James A. Resnick, MHS Public Health Analyst Health Resources and Services Administration

1. Impact of the Deficit Reduction Act (DRA) on Maternal and Child Health (MCH) Programs and Populations James A. Resnick, MHS Public Health Analyst Health Resources and Services Administration Maternal and Child Health Bureau/ Office of Data and Program Development

2. Title V Maternal and Child Health Services Block Grant: SEC. 501. [42 U.S.C. 701] (a) To improve the health of all mothers and children consistent with the applicable health status goals and national health objectives established by the Secretary under the Public Health Service Act .

3. Percentage of Individuals Served by Title V, by Source of Coverage As reported by States in their Title V Block Grant FY 2004 Annual Report and FY 2006 Application

4. DRA Impact on Maternal and Child Health Programs and Populations (Clear)  (Not-So-Clear)

5. Deficit Reduction Act of 2005 • Eligibility • Premiums and cost-sharing • “Benchmark” coverage • Targeted case management • Citizen Requirements

6. 2007 HHS Poverty Guidelines SOURCE:  Federal Register, Vol. 72, No. 15, January 24, 2007, pp. 3147–3148

7. A Quick Analysis: Premiums, Cost Sharing and Flexibility • DRA Provides Protections for Pregnant Women and Low-Income Children

8. Exempted Cost-Sharing Services Emergency Family Planning Services to Mandatory Medicaid Women Benchmark Plans Must Include: Well-baby and well-child care, including age appropriate immunizations Secretary approved preventative services EPSDT Wrap-around Overview: Protected Services for Women and Children

9. 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 Mandated up to 133% of poverty Mandatedup to 100% of poverty Birth to 6 Ages 6 -18 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

10. Eligibility Child is defined as disabled Income does not exceed 300% FPL Incomes above 300% FPL must only use State funds Premiums and Cost Sharing (<200% FPL) – Not to exceed 5% of family income (200% - 300% FPL) – Not to exceed 7.5% of family income Family Opportunity Act • Provides an option to States to allow families of disabled children (SSI definition for severity of disability but meet income) to buy into Medicaid  Supports Family-to-Family Health Information Centers Effective Date: January 1, 2007

11. Insurance by Income Level Source: The Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health (www.childhealthdata.org), Special Analysis Produced by CAHMI/DRC Staff for James Resnick, HRSA (November 28, 2006)

12. New or increased premiums served as a barrier to obtaining and/or maintaining public coverage Premiums disproportionately impacted those with lower incomes, but also led disenrollment among those with incomes about 150% of poverty While some disenrollees obtained other coverage, many became uninsured Cost sharing led to unmet medical need and financial stress, even when amounts were nominal or modest Coverage losses and affordability problems stemming from increased out-of-pocket costs let to increased pressures on providers and the health are safety-net Increases in beneficiary costs may have created savings for States, but they may accrue more from reduced coverage and utilization rather than increased revenue. Impact of Cost Sharing Research Report Conducted by: Kaiser Commission on Medicaid and the Uninsured, May 2005

13. 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 need for waiver; State Plan Amendment suffices • This is similar to what is used for State (non-Medicaid) SCHIP programs • EPSDT wraparound required

14. Benchmark Plans • Federal Employee Health Benefits Program (FEHBP) • Standard Blue Cross/Blue Shield (preferred provider option) • State Employee Coverage • Coverage Offered Through HMO • Largest insured commercial, non-Medicaid plan in State • Secretary-Approved Coverage

15. Benchmark Plans • Additional services must have an “…actuarial value that is equal to at least 75% of the actuarial value of the coverage of that category of services in such package.” (DRA) • Coverage of prescription drugs • Mental health services • Vision services • Hearing Services

16. Impact of Benefits Flexibility-Unclear • Family Planning • Duration and scope of services • Hearing, Vision, Mental/Behavioral Services • Services for Children with Special Health Care Needs (CSHCN) • Physical therapy/Occupational therapy • Durable medical equipment • Supplies (Asthma, trach, hearing aids, eyeglasses) • Medical necessity: (No baseline for kids) • Prescription Drugs (Generic versus Brand) • EPSDT • Coordination of wrap-around services • **Families need to promote EPSDT**

17. Citizen Requirements • States required to obtain documentation of citizenship. Declaration of citizenship no longer allowed. • Dear State Medicaid Level Identified various levels and degrees of documentation. • Examples include: • U.S. passport, certificate of naturalization, certificate of citizenship, valid drivers licenses, birth certificates • Children born in the U.S. to illegal immigrants with low incomes are no longer automatically entitled to Medicaid (New York Times Article)

18. Citizen Requirements • Update: • December 20, 2006: Tax Relief and Health Care Act of 2006 (TRHCA) • Exempted Groups from Citizen Requirements: • Citizens receiving Social Security Disability Insurance (SSDI) • Children receiving foster care • March 20, 2007 CMS News Release • “All babies born in the United States whose deliveries are covered by Medicaid may remain eligible under certain circumstances for Medicaid for up to a year after their birth…”

19. Case Management: PRIOR DRA Source: Johnson K. Prepared for HRSA Managed Care TA Project. May 2005.

20. Case Management DRA Defined: “…Services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational and other services.”

21. Allowable DRA: “…directly related to the management of the eligible individual’s care” Not Allowable DRA: “…relate directly to the identification and management of the noneligible or nontargeted individual’s needs and care” DRA Defined: FMAP is Available Only “…if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program.” Targeted Case Management DRA Defined: “Furnished without regard to the requirements of section 1902(a)(1) and section 1902(a)(10)(B) to specific classes of individuals or to individuals who reside in specific areas.” K Johnson Defined: “For specific categories of beneficiaries, specific geographic areas, or specific sets of services.”

22. Impact of Medicaid Case Management Changes • Examples of Title V MCH case management services • Outreach for pregnant women • Home visiting programs for CSHCN • Prenatal education services • Medical coordination for individuals with severe medical conditions • Care coordination to support the medical home • It is unclear if changes to Medicaid law will impact reimbursement of services performed by MCH programs

23. Examples of Targeted C.M. • Utah: A "targeted case management" protocol will be developed for use with home health nurses that identify infants who missed or failed initial newborn hearing screening. • Utah: with the targeted case management staff in local health departments to help improve coordination between health care providers and families and to ensure that families have information about their Medicaid benefits and know how to access care. • Utah: The local health departments also provide targeted case management services for Medicaid families that include education about the importance of the well child visits, especially for children under age one year, and assistance with referrals to needed health care services when appropriate. • Alaska: the Title V program is working in collaboration with the Medicaid program, and Behavioral health to offer targeted case management services as part of the Medicaid program for children with special health care needs who do not qualify for one of the waiver programs.

24. Examples of Targeted C.M. • Kentucky: Medicaid reimbursement for targeted case management for Medicaid patients (including children in custody or at risk of being in custody of the state and adults in need of protective services) and for rehabilitative services for Medicaid-eligible children in custody or at risk of being in custody of the state. • Colorado: The Children, Adolescent and School Health Section, Nurse-Family Partnership Program is working with the Colorado Department of Health Care Policy and Financing to secure Medicaid reimbursement for targeted case management services, which will lead to an increase in the number of clients served. • North Carolina: CSC services are available in each county through LHDs or other providers to offer case management/care coordination for families of children at risk for or diagnosed with developmental delays, chronic illness, or social/emotional disorders. The CSC Program works with DMA to develop new policy, revise risk indicators, and address other programmatic components based on CMS restrictions on targeted case management.

25. Conclusion: Increased flexibility • States have multiple options to change Medicaid programs. • Impact will only be known once changes are implemented by States • Many policy decisions affecting MCH populations and programs will be made in the near future • Update of Medicaid regulation • Revision of Medicaid manual • Review of CMS approved Medicaid State Plan Amendments

26. Conclusion: Monitoring Role • Monitoring the impact of these changes on public health/ MCH programs at the national, state and local levels • Does the number of individuals requesting services and assistance from MCH public health programs increase? • Do higher co-payments/premiums cause individuals to seek care from safety-net providers? • Will costs shift to public health programs? • Analysis of TVIS data to determine if States have shifted funds from Infrastructure, Enabling and Population services to Direct health services

27. Conclusion: Title V Coordination • Title V MCH programs lead in coordination, infrastructure, and enabling services • How can you provide information to families when benefit, cost-sharing, and case management rules change? • Toll-free hotline updates • Outreach & informational materials • Engage families, providers, and other agency partners in designing approaches to continue care coordination for children with special health care needs (CSHCN). • Study impact on systems of care (perinatal, early childhood, CSHCN, genetics, mental health, etc.)

28. For More InformationVisit the EPSDT Web-Based Modulewww.hrsa.gov/epsdt James A. Resnick MHS (301) 443-3222 JResnick@hrsa.gov