+

March 5, 2014

Session 2:Public

Insurance

+ Objectives

Provide foundational background for learning Public Insurance

Introduce key types of Public Insurance and their components related to Part C

Display public insurance information from the 2012 ITCA Financial Survey and what forms of Public Insurance state Part C systems are accessing

Highlight developments and directions in State Public Insurance programs and opportunities they may offer Part C systems

2

+ Overview

Medicaid Background Eligibility and Benefits Medicaid Waivers Early Periodic Screening Detection Treatment (EPSDT)

Children’s Health Insurance Program (CHIP)

Delivery systems and sources of State share

National Part C uses of Medicaid and CHIP

Recent Developments, future directions, and opportunities

3

+ Medicaid Background

State and Federal FinancingFederal Medical Assistance Percentage (FMAP)*

50% - 76% 2014 ACA – 100% Federal

50% Administrative Claiming

No Cap on Federal DollarsWaiver exception

Entitlement ProgramStateEligible Individual

4

+ Medicaid Background (continued)

Covers nearly 1/3 of all children in the United States

State administered program Eligibility standards Payment rates Benefits Packages Administration policies

Medicaid State Plan serves as the contract between the State and CMS

5

+ Medicaid Background (continued)

Medicaid/CHIP Program Information http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html

State Plan Amendments   http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Plan-Amendments/Medicaid-State-Plan-Amendments.html

6

+ Medicaid Eligibility

General Eligibility Children in Foster Care Low Income Families with Children People receiving SSI due to disability People over 65

Optional Eligibility Higher Income

Medically needy Other Groups

7

+ Medicaid Background Eligibility and FMAP Under ACA

Single Standard Under 65: income < 133% of federal poverty level

($25,390 for family of three)

FMAP 100% from 2014-2016 Gradual decline to 90% by 2020

8

+ Medicaid Eligibility (continued)

Eligibility Criteria:Required for:

children birth to 5 with family incomes below 133% of FPL

children 6 through 18 with incomes below 100% of FPL

Optional for: Children at higher income levels Children with severe disabilities who live at home

but qualify for institutional care – Katie Beckett waiver

Children who meet SSI disability criteria with income less that 300% - buy-in

9

+ Medicaid BenefitsMandatory Benefits:

Inpatient and Outpatient Hospital Services Physician Services Early Periodic Screening, Diagnosis and Treatment (EPSDT) Family Planning services and supplies Nursing Facilities Certified Pediatric and Family Nurse Practitioner services Laboratory and X-ray Services Tobacco cessation for pregnant women Transportation for non-emergency medical services Home Health services Rural health clinic services Federally qualified health center services Nurse Midwife services Freestanding Birth Center services (licensed or otherwise recognized by state)

10

+ Medicaid Benefits (continued)

Optional Benefits include: Prescription Drugs

OT, PT and Speech Therapy Optometry

Targeted case management Skilled Nursing Facilities for children under 21

Rehabilitative services Personal Care services Private Duty Nursing services Dental services Hospice services Inpatient psychiatric services for children under 21 Medical and remedial care from other licensed providers includes psychologists

11

+ Medicaid Cost Participation

In some situations states may require cost sharing.

Children are exempt from : Copayments Deductibles Co-insurance Cost-sharing

12

+ Medicaid Waivers

Request to CMS to “waive” certain requirements Statewide availability Freedom of choice of providers Universal access to all benefits

Must have cost neutrality Cannot cost the federal government no more than the amount

projected if there was no waiver Caps for numbers served

13

+Medicaid Waivers

1115 Research and Demonstration

1915 (b) - Managed Care

1915 © Home and Community-based Services

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Waivers.htmlervices

14

+ EPSDT

“The EPSDT program consists of two mutually supportive, operational components: assuring the availability and accessibility of required health care resources; and helping Medicaid recipients and their parents or guardians effectively use them.”

15

+ EPSDT (continued)

Benefits for children are guaranteed and are required to prevent as well as treat conditions.

Treatment is defined as: Necessary health care diagnosis services, treatment,

and other measures classified as medical assistance to

correct or ameliorate defects and physical and mental health

conditions discovered by screening services, whether or not

such services are covered under the state medical

assistance plan

16

+EPSDT (continued)

EPSDT also requires states to do more than

merely offer to cover services. States are

obligated to actively arrange for treatment,

either by providing the service itself or

through referral to appropriate agencies,

organizations or individual

17

+ Early Periodic Screening Diagnosis Treatment (EPSDT) Benefits

Screening through Comprehensive Well-Child Exams: Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations Laboratory tests Health Education Vision, hearing and dental screening in primary care

Diagnosis

Treatment

Other Necessary Health Care

18

+ Children’s Health Insurance Program (CHIP)Exclusively for Children

If a state chooses, for pregnant women

Also State/Federal Partnership

Higher match rate

Highest income level is 405% 14 states above 300% (5 additional with Medicaid) 10 states between 235-290% 20 states at 200 -235% 2 states < 200%

19

+ 20

Notes: Eligibility levels are based on 2013 federal poverty levels. January 2014 income limits reflect MAGI converted income standards, and include a 5 percentage point of federal poverty level disregard. Eligibility standards include CHIP-funded Medicaid expansions. Eligibility levels are based on a family of three. Eligibility levels reflect state decisions on the Medicaid expansion as of September 30, 2013, available here. Per CMS guidance, there is no deadline for states to implement the Medicaid expansion. Eligibility limits for adults in Michigan, reflect levels effective April 2014, when the state plans to adopt the Medicaid expansion. This table does not include notations of states that have elected to provide CHIP coverage from conception to birth.

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CHIP

Medicaid Birth to 1 (no coverage > 1)

Medicaid to age 1, CHIP >1 to 5 yo

Medicaid

Medicaid/ CHIP Income Eligibility Limits Children Birth to 5, Effective January 1, 2014

Data from Kaiser Family Foundation: http://kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-children-at-application-effective-january-1-2014

+ CHIP (continued)

Capped federal funds

Increased flexibility Medicaid expansion Separate program Combination

Benefits

Link to the CMS Website with State by State and program wide information. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Childrens-Health-Insurance-Program-CHIP.htm

21

+ CHIP Benefits

Expansion – same as Medicaid

Separate Program Benchmark Coverage

Federal Employee Benefits State Employee Coverage HMO with largest commercial enrollment

Benchmark Equivalent Coverage Coverage approved by HHS Comprehensive state-based coverage that existed

when CHIP was enacted (FL, NY, PA)

22

+ How Are Public Insurance Services Delivered?

Managed Care Mandatory/Voluntary Prepaid/capitated (actuarially sound)

Risk adjustment Some services may be carved out

Fee for Service

Combination Primary Care Case Management

23

+How do States fund their share of Medicaid ?

CMS approved Medicaid State Plans include the source of the state share of Medicaid expenditures.

CMS approved state plan amendments include the authorization of state funding sources as the federal financial participation (FFP) for the covered services.

24

+How do States fund their share of Medicaid ?

Recognized sources of funding for the state share of Medicaid payments include:

Legislative appropriations to the single state agency

Inter-governmental transfers (IGTs)Certified public expenditures (CPEs)Permissible taxes and provider donations

25

+

Part C Use of Public Insurance

26

+Public Insurance in Part C Systems

FY 2012 ITCA Financial Survey

States reported Public Insurance funding:

$495,914,000 Federal Medicaid

$335,900,000 State Medicaid Match

$21,069,000 Managed Care (collected locally)

$3,480,000 CHIP

27

+ National Part C System Funding 28

+Assessing Factors Influencing Funding from Public Insurance

What are the structures and relationships between your State’s Public Insurance and Part C systems? Are Part C services addressed in Medicaid State Plan? Under which

sections? What types of providers deliver Part C services and does your Part C

system, have a certification process? Has your state identified the sources for the state share?

What percent of children in Part C are eligible and enrolled in Medicaid or CHIP? How do your Part C demographics and Medicaid and CHIP eligibility

compare? Is the Part C system reaching families with Public Insurance eligible

children? Is service coordination assisting families eligible for Public Insurance

but not enrolled?

29

+

FY 12 ITCA Finance Survey: 32 States and territories reported Medicaid as Part C system funding

Part C System FundingStates by Medicaid % of State Part C System Funding

+

FY 12 ITCA Finance Survey: 34 States and territories reported using at least one type of Medicaid for Part C system funding

Part C System Funding

+ Infrastructure Number of States Funding Function with Medicaid /CHIP by Type

Admin Gen EPSDT RehabManaged

CareWaivers CHIP

State Administration

4 3 3 1 3 0 2

Local Administration

8 0 3 1 2 1 1

Eligibility Determination

4 5 9 3 7 3 6

IFSP Development

2 5 9 2 5 2 3

32

+ Direct ServicesNumber of States Funding Service with Medicaid/ CHIP by Type

Admin Gen EPSDT RehabManaged

CareWaivers CHIP

Assistive Technology 1 11 13 2 9 3 6

Audiology 2 12 14 3 10 3 6

Family Train/ Counseling

2 5 10 3 5 2 5

Health 2 11 12 4 9 1 7

Medical 2 11 12 4 8 2 9

Nursing 2 11 14 4 10 3 7

Occupational Therapy 2 12 14 6 10 3 6

Physical Therapy 2 12 14 6 10 3 6

Psychology 2 9 13 3 7 3 5

Respite 1 3 1 1 1 0 1

Service Coordination 5 8 9 4 5 3 2

Special Instruction 2 4 10 4 4 3 2

Speech 2 12 13 6 10 3 6

Vision 2 10 11 4 9 3 5

33

+

Developments and Directions in Public Insurance

34

+ Developments and Directions

Nearly all states are developing and payment and delivery system reforms designed to: Improve quality Manage costs Better balance the delivery of long-term services and

supports across institutional and community based settings

Nearly all states developed at least one new policy to control Medicaid costs in the past two years.  Most frequently states: Expanded Managed Care Initiated and Enhanced Care Coordination Strategies Increased Program Integrity Activities

35

+ Directions: Managed Care

The majority of states have expanded Medicaid Managed Care in recent years

States are expanding both services (carved in) and populations covered

Objectives of expanding Managed Care include: improvement in health plan performance increased health care quality improvement in health care outcomes

36

+ Directions: Care Coordination

All but six States reported new care coordination in FY 2012 and 2013

Care Coordination includes: Health Homes and Patient-Centered Medicaid

Homes that focus on coordinating and integrating care for persons with chronic conditions and disabilities.  Health/Medicaid Homes coordinate primary, acute, mental and behavioral health, and long term services and supports.

37

+ Directions: Program Integrity

Enhanced provider screening, use of various data bases for electronic verification, and advanced data analysis and predictive modeling

Detailed utilization review of paid claims, access to other data including provider ownership and death records, increased targeted field audits

Efforts to develop and increase collaborations across state agencies, private entities and CMS

38

+ Medicaid Directors Top Issues and Challenges for FY 2014 and Beyond

Development of new strategies to improve care, quality and outcomes which include: new requirements for MCOs and Health Homes coordination and integration of physical and

behavioral health new quality improvement activities integrated with

reimbursement methodologies

Development of new systems of care for seniors and persons with disabilities including managed care and coordinated systems for dual eligibility beneficiaries

39

+ Opportunities for Part C in changing public insurance systems

State Plan Amendments negotiations are opportunities for the addition of Part C system services in State Plans

Managed Care Contracts and Part C Systems State level system requirements for Part C providers and

MCO relationships MCO facilitation of local level public awareness and child

find activities including Physician / Health care referrals

New waivers Part C systems accessing payments for services Waivers facilitating payment for populations and services

within Part C systems

40

Thank you for your attention!This is the second of four webinars in a series on Part C Finance presented in 2014. Resources related to this call and other calls in the series are available at the following URL:

http://ectacenter.org/~calls/2014/financepartc/financepartc.asp