SUSTAINABILITY: MEDICAID AND OTHER HEALTH INSURANCE

1. SUSTAINABILITY: MEDICAID AND OTHER HEALTH INSURANCE MARY B. TIERNEY, M.D. August 21, 2003

2. Discussion Points • Relevant Medicaid legislative mandates and options • Waiver options

3. MEDICAIDREVELANT PROGRAMS • EPSDT • TEFRA OPTION • 1915 B WAIVERS • 1915 C WAIVERS • 1115 WAIVERS

4. EPSDT • A Benefit Under Medicaid • Mandates a Set of Benefits Including Preventive, Diagnostic, and Treatment Services, Such as Health Histories; Physical Examinations; Developmental Assessments;Vision, Hearing and Dental Services; Immunizations • Mandates Screening for Both Physical and Mental Health Issues

5. EPSDT SCREENING SERVICES • Type and frequency of services must be based on nationally recognized standards of medical and dental care. They also must be developed in consultation with recognized medical and dental organizations in the state with expertise in child health. • Periodicity schedule must ensure that a MINIMUM number of health examinations occur at critical points in a child’s life.

6. EPSDT Diagnosis and Treatment • When screening examinations so indicate • What services – all services covered under the state plan and any additional services (diagnostic or therapeutic) that are found necessary to diagnose and treat conditions found as a result of a screen regardless of any limitations under the state plan

7. EPSDT UTILIZATION OF PROVIDERS AND COORDINATION WITH RELATED PROGRAMS • States must use all categories of providers, including private practitioners and group practices, and encourage developments of a permanent relationship with a provider to have continuity of care. They must also coordinate with other human services, including Education, Early Intervention, Maternal and Child Health, and Behavioral Health.

8. Tax Equity and Fiscal Responsibility Act • Known as TEFRA or Katie Beckett • States are allowed at their option to make Medicaid benefits available to children age 18 or under even though they would not be eligible because of parental income

9. TEFRA • Found under 1902 (e) of the Social Security Act • States do not need to have a Home and Community-Based Waiver • Home and Community-Based Waivers allow for more flexibility in providing services

10. Child would be eligible if he/she was in an institution Child requires a level of care provided in a hospital, skilled nursing or intermediate care facility It is appropriate to provide the care in the home The cost of caring for the child in the home cannot exceed that of the institution ELIGIBILITY FOR TEFRA

11. 1915 B WAIVERS • State permitted to waive statewideness, comparability of services, and freedom of choice, • Limited in that they apply to existing groups of individuals who are or would be eligible for Medicaid

12. 1915 B WAIVERS • Have four types of waivers • Mandate enrollment into Managed Care • Use a Central Broker • Use cost savings to provide additional services • Limit the number of providers for services

13. 1915 B WAIVERS • Can create a carve-out delivery system for specialty care such as Managed Behavioral Health Care Plan • Can create programs that are not available statewide • Can provide an enhanced service package allowing States to provide additional services from savings from managed care

14. 1915 C WAIVERS • Home and Community-BasedServices Waiver • Afford States opportunity to develop and implement creative alternatives to placing Medicaid-eligible individuals in institutional settings and rather place them in their homes and communities • Allow States to request waivers of statewideness, comparability of services, and community income and resource rules

15. 1915 C WAIVERS • Case Management • Homemaker • Home Health Services • Personal Care Services • Adult day health • Habilitation and • Respite Services • The law lists seven services allowed in these programs

16. 1915 C WAIVERS • Non-Medical Transportation • In-Home Support Services • Minor Home Modifications • Adult Day Care • Day Treatment • Partial Hospitalization • Optional Services

17. 1915 C WAIVERS • Elderly • Persons with Physical Disabilities • Technology Dependent Children • Persons with Mental Retardation • Persons with Chronic Mental Illness and Behavioral Health Issues, Including Substance Abuse • Persons with AIDS • Individuals who would qualify only if they were served in an institutional setting • Who Is Targeted to Be Served

18. 1915 B & C WAIVERS • Both are approved through the Regional Office. • Both must be cost neutral. • Both are approved for an initial 2 years with subsequent renewal every 5 years.

19. 1115 WAIVERS • Provide the Secretary of Health and Human Services with broad authority to authorize experimental, pilot, or demonstration projects that are “likely to assist in promoting the objective of the Medicaid Statute.” • Allow States to test substantially new ideas and demonstrate something that has not been widespread and has a specific research design.

20. 1115 WAIVERS • Allow expansion of eligibility – unlike the 1915 Waivers • Allow expansion of services over and above those listed in the 1915 Waivers • CMS must evaluate the project including state-specific and cross-state analysis on utilization, insurance coverage, public and private expenditures, quality, access and satisfaction.

21. 1115 WAIVERS • Approved through the Central Office of CMS • Are subject to CMS, OMB, and HHS Secretarial approval • Must be cost neutral • Are approved for an initial 5 years, usually • May be renewed at the discretion of the HHS Secretary

22. PRIVATE INSURANCE • Parity of services for behavioral health • Institute of Medicine Report on the Consequences of Uninsurance–Care Without Coverage • Surgeon General Reports: Mental Health: A Report of the Surgeon General • Report to Congress on the Prevention and Treatment of Co-Occuring Substance Abuse Disorders and Mental Disorders

23. EXAMPLES OF STATE PROGRAMS • Pennsylvania – EPSDT • Colorado – 1915 B • Minnesota – 1915 C • Washington, DC – 1115

24. NEXT STEPS IT’S UP TO YOU