state).
Selected exceptions to the 50/50 admin matching rate are:• Development of IT systems are matched at 90/10
• Operation of claims payment systems are 75/25• Services performed by skilled medical professionals, for tasks that require this
training: 75/25• Utilization review activities by qualified organizations: 75/25
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Maryland and Virginia 50.00%
District of Columbia 70.00%
Mississippi (highest) 75.89%
On average about 57 %
States 65%: AL, AR, AZ, ID, KY, LA, MS, MT, NM,OK, SC, UT, WV
States at 50%: CA, CO, CT, DE, IL, MD, MA, MN, NV,
NH, NJ, NY, VA
w. . . w i t h FMAPs t hat look l i k e t h is .
FY 2007
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S-CHIP has an “enhanced” match rate to incentivize active
participation by states
In S-CHIP, the federal government picks up an additional 30% of thestate’s “Medicaid” share
Example:
Maryland’s FMAP (Medicaid) 50.00%plus 30% of the state’s Medicaid share
(50%) 15.00%
Maryland’s S-CHIP Federal Match 65.00%
S-CHIP matching rates are an even
better deal for the states.
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Oversight
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Overs ight t ak es severa l
fo rms
Independent “Medicaid Fraud and AbuseControl Unit” Prosecutorial authority, usually at the Attorney
General’s office Mandatory external contractors
For example, EQROs for managed care
Mandatory Fraud and Abuse programs
Federal oversight
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Medic a id f raud, w ast e and abuse
ac t i v i t i es have m any fo rm s.
Cost avoidance “Pay and chase” third-party insurance
Recoveries (tort and estate)
Provider audits and settlements
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“ Per fec t ing” f raud and abuse
prevent ion is d i f f i c u l t and ongoing
w ork , g iven t he l ink t o ac c ess . . .
Did Medicaid pay for the care?
Was the careappropriate?
Yes No
Yes
No
Type I Error: Medicaid paid for medically-inappropriate care.Fraud and abuse problem.
Type II Error: Medicaid did not pay for medically-appropriate care.Access problem.
CorrectType I Error
Correct Type II Error
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. . . im proving f raud and abuse
prevent ion r isk s denia l o f
appropr ia t e c are . . .
Did Medicaid pay for the care?
Was the careappropriate?
Yes No
Yes
No
Type I Error: Medicaid paid for medically-appropriate care.Fraud and abuse problem.
Type II Error: Medicaid did not pay for medically-appropriate care.Access problem.
Correct
Type II ErrorCorrect
Type I
Error
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. . . t o d isc ern w het her c are should be
pa id requ ires good dat a on w het her t he
c are i s appropriat e for t hat pat ien t .
Did Medicaid pay for the care?
Was the careappropriate?
Yes No
Yes
No
Type I Error: Medicaid paid for medically-appropriate care.Fraud and abuse problem.
Type II Error: Medicaid did not pay for medically-appropriate care.Access problem.
Correct
Correct II
I
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Work forc e Issues
For l ic ensed heal t h profess iona ls
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For l ic ensed heal t h pro fess iona ls ,
Med ic a id fac es m any o f t he sam e
issues in hea l t h c are general ly
Demographic challenges
Recruitment and retention keyed toreimbursement rates
Providers’ increasing attention to lifestyleissues as health care is delivered in an
increasingly corporate model
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For paraprofess ionals , s t at es
have inc reas ing f lex ib i l i t y
States set provider participation criteria intheir state Medicaid plans
There is a movement in favor of consumer-
directed care, which expands the availableworkforce
Countervailing factors: State scope of practice laws
Medicaid “freedom of choice” creates crude
tools to open or close workforce options
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Medic aid Reform /Globa l
Dem onst rat ion Waivers
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An 1115 dem onst rat ion w a iver perm i t s t he
Sec re t ary t o w a ive o t herw ise requ i red
e lement s o f the s t a t e p lan
An 1115 waiver specifically allows waiver of the
terms of 42 USC Section 1396a (“Section 1902”) Must be budget neutral (cannot cost the federal
government more money than the status quo)
Theoretically, this governs many key elements.E.g.: Mandatory eligibility groups
Mandatory benefits
Delivery system/managed care
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. . . bu t m any areas are not “ w a iveab le”
by t he Sec re t ary under t he law (s inc e
t hey aren ’t in Sec t ion 1902) . . .
FMAP rates
Rx rebate provisions
Prohibition on copayments for services by
pregnant women, kids, others Spousal impoverishment protections
Estate recovery
Payment rates to FQHCs and IHS Medicare cost sharing
and ot hers have not been
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. . . and ot hers have not been
c onsidered “ w aiveable” under
longst and ing po l ic y f rom HHS.
Provision of mandatory benefits tomandatory populations
Entitlement nature of program formandatory populations (i.e., the prohibitionof an enrollment cap for these groups)
This reflects a view about federalism
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Reform /Global w aivers Emerging model involves re-directing large sources of
Medicaid uncompensated care funds, often initially builtthrough provider tax or upper payment limit techniques These funds generally used for:
Expansions of insurance to low-income uninsured working adults,
where The Medicaid program designs the program in coordination with,
and to fill in gaps, in employer-sponsored insurance models, oftenwith small employers, and where
The product is a basic benefit package with sliding scale out-of-
pocket, and where There are elements of consumer-directed care and personal
responsibility
1115 waivers are discretionary, and CMS uses its carrot to
drive policy
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Quest ions
Charles Milligan
Executive Director, UMBC/CHPDM
410.455.6274
www.chpdm.org
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