Introduction to Medicaid

1
Introduction to Medicaid
Presented to Kansas Health Policy Authority April
18, 2006

• Scott Brunner
• State Medicaid Director

2
What is Medicaid?

• Safety Net
• State and Federal Program
• Public Health Program
• Health Insurance Program
• Funding Stream

3
How does Medicaid work?

• Health Insurance Business Model
• Customers
• Products
• Business Process

4
Purpose

• To discuss policy initiatives in terms of the
  business rationale.
• To demonstrate the connection between the key
  values and business operations.

5
Medicaid as Insurer

• Medicaid is the 3rd largest provider of health
  benefits coverage in Kansas after Blue Cross/
  Blue Shield and Medicare
• Single largest insurer of children
• Medicaid pays for 40 of births in Kansas

6
Medicaid -- Customers

• Eligibility by reason of income level only
• Eligibility by reason of income and disability
• Eligibility by reason of income and age

7
Customers Populations

• Mandatory
• SSI Aged/Blind/Disabled
• Medically Needy
• TAF Caretaker/Transitional Medical
• Poverty Level Infants/Children/Pregnant Women
• Children in Foster Care/JJA
• QMB/SLMBs

• Optional
• Home and Community Based Service Waivers
• Breast and Cervical Cancer
• AIDS Drug recipients
• Working Healthy

8
Customers

• Presumptive Eligibility
• Policy objective of increasing access to health
  care.
• Enrolls people eligible within current
  populations, but havent been reached under
  current programs.
• Meets a business need of ensuring payment for
  providers.

9
Products Medicaid Services

• Mandatory Services
• Dr. services
• Lab X-rays
• Inpatient Outpatient Hospital
• EPSDT
• Family Planning
• FQHC Services
• RHC Services
• Transportation
• Nursing Facility Care
• Home Health Care (DME)

• Optional Services
• Prescription Drugs
• Dental Services
• Case Management
• Diagnostic, rehabilitation, preventative services
• ICF/MR
• Private duty nursing
• Personal Care Services

10
Products Benefit Plans

• Title XIX Medicaid Fee for Service
• Aged disabled populations
• Adults
• Title XIX Medicaid PCCM Managed Care
• HealthConnect
• Available in all counties.

11
Products Benefit Plans

• HealthWave
• Blended program for infants, children, pregnant
  women, and SCHIP populations
• Capitated managed care plan for physical, mental,
  and dental health.
• 101,971 children and adults
• 67,360 from Title XIX
• 34,611 from Title XXI

12
Products

• MediKan Presumptive Disability
• Placing people with disabilities in a more
  comprehensive benefit package.
• Phase out a secondary payment mechanism using
  only state funds.
• Product line is not doing what it is intended to
  do.
• Fit the population need to an existing product
  line.

13
Managing the Business

• Relies on
• State Staff
• Contractors
• Other agencies SRS, Dept. on Aging, Juvenile
  Justice Authority

14
Business Process Eligibility
DHPF determines eligibility policy and
rules. Eligibility determination performed
by SRS 20 of family cases Adult and
Elderly cases Maximus Enrollment
Clearinghouse All SCHIP eligibility
cases Screen and forward Medicaid to DHPF staff
for final determination.
15
THE MMIS
Business Process Administrative Process
(Medicaid Management Information System)

• Claims Processing
• Payments
• Administrative functions
• Management of information

16
About the MMIS

• Currently operated by E.D.S.
• Requirement for Medicaid
• Must be CMS certified
• Federal funding 75 for operations 90 for new
  system development 50 for other administrative
  functions
• Permits electronic filing of claims

17
A complex system

• On-line eligibility inquiry beneficiaries and
  providers
• Prior authorization
• Third party liability
• Electronic claims submission and adjudication

18
More complexity

• Generates letters, ID cards and enrollment
  packets
• Document imaging, archival
• On line Pharmacy instant claims adjudication
• Managed care enrollment and processing

19
Still more

• Drug rebate (80 million returned to State)
• Fraud abuse detection
• Documents CMS reports to draw down federal FFP
  contributions
• Tracks consumer and provider inquiries
• Pays claims to providers and health care plans
• Produces rosters and remittance advices for
  providers
• Produce over 1500 reports monthly

20
MMIS Interfaces
21
Other Features of the Fiscal Agent Contract

• Surveillance and utilization review
• Provider consumer help desk
• Provider recruitment activities
• Provider enrollment activities
• Provider education avg. 80 sessions yearly
• Billing assistance over 3000 on-site visits
• Mass mailing medical cards, creditable coverage
  certificates, warrants
• Produces and maintains provider manuals and user
  manuals

22
Claims Adjudication
Number Of Claims Adjudicated Per Month In
Millions
23
Days to Process
Days For Processing
24
Business Process Delivering Services

• Managed Care Organizations
• FirstGuard Health Plans/Centene
• Doral Dental
• Cenpatico Behavioral Health

25
Simplify business processes

• Shifting dental payments to fee for service
• Business goal is to improve dental access.
• Barrier is complexity of billing (dual systems,
  dual rules)
• Move to a single access point for simplicity to
  providers and accountability
• Managed care improves the value of services
  purchased, but have to improve the base level of
  access.

26
Conclusion

• As an insurance company, Medicaid meets customer
  needs with variable products and services.
• Medicaid must work across agencies and
  contractors to meet the complex needs of
  different populations.
• Compliance with rules (state and federal) and
  mandates.
• Policy change starts with values and goals.
• Fit the policy direction into operational
  realities.