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Texas Medicaid. Medical and Dental Information Series. Version 1.2 (6/22/2010). 2/22/2013. 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 - PowerPoint PPT Presentation
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Texas Medicaid
Medical and Dental Information Series
1Module 1Version 1.2 (6/22/2010)
2/22/2013
Medicaid Curriculum Overview
Module 1: General Structure of the Texas Medicaid SystemModule 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
2
Module 1
Module 1
General Structure of the Texas Medicaid Program
3
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
4
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.
5
Module 1
What is Medicaid?
6
Module 1
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 TexasAbout 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.
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
7
Module 1
Dental Services (for patients under the age of 21)
Preventive
Therapeutic
Basic Principles of MedicaidSocial Security Act
8
Module 1
Statewideness
All services must be available statewide.
Comparability
The same level of services must be
available to all clients or patients (e.g., those with
similar disabilities).
Freedom of Choice
With certain exceptions, including for
managed care, the States must allow
Medicaid recipients freedom of choice
among participating providers of health
care services.
Amount, Duration and Scope
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.
Medicaid Benefits
The Social Security Act specifies…
9
Module 1
Required Benefits Optional Benefits
States may define their own amount, duration, and scopeof (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.
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 planning services
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 practitioners10
Module 1
Examples of Optional Services Covered by Texas Medicaid, 2013
11
Module 1
Hospice servicesMaternity service clinicsPrescription drugsPodiatryOptometry, including glassesHearing instrumentsRenal dialysisRehabilitation services
Medical or remedial care provided by:
Physician extendersMental health providersChiropractorsPhysical therapistsOccupational therapistsSpeech therapists
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 illnessIn-home respiratory careAttendant servicesProgram for All-Inclusive Care for the Elderly (PACE)
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)
Caseload Costs0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aged & Disability Re-lated30%
Aged & Disability Re-lated58%
Non-Disabled Adults 9%
Non-Disabled Adults 10%Non-Disabled Children
61%
Non-Disabled Children32%
Texas Medicaid 2011
12
Module 1
Who is Eligible to Deliver Medicaid Funded Services?
13
Module 1
Individual Health Care ProvidersDoctors, 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 FacilitiesHospitals and skilled nursing facilities
Providers of Goods & ServicesDurable medical equipment, ambulance,
pharmacies, radiology, and labs
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
14
Module 1
Medicaid vs. MedicareWhat is the difference?
15
Module 1
Texas Medicaid Medicare
Eligibility and enrollment in both programs concurrently is possible
CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program.
Authorized by Social Security Act of 1965Established in Texas – 1967
Jointly Funded by State and Federal Government, administered by State &
regulated by CMS
Funded by Federal Government & administered by CMS
Entitlement programbased on income
Entitlement programbased on age or disability
Low income families, children, pregnant women, disabled, elderly
People 65 years or older, or people with disabilities
Medicaid vs. CHIPWhat is the difference?
16
Module 1
Texas MedicaidChildren’s Health
Insurance Program(CHIP)
Authorized by Social Security Actof 1965
Jointly Funded by State and Federal Government
Entitlement program based on income, assets and/or disability
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
Authorized by Balance Budget Actof 1997
Enrollment based on income(not an entitlement program)
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
17
Module 1
Who can receive Limited Medicaid 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.
18
Module 1
How Many People DoesTexas Medicaid Serve?
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
1.872.10
2.492.68
2.88 2.79 2.83 2.88 3.003.30
3.54
Texas Average Monthly Medicaid Enrollment
SFYs 2001-2011
Mill
ions
At any one time, how many individuals are enrolled in Medicaid? About 3.54 million
19
Module 1
How Many People DoesTexas Medicaid Serve?
2001 2002 2003 2004 2005 2006 2007 2008 20090.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
2.612.96
3.363.63 3.73 3.81 3.83 3.85 4.02
Texas Annual Unduplicated Medicaid EnrollmentSFYs 2001-2011
Mill
ions
How many individual Texans received Medicaid-funded services at some point in the year? About 4.57 million
20
Module 1
Distribution of Medicaid Enrollees
State Total = 3,098,169As of: August 2010
21
Module 1
Texas Medicaid Recipients State Fiscal Year 2011
Gender
Age
Ethnicity
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
55%
36%
54%
45%
30%
22%
11%
17%
17%
8%
6%
22
Module 1
Female Male
0-5 6-14 15-20 21-64 65+
Hispanic Caucasian African-American
Other
Unduplicated ClientsSFY 2011 = 4,567,077
How does Texas enroll Medicaid participants?
23
Module 1
Fee for Service
Traditional arrangement in which a provider is paid for each individual service that
a patient receives
Managed Care
Structured clinical, financial, and
organizational activities designed to improve
continuity and access to health care services,
promote appropriate use of services, and contain
costs.
MCO: Managed Care Organization, a health organization that finances and delivers health care through a specific provider network and
defined services and products
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 PediatriciansGeneral internistsObstetricians/gynecologistsPhysicians’ assistantsAdvanced practice registered nursesCommunity clinics including federally qualified health centers (FQHCs) and rural health centers
24
Module 1
Medicaid Managed Care in 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+PLUSProvides 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 HealthA statewide program to provide coordinated care to children and youth in foster and kinship care
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Module 1
Percentage of Medicaid Clients by Delivery Type, State Fiscal Year 2011
26
Module 1
Fee-for-
service24%
Star PCCM25%
STAR MCO43%
STAR+PLUS6%
Star Health1%
Service Delivery Types
What are Examples of Texas Medicaid Programs?
27
Module 1
Texas Health Steps Provides medical prevention and dental preventive/treatment services to eligible children
Programs for Women and ChildrenPrograms 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
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.
28
Module 1
Module 3 will focus specifically on Texas Health
Steps.
Components of THSteps Medical 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
29
Module 1
Components of THSteps Dental Checkups and Services
Preventive servicesDental examinations, cleanings, oral health education, topical fluoride applications, application of sealants, maintenance of space
Treatment servicesRestorations (fillings and crowns), endodontic treatment, periodontic treatment, prosthodontics, oral surgery, implant services and maxillofacial prosthetics
Emergency treatmentProcedures 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
30
Module 1
MCOs: Managed Care Organizations
Providers: Medical, Dental and Other Services
ICHP: Quality Monitor
MAXIMUS: Medicaid andCHIP Enrollment Broker
TMHP: Claims Administrator
DARS
DADS
DSHS
The Medicaid Team
31
Module 1
HHSC: Single State Agency charged with the administration & supervision of the Medicaid plan
Texas MedicaidOperating Departments
Governor of Texas
Health & Human Services (HHSC) Executive CommissionerSingle State
Agency (HHSC)Department of State Health Services
(DSHS)
Department of Assistive & Rehabilitative Services (DARS)
Department of Aging & Disability Services (DADS)
32
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)
33
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
34
Module 1
Medicaid Functions
Early childhood intervention
Targeted case management for Blind Children’s Vocational Discover and Developmental Program (BCVDDP)
35
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
36
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).
ResponsibilitiesAdministers fee-for-service Medicaid claims
Manages policy development
Collects HMO encounter data
Enrolls providers
Supplies provider relations representatives to enrolled providers
37
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
38
Module 1
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%.
*Note: Percentages do not reflect temporary increases in FMAP provided by the American Recovery and Reinvestment Act of 2009.
Federal Medical Assistance Percentages (FMAP), Fiscal Year 2011
Texas66.46%
39
Module 1
Texas Medicaid SpendingThe Big Picture
40
Module 1
By Services Type, State Fiscal Year 2010
Texas Medicaid SpendingThe Major Categories
41
Module 1
Prescription Drugs $2.6 billion9%
Long Term Services & Supports $6.3 billion
23%
Dental $1.8 billion5%
Physician & Professional $5.1 billion18%
Clinic & Hospital Outpa-tient $2.9 billion
10%
Hospital Inpatient $3.5 billion13%
Medicare Parts A, B & D $1.5B
Disproportionate Share Hospital Program $1.6B
Upper Payment Limit $2.8B
By Services Type, State Fiscal Year 2011
Average Monthly Medicaid Spendingby Type of Eligibility, State Fiscal Year 2011
Non-disabled children Aged, blind & disabled Non-disabled adults, including pregnant women
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$259
$1,350
$640
42
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 abuseIncreased 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
43
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
44
Module 1
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.
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 reimbursehospitals for Uncompensated Care (UC) forMedicaid and uninsured patients and one forDelivery System Reform Incentive Payment(DSRIP) to provide financial incentives toencourage hospitals and other providers toachieve quality health outcomes
What is being “waived”?Certain aspects of the Statewideness,Comparability of Services and Freedom ofChoice requirements of the Social Security Act
45
Module 1
Regional HealthcarePartnership Regions
The Face of Medicaid:The Patient’s Perspective
Amy and her husband Josh havea 4-year old son, Ian, and anotherchild due in 6 months.
Josh’s work hours at a locallumberyard have recently beenreduced. Amy is a full-timecosmetology student anddoes 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?
46
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
AmyMedicaid: 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
47
Module 1
The Face of Medicaid:The Provider’s Perspective
Lauren will graduate from dental school inTexas this year, and she plans to establisha general practice in her hometown in theTexas Panhandle, in a county consideredto be “dental lagging.”
She’s looking forward to buildinga practice and taking care of a wide rangeof patients, including those with Medicaid.
What services and support can Lauren expect from Texas Medicaid when she enrolls as a Texas Health Steps Provider?
48
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.
49
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
50
Module 1
www.improvetxmedicaid.com
The Interactive Medicaid Provider Voice System allows
providers to submit concerns & suggestions to share with the
HHSC Medicaid Staff
Common Medicaid Myths
Medicaid is designed with minimum federal standards, which require states to cover certain populations and provide certain benefits to key populations.
In many ways it is a system that operates as 50 separate state coverage programs, with states having the choice to cover populations and services beyond minimum standards.
51
Module 1
MythMedicaid is a rigid, one-size-fits-
all program.
FactStates have taken advantage of
Medicaid’s flexibility to customize their programs—about 2/3 of
Medicaid spending is for “optional” services or populations.
Common Medicaid Myths
Research supports Medicaid’s role in improving access to care for the people it serves.
Medicaid beneficiaries value their coverage, are grateful for the assistance it provides, and often report satisfaction with their coverage at the same levels as those with commercial insurance coverage.
52
Module 1
MythMedicaid is a poor-quality
program that has little impact on access to care or health and Medicaid patients dislike the
program.
FactMedicaid offers access to primary and preventive health care for its patients that is comparable to that
of commercial coverage and greatly exceeds that of the
uninsured.
Test Your Knowledge about Texas Medicaid: True or False?
Medicaid is funded by the federal government.FALSE: Medicaid is jointly funded by the federal and state governments. In 2011, the state funded more than 33% of Medicaid costs.
Medicaid is an entitlement program based on age.FALSE: Medicaid is an entitlement program, but one based on income, assets, and disability/age.
Medicaid benefits include many optional services that a state can choose to provide.
TRUE: About 2/3 of the services provided under Texas Medicaid are considered optional for adults, rather than mandatory. Optional benefits in Texas include durable medical equipment, optometry, and prescription drugs. All federally allowable and medically necessary services are provided to children under 21 years of age.
53
Module 1
Test Your Knowledge about Texas Medicaid: True or False?
Non-disabled children account for more than half of Texas Medicaid spending.
FALSE: Although non-disabled children account for about 66% of the Medicaid caseload, they account for only about 33% of the costs
Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.
TRUE: Medicaid covers all such acute care costs.
54
Module 1
Medicaid Resources
Texas Health & Human Services Commissionwww.hhsc.state.tx.us/medicaid
Texas Medicaid & Healthcare Partnershipwww.tmhp.com
Texas Health Stepswww.dshs.state.tx.us/thsteps/providers.shtm
www.dshs.state.tx.us/dental/thsteps_dental.shtmwww.dshs.state.tx.us/thsteps/default.shtm
CHIP/Children’s Medicaidwww.chipmedicaid.org
56
Module 1
This Texas Medicaid curriculumwas prepared by
Betsy Goebel Jones, EdDProject Director
Tim Hayes, MAMProject Designer
Authors: Module 1 Betsy Goebel Jones, EdD
David Trotter, MADepartment of Family & Community Medicine
57Module 1