Overview on Medicaid and the Deficit Reduction Act of 2005 (DRA)

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Overview on Medicaid and the Deficit Reduction
Act of 2005 (DRA)

• Presentation by Kay Johnson
• Director, Project THRIVE at NCCP
• Building Systems for Babies Conference
• November 16, 2006

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• Established at the National Center for Children
  in Poverty,
• Project THRIVE provides public policy analysis
  and education to promote healthy child
  development. THRIVE work informs State Early
  Childhood Comprehensive System (ECCS) initiatives
  and others in the field.

This work is supported by the Maternal and Child
Health Bureau, HRSA-DHHS.
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MEDICAID ELIGIBILITY
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Eligibility
Optional Medicaid for children with disabilities
up to or above 300 of poverty

• Federal law mandates
• Infants and children to age 6 up to 133 of
  poverty
• Children ages 6-18 up to 100 of poverty
• State options to cover
• Children in Medicaid at any income level
• SCHIP gt 200 of poverty
• Children with disabilities and special needs gt
  300 of poverty

Optional Medicaid and/or SCHIP up to or above
200 of poverty
Mandated up to 133 of poverty
Mandated up to 100 of poverty
Birth to 6 Ages 6 -18
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Post DRA Family Opportunity Act (Effective
1/1/2007)

• New State option allows families of children with
  severe disabilities to buy-into Medicaid
• Age
• Target group children birth to age 19 (qualified
  for SSI)
• Phased-in, starting with younger children under
  age 6
• Income
• Up to 300 FPL
• At higher income levels with state funds only
• Premium caps
• 5 cap lt200 FPL, 7.5 cap 200-300 FPL
• Employer-sponsored family coverage
• If eligible must enroll 50 of premium paid by
  employer
• Premium subsidy at option of state
• Parent-to-Parent Information Centers (Title V)

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Post-DRA Citizenship Documentation (Effective
7/1/2006)

• Citizens
• No self-declaration of U.S. citizenship
• Must present
• U.S. passport, certificate of naturalization,
  certificate of U.S. citizenship, valid drivers
  license, or other ID document deemed valid, or
• birth certificate or other ID document deemed
  appropriate (e.g., school id, medical record)
• Other documents by special exception
• Special challenges for babies born to non-citizens

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MEDICAID FINANCING FAMILY CONTRIBUTIONS
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Post DRA Premiums Cost SharingEffective
January 1, 2007
Above 300 FPL no federal participation family
buy in at full cost anticipated

• For mandatory groups of children and pregnant
  women no premiums and cost sharing
• For child/family income below 150 FPL
• No premiums
• Cost sharing limited to 5 of income
• Co-insurance to 10 of cost for service
• For child/family income above 150 FPL
• Premiums and cost sharing limited to 5 of income
• Co-insurance to 20 of cost for service
• For new disability optional group
• For child family income 150-200 FPL, premiums
  and cost sharing limited to 5 of income
• For child family income 200-300 FPL, premiums
  and cost sharing limited to 7.5 of income

Optional Medicaid for children with disabilities
up to or above 300 of poverty
Optional Medicaid and/or SCHIP up to or above
200 of poverty
Optional group to 150 has special cost sharing
rules
Mandated up to 133 of poverty
Mandated up to 100 of poverty
Birth to 6 Ages 6 -18
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Post-DRA Premiums Cost-Sharing (Effective
3/31/06, except ER 1/1/07)

• State may impose premiums, cost-sharing, or both
• Protections for certain groups
• Providers may require payment or waive at time of
  service (case-by-case)
• States may terminate coverage for failure to pay
  premiums gt60 days may waive if undue hardship

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MEDICAID BENEFITS
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Post-DRA Medicaid Benefits

• Benefits required for children
• Guarantee is not the same.
• States may change benefit package based on
  benchmark plans.
• EPSDT benefits are required for mandatory
  children under age 19
• But will not be offered in same manner
• wrap-around concept to be tested in
  implementation.

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Post-DRA Coverage Rules (Effective 3/31/2006)

• States have the option to use a benchmark
  benefit package and require enrollment for
  certain groups.
• No waiver State Plan Amendment suffices
• This is similar to what is used for State
  (non-Medicaid) SCHIP programs.

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Benchmark Plans State Options

• FEHBP standard Blue Cross/Blue Shield PPO option
• State employee benefit plan
• Coverage by HMO with largest insured, commercial,
  non-Medicaid enrollment in the state
• Another benefit package designed by the state and
  approved by HHS

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Post-DRA Coverage Wrap-around(Effective
3/31/2006)

• For children, states must supplement with
  wrap-around EPSDT coverage
• Benefits as defined since 1989 in Sec. 1905(r) of
  Medicaid law
• Obligation to provide comprehensive childrens
  services appears to be maintained.
• Further CMS guidance expected

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MEDICAID CASE MANAGEMENT
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Post DRA Case Management (Effective 1/1/2006)

• Definition clarified
• Assessment
• Development of care plan
• Referrals
• Monitoring and follow-up
• Excludes from the definition
• Direct delivery of referred medical, educational,
  social, or other services
• Foster care administrative supports
• Potentially related to Part C, home visiting,
  mental health, child development, etc.

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Spending Smarter Using Federal Programs and
Policies to Promote Healthy Social and Emotional
Development Among Our Most Vulnerable Young
ChildrenKay Johnson and Jane KnitzerNational
Center for Children in Poverty, 2005.
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Spending Smarter means

• Paying for appropriate services.
• Capturing existing dollars from federal funding
  streams.
• Blending and braiding funds.
• Using flexible funds to fill gaps.
• Leveraging both smaller grant funds and
  entitlement dollars.
• Creating efficiencies through systems approach.

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Promising practices Medicaid/EPSDT

• Use uniform billing, blended funds
• Maximize federal matching
• Expand list of professionals who may bill
• Pay for family therapy
• Permit payment for services delivered outside of
  physicians offices.

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Promising practices EPSDT

• Early and Periodic Screening, Diagnosis, and
  Treatment
• Clarify distinction between EPSDT developmental
  screening and diagnostic assessment
• Specify benefit definitions
• Use age-appropriate billing codes
• Apply EPSDT medical necessity standard

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Lessons from ABCD II Projects

• Payment not greatest barrier
• Providers willing to use recommended screening
  tools
• Parents and providers appreciate information
• Referral resources must be available
• Billing codes are available
• Serving at-risk without diagnosis toughest

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For more information or questions, contact us at
Project THRIVE
646-284-9644 ext. 6456 Thrive_at_nccp.org
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More Resources www.hrsa.gov/epsdt

• For general use
• www.cms.gov
• https//www.cms.hhs.gov/medicaid/epsdt/default.asp
  
• www.cms.hhs.gov/EPSDTDentalCoverage
• http//www.hrsa.gov/medicaidprimer/maternal_child_
  part3only.htm
• www.kff.org
• www.gwumc.edu/sphhs/healthpolicy/chsrp/newsps
• www.cmwf.org
• www.nashp.org
• www.mchlibrary.info/KnowledgePaths
• www.chcs.org
• www.mchpolicy.org

• For families
• www.family-networks.org
• www.partoparvt.org
• www.healthconsumer.org/cs009epsdt.pdf
• www.familyvoices.org
• www.wpas-rights.org
• For providers
• www.aap.org
• www.brightfutures.org/mchepsdt.html
• www.medicalhomeinfo.org/tools/screening.html