Medicaid Reimbursement for TB Services

1. Medicaid Reimbursement for TB Services Carol J. Pozsik, RN MPH Executive Director National TB Controllers Assn.

2. History of TB Funding • Prior to 1982 states were dependent on State or local funds for program operation • 1982 Federal Cooperative Agreements for TB began providing staff and travel • Today, State and local funds still provide some financial support for patient diagnosis, treatment, prevention and surveillance. • In general, funding for TB from both state and federal sources has been on the decline for several years.

3. Background Many TB programs still provide free outpatient services to clients using state and local funds. • Because TB is a communicable disease, if patient doesn’t have to pay for clinic visits and medications they will be more likely seek and complete treatment.

4. Background • Majority of TB clients are low income • Majority of TB clients are male and do not qualify for traditional Medicaid services • Females are more likely to be Medicaid eligible because they can be enrolled in Maternity, Family Planning and the WIC Program

5. Background • Some Medicaid programs cover limited TB services if the client is already eligible and if there is an existing billing system in place. • Most TB programs do not collect income information unless they are trying to bill traditional Medicaid.

6. Background • Some TB programs provide funding for inpatient hospitalization for complicated diagnosis and treatment that is beyond the scope of regular outpatient services • CDC Cooperative Agreement funds do not pay for drugs, x-rays and other direct treatment services

7. What is Medicaid? • Federal-State matching entitlement program • Title XIX of the Social Security Act • Provides medical assistance for certain individuals and families who have low incomes and resources • Largest program providing medical and health related services to America’s poorest people

8. Implementation • Federal govt. sets broad guidelines • States: • Establish their own eligibility standards • Determine type, amount, duration and scope of services • Set rates of payment for services • Administer their own programs • Programs vary from state to state

9. Basis of Eligibility • Medicaid does not provide medical assistance for all poor persons even under the broadest provision of Federal statute • To qualify must be in Mandatory Eligibility group • Low income is only one test of established thresholds for eligibility (determined by each state within the Federal guidelines) • States generally have broad discretion in determining which groups Medicaid will cover

10. Examples of Mandatory Eligible Groups • Recipients of AFDC (Aid to Families with Dependent Children) • SSI Recipients (Supplemental Security Income (aged, blind, disabled) who qualify in states with more restrictive eligibility requirements • Pregnant women whose family income is below 133% of poverty level

11. Examples of State Options • Infants up to age one and pregnant women not covered under the mandatory rules • Persons receiving care under home or community based waivers are eligible. • TB-infected persons who would be financially eligible for Medicaid at the SSI income level (only for TB-related ambulatory services and for TB drugs)

12. The TB Medicaid Option • 1993 Medicaid Act was amended to allow states to extend eligibility for Medicaid to TB infected persons • Must meet State income eligibility criteria • Covers both TB infection and disease, including suspected cases • Coverage limited to treatment period • Does not qualify client for other Medicaid services

13. Federal – State Match • Match is determined at Federal level by a Committee • Federal “matches” State cost of services • Example: May be 50% State and 50% Federal • Match differs from state to state.

14. Eligibility • Medicaid policies for eligibility and services are complex, and vary considerably among similar sized and/or adjacent states • A person eligible for Medicaid in one State might not be eligible in another state. • Services within a State may change from year to year

15. Medicaid TB Option Coverage(State dependent) • Outpatient Clinic visits • Medications • DOT (Directly Observed Therapy) visits • X-rays (Diagnostic and Follow-up) • Laboratory tests

16. Major Limitations of Medicaid TB Option • Does not pay for: Contact Investigation (rules vary) Hospitalization

17. Payment for Services • Operates as a Vendor System • State pays providers directly (includes health departments) • Providers must accept reimbursement as payment in full • State generally has broad discretion to implement reimbursement methodology and rate for services (There is a Federally imposed upper limit and specific restrictions.)

18. Payment for Services • Some states impose nominal deductibles or co-payments from clients

19. Medicaid Option Sounded Good 1993 - 2007 • NTCA survey about the Medicaid Option done in 2006 – 2007 • All fifty states surveyed

20. Who has the TB Medicaid Option? Only five states: Arkansas California Maine South Dakota Wisconsin

21. Why Other Programs Don’t Have The Medicaid Option? • State covers the costs of treatment: drugs, clinic operations (Some pay for hospitalization) • Medicaid agency does not have funds for the TB Option • Public health administration will not support applying for the Option • Administrative set-up too difficult for TB program – few clerical staff to do the work • Bill Medicaid, then must bill all clients – not enough staff • Match is too large up front – funds taken from TB Program’s State monies causing deficits in funding required services • Two states did not know about Medicaid Option

22. Why Don’t Other Programs Have The Medicaid Option? • Too time consuming to apply (2 years) • Sufficient funding from Medicaid eligible pts. • State has the Option – not all counties use it • Indian Health Service covers most clients • Gaps in coverage – drugs, hospitalization, no field DOT • Has expanded coverage for Medicaid eligibles • Medicaid reimburses for lab, diagnostic tests, xrays and private M.D. visits

23. Undocumented cannot qualify for Medicaid programs Path to Citizenship and Guest Relations programs require 5 years in US even after becoming citizens to become eligible for Medicaid Refugees are only eligible for 6 – 9 months Financial burden is great upon TB programs who have large population of foreign born clients Problems for States with Immigrants

24. Information About Medicaid Option • Institute of Medicine Report, “Ending Neglect”, 2000, pages 68 – 70, California Case Study pages 72-73. • Wisconsin TB Program Website: http://dhfs.wisconsin.gov/tb/resources

25. “All That Glitters Is Not Gold” Some things will have to change