Medicare

1
Medicare MedicaidRecent Advances
Mary B. Tierney, MD Keynote, International
Society of Psychiatric-Mental Health
Nurses April 2006 Denver, Colorado
2
Background and History Social Security Act

• Title I Old Age Assistance/Social Security
• Title IV TANF and Foster Care
• Title V Maternal and Child Health Block Grant
• Title XVI SSI/Aged Blind and Disabled
• Title XVIII Medicare
• Title XIX Medicaid
• Title XXI SCHIP

3
Medicare Medicaid

• Eligibility Requirements and Options

4
Federally Funded Insurance and Eligibility
Requirements

• INSURANCE
• Medicare/Title XVIII of the Social Security Act

• ELIGIBILITY
• Title I of the Social Security Act/Social
  Security
• End Stage Renal Disease

5
Federally Funded Insurance and Eligibility
Requirements - Medicaid

• INSURANCE
• Medicaid/TitleXIX of the Social Security Act
• State Childrens Health Insurance Program/Title
  XXI of the Social Security Act

• ELIGIBILITY
• TANF
• SSI
• Multiple other categories that are de-linked from
  welfare such as TANF
• Flexible eligibility
• Medicaid expansion
• Separate Program
• Combination of the two

6
MANDATORY OPTIONAL COVERAGE - Medicaid

• MANDATORY
• TANF
• SSI
• Pregnant Women Children
• Low Income Children under 19 years
• Foster Care and Adoption Assistance

• OPTIONAL
• Infants to age 1 year
• Non-institutionalized Disabled Children
• Home and Community Based Services
• Children meeting income requirements but not TANF
  eligible

7
SUMMARY

• Medicare eligibility is relatively narrowly
  defined
• Medicaid is complex, broad, expansive and variable

8
Medicare Medicaid

• Services Benefits

9
MEDICARE BENEFITS

• Part A Hospital Skilled Nursing Facilities
• Part B Supplementary Services includes
  Physician Services, diagnostic services,
  supplies, PT, psychologists, radiology and
  therapeutic services
• Therapeutic rather than preventive

10
MMA Benefit

• One time initial wellness physical examination
  within 6 months of enrollment
• Screening for heart disease and diabetes
• Added to cancer screenings, bone mass measurement
  and vaccinations
• Prescription drug benefit

11
Medicaid Services

• Inpatient hospital services
• Outpatient hospital services
• Rural Health Clinic Services
• Federally Qualified Health Centers

• Nursing Facilities other than IMD for over age 21
  years
• EPSDT under age 21 years
• Family Planning
• Physician services

12
Medicaid Services

• Medical and dental surgical services
• Pediatric and Family Practice Nurse Practitioners
• Nurse Midwives

• Health care by licensed practitioners (e.g.
  Psychologists)
• Laboratory and X-Ray
• Home Health

13
Optional Services

• Physical and Occupational Therapy
• Prescription Drugs
• Rehabilitation Option
• Clinic Option
• Targeted Case Management
• Any other medical or remedial care recognized
  under State law and specified by the Secretary of
  HHS

14
EPSDT

• A Benefit Under Medicaid birth -21 years
• Mandates a Set of Benefits Including Preventive,
  Diagnostic, and Treatment Services, Such as
  Health Histories Physical Examinations
  Developmental Assessments Vision, Hearing and
  Dental Services Immunizations
• Mandates Screening for Both Physical and Mental
  Health Issues

15
EPSDT Diagnosis and Treatment

• When screening examinations so indicate.
• What services all services covered under the
  state plan and any additional services
  (diagnostic or therapeutic) that are round
  necessary to diagnose and treat conditions found
  as a result of a screen regardless of any
  limitations under the state plan

16
WAIVERS

• 1915 b mental health carve out
• 1915c home and community-based waivers
• 1115 waivers

17
SUMMARY

• Medicaid services are much broader and deeper
  than Medicare and private health insurance
  especially for behavioral health services
• Medicaid services for children and adolescents
  are much broader and deeper than those for adults
  over 21 years
• Much of the differential is due to EPSDT

18
Trends in Medicare and Medicaid
19
(No Transcript)
20
Largest Health Care and Financing Program

• Medicaid Spending in FY 2004 300 billion
  (compared to Medicare 290 billion)
• Health coverage for over 59 million in U.S. at
  some point during the year (Compared to Medicare
  43 million)
• Medicaid covers more than 17 of the population
• Medicaid funds over half of publicly financed
  mental health services in U.S.

Sources CMS, CBO Medicaid Baseline March 2006
21
Medicaid Enrollees by Eligibility Group
Children historically represent the largest
eligibility group of Medicaid enrollees.
2004 Total 52 million Adults 13
million Children Under Age 21 25
million Blind Disabled 9 million Age 65
Older 5 million
Note Adults refers to non-elderly,
non-disabled adults disabled children are
included in the blind disabled category. The
Other category was dropped in 1999. Source
CMS, CMSO, Medicaid Statistical Information
System, CBO.
22
Medicaid Enrollment and Eligibility Milestones,
1965-2006
59 Million Beneficiaries
Millions of Medicaid Beneficiaries during year
Recession and State Fiscal Crisis (2001-2004)
AFDC Repealed (1996)
SOURCE Kaiser Commission on Medicaid and the
Uninsured analysis of data from the Centers for
Medicare and Medicaid Services, 2004. CBO March
2005 Medicaid Baseline.
23
New Trends in Medicare
Medicare Prescription Drug Improvement and
Modernization Act of 2003(MMA)
24
MMA Drug Benefit

• Full implementation of prescription drug benefit
  in 2006
• Choose a prescription drug plan and pay a premium
  of 35/month
• Cost sharing with Medicare depending upon the
  amount spent
• Managed Care Option

25
Source Congressional Budget Office estimates
26
Source Congressional Budget Office estimates
27
Source Congressional Budget Office estimates
28
RECENT DEVELOPMENTS

• Major problems with implementation
• Multiple choices in drug coverage plans and
  variation in what drugs are covered by plan
• Delay in ability to sign up for program due to
  bureaucratic glitches
• Major problems in serving people eligible for
  both Medicare and Medicaid Dual Eligibles

29
RECENT DEVELOPMENTS

• Major impact on the Medicaid budgets
• State Medicaid agencies are continuing to cover
  the dual eligibles
• Recent Federal response to Medicaid agencies
  continuation of coverage

30
(No Transcript)
31
RECENT CHANGES IN THE MEDICAID PROGRAM

• Increased economic pressure on the States because
  of the
• Problems with the Medicare prescription drug
  benefit for dual eligibles and the Claw Back
  provision
• The effects of Katrina and people losing health
  insurance through their jobs
• Reduction in the Federal Medicaid match of 10
  billion

32
RECENT CHANGES IN THE MEDICAID PROGRAM

• Katrina individuals and families lost private
  health insurance due to the devastation in the
  Gulf Coast
• Medicaid will cover those individuals through an
  waiver of Federal Regulations
• Individuals will be covered in the States in
  which they and their families will be living
• Pressure could be on Medicaid programs that are
  optional including mental health services,
  especially those that are community based

33
RECENT CHANGES IN THE MEDICAID PROGRAM

• 10 billion reduction in Medicaid Federal
  legislative changes put financial pressure to cut
  services including behavioral health
• Changes in eligibility and services provided to
  different categories of people who are enrolled
  in Medicaid
• Also there are major changes in the Deficit
  Reduction Act that reducing the scope of
  important programs that serve children and adults
  with behavioral health issues including
• - Targeted Case Management
• - EPSDT
• - Rehab option

34
Deficit Reduction ActMajor Implications for
Medicaid

• Requires proof of citizenship
• Limits Targeted Case Management
• Gives states authority (for some groups of
  children and adults) to
• Offer alternative benefit packages
• Require premiums
• Require coinsurance
• Require copayments to be paid before a service
• Allows coverage of certain disabled children
• Born in 2001 or after
• Allows premiums up to 7.5 of income

35
TCM Changes

• No Medicaid for foster care services --
  whether paid thru Title IV-E or state (reinforces
  current rules)
• Nor if any other third party liable to pay for
  service, including
• as reimbursement under a medical, social,
  educational or other program

36
S-CHP-Like Benchmark Plans

• States may move certain groups into plans
  (requirements re plans same as under S-CHIP).
  Private insurance model
• Exceptions SSI, disabled, CW children, those
  with any spend-down requirements, TEFRA children
  and TANF-recipients
• State must provide wraparound EPSDT benefit to
  children under 19 unclear for children 19

37
Premiums Copays

• New state options
• No cost sharing for those in poverty
• 100-150 FPL no premium 10 copays, capped at 5
  family income
• Over 150 FPL premiums, 20 copays total capped
  at 5 family income
• All indexed to medical inflation

38
Penalities for non payment

• State may terminate Medicaid if some or all
  premium is unpaid
• State may permit providers to deny services if
  copayments not met
• Providers may waiver this requirement on a case
  by case basis

39
Who Can/Cannot be Charged

• For children
• No premiums or cost sharing for children under 18
  in mandatory eligibility groups (including IV-E
  IV-B kids regardless of age)
• No cost sharing for emergency services
• For drugs
• Up to 20 of cost of drug for families 150 FPL
  or above, nominal amounts for others

40
Budget Bill Plusses

• Family Opportunity Act phased in
• Family income above Medicaid but under 300 FPL
  (58,500) can buy into Medicaid at state option
  for disabled child under age 19
• Phased in by age those 6 or under in 2007 13 or
  under in 2008, under 19 in 2009.
• State can charge sliding scale premiums no more
  than 5 income if under 200 FPL 7.5 income if
  200-300 FPL

41
Budget Bill Plusses

• Authorizes 10 state demonstrations of home
  community-based services waiver for children in
  RTCs
• Begins in 2007
• For children in demo when it ends, state may
  continue to provide HCB services
• Budget neutrality and other rules the same as
  current HCB waiver rules

42
Budget Bill Plusses

• Authorizes 10 state demonstrations of home
  community-based services waiver for children in
  RTCs
• Begins in 2007
• For children in demo when it ends, state may
  continue to provide HCB services
• Budget neutrality and other rules the same as
  current HCB waiver rules

43
YOUR THOUGHTS
44
Contact Information
Mary B. Tierney, MD 202-403-5620 mtierney_at_air.org