Medicaid

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Medicaid

• Jeff Buska
• Department of Public Health Human Services

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Medicare / Medicaid / CHIP

• Medicare Title 18 of the Social Security Act
• Over 65 or Disabled
• Federally Managed program
• Medicaid Title 19 of the Social Security Act
• Resource Need Based
• State / Federal Partnership
• CHIP Title 21 of the Social Security Act
• Need Based
• Children Age 0-18
• State/Federal/Private Partnership

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Medicaid Title 19Federal State Partnership

• Federal Government
• Center for Medicare and Medicaid Services CMS
  formerly known as the Health Care Financing
  Administration
• Provides guidelines
• CFRs
• 70 Federal Financial Participation
  (approximately)
• 50 Federal Financial Participation for
  Administrative Costs

• State Government
• DPHHS
• Manages Medicaid programs based on ARMs and
  Legislative Authority
• 30 State Financial Participation (approximately)
• 50 State Financial Participation for
  Administrative Costs

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Administration of Medicaid Services

• DPHHS Designated as the Single State Agency
  for the Administration of Medicaid (Title 19).
• Clients receive Medicaid services from many
  different divisions within the Department of
  Public Health Human Services (DPHHS).

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Administration of Medicaid Services

• Human and Community Services Division (HCSD)
• Addictive and Mental Disorders Division (AMDD)
• Disability Services Division (DSD)
• Health Resources Division (HRD)
• Senior and Long Term Care Division (SLTCD)
• Quality Assurance Division (QAD)

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Medicaid Eligibility Determination

• Human and Community Services Division (HCSD)
• Eligibility is determined in the local office of
  public assistance local phone book
• SSI Disability is determined in the Disability
  Services Division

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Medicaid Card

• Implemented Client Hard Card September 2003.
• Card contains basic information to identify the
  client. Name, member number, and date of birth
  (DOB).

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Medicaid Policy and Reimbursement

• Determined in multiple Divisions
• Addictive and Mental Disorders Division (AMDD)
• Health Resources Division (HRD)
• Disability Services Division (DSD)
• Senior and Long Term Care Division (SLTCD)
• Administrative policy support
• Directors Office Office of Planning
  Coordination and Analysis (OPCA)
• Medicaid Management Information System (MMIS)
• Quality Assurance Division (QAD)
• Surveillance Utilization and Review Section
  (SURS)
• Third Party Liability (TPL)

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Services from DSD and AMDD

• Addictive Mental Disorders Division
• Manages services for individuals with mental
  illness, whether Medicaid eligible or not.
• Manage state institutions Montana State
  Hospital (MSH)

• Disability Services Division
• Manage services for individuals with DD, whether
  Medicaid eligible or not.
• Manages Medicaid HCBS program for DD population
• Manage state institutions for DD

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Services from Senior and Long Term Care Division

• Personal Assistance Services
• Self-Directed Personal Assistance Services
• Home Health
• Hospice
• Home Dialysis
• Nursing Facilities
• HCBS Waiver

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Services from Health Resources Division

• Inpatient Hospital
• Outpatient Hospital
• Physician
• Pharmacy
• DME
• Dental Denturist
• RHC (Rural Health Clinic)
• FQHC (Federally Qualified Health Center)
• Ambulance
• Therapies (OT,ST, PT)
• Others
• Nurse Call Line

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Medicaid State Plan Services

• Under federal law, if a state chooses to
  participate in Medicaid, then every resident of
  the state who meets the States Medicaid
  eligibility requirements is entitled to have
  payment made on his or her behalf for covered
  services.
• State Plan services are the fundamental basis of
  the Montana Medicaid program that provides the
  health care safety net for low-income Montanans.

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Medicaid Services

• Entitlement Program - A state plan service is
  available to all Medicaid individuals who need
  the service.
• States participating in Medicaid are required to
  provide specific services.
• States have the option to provide others.
• Medicaid programs vary considerably from state to
  state.

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Mandatory State Plan Services

• Inpatient Hospital
• Outpatient Hospital
• Physician
• Mid Level Practitioners
• Laboratory X-ray
• Nursing Facility Care for 21 yrs and older
• Family Planning
• Home Health
• Rural Health Clinics
• Federally Qualified Health Centers
• Medical and Surgical Services of a Dentist
• Transportation
• Early Periodic Screening, Diagnosis and
  Treatment (EPSDT)

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EPSDT

• Early Periodic Screening, Diagnosis, and
  Treatment Services
• Under the age of 21
• State is obligated to provide all medically
  necessary care available under Federal Medicaid
  regulations
• All services are mandatory for children
  (Including the optional services)
• Place of service and cost of the service are
  still factors
• Medical necessity
• Child is not entitled to a certain dollar amount
  or level of service

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Optional State Plan Services

• Ambulance
• Ambulatory Surgical Centers
• Dental/Denturist
• Audiology/Hearing Aids
• Eyeglasses/Optometric
• Community Mental Health Centers
• Home and Community Based Services
• Psychological
• Licensed Professional Counselors
• Freestanding Dialysis Clinic

• Outpatient Drugs
• DME/Medical Supplies
• Therapies (SP/PT/OT)
• Personal Care
• Podiatry
• Social Work
• Home Infusion Therapy
• Diagnostic Clinic
• Targeted Case Management
• Public Health Clinics
• Swing Bed Hospital
• Transportation

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Medicaid Requirements

• Additional requirements under the Social Security
  Act
• Comparability of Services Section
  1902(a)(10)(A) Services, eligibility methods and
  standards will apply to all individuals receiving
  medical assistance under any approved State Plan.
  
• State-Wideness Section 1902(a)(1) Services,
  eligibility methods and standards will be in
  effect in all political subdivisions of the
  State.
• Freedom of Choice Section 1902(a)(23)
  Individuals eligible for medical assistance may
  obtain assistance from any qualified provider
  that is enrolled as a Medicaid provider.
• Cost Sharing Section 1902(a)(14)/Section 1916
  Any deduction, cost sharing, or similar charge
  imposed under the plan with respect to other such
  individuals or other care and services will be
  nominal in amount.

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Medicaid and Waivers

• Vehicle used by the federal government that
  enables States to experiment with new ways of
  delivering healthcare.
• Waive provisions of the Social Security Act
• The Social Security Act authorizes multiple
  waiver and demonstration authorities to allow
  states flexibility in operating Medicaid
  programs. Each authority has a distinct purpose,
  and distinct requirements.
• Waiver authority has the ability to change the
  basic concept of entitled benefits that only
  applies to waiver eligible clients.

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Types of Medicaid Waivers

• Section 1115 Research Demonstration Projects
  This section provides the Secretary of Health and
  Human Services broad authority to approve
  projects that test policy innovations likely to
  further the objectives of the Medicaid program.
• Section 1915(b) Managed Care/Freedom of Choice
  Waivers This section provides the Secretary
  authority to grant waivers that allow states to
  implement managed care delivery systems, or
  otherwise limit individuals' choice of provider
  under Medicaid.
• Section 1915(c) Home and Community-Based Services
  Waivers This section provides the Secretary
  authority to waive Medicaid provisions in order
  to allow long-term care services to be delivered
  in community settings. This program is the
  Medicaid alternative to providing comprehensive
  long-term services in institutional settings.

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1115 Research Demonstration

• Test substantially new ideas of policy merit.
• Expand eligibility to individuals not otherwise
  eligible under the Medicaid program.
• Provide services that are not typically covered.
• Use innovative service delivery systems.
• Projects are generally approved to operate for a
  five-year period.
• Demonstrations must be "budget neutral" over the
  life of the project, meaning they cannot be
  expected to cost the Federal government more than
  it would cost without the waiver.

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Managed Care/Freedom of Choice Waivers - Section
1915(b)

• Authority to operate programs that impact the
  delivery system of some or all of the individuals
  eligible for Medicaid in a state by
• mandatory enrollment of beneficiaries into
  managed care programs, or
• creating a "carve out" delivery system for
  specialty care, such as behavioral health care.
• Do not have to be operated statewide.
• May not be used to expand eligibility to
  individuals not eligible under the approved
  Medicaid state plan.
• States has the option to use savings achieved by
  using managed care to provide additional services
  to Medicaid beneficiaries not typically provided
  under the state plan.
• Cannot negatively impact beneficiary access,
  quality of care of services, and
• Must be cost effective (cannot cost more than
  what the Medicaid program would have cost without
  the waiver).

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HCBS Waivers - Section 1915 (c)

• States may offer a variety of services to
  consumers under an HCBS waiver program and the
  number of  services that can be provided is not
  limited.
• Programs may provide a combination of both
  traditional medical services (i.e. dental
  services, skilled nursing services) as well as
  non-medical services (i.e. respite, case
  management, environmental modifications). 
• States have the discretion to choose the number
  of consumers to serve in a HCBS waiver program.
• Initial HCBS waivers are approved for a
  three-year period, and waivers are renewed for
  five-year intervals.
• States have the flexibility to develop HCBS
  waiver programs designed to meet the specific
  needs of targeted populations.
• Demonstrate that providing waiver services to a
  target population is no more costly than the cost
  of services these individuals would receive in an
  institution.

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Medicaid Contact Information

• Jeff Buska, Senior Medicaid Policy Analyst
• (406)-444-4145
• Jbuska_at_state.mt.us
• Medicaid Information
• http//www.mtmedicaid.org