Update: Children

1
Update Childrens Health Care and More
900 Lydia Street - Austin, Texas 78702 Phone
[phone] fax [phone] - www.cppp.org

• Childrens Health Coalition of the Rio Grande
  Valley
• Department of State Health Services
• 601 W. Sesame Drive
• Harlingen, Texas
• October 4, 2005
• Anne Dunkelberg, Assistant Director
  (dunkelberg_at_cppp.org)

2
Context for Funding Texas Health Care System

• US Census Bureau Statistics
• Approximately 5.6 million Texans uninsured in
  2004
• 25.1 of Texans of all ages were uninsured
• 27.6 of Texans under age of 65 were uninsured
• Another three million Texans covered by Medicaid
  or CHIP
• Why are so many Texans uninsured?
• Low percentage of employer-sponsored
  insurance (ESI)
• 7.6 below national average for lt 65 (55.6)
• 9.3 below national average for lt18
• Approximately 83 Texas Medicaid recipients are
  below poverty
• Fewer than 14 of Americans below poverty have
  ESI

3
Medicaid in Texas Who it Helps

• Medicaid
• As of August 2005, 2.7 million Texans were
  enrolled in Medicaid
• 1.8 million were children
• about 83,000 of these children, or 4.6, were
  receiving disability-related Medicaid (97 of
  these on SSI)
• about 13,500 were pregnant teens
• 144,750 in TANF families (5.4 of total caseload)
• OTHER 1.58 MILLION Are in WORKING POOR FAMILIES
• 873,000 were adults
• 678,000 (78 of the adults) were elderly or
  disabled. Adults on SSI account for 60 of the
  aged and disabled recipients
• Other adults 96,200 maternity coverage 38,600
  TANF parents (1.4 of total caseload) 61,100
  either TMA (Transitional Medicaid Assistance) or
  parents who are at or below TANF income, but not
  receiving TANF cash assistance
• Childrens Health Insurance Program (CHIP)
• as of September 1, 2003 507,259 children
• as of July 1, 2005 326,809 (drop of 179,992, or
  35)

4
Texas Medicaid Who it Helps
August 2005, HHSC data.
Total enrolled 8/1/2005 2,693,286
5
Medicaid Cuts What was Reversed by 2005
Legislature

• Adults Medicaid Services Restored (eff. 10/05)
• Podiatrists
• Eyeglasses and Hearing Aids
• Mental health services by social workers,
  psychologists, licensed professional counselors,
  and licensed marriage and family therapists.
  There was complication with the funding for this
  benefit, but at this time it appears services by
  all 4 mental health provider types will be
  restored December 1, 2005.

Center for Public Policy Priorities www.cppp.o
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6
Medicaid Cuts What was Reversedby 2005
Legislature

• PROBABLY Restored
• The Personal Needs Allowance of Medicaid nursing
  home residents (the monthly amount that Medicaid
  nursing home residents may keep from SSI, Social
  Security or other pension income the rest goes
  to the nursing home)
• was cut in 2003 from 60 to 45.
• Though not restored by the budget or other bill,
  Gov. Perry and Senator Zaffirini have pledged to
  ask LBB for budget execution to allocate the
  13 million in state dollars needed to restore
  this.
• LBB meeting delayed due to hurricanes Katrina and
  Rita. STAY TUNED!

Center for Public Policy Priorities www.cppp.o
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7
Medicaid Cuts What was Reversed by 2005
Legislature

• Not exactly restored
• Medically Needy Spend-Down Program for Parents
  (Temporary Coverage for Poor Families with
  Catastrophic Medical Bills)
• HHSC estimated that full restoration of MN would
  cost 175 million GR for 2006-2007 SB1
  authorizes just 35 million for partial
  restoration but assumes this will be funded
  entirely by voluntary contributions of local tax
  dollars (IGT) from the big urban hospital
  districts
• Also says 20 million GR could be added to this
  IF the local funds are provided first (the 20
  million would come from savings achieved due to
  the Womens Health and Family Planning Waiver,
  more later on this)
• No action so far to restore. STAY TUNED!

Center for Public Policy Priorities www.cppp.o
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8
Medicaid Cuts that Remain

• Medicaid and CHIP provider rate cuts
• Most Medicaid and CHIP providers had rates cut in
  2003 hospitals and doctors had a rate cut of
  2.5 nursing homes 1.75, and community care
  providers 1.1.
• In August 2004, HHSC proposed and LBB approved
  keeping most the cuts at the same level for 2005
  (i.e., not making deeper cuts) but hospitals
  took a deeper 5 cut.
• 2005 legislature restores rates to 2003 levels
  for Community Care services and Waivers, and for
  ICF-MR (all at DADS), but not for doctors, other
  professionals, hospitals, or CHIP.
• All other rate cuts remain. Rate cuts were the
  largest HHS cut made in 2003 much larger than
  the CHIP cuts.

Center for Public Policy Priorities www.cppp.o
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9
Income Caps for Texas Medicaid and CHIP, 2005
20,844
32,180
29,767/yr
29,767/yr
21,400/yr
219
200
16,090
6,948
185
185
2,256
3,696
133
100
73
14
23
Income Limit as Percentage of Federal Poverty
Income Annual Income for a family of 3, Except
Individual Incomes for SSI and Long Term Care
10
Community Care and Waiting Listsfunding for
enrollment increases

• 2003 Legislature reduced numbers and/or levels of
  services in capped Community Care and Health
  programs
• 2006-2007 budget provides funds to increase a
  number of non-entitlement programs enrollment
• For children
• MDCP increased from 977 in 03, 983 in 05, to
  1,993 in 2007.
• CSHCN increased from 1,463 in 03, 2,114 in 05,
  to 2,293 in 07
• Most Medicaid waivers, HIV Meds increased
• Exceptions
• CBA was 30,279 in 03 26,100 in 05 to 28,401
  in 07,
• Kidney Health Program 22,834 in 03 21,247 in
  05 to 20,415 in 07
• In-Home and Family Support for aged disabled,
  MR still below 03 levels (MH IHFS program
  eliminated in 03 and not restored)

11
Medicaid Caseloads Actual and Projected Medicaid Caseloads Actual and Projected Medicaid Caseloads Actual and Projected
Actual Medicaid enrollment, May 2005 (Final recipient months average 104 of point-in-time enrollment, after retroactive coverage is included) 2,686,699 (equals about 2,794,167 recipient months) 2,686,699 (equals about 2,794,167 recipient months)
2006 2007
HHSC 2/05 estimated, (6-month coverage for children) 3,124,110 3,356,597
Introduced version, SB 1 (6-month coverage of children) REDUCES BUDGET 930 MILLION GR 2,987,578 3,137,045
Medicaid Buy-In (New Clients) 2,273 2,273
Waiting List (New Clients) 1,078 3,196
Perinatal Subtractions (i.e., moved to CHIP) (14,386) (39,214)
Medically Needy 10,118 10,918
Final Budget,SB1 (6-month coverage of children) 2,986,661 3,114,218
Difference, HHSC projected and budgeted in SB 1 -137,449 -242,379
Center for Public Policy Priorities www.cppp.o
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12
CHIP Cuts, 2004-05 Budget

• Summary of 2003 CHIP changes
• Benefits eliminated dental vision (eyeglasses
  and exams) hospice skilled nursing facilities
  tobacco cessation chiropractic services. Mental
  health coverage was reduced to about half of the
  coverage provided in 2003
• Premiums and co-payments increased
• Coverage period reduced from 12 months to six
• New coverage delayed for 90 days
• Income deductions eliminated (gross income
  determines eligibility)
• Asset test (limit) added for those above 150 of
  the poverty Line (took effect August 2004)
• Outreach and marketing reduced
• Underlined Items Restored by 2005 Legislature

13
How CHIP Fared in 2005 Session

• Restored Dental, vision, hospice and mental
  health benefits restored to 2003 levels
• Funding to replace monthly premiums with more
  affordable and convenient enrollment fees. HHSC
  presentations have outlined an annual fee of
• No enrollment fee below 133 of the federal
  poverty level (FPL) (lt2,145/ family of 4)
• 25 per family (per 6-month period) from 133-150
  FPL (2,145-2,419/family of 4)
• 35 per family (per 6-month period) from
  151-185 FPL (2,420-2,983/family of 4) and
• 50 per family (per 6-month period) from
  186-200 FPL (2,984-3,225/family of 4)

14
How CHIP Fared in 2005 Session

• None of the CHIP restoration bills ever had a
  public hearing, not even Senator Averitts SB 59.
  Restorations made were all done via the budget.
• These 2003 Changes Remain
• Coverage period reduced from 12 months to six.
  Language in law now makes this permanent, rather
  than planning for a return to 12 month coverage
  at a future date.
• New coverage delayed for 90 days. (New perinatal
  coverage could eliminate this for many newborns.)
• Income deductions eliminated (gross income
  determines eligibility).
• Asset test (limit) added for those above 150 of
  the poverty line (took effect August 2004).
• Outreach and marketing were reduced in 04-05,
  important to monitor and push for strong
  investment in both in 06-07.

15
Texas Child Medicaid and CHIP Combined
Enrollment (January 2002-August 2005)
Source All figures from Texas Health and Human
Services Commission
Center for Public Policy Priorities www.cppp.o
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16
CHIP Caseloads Now and Projected
2006 2007
September 2003 actual caseload 507,259
August 2005 actual caseload 326,770
decline, 9/03 to 5/05 (36) (-180,489)
HHSC 2/05 projected enrollment, if 12-month eligibility restored 386,110 467,404
HHSC 2/05 projected enrollment (6 month renewal) 360,786 388,920
SB 1 funded caseload, traditional CHIP (6 month renewal) 344,750 351,132
Additional caseload, perinatal coverage 17,425 47,498
Total ,SB 1 projected CHIP caseload, traditional perinatal CHIP 362,175 398,630
Rider 57 HHSC (SB 1) requires agency to request
addl. for CHIP from LBB if needed for
enrollment and benefits.
17
New CHIP Perinatal Coverage Planned

• Last-minute addition to the budget bill
  authorizes this (Rider 70 HHSC). No previous
  bill or public discussion, but agency has done
  significant lead work behind the scenes
• HHSC assumes start-up 1/2006. The benefit and
  eligibility belong to the perinate, not the
  mother. Will provide prenatal care and delivery
  to women 186-200 FPL (who make too much for
  Medicaid)
• ALSO will pick up mothers 0-200 FPL who do not
  qualify for Medicaid maternity coverage because
  they are either a legal immigrant or an
  undocumented resident. This means that many of
  the covered perinates would have been eligible
  for Medicaid at birth, i.e. all those with
  incomes below 185 FPL

Center for Public Policy Priorities www.cppp.o
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18
New CHIP Perinatal Coverage Planned

• At some point before or at the first birthday,
  Medicaid-eligible children will be switched back
  to that program.
• Of the nearly 48,000 perinates per month
  projected in FY 2007, over 39,000 are infants who
  would have been enrolled in Medicaid under
  current rules, and about 8,300 are perinates who
  would not have been covered without this option.
• 7 states have these programs (AR, IL, MA, MN, MI,
  RI, WA) all but AR provided prenatal care to
  immigrants with state dollars before the CHIP
  program.
• Controversy because (1) created under federal
  rule (not law) and (2) gives person status to
  the unborn.

Center for Public Policy Priorities www.cppp.o
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19
Womens Health and Family Planning Medicaid
Waiver

• SB 747 by Senator John Carona,.
• Texas Medicaid will provide basic medical
  check-ups and birth control services to adult
  Texas women (ages 18 and older) up to 185 of the
  poverty line (thats 2,481 per month pre-tax
  income for a family of 3 in 2005).
• Currently in Texas, working mothers must live at
  or below 23 of the FPL to qualify for Medicaid
  (23 of poverty is less than 308 per month for a
  family of 3) and childless women cant qualify at
  all so the waiver could help many thousands of
  women who cant get full Medicaid benefits.
• Texas has the highest of uninsured women aged
  18 to 64 (28.3) in the nation (the U.S. average
  is 17.7)
• About 40 of all Texas women live below 200 of
  poverty, and 50 of them are uninsured.
• HHSC submitted an outline to federal govt. in
  August no target date has been announced for
  start-up.

20
Womens Health and Family Planning Medicaid Waiver

• Services covered will include
• well-woman exams,
• counseling and education on contraceptive
  methods,
• provision of contraception,
• screenings for diabetes, breast and cervical
  cancer, sexually transmitted diseases,
  hypertension, cholesterol and tuberculosis,
• risk assessment and referral of medical problems
  to appropriate providers.
• It is against federal and state law to use
  Medicaid funds for abortion, and SB 747
  specifically excludes abortion providers.
• The bill also excludes coverage of emergency
  contraceptives.
• Outreach will be critical once the program
  starts, so STAY TUNED!!

21
Medicaid Buy-in Program for Working Disabled
MBI

• SB 566 by Deuell
• Directs HHSC to develop/start program to allow
  working individuals who earn too much to qualify
  for Medicaid, but less than 250 FPL
  (23,925/year for a single person) to pay
  premiums to get Medicaid coverage.
• Premiums amounts will depend on income level, and
  have 2 parts
• one is based on unearned income (like
  disability benefits) and
• the other part on earned income (like wages from
  a job)
• Latest HHSC information suggests September 2006
  as earliest start-up.

22
Universal Services Card Medicaid Biometric
Finger Imaging

• Universal Services card authorized (SB 46, by
  Nelson)
• HHSC can develop a single smart card for use
  both as an ID for benefits like Medicaid, Food
  Stamps, and TANF, as well as an EBT card (like
  the Lone Star card)
• CAN include finger imaging
• MUST protect client privacy
• Statewide Expansion of Medicaid Finger Imaging
  authorized (SB 563 by Janek)
• HHSC can proceed to mandatory statewide use of
  finger image cards
• Would be done in stages, and HHSC must adopt a
  plan for how to deal with lost and forgotten
  cards, who to exempt, and how to deal with no
  match situations BEFORE expanding
• No HHSC timeline announced yet for either of
  these projects

23
Medicaid Managed Care Statewide Expansion (PCCM,
STARPlus, ICM)

• Primary Care Case Management
• PCCM expanded to 197 additional Texas counties on
  September 1, 2005
• Some Medicaid clients who do not live in a PCCM
  expansion county were enrolled in PCCM by
  mistake.
• Date for clients to pick a PCP extended to
  November 11.
• a referral from the client's PCP will not be
  required until December.
• PCCM Client Helpline 1-888-302-6688
• When all PCCM Client helpline phone lines are
  tied up, the recording tells PCCM clients to call
  back from 7 a.m. to 9 a.m. or 4 p.m. to 7 p.m.
  then they are disconnected. HHSC may have fixed
  this by now.
• Can also change PCP by mail (by mailing the PCP
  Selection form enclosed in packet, or go to
  http//www.tmhp.com/C8/PCCMClients/default.aspx
  to get a new form)

24
Medicaid Managed Care Statewide Expansion (PCCM,
STARPlus, ICM)

• STARPLUS
• These provisions do not affect RGV for now.
• The STARPLUS managed long term care HMO model
  serves aged and disabled Medicaid clients in the
  Houston area.
• New state laws and the state budget assumed
  savings from greater management of care for aged,
  blind and disabled Medicaid clients, via three
  models of care
• a modified STARPLUS HMO model, a new Integrated
  Care Management approach, or primary care case
  management
• reduces Medicaid funding by 109.5 million GR
• A new enhanced PCCM-type Integrated Care
  Management (ICM) model will be implemented in
  the Dallas service area
• Where the HMO-style STARPLUS model is used, the
  state will modify that model to protect federal
  UPL payments to local public hospitals.
• Savings guaranteed by allowing HHSC to cut
  provider rates if the new model does not produce
  the required savings.

25
Integrated Eligibility and Enrollment

• June 30, HHSC announced 5-year, 899 million
  contract with Accenture, to take over operation
  of the state's eligibility and enrollment systems
  for Medicaid, CHIP, Food Stamps, and TANF cash
  assistance.
• Local offices will drop from 381DHS offices to
  167 full-service offices and 44 satellite
  offices open on certain days only the state will
  close 99 eligibility offices.
• Four call centers will provide assistance from 8
  a.m. to 8 p.m., will receive and process
  applications, and consumers will be able to track
  their applications through an automated phone
  system.
• The number for assistance will be 2-1-1.

Center for Public Policy Priorities www.cppp.o
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26
Integrated Eligibility and Enrollment

• Eventually will be able to apply through the
  Internet, over the phone and by fax or mail.
• Over 10,000 DHS state eligibility workers in 1997
  reduced to 2,900 in IEE (counting the 600
  out-stationed workers)
• Call centers will employ about 2,500 (total
  system about 5,400)
• The transition to the new office structure will
  begin in January and will be phased in over a
  10-month period. RGV will be last (September
  2006, if on schedule)
• First step is takeover of CHIP enrollment in
  November (from current contractor, ACS)

27
Katrina and Health Care Texas So far

• Texas waiver will allow simplified Medicaid or
  CHIP eligibility for Katrina evacuees.
• will cover, for a one-time period of 5 months,
  evacuees who meet Texas current Medicaid or CHIP
  categories and income limits.
• A major exception is that the disaster coverage
  will be available to parents (with dependent
  children) who have incomes as high as the federal
  poverty line (FPL 1,341 per month for a family
  of 3 in 2005), compared to regular Texas
  Medicaid, which only covers parents up to 23 FPL
  (about 308 per month for a family of 3, or even
  less if the parent is not working).
• Childless adults are not included in this
  Medicaid coverage, but costs for such adults can
  be paid for under an uncompensated care pool.

28
Katrina and Health Care Texas So far

• Evacuees can get their 5 months of Medicaid
  coverage any time between September 1, 2005 and
  June 30, 2006, as long as they apply by January
  31, 2006.
• There will be no asset limits, and no premiums or
  co-payments required.
• Benefits will include what Texas Medicaid and
  CHIP now cover mental health services not yet
  restored for adults in Texas Medicaid will be
  provided, but paid for through an uncompensated
  care pool and not treated as a Medicaid expense.
• HHSC says the pool will pay for care to all
  evacuees (if not covered by Medicaid) up to 200
  FPL, for services delivered between 8/24/05 and
  1/31/06.

29
Katrina and Health Care National Scene

• Bi-partisan Katrina health care relief bill by
  U.S. Senate leaders does more for Texas and the
  Nation
• goes significantly beyond Texas waiver in the
  number of evacuees eligible for Medicaid
  coverage
• provides relief to evacuees in every state where
  they may have re-located (i.e., without a
  waiver)
• every state that receives evacuees will get the
  same 100 federal funding of the emergency
  coverage
• provides major Medicaid matching fund relief to
  Louisiana, Mississippi, and Alabama
• protects Texas and other states from a scheduled
  drop in federal Medicaid matching funds in 2006,
  worth an estimated 40 million to Texas (Texas
  match rate drops when our average per capita
  income improves relative to the national average
  and other states averages)

30
Katrina and Health Care National Scene

• provides far more certainty about the manner and
  amount of federal funding of the health care than
  does the Texas waiver and
• provides relief for Medicare beneficiaries, TANF
  recipients and programs, and Emergency
  Unemployment Compensation, none of which are
  addressed by the Texas Waiver.
• Supported by Texas Senators, national Governors
  Association, AMA, Senate Majority and Minority
  Leaders Frist and Reid.
• Opposed by Bush administration.
• As of last Friday, FEMA had reportedly received
  applications for assistance from 1.3 million
  displaced Gulf Coast residents. These
  applications came from 18,700 zip codes, nearly
  half of the nation's residential postal zones.
• To read the article, go to
• http//www.usatoday.com/news/nation/2005-09-28-kat
  rina-exodus_x.htm

31
Despite Katrina, Medicaid Cuts Still a Threat in
Washington

• 2006 federal budget blueprint passed in April
  05
• Congress directed to make significant cuts (over
  5 yrs)
• 24 billion in cuts to domestic discretionary
  programs (non-defense Head Start, education,
  housing, etc)
• 35 billion in cuts to mandatory programs
  (entitlements, incl. Medicaid and Food Stamps)
• Medicaid targeted for 10 billion in cuts
• Original schedule Proposals on cuts to be made
  by September 16 by Senate Finance/House Energy
  Commerce. Postponed until October 17 due to
  Katrina
• Despite Katrina, some in Congress still pushing
  to cut Medicaid, some want to cut by MORE than
  10 billion.

32
Despite Katrina, Medicaid Cuts Still a Threat in
Washington

• Federal budget resolution authorizes additional
  106 billion in tax cuts over 5 years
• Cuts will increase federal deficit by 168
  billion over next 5 years
• Original schedule 1st vote on tax cuts week of
  Sept. 5
• Extension of 70 billion cut to capital
  gains/dividend income
• 53 of benefits go to 0.2 households with
  incomes of 1 million and more per year
• Cuts to Medicaid would partially pay for these
  tax cuts do not contribute to federal deficit
  reduction

33
Federal tax cuts passed in 2001 and 2003 cost
more each year than the total amount likely to be
spent on Katrina

• The cost of the tax cuts enacted in 2001 and 2003
  is 225 billion this year alone and will climb to
  higher levels each year in the future, as more of
  the tax cuts enacted in 2001 take full effect.
• If Congress votes soon to extend and expand tax
  cuts, the cost of the tax cuts will increase to
  an average 250 billion a year over the next five
  years.
• The cost of the tax cuts in a single year exceeds
  the total anticipated costs of all expenses
  related to the hurricane over the years to come.

34
Ways to Be Informed and Involved

• Go to www.cppp.org and subscribe to CPPPs e-mail
  publication, the Policy Page.
• Go to www.texaschip.org to get on Texas CHIP
  Coalition listserve (be sure to read the
  minutes!)
• for National information about Congress, the
  President, Medicaid and CHIP www.familiesusa.org
  
• for more technical and detailed information about
  Congress, the President, Medicaid CHIP, and the
  federal budget taxes www.cbpp.org