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MEDICAID 101. Health Care Financing for Children and Youth. This presentation may be shared. Please give credit as appropriate. Prepared by Kay Johnson, Johnson Group Consulting for CityMatCH Technical Assistance call March 18, 2004. Medicaid 101: Basic facts. - PowerPoint PPT Presentation
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Health Care Financing for
Children and Youth
This presentation may be shared. Please give credit as appropriate.
Prepared by Kay Johnson, Johnson Group Consulting for CityMatCH
Technical Assistance call March 18, 2004.
MEDICAID 101
March, 2004
Medicaid 101: Basic facts
Medicaid is health care financing It works like insurance but pays for many
things most private insurance doesn’t cover.
Medicaid is a federal-state partnershipSome program rules are set by the federal
government, others by the state.
Federal and state dollars pay for services.
Who is eligible for Medicaid?
What special enrollment rules apply?
MEDICAID ELIGIBILITY
March, 2004
Medicaid 101: Eligibility groups
Low income senior citizens
Low income children and pregnant
women
Persons with physical and mental
disabilities (including children)
Individuals receiving cash public
assistance (welfare)
March, 2004
Eligibility for Children
Children more likely than adults to be eligible. Congress and states approved Medicaid
expansions between1984-1990. One main goal was to finance more prevention and early
intervention.
Since 1996, the State Children’s Health Insurance
Program (SCHIP) has covered more children. In 21 other states SCHIP = Medicaid.
Medicaid-SCHIP expansions equalize benefits.
March, 2004
Eligibility for US Children
Federal law mandates:
Infants and children to age 6
up to 133% of poverty
Children ages 6-18 up to
100% of poverty
States have options to
cover other children
Medicaid at any level
SCHIP up to 200% of
poverty and above Birth to 6 Ages 6 -18
Mandated up to 100% of poverty
Mandated up to 133% of poverty
Optional Medicaid and/or SCHIP up to or above 200% of poverty
March, 2004
Benefits of Medicaid Expansion for Maternal & Child Health
Medicaid has: Become an important source of
insurance for working families. Offset losses in employer coverage for
dependents. Provided comprehensive coverage for
more children with special needs.
March, 2004
Medicaid Eligibility & Enrollment Continued coverage once enrolled
guaranteed for pregnancy and 60 days after
guaranteed for infants through first year
Among those with birth financed by Medicaid most
remain eligible throughout full 12 months.
optional 6 or 12 month continuous coverage
for children older than age one
Instead of renewing coverage every month, family
can renew for 6 or 12 month periods.
March, 2004
Medicaid Eligibility & Enrollment Enrollment rules
Automatic enrollment for newborns requiredAll babies whose birth was paid for by Medicaid
must be automatically enrolled.Most babies qualify for first full year.
Expedited for children & pregnant womenKnown as presumptive eligibility optionMeans that some providers can “presume
eligibility” based on income and certify temporary eligibility until the paperwork is done by the state.
What services are covered?
What enhanced benefits are available to children under EPSDT?
MEDICAID BENEFITS
March, 2004
Medicaid Benefits
Some federally mandated Some optional selected by state For children, more covered
all allowable under federal laweven if not in state plan
Kay says: “If its covered and approved for children in one state, it should be covered in all states.”
March, 2004
Medicaid Benefits
States must cover: Inpatient hospital services
Outpatient hospital services
Physician services
Nurse midwife and pediatric /
family nurse practitioner services
Medical & surgical dental care
Laboratory & x-ray services
EPSDT services
Family planning services
Rural health clinic and federally-
qualified health center services
Home health & nursing facilities
Optional, covered for children as necessary
Prescription drugs Dental services Optometrist & eyeglasses Mental health services Prosthetic devices Intermediate nursing facility /
mental retardation services Nursing facility for < age 21
March, 2004
EPSDT
“We think of EPSDT as a set of requirements, not a specific service or benefit package.”
Paul Wallace Brodeur
Former Medicaid director, VT
March, 2004
EPSDT Framework
Follow the letters:
Early - starting before problems worsen
Periodic - at regular intervals & as needed
Screening - comprehensive well child exams with developmental, physical, and mental, plus separate
vision, hearing, dental
Diagnosis - as appropriate
Treatment - all services (covered under federal law) needed for diagnosed conditions
March, 2004
EPSDT offers unique benefit list
Examples of services covered for children, even if not included in state plan for adults
therapeutic child care, preschool, and school day treatment
case management individual child care consultation home visits/intensive home-based services therapeutic behavioral health services speech-language-hearing & physical therapy eyeglasses, hearing aids, & assistive technology
March, 2004
EPSDT “Medical Necessity” “Medically necessary” services covered
EPSDT definition is broader than most private insurance plans
EPSDT purpose includes prevention & early intervention -- if service will prevention condition if service will improve health or ameliorate
condition if service will cure or restore health
March, 2004
Parent-Child Focus
Medicaid can support the family,
even if only one child is eligible.
Examples: Informing parents about coverage and
available services Parent health education & guidance Parent-child mental health therapy Foster parent support Family-focused case management
March, 2004
Varieties of Case Management
TYPE SAMPLE ACTIVITIES MATCHRATE
EPSDT casemanagement
• Outreach & informing• Assisting with transportation
50/50
Administrative casemanagement
• Assisting with applications• Assisting providers
50/50
Targeted casemanagement
• Help in identifying services• Care coordination
63/37(state's servicematch rate)
Case managementrequiring expertiseof skilled medicalpersonnel
• Reviewing care plans• Approving provider
payments• Certain referrals
75/25
How are Medicaid services financed?
What are matching funds?
MEDICAID FINANCING
March, 2004
Federal / State Matching Under a federal - state partnership
Federal financial participation (FFP) Level set under federal law for each state. FFP can vary by service.
States must provide matching funds. States must come up with funds to “draw
down” federal dollars.Matching funds are generally state and local
public dollars.
March, 2004
Medicaid Matching - CAUTIONS
To match with Medicaid federal financial
participation (FFP) Cannot use other federal dollars State dollars may be best source of match Local dollars okay where available Provider taxes and provider voluntary
contributions not okay Sometimes private funds okay
Tricky - needs state and federal approval
March, 2004
Federal / State Matching RatesTYPE SAMPLE ACTIVITIES MATCH
RATE Medical assistance • Paying for health services
and coverage
75/25 to 50/50 (medical service match rate)
Administration • Determining eligibility • Paying the bills
50/50
Skilled medical personnel
• Reviewing care plans • Approving claims
75/25
Management information system (MIS)
• EDS has contract 75/25
Family planning • Services, counseling, education, and supplies
80/10
March, 2004
Medicaid & Private Insurance
. Dual coverage okay for some services. Children who have private insurance can
qualify for Medicaid, which may pay for
services not covered in private and employer
plans.
Dual coverage most valuable for children with
special needs.
Medicaid pays last, after private coverage known as “payer of last resort”
March, 2004
Medicaid Financing: State dollars
State must appropriate funds to match federal financial participation general revenue dollars limited legislature has to approve
Maximizing use of state dollars key Use state general fund $ for matching Use other federal program and private
dollars for non-Medicaid activities
Who can be a provider and bill for Medicaid services?
MEDICAID PROVIDERS
March, 2004
Medicaid Providers - who? Providers must:
apply & be approved by the state be licensed to practice in the state be in a “qualified” category -- for example:
Physicians, nurses, dentists Psychiatrists, psychologists, social workers Hospitals, clinics, schools Managed care plans NOT professionals with education degrees only
be in state plan or subcontract with state
March, 2004
Medicaid Providers - special A provider may be an individual or be an
institution or facility. Facilities may be reimbursed cover time of staff
team, including some individuals who would not qualify as providers otherwise.
Hospital - physicians, nurses, nurses aides
Mental health center - therapists, aides
School - therapists, nurse, special ed. teachers
Managed care plans - medical & administrative staff
March, 2004
Medicaid Provider Payments
The state sets provider payment (fee) levels
Medicaid can pay fee-for-service or capitated.
Some federal rules apply
Under fee-for-service arrangements, Medicaid may pay
at cost or usual fee for services
Except for federally qualified health centers (and some other
types of clinics), no set way of assessing the cost of doing
business
Facilities are more likely to be paid on cost basis
ligible childligible serviceligible provider
MEDICAID Summary
March, 2004
Summary: Eligible children Nationally:
Over 40% of births nationally 1 in 3 toddlers 1 in 4 preschoolers 1 in 5 school age and teen age
Millions of eligible children not enrolled.
Yet we know: Outreach methods that work Enrollment/application assistance helps
March, 2004
Summary: Child benefits Additional child benefits under EPSDT
preventive care early interventions special needs care dental care family support services
Service may address physical, mental, developmental, rehabilitation, or another category.
March, 2004
Summary: Two components Direct health/ medical
care services immunizations well child exam doctor visit for illness eyeglasses mental health therapy dental examination
Support services to give information or access to care
informing parents about preventive care
transportation aid assistance in
completing enrollment application
PLUS Administrative services to operate state’s Medicaid program
March, 2004
Summary: Providers
Individual or facility(group) Be qualified type
Public agency Licensed provider
Apply and be approved by state May have limits
on types of services for which they can bill Medicaid
on their provider payment rates
March, 2004
Local Public Health agencies can --
Inform families about available coverage
Assist families in completing applications
Assist with transportation and appointment scheduling
Provide health services on site
Link with pediatric medical providers
Provide case management or care coordination
March, 2004
Public Health Core Functions Medicaid
providers
Assure appropriate access & use of coverage
Assessment
PolicyDevelopment
Assurancesurveillance access to providers
contract is policy
March, 2004
Other Resources
www.cms.gov www.gwhealthpolicy.org www.nhelp.org www.nccp.org (MCH Bureau webcast on EPSDT)
http://www.mchcom.com/archivedWebcastDetail.asp?aeid=234
