Texas Medicaid

1. Module 1 Texas Medicaid Medical and Dental Information Series Version 1.2 (6/22/2010) 2/22/2013

2. Module 1 Medicaid Curriculum Overview • Module 1: General Structure of the Texas Medicaid System • Module 2: Understanding Medicaid Clients and Health Literacy • Module 3: Texas Health Steps • Module 4: Navigating Insurance and Managed Care • Module 5: Interfacing with Medicaid as a Provider • Module 6: Special Medicaid Programs • Module 7: Special Medical Issues • Module 8: Special Dental Issues

3. Module 1 General Structure of the Texas Medicaid Program

4. Module 1 Module 1: ObjectivesAfter completing this module, you should be able to: • Describe the purpose and background of Medicaid • Identify who benefits from services supported by Texas Medicaid • Contrast Medicaid with other major health programs • Describe the organization of Medicaid in Texas • List features of Medicaid Managed Care • Identify examples of Texas Medicaid programs • Outline advantages to serving as a Medicaid provider • Find Medicaid resources

5. Module 1 True or False?Test Your Knowledge about Texas Medicaid: • Medicaid is funded solely by the federal government. • Medicaid is an entitlement program based solely on age. • Medicaid benefits include many optional services that a state can choose to provide. • Non-disabled children account for more than half of Texas Medicaid spending. • Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.

6. Module 1 What is Medicaid? • Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments: • About one-third funded by the State of Texas • About two-thirds funded by the Federal Government • In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million). • Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967. • In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC). • Medicaid is an entitlement program, which means: • The number of eligible people who can enroll cannot be limited. • Any services covered under the program must be paid.

7. Module 1 What Does Medicaid Cover? • Long-term services for elderly and disabled clients • Mental health and substance abuse treatment • Acute and preventive health care for all ages • Physician visits • Inpatient and outpatient services • Pharmacy, lab, and radiology costs • Dental Services (for patients under the age of 21) • Preventive • Therapeutic

8. Module 1 Basic Principles of MedicaidSocial Security Act Amount, Duration and Scope Freedom of Choice • States must cover each service in an amount, duration, and scope that is “reasonably sufficient” and may impose limits on services for adult clients. A state may not arbitrarily limit services for any specific illness or condition. Comparability • With certain exceptions, including for managed care, the States must allow Medicaid recipients freedom of choice among participating providers of health care services. Statewideness • The same level of services must be available to all clients or patients (e.g., those with similar disabilities). • All services must be available statewide.

9. Module 1 Medicaid Benefits • The Social Security Act specifies… Required Benefits Optional Benefits States may define their own amount, duration, and scope of (or limitations on) Medicaid benefits Example: Limitations on prescription drugs Limits on coverage, for both required and optional services, may not be imposed for children under 21 if there is a medical necessity.

10. Module 1 Mandated ServicesCovered by Texas Medicaid, 2013 • EPSDT (Texas Health Steps) medical and dental check-ups and treatments for persons under 21 • Physician services • Dental services • Family planningservices • Inpatient & outpatient hospital • Lab and radiology • Nursing facility care • Home health care • Services by: • Federally Qualified Health Centers • Rural Health Clinics • Certified Nurse Midwives • Clinical nurse specialists and nurse practitioners

11. Hospice services Maternity service clinics Prescription drugs Podiatry Optometry, including glasses Hearing instruments Renal dialysis Rehabilitation services Medical or remedial care provided by: Physician extenders Mental health providers Chiropractors Physical therapists Occupational therapists Speech therapists Module 1 Examples of Optional Services Covered by Texas Medicaid, 2013 All services are required for children under 21 years of age if medically necessary; restrictions apply for many services to adults. • Rehabilitative services for mental illness • In-home respiratory care • Attendant services • Program for All-Inclusive Care for the Elderly (PACE)

12. Module 1 Who is Eligible for Medicaid Benefits? • Medicaid primarily serves: • Low-income families • Foster children • Pregnant women • The elderly • People with disabilities • Babies born to mothers receiving benefits at time of delivery (Services available for one year)

13. Module 1 Who is Eligible to Deliver Medicaid Funded Services? • Individual Health Care Providers • Doctors, dentists, advanced practice registered nurses, physician assistants, physical therapists, optometrists, and psychologists • Outpatient Facilities • Rural health clinics, federally qualified health centers, school clinics, family planning agencies, and mental health centers • Inpatient Facilities • Hospitals and skilled nursing facilities • Providers of Goods & Services • Durable medical equipment, ambulance, pharmacies, radiology, and labs

14. Module 1 Choosing a Provider:Patient Options • Although the Social Security Act requires freedom of choice in selecting Medicaid providers, it also allows states to set specific guidelines, especially for managed care organizations • Medicaid fee-for-service patients may choose any Medicaid provider • Patients enrolled in Health Maintenance Organizations (HMOs) have a primary care provider (or PCP) in a medical home • Patients in an HMO may choose any Medicaid primary care provider or specialist within the HMO network • In most cases, a referral for specialty care from the PCP is required for HMO patients

15. Texas Medicaid Medicare Module 1 Medicaid vs. MedicareWhat is the difference? Authorized by Social Security Act of 1965 Established in Texas – 1967 Jointly Funded by State and Federal Government, administered by State & regulated by CMS Funded by Federal Government & administered by CMS Entitlement program based on income Entitlement program based on age or disability Low income families, children, pregnant women, disabled, elderly People 65 years or older, or people with disabilities CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program. Eligibility and enrollment in both programs concurrently is possible

16. Texas Medicaid Children’s Health Insurance Program(CHIP) Module 1 Medicaid vs. CHIPWhat is the difference? Authorized by Social Security Act of 1965 Authorized by Balance Budget Act of 1997 Jointly Funded by State and Federal Government Entitlement program based on income, assets and/or disability Enrollment based on income (not an entitlement program) Low income families, children, pregnant women, disabled, elderly Children in families with too much income or too many assets to qualify for Medicaid and who meet the CHIP income requirements

17. Module 1 Who can receive FullMedicaid Benefits?Categories of Eligibility • Low income families, pregnant women, and children • Based on income level, age, caring for a related Medicaid eligible dependent child or pregnancy • Cash assistance recipients • Based on receipt of Supplemental Security Income (SSI) • People age 65 and older and those with disabilities • Based on income level, age, and physical or mental disability

18. Module 1 Who can receive LimitedMedicaid Benefits?Categories of Eligibility • Medicare Beneficiaries • Based on income level and age • Non-Citizens • Legal permanent residents and undocumented persons who are not eligible for Medicaid based on citizenship status may receive emergency services.

19. Module 1 How Many People DoesTexas Medicaid Serve? At any one time, how many individuals are enrolled in Medicaid? About 3.54 million

20. Module 1 How Many People DoesTexas Medicaid Serve? How many individual Texans received Medicaid-funded services at some point in the year? About 4.57 million

21. Module 1 Distribution of Medicaid Enrollees State Total = 3,098,169 As of: August 2010

22. Module 1 Texas Medicaid Recipients State Fiscal Year 2011 Unduplicated Clients SFY 2011 = 4,567,077 Hispanic Caucasian African-American Other 0-5 6-14 15-20 21-64 65+ Female Male

23. Module 1 How does Texas enroll Medicaid participants? Managed Care Fee for Service • Structured clinical, financial, and organizational activities designed to improve continuity and access to health care services, promote appropriate use of services, and contain costs. • Traditional arrangement in which a provider is paid for each individual service that a patient receives • MCO: Managed Care Organization, a health organization that finances and delivers health care through a specific provider network and defined services and products

24. Module 1 The Medical HomeKey Feature of Medicaid Managed Care • Serves as a source for continuity of care from a primary care provider (PCPs) • Provides comprehensive preventive and primary acute care • Provides specialty referrals and other services offered by a managed care organization and coordinates all levels of patient care • Texas Medicaid PCPs: • Family physicians • Pediatricians • General internists • Obstetricians/gynecologists • Physicians’ assistants • Advanced practice registered nurses • Community clinics including federally qualified health centers (FQHCs) and rural health centers

25. Module 1 Medicaid Managed Carein TexasOverview of Plans • STAR (Originally an acronym for State of Texas Access Reform) A statewide managed care program in which HHSC contracts with MCOs to provide, arrange for, and coordinate preventative, primary, and acute care covered services • STAR+PLUS Provides integrated acute and long-term services and supports to people with disabilities and the elderly • NorthSTAR A capitated program in Dallas and surrounding counties that provides behavioral health (mental health and substance abuse) services to Medicaid and medically indigent patients • STAR Health A statewide program to provide coordinated care to children and youth in foster and kinship care

26. Module 1 Percentage of Medicaid Clients by Delivery Type, State Fiscal Year 2011

27. Module 1 What are Examples of Texas Medicaid Programs? Texas Health Steps • Provides medical prevention and dental preventive/treatment services to eligible children Programs for Women and Children • Programs for family planning and pregnant women, Medicaid Buy-In for Children, and women’s cancers Prescription Drugs • Prescription medications through local pharmacies Behavioral Health Services • Mental, emotional, and chemical dependency treatment for eligible patients Long-Term Services and Supports • Programs for those with physical, intellectual and developmental disabilities

28. Module 1 Texas Health Steps • Perhaps the best known of Texas Medicaid programs is THSteps, which provides medial and dental preventive care and screening to eligible children. • THSteps is the name for the federally-required Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in Texas. Module 3 will focus specifically on Texas Health Steps.

29. Module 1 Components of THStepsMedical Checkups • Medical history • A complete physical examination • Screening of nutritional, developmental, and mental-health needs • Age appropriate laboratory tests (including lead screening) • Routine immunizations • Health education • Vision and hearing screening • Oral health screening and referral to a dental home • Referrals to other health care providers as needed

30. Module 1 Components of THStepsDental Checkups and Services • Preventive services • Dental examinations, cleanings, oral health education, topical fluoride applications, application of sealants, maintenance of space • Treatment services • Restorations (fillings and crowns), endodontic treatment, periodontic treatment, prosthodontics, oral surgery, implant services and maxillofacial prosthetics • Emergency treatment • Procedures to control and treat bleeding, pain, acute infection, immediate tooth loss, and injury to teeth or supporting structures • Health Related Orthodontic Services (prior authorization needed) • Correction of cleft palate, crossbite therapy, treatment of severe malocclusion, and treatment of facial accidents involving severe traumatic deviation

31. Module 1 The Medicaid Team Providers: Medical, Dental and Other Services HHSC:Single State Agency charged with the administration & supervision of the Medicaid plan MCOs: Managed Care Organizations TMHP: Claims Administrator DSHS DARS MAXIMUS: Medicaid and CHIP Enrollment Broker DADS ICHP: Quality Monitor

32. Module 1 Texas MedicaidOperating Departments

33. Module 1 Medicaid Functions • Operates as the single state agency responsible for Medicaid • Serves as primary contact point for the federal government • Administers the state Medicaid plan • Contracts with other state agencies to carryout certain Medicaid functions • Determines Medicaid eligibility • Operates the state’s acute care, prescription drug, and most managed care programs • Develops Medicaid policies, rules, and reimbursement rates • Organizes and coordinates initiatives to maximize federal funding • Manages the Medical Care Advisory Committee (MCAC)

34. Module 1 Medicaid Functions • Texas Health Steps • Case Management for pregnant women and children • Newborn metabolic screening, newborn hearing screening • Family planning • Targeted case management and rehabilitation • Services for people diagnosed with a mental health condition • NorthSTAR Administrator • YES Waiver program for children with severe emotional disturbance

35. Module 1 Medicaid Functions • Early childhood intervention • Targeted case management for Blind Children’s Vocational Discover and Developmental Program (BCVDDP)

36. Module 1 Medicaid Functions • Nursing facility programs and services • Long-term care licensing and certification • Program of All-Inclusive Care for the Elderly (PACE) • Hospice • Nursing home Preadmission Screening and Resident Review (PASRR) • Intermediate Care Facilities and Mental Retardation Facilities, including State Supported Living Centers. • Targeted case management for people with intellectual disabilities • Home and community-based services for people with developmental disabilities and those who would otherwise require nursing facility level of care

37. Module 1 • TMHP acts as the state's Medicaid fiscal agent and is responsible for paying acute care claims, while the state of Texas is responsible for covering the cost of claims. • Affiliated Computer Services, Inc. (ACS) meets consolidated contractual Medicaid responsibilities with a team of subcontractors under the name of TMHP (Texas Medicaid & Healthcare Partnership). Responsibilities • Administers fee-for-service Medicaid claims • Manages policy development • Collects HMO encounter data • Enrolls providers • Supplies provider relations representatives to enrolled providers

38. Module 1 What Does Medicaid Cost? • In 1967, Texas Medicaid served fewer than 1 million people at a cost of less than $200 million • In 2011, Texas Medicaid served more than 3 million people at a cost of $29.4 billion, representing about 26% of the total state budget Federal funds are based on the Federal Medicaid Assistance Percentage (FMAP) the matching rate that changes annually. For federal fiscal year (FFY) 2011, the Texas FMAP was 66.46%.

39. Module 1 Federal Medical Assistance Percentages (FMAP), Fiscal Year 2011 Texas 66.46% *Note: Percentages do not reflect temporary increases in FMAP provided by the American Recovery and Reinvestment Act of 2009.

40. Module 1 Texas Medicaid SpendingThe Big Picture By Services Type, State Fiscal Year 2010

41. Module 1 Texas Medicaid SpendingThe Major Categories By Services Type, State Fiscal Year 2011

42. Module 1 Average Monthly Medicaid Spendingby Type of Eligibility, State Fiscal Year 2011

43. Module 1 Federal Health Care Reform and Texas Medicaid • The federal health care reform Affordable Care Act (ACA) will impact Texas Medicaid, the Texas HHSC and other agencies. Examples of ACA changes include: • Benefit changes: • Concurrent hospice care and treatment services for children enrolled in Medicaid and CHIP • Birthing centers as a Medicaid provider • Expanded Medicaid formulary • New provisions to address fraud and abuse • Increased use of the National Provider Identifier (NPI) on claims and applications • Requiring face-to-face encounters with patients for the certification of home health services and durable medical equipment

44. Module 1 ACA Medicaid Eligibility Expansion • Effective January 1, 2014, ACA expands Medicaid to the following groups: • Former foster care youth through age 25 • Children ages 6-18 whose families have an income 100%-133% of the FPL; this is the population of children currently eligible for CHIP • The “individual mandate” for health insurance could lead to the enrollment of about 130,000 people who are currently eligible for Medicaid or CHIP, but are not currently enrolled If a Medicaid expansion is pursued by the state, income eligibility could be expanded to adults ages 19 to 64 who are not currently eligible for Medicaid, and have incomes ≤133% of the FPL. With this option Texas could expect to experience a caseload growth in 2014 of approximately 340,976.

45. Module 1 Texas Healthcare Transformationand Quality Improvement Program 1115 Waiver • In December 2011, Texas was granted a waiver of certain federal Medicaid requirements under Section 1115 of the Social Security Act; the waiver: • Expands Medicaid managed care to the entire state, including managed care for dental and prescription drug services • Creates 2 new funding pools, one to reimburse hospitals for Uncompensated Care (UC) for Medicaid and uninsured patients and one for Delivery System Reform Incentive Payment (DSRIP) to provide financial incentives to encourage hospitals and other providers to achieve quality health outcomes • What is being “waived”? • Certain aspects of the Statewideness, Comparabilityof Services and Freedom of Choice requirements of the Social Security Act Regional Healthcare Partnership Regions

46. Module 1 The Face of Medicaid:The Patient’s Perspective • Amy and her husband Josh have a 4-year old son, Ian, and another child due in 6 months. • Josh’s work hours at a local lumberyard have recently been reduced. Amy is a full-time cosmetology student and does not currently work. • The family income is currently about $1,900 per month, which is less than 120% of the current federal poverty level for a family of 3. • What services and support can Amy’s family expect from Texas Medicaid this year?

47. Module 1 How Can Texas Medicaid HelpAmy’s Family? • Medicaid for Ian and the new baby (when it is born) • Medicaid: Treatment and prescriptions for any of the children's acute illnesses or chronic conditions that are medically necessary • THSteps • Medical check-ups, including routine immunizations, physical examinations, and anticipatory guidance/health education • Dental check-ups, including preventive services and treatment • Amy • Medicaid: Pre-natal and pregnancy services for Amy, including the delivery of her baby, and post-partum care • Women’s Health Program: Family planning after the baby is born

48. Module 1 The Face of Medicaid:The Provider’s Perspective • Lauren will graduate from dental school in Texas this year, and she plans to establish a general practice in her hometown in the Texas Panhandle, in a county considered to be “dental lagging.” • She’s looking forward to building a practice and taking care of a wide range of patients, including those with Medicaid. • What services and support can Lauren expect from Texas Medicaid when she enrolls as a Texas Health Steps Provider?

49. Module 1 How Can Texas Medicaid Help Lauren Build Her Practice? • Payment to establish a dental home for her patients as young as 6 months of age. The first dental home visit can include (but is not limited to) an oral exam, oral hygiene instruction, dental prophylaxis, topical fluoride application, and caries risk assessment. • Payment for dental services for her child patients, 6 months to 21 years, to cover dental visits every 6 months for diagnostic, preventive, and routine therapeutic care.

50. Module 1 How Does Texas Medicaid Remain Dynamic & Progressive? • Medicaid adjusts and grows to meet Texas’ changing health care needs of its recipients and providers: • Legislation has led to expanded services and populations covered • Professional organizations provide feedback, medical recommendations, and suggestions about practice guidelines • Provider feedback is actively sought www.improvetxmedicaid.com The Interactive Medicaid Provider Voice System allows providers to submit concerns & suggestions to share with the HHSC Medicaid Staff