Overview on Medicaid and the Deficit Reduction Act of 2005 (DRA)

1. Overview on Medicaid and the Deficit Reduction Act of 2005 (DRA) Presentation by Kay Johnson Director, Project THRIVE at NCCP Building Systems for Babies Conference November 16, 2006

2. 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.

3. MEDICAID ELIGIBILITY

4. Eligibility Optional Medicaid for children with disabilities up to or above 300% of poverty • 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 Optional Medicaid and/or SCHIP up to or above 200% of poverty Mandated up to 133% of poverty Mandatedup to 100% of poverty Birth to 6 Ages 6 -18

5. 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)

6. Post-DRA: Citizenship Documentation (Effective 7/1/2006) • Citizens: • No self-declaration of U.S. citizenship • Must present: • U.S. passport, certificate of naturalization, certificate of U.S. citizenship, valid driver’s license, or other ID document deemed valid, or • birth certificate or other ID document deemed appropriate (e.g., school id, medical record) • Other documents by special exception • Special challenges for babies born to non-citizens

7. MEDICAID FINANCING: FAMILY CONTRIBUTIONS

8. Post DRA: Premiums & Cost SharingEffective January 1, 2007 Above 300% FPL no federal participation; family buy in at full cost anticipated • 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 Optional Medicaid for children with disabilities up to or above 300% of poverty Optional Medicaid and/or SCHIP up to or above 200% of poverty Optional group to 150% has special cost sharing rules Mandated up to 133% of poverty Mandatedup to 100% of poverty Birth to 6 Ages 6 -18

9. 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”

10. MEDICAID BENEFITS

11. 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.

12. 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.

13. “Benchmark” Plans: State Options • FEHBP standard Blue Cross/Blue Shield PPO option • State employee benefit plan • Coverage by HMO with largest insured, commercial, non-Medicaid enrollment in the state • Another benefit package designed by the state and approved by HHS

14. 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

15. MEDICAID CASE MANAGEMENT

16. 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.

17. Spending SmarterUsing Federal Programs and Policies to Promote Healthy Social and Emotional Development Among Our Most Vulnerable Young ChildrenKay Johnson and Jane KnitzerNational Center for Children in Poverty, 2005.

18. 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.

19. 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.

20. 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

21. 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

22. For more information or questions, contact us at Project THRIVE 646-284-9644 ext. 6456 Thrive@nccp.org

23. 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/chsrp/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 More Resources www.hrsa.gov/epsdt