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Paths to Payment under Medicaid: The Web We Weave for Mental

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Title: Paths to Payment under Medicaid: The Web We Weave for Mental


1
Paths to Payment under Medicaid The Web We
Weave for Mental Substance Use Disorders
Treatment
Rita Vandivort-Warren Organization and Financing
Branch Div of Services Improvement, CSAT
2
MH/SA Treatment is 7.5 Percent of All Health,
2001
SA 1.3 SA 18.3 billion
MH 6.2 MH 85.4 billion
All Health, 2001 All Health 1,372.5 B

MH/SA 7.5 104 billion
3
The Proportion of Public Spending in SA Treatment
Grew between 1991 and 2001
All SA, 2001 Public, 76
All Health 2001 Public, 45
All SA, 1991 Public, 62
All SA 11.4 B Public 7.1 B Private 4.3 B
All Health 1,373 B Public 613 B Private
759 B
All SA 18.3 B Public 13.8 B Private 4.5 B
4
Private and Public Average Annual Growth Rate,
1991 - 2001
Average Annual Growth Rate
5
State Counties Design and Administer 63 of
All SA Spending in 2001
6
Public Payments to SA Grew Faster Annual Growth
Rates, 1991 to 2001
Overall SA Growth Rate 4.8
7
Private Insurance Over All SA Services,
19922001
8
Percent Change in SA Outpatient Services,
19922001
9
  • Although Medicaid Portion of All MH/Sa Tx
    Spending is Large, Especially MH
  • 27 of all MH
  • 19 of all SA


SUD Tx 1.5
MH Svc 10
Medicaid MH/SA as Portion in Total Medicaid
Spending
All Medicaid 225, 511 Billion
10
SA/MH of All Expenditures, Each Payer, 2001
Medicaid includes Federal and State Dollars
Other Federal includes VA, DOD, Block Grant etc
22.3
11
State Childrens Health Insurance Program (SCHIP)
Facts
  • 1997, Title XXI, SCHIP States choose either
    Medicaid expansion, separate commercial MCO/HMO
    plan with narrow and limited benefits for MH/SA
  • If Medicaid expansion, EPSDT entitlement
  • Separate SCHIP plans,
  • No SA requirements weak MH
  • no prevention or screening requirement
  • medical necessity only to cure not ameliorate
  • In 2004, SCHIP enrolled 3.9 million children,
    Medicaid 41.3 million children
  • Deficit Reduction Act Prohibit SCHIP for
    childless adults

12
SCHIP State Design, 2002
MH/SA Benefits in 36 Separate Programs 16 states
provide MH benefit available through Medicaid
20 states separate benefit, usually both SA and
MH, with limits
13
Coverage Limitations for MH/SA for 21 Separate
SCHIP Programs
  • States That Have
  • Coverage- Limit Day/
  • 4 3 (75)
  • 17 16 (94)
  • 21 20 (95)
  • 5 ?
  • 6 ?
  • 21 19 (90)
  • 21 17 (81)
  • Inpatient Only for Detox
  • Inpatient SA Tx Detox
  • Outpatient SA
  • Opioid Treatment
  • Residential Treatment
  • Inpatient MH
  • Outpatient MH

In 9 of 21 States, Combined MH and SA Benefits
14
MH/SA Services Paths to Inclusion Under Medicaid
Coverage
  • Waivers and Managed Care Program
  • EPSDT for Children and Youth
  • Through State Plan Amendment
  • Rehab Option
  • Targeted Case management
  • Other Providers
  • Clinic Services
  • Collateral Contacts

15
Waivers and Managed Care
  • Waivers to mandatory enroll Medicaid
    beneficiaries
  • 1915b Waiver
  • largely irrelevant as 1997 Balanced Budget
    Amendment allowed involuntary managed care
    enrollment without waiver if certain consumer
    protections
  • Under 2006 Deficit Reduction Act (DRA), Medicaid
    programs need not meet standards of
    comparability, statewidedness, freedom of choice
    (State Medicaid Director, 3/06, 06-008)
  • 1915c Home and Community Based Waiver Under 2006
    Deficit Reduction Act (DRA), can implement svc
    without waivers and now IMD less an obstruction
  • 1115 Waiver Research support state health
    reform i.e. HIFA more states are using,
    especially to make special agreements on aspects
    that CMS doesnt like IGT, UPL, DSH

16
Recent 1115 Waivers Changing Key Medicaid
Elements (C. Mann)
  • Conversion to defined contribution (away from
    defined benefit)
  • Annual dollar caps on benefits
  • Enrollment caps allowed
  • EPSDT waived (in one state)
  • Per person and global caps on federal
  • Inter Govt Transfer to Certified Public Expenses
    (CPE)
  • DSH into Safety Net Care Fund (SNCF)
  • In Waiver Approval Processing
  • Closed negotiations between CMS and Gov/State
    agency State seeks input, CMS does not
  • States negotiate to keep - FL in UPL MA in
    DSSH
  • No written rules States ask Did I get as good
    a deal?

17
EPSDT Early Periodic Screening, Diagnosis
Treatment
  • EPSDT mandate passed in 1969, but expanded in
    1989 to explicitly include Mental illnesses
    (include SUD) and developmental delays
  • Must cover all svcs Medicaid pays, even if not in
    State Medicaid state plan
  • When studied MHSA screening instruments, 16
    states recommended tool for MH 4 states for SA
  • Primary care MDs often dont screen because
    dont know what to do with a positive screen
    build it
  • Children lt19 y/o in DRA Benchmark Plan
  • must have wraparound of EPSDT services state
    plan must specify how ensure
  • Not clear what this includes

18
Designing Medicaid 3 options Services,
Eligibility Provider Payments
  • MANDATORY SVC
  • Inpatient hospital services
  • Outpatient hospital services
  • Physician services
  • Lab/X-ray
  • Nursing facility care
  • FQHC/Rural health clinic services
  • EPSDT services for all children
  • Nurse midwife/nurse practitioner
  • Family planning services
  • Home health care
  • OPTIONAL SVC
  • Prescription Drugs
  • Clinic Services
  • Inpatient psychiatric services for individuals
    under 21
  • Other practitioners
  • Collateral Contacts
  • Targeted case management
  • Diagnostic, screening, prevention and
    rehabilitation Rehab Option
  • Transportation
  • Dental, eyeglasses, podiatry

19
Rehabilitation Option under Medicaid Through
State Plan Amendment
  • Major pathway for including IOP, other community
    based and consumer run services
  • Services can be screening, diagnostic,
    prevention, and rehabilitation services
  • Instead of medical necessity, can be to
    maintain functioning or prevent conditions
  • Still provided by or under supervision of
    licensed staff
  • Define clearly what services are
  • Require services must meet specific goals in
    individual service plan
  • Presidents 2007 Budget, stating Medicaid is the
    payer of last resort,
  • REGS redefine allowable costs under Rehab Option
    and DSSH,
  • REGS will prohibit school administrative charges,
    transportation costs under IDEA,
  • LEG change administrative matching rate on
    targeted CM to 50

20
Use Other Optional Categories covering MH/SA
Providers
  • Clinic Services Are diagnostic, therapeutic or
    rehabilitative svc under direction of MD Can
    incorporate MHSA clinics, non-MD therapist
  • Other Providers medical or remedial care by
    licensed practitioners within scope of practice
  • Targeted Case management svcs to assist
    individuals to get needed tx may be limited to
    MH or AIDs/HIV
  • Collateral Contacts contacts with family members
    or other significant others to the person in
    treatment

21
In 8 States, SA Services in St Plans
Service Rehab TCM Clinic lt21 EPSDT
IOP/PH- 4/8 St FL, GA, IL, VA GA GA, VA
Casemgt 2/8 St GA, SC
Opioid 3/8 St AZ, GA, VT GA
Resident 3/8 St IL, VA, VT IL
  • States have latitude in how define the services
    under Optional Categories
  • States can exercise multiple Options for same
    service
  • States have used different Optional Categories to
    cover the same service
  • State optional service definition approved in one
    state may not be approved in another

22
2006 Deficit Reduction Act (DRA)
  • Harder to qualify
  • Citizen documentation requirement
  • Assets transfer look back 5 yrs from 3 yrs
  • Greater co-payment under Medicaid

ltFPL 100 -150 FPL gt 150 FPL
Premium N N Y
Cost Share N Y to 10 income Y to 20 income
Not Preferred Drugs Nominal cost share Nominal cost share Up to 20 cost share
  • Not pay premium (up to 5 of income) in 60 days,
    can terminate
  • If enforceable, providers can turn clients away
  • Not cost share on prevention to kids, pregnancy
    svcs, family planning, and proper Emergency Room
    svc

23
2006 Deficit Reduction Act (DRA)
  • SChipping away Benchmark Plans, primary care
    benefit,
  • MH (SUD?) 75 actuarial value (with pharm,
    vision, hearing) but if benchmark does not
    include MH, state need not include
  • Exempt from participation pregnant, blind, dual,
    institutional, foster care, hospice, sp needs
    children
  • If exempt individual opts for Benchmark plan,
    state must show informed consent, including
    benefits comparison
  • Benchmark plans guarantee access to FQHC and RHC
  • Home and community based without waivers
  • Needs based criteria otherwise need institution-
    developed by states
  • Independent assess plan may self-direct
    purchase care
  • Can cap numbers served waitlist for services
  • Svc respite care, family support, supported
    employment
  • Targeted case management emphasized medical
    service, excludes for CM in child welfare or
    foster care seem chg to preclude IDEA

24
More DRA Demonstration Programs
  • Health Opportunity Accounts similar to under
    Medicare, states pre-fund an account that client
    self directs care, roll over unspent , retain a
    portion if leave Medicaid up to 10 state demos
    for 5 yrs requires annual deductible pymt rate
    not gt 125 Medicaid rate
  • Home Com-Based Alternative to Psych Residential
    Treatment Facilities for Kids up to 10 states
    218 over 5s Demos on cost-effectiveness of
    alternatives to child psych residential care
    but must meet all HCBS waiver requirements, i.e.
    budget neutral
  • Money Follows the Person Rebalancing for
    residents of OCF-MR, hospital, nursing home, or
    IMD States awarded will receive up to 90
    federal match for home and community based
    services but maintenance of effort required
  • Added 3 to 4 Million dollars annually to expand
    the family information centers under maternal
    Child Health BG - 07 25 states, 08 40 states, 09
    all states
  • TANF- increased state requirements of work
    participation, decrease flexibility

25
Implement FY02 and Planned FY03 Cost Containment
Strategies (Kaiser, 5/2003)
26
Covering MH SA Under Medicaid
  • Golden Rule Even if build a beautiful system,
    State must fund it
  • CHC/FQHC/RHC, mandated provider, collaborations?
  • CMS for IMD, SA is Mental Disorder, Joint MH/SA
    Benefits?
  • Commercial plans dont differentiate MH SA
    benefits as SCHIPPing, could follow this
    pattern?
  • DRA flexibility in home and community based
    options without waivers or cost effective
    formula no comparability, easier to target to
    specific disorders
  • Self directed care and Health Opportunity
    accounts more flexible spending on services?
  • Medicaid another Payer of Least Resort, but
    DRA only state options
  • Cant ignore Medicaid but must also look
    elsewhere too
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