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Medicaid and CHIP New and Upcoming Developments

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Title: Leadership Briefing Outline Author: lcarruth Last modified by: sthomas03 Created Date: 12/3/2003 5:16:06 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Medicaid and CHIP New and Upcoming Developments


1
Medicaid and CHIP New and Upcoming Developments

Kimberly Davis Medicaid and CHIP Division August
13, 2010
2
Presentation Overview
  • Overview of Medicaid eligibility, enrollment, and
    budget.
  • Legislation from 81st Texas Legislature that
    impacts clients.
  • Updates on Texas managed care initiatives.
  • Federal legislation impacting Texas Medicaid and
    CHIP programs.

3
Overview Medicaid
  • What is Medicaid?
  • Medicaid is a jointly funded state-federal
    health-care program, established in Texas in
    1967.
  • Medicaid is an entitlement program, which means
    the federal government does not, and a state
    cannot, limit the number of eligible people who
    can enroll, and Medicaid must pay for any
    services covered under the program.
  • Serves primarily low-income families,
    non-disabled children, related caretakers of
    dependent children, pregnant women, the elderly,
    and people with disabilities.
  • Covers acute health care (physician, inpatient,
    outpatient, pharmacy, lab, and X-ray services),
    and long-term services and supports for aged and
    disabled clients.

4
Overview CHIP
  • What is the Childrens Health Insurance Program
    (CHIP)?
  • CHIP is jointly funded state-federal health
    insurance program for children, established in
    Texas in 1998.
  • Provides health insurance to low-income,
    uninsured children in families with incomes too
    high to qualify for Medicaid.
  • Texas operates a separate CHIP program that
    requires all benefits to be approved by the U.S.
    Secretary of Health and Human Services.
  • Benefit package includes a basic set of
    health-care benefits that are cost effective and
    focuses on primary health-care needs.

5
  • Medicaid Eligibility

6
Medicaid Eligibility
7
  • Medicaid Enrollment

8
Medicaid Enrollment
  • January 2009
  • 14 percent (1 in 7) of Texans received Medicaid.
  • Fiscal year 2009 caseloads
  • 3 million individuals received Medicaid.
  • 534,000 children received CHIP.
  • Medicaid enrollment is projected to continue to
    increase.

9
Medicaid Enrollment
10
Medicaid Enrollment
11
  • Medicaid Spending

12
Medicaid Spending
  • Total Medicaid spending in 2009
  • Estimated 24.6 billion (all funds).
  • Includes Disproportionate Share Hospital (DSH),
    Upper Payment Limit payments, and administration.
  • Medicaid spending increasing in both federal and
    Texas budgets.
  • In 2008-2009 biennium, Health and Human Services
    was approximately 26.7 percent of the total state
    budget (excludes DSH).
  • Like Medicaid enrollment, Medicaid spending is
    projected to continue to increase.

13
Medicaid Spending
14
  • 81st Session Legislation Impacting Clients

15
81st Session Legislation Impacting Clients
  • Medicaid Buy-In Program for Disabled Children
    SB 187
  • Allows families whose income does not exceed 300
    of FPL to buy-in to the Medicaid Program for
    their child with a disability.
  • Benefits will be the same state plan services as
    other Medicaid children.
  • Projected implementation is January 2011.
  • Appropriation for Medicaid Services for Qualified
    Alien Children
  • CHIPRA allows states to cover Qualified Aliens in
    Medicaid and CHIP with federal matching funds.

16
81st Session Legislation Impacting Clients
  • Obesity prevention pilot for Medicaid or CHIP
    enrollees SB 870
  • Creates a pilot in at least one area of the
    state.
  • Pilot is jointly conducted by HHSC and DSHS for
    children enrolled in Medicaid in the Travis
    Service Area.
  • Pilot goals include
  • Decrease rate of obesity in Medicaid children
  • Improve nutritional choices
  • Increase physical activity and
  • Decrease long-term costs to Medicaid incurred as
    a result of obesity.

17
81st Session Legislation Impacting Clients
  • Electronic health information exchange (HIE) HB
    1218
  • Directed HHSC to develop an electronic HIE system
    HHSC will implement the HIE system, known as
    Medicaid Eligibility and Health Information
    services (MEHIS) in 3 phases.
  • Phase 1 will replace paper Medicaid ID forms
    with magnetic strip cards, implement rudimentary
    EHR, and evaluate options for e-prescribing in
    2010.
  • Phase 2 will provide EHR for CHIP clients,
    integrate state lab data in the EHR, improve data
    gathering capabilities and system enhancements.
  • Phase 3 will develop and integrate
    evidence-based benchmarking for providers and
    expands HIE system to include other data exchange
    partners.

18
81st Session Legislation Impacting Clients
  • Medicaid Substance Abuse Services 2010-11
    General Appropriations Act, S.B. 1
  • Directs HHSC to implement a substance abuse
    benefit for adults in Medicaid.
  • The benefits are subject to approval by the
    Center for Medicare and Medicaid Services (CMS)
    and will be implemented in two phase.
  • Phase I - will included a outpatient benefit and
    is anticipated to be available in September 2010.
  • Phase II - will included the addition of
    residential detoxification and treatment services
    and are anticipated to be available in January 1,
    2011.

19
81st Session Legislation Impacting Clients
  • Health Home Pilot Project strategic medical
    initiatives under Frew v. Suehs corrective action
    order
  • 20 million for pilot health home models for
    primary care practices serving Medicaid children
    (through age 20).
  • Pilot projects will be used determine which
    model(s) may be appropriate for state-wide
    implementation.
  • HHSC may select up to 8 different types of pilot
    health home models to be operational for 24
    months.
  • Projects must focus on (1) patient access (2)
    quality improvement (3) patient/family
    centeredness (4) population approach to care
    (5) coordinated and clinically managed care and
    (6) team-based comprehensive care.

20
  • Managed Care Initiatives

21
Managed Care Initiatives
  • Elimination of Integrated Care Model in
    Dallas/Fort Worth
  • Operations ended on May 31, 2010.
  • STARPLUS Expansion
  • The STARPLUS program is expanding into the
    Tarrant and Dallas Medicaid Service Areas.
  • Projected implementation February 1, 2011.

22
Managed Care Initiatives
  • CHIP Rural Service Area MCO Procurement
  • Awards to Superior and Molina health plans.
  • Both health plans will use Texas True Choice
    network.
  • RSA has been expanded to include the Webb Service
    Area in CHIP.
  • Effective September 1, 2010.

23
  • Federal Legislation

24
Federal Legislation
  • American Recovery and Reinvestment Act (ARRA)
  • Prohibits states from implementing more
    restrictive Medicaid eligibility standards,
    methodologies, or procedures than those in effect
    on July 1, 2008.
  • Establishes grant and loan programs for states
    and health entities.
  • Provides incentive payments for meaningful use of
    electronic health (medical) records by qualifying
    Medicaid providers.

25
ARRA contd
  • Medicaid Electronic Health Record (EHR) Incentive
    Program
  • Incentives payments are for meaningful use of
    certified EHRs by qualifying Medicaid providers.
  • The provider is responsible for payment of EHR
    costs and certifying meaningful use of the HER.
  • Authorizes a 100 federal match for incentive
    payments to providers.
  • Texas goal to begin provider enrollment is
    January 2011.
  • Authorizes a 90 federal match for states
    administrative costs to establish process for
    incentive payments.
  • Eligible professionals must choose if they will
    receive the incentive payment as a Medicaid or
    Medicare provider.
  • Hospitals can receive both the Medicaid and
    Medicare incentive payment.

26
ARRA contd
  • Medicaid Electronic Health Record (EHR) Incentive
    Program
  • Payment is an incentive for using certified EHRs
    in a meaningful way.
  • Not a reimbursement and not intended to penalize
    early adopters.
  • First year payment can be received in 2011
    through 2016.
  • Final payment can be received up to 2021.
  • Incentive payments do not need to be for
    consecutive years.
  • Eligible professionals must meet certain
    criteria
  • Eligible provider type
  • Medicaid patient volume thresholds and
  • Meaningful use of certified EHRs for at least 50
    of patient encounters during the reporting period.

27
ARRA contd
  • Medicaid Electronic Health Record (EHR) Incentive
    Program

Provider Minimum Medicaid Patient Volume Threshold OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Physicians 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
- Pediatricians 20 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Dentists 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Nurse Practitioners 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Certified Nurse Midwives 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Physician Assistants when practicing at an FQHC/RHC that is led by a PA 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Acute Care Hospitals 10 Not an option for hospitals
Children's Hospitals No requirement Not an option for hospitals
28
Federal Legislation
  • CHIP Reauthorization Act of 2009 (CHIPRA)
  • Reauthorized federal CHIP funding from 2009 -
    2013.
  • Reduces time-frame for states to use unspent
    federal allotment from three years to two years
    for 2009 and beyond.
  • CHIP programs must comply with Mental Health
    Parity.
  • Mandates dental services in CHIP.
  • Allows for federally matched coverage of
    qualified alien children in Medicaid and CHIP by
    removing the 5-year bar.
  • Requires citizenship verification.
  • Applies Medicaid managed care safeguards and
    standards.
  • Prospective payment system for FQHCs and RHCs in
    CHIP.

29
CHIPRA contd
  • Prospective payment system (PPS) for FQHCs and
    RHCs in CHIP
  • CHIPRA requires states to apply the Medicaid PPS
    for federally qualified heatlh centers (FQHCs)
    and rural health clinics (RHCs) to CHIP.
  • In CHIP FQHCs and RHCs receive full encounter
    rates for dates of services rendered to CHIP
    members on or after October 1, 2009.

30
Federal Legislation
  • Mental Health Parity and Addiction Equity Act of
    2008 (MHPAEA)
  • Requires group health plans that offer behavioral
    health benefits (mental health and substance
    abuse) to provide those services at parity with
    medical/surgical services.
  • Parity requirements apply to financial
    requirements (e.g., co-payments), treatment
    limitations (e.g., number of visits), and
    out-of-network coverage.
  • MHPAEA does not impact traditional Medicaid
    fee-for-service however the requirements apply
    to Medicaid managed care and state CHIP programs.

31
  • Federal Health Care Reform
  • The Affordable Care Act

32
The Affordable Care Act
  • The Patient Protection and Affordable Care Act
    (PPACA), was enacted on March 23, 2010.
  • The Health Care and Education Reconciliation Act
    of 2010 (HCERA) was enacted on March 30, 2010.
  • Together, these two pieces of legislation are
    called the Affordable Care Act (ACA).
  • The Affordable Care Act will make significant
    changes to the health care market.

33
The Affordable Care Act
  • The Health Insurance Exchange
  • Must be operational by January 2014.
  • Failure to establish Exchange will result in HHS
    establishing an Exchange within any
    non-participating state.
  • State must be able to demonstrate by January 1,
    2013, that it will have Exchange operational by
    January 1, 2014.
  • Must be administered by governmental agency or
    non-profit organization.

34
The Affordable Care Act
  • The Health Insurance Exchange
  • Provides one-stop insurance shopping for
    individuals and small businesses.
  • All plans sold in the Exchange must be certified
    by TDI as meeting minimum federal benefit
    standards.
  • Exchange must provide a seamless application and
    enrollment process for individuals who qualify
    for subsidies, requiring coordination with HHSC
    for Medicaid and CHIP inclusion.
  • Federal funding HHS will distribute
    implementation grants to states within one year
    after date of enactment of legislation.

35
The Affordable Care Act
  • Expansion of Health Insurance Coverage,
    Individual Mandate
  • Effective January 2014.
  • Individuals (US citizens and legal residents)
    required to obtain qualifying coverage that meets
    federal standards.
  • Can be an individual or group health plan.
  • Exemptions for individuals meeting any of the
    following
  • Earnings fall below tax filing threshold
    (currently 12,050 for individual and 18,700 for
    couple), religious objections, members of Indian
    tribes, or not covered by insurance for less than
    three months.
  • Subsidies for families/individuals up to 400 of
    federal poverty level (approx 43,000 individual,
    88,000 family of 4) to apply towards premium
    costs.

36
The Affordable Care Act
  • Expansion of Health Insurance Coverage,
    Individual Mandate
  • Penalties for non-compliance
  • 2014 - 95/person
  • 2015 - 325/person
  • 2016 - 695/person
  • Alternative 2.5 of income above tax filing
    threshold (whichever is greater)
  • Enforcement individuals required to file with
    IRS must include IRS form to verify qualifying
    coverage. Individuals exempt from filing taxes
    also exempt from insurance requirement.

37
The Affordable Care Act
  • Medicaid Expansion and Caseload Impact
  • Expands Medicaid eligibility to individuals under
    age 65 with incomes up to 133 of the Federal
    Poverty Limit (FPL).
  • Income deduction allowance of five percentage
    points creates effective eligibility level of
    138 FPL.
  • New client populations in Texas include
  • Parents and caretakers 14- 133.
  • Childless adults up to 133 FPL.
  • Emergency Medicaid in Expansion Populations.
  • Foster-care through age 25.
  • Texas will experience caseload growth both from
    newly eligible individuals and those individuals
    who are currently eligible but not enrolled.
  • With an individual mandate, enrollment of current
    eligibles is projected to increase.

38
The Affordable Care Act
  • Medicaid Expansion and Caseload Impact
  • Changes Medicaid income eligibility requirements.
  • Requires use of modified gross income and
    prohibits assets test and most income deductions.
  • Requires that states maintain existing
    eligibility until the states exchange is fully
    operational.
  • Optional populations covered above 133 FPL may
    be moved to the Exchange upon implementation in
    2014.
  • Childrens Medicaid and CHIP eligibility levels
    must be maintained until 2019.

39
The Affordable Care Act
Current Future Medicaid/CHIP Eligibility Levels
CHIP 200 FPL
CHIP 200 FPL
CHIP 200 FPL
CHIP 200 FPL
133
Current Medicaid 185 FPL
Current Medicaid 185 FPL
Current Medicaid 185 FPL
Current Medicaid 220 FPL
Current Medicaid 133 FPL
NEW Medicaid 133 FPL
NEW Medicaid 133 FPL
NEW Medicaid 133 FPL
NEW Medicaid 133 FPL
Current Medicaid 100 FPL
Current Medicaid 74 FPL
14 FPL
40
The Affordable Care Act
41
The Affordable Care Act
42
The Affordable Care Act
  • Medicaid Rate Increases
  • States are required to increase Medicaid rates to
    100 of Medicare rates in 2013 and 2014 for
    certain services provided by primary care
    providers (PCPs).
  • The incremental rate costs for 2013 and 2014 are
    100 federally funded.
  • Childrens Health Insurance Program (CHIP) Rates
  • Historically CHIP and Medicaid provider rates
    have been aligned.
  • State will need to decide whether to provide the
    same increase for CHIP rates as for Medicaid.
  • Any increase in CHIP provider rates will be at
    the CHIP FFP for all years.
  • CHIP FFP increases by 23 points from 2016 to
    2019.

43
The Affordable Care Act
  • When to Implement Medicaid Expansion
  • States may opt to expand Medicaid coverage to
    133 FPL on or after April 1, 2010 without a
    waiver at regular Federal Financial Participation
    (FFP).
  • Expansion is mandatory in 2014.
  • Medicaid Expansion Benchmark Benefit Plan
  • States are required to create a
    Secretary-approved benchmark benefit package for
    newly eligible Medicaid groups by January 2014.
  • This could result in different benefit packages
    for existing and expansion Medicaid populations.
  • Potential differences in current Texas Medicaid
    benefits and a benchmark plan include
  • Prescription Drug Limit
  • In-Patient Hospitalization Limits
  • Mental Health Benefits

44
The Affordable Care Act
  • New Medicaid and/or CHIP Benefits
  • Requires Medicaid coverage for freestanding
    birthing centers.
  • Requires Medicaid coverage of tobacco cessation
    counseling and pharmacotherapy for pregnant
    women.
  • Requires Medicaid and CHIP to allow a child to
    elect hospice care without waiving their rights
    to treatment services for the childs terminal
    illness.

45
The Affordable Care Act
  • Medicaid Pharmacy Program Changes
  • Federal Rebate Percentages for Outpatient Drugs
    Increases the minimum Medicaid federal rebate
    amount for drug products.
  • Rebates for Medicaid MCO Drugs Allows states to
    collect Medicaid rebates for drugs dispensed
    through managed care organizations (MCOs).

46
The Affordable Care Act
  • Impact to Texas Healthcare Delivery Systems
  • Many of the states indigent care and charity
    statutes may need to be restructured.
  • Core functions of the Department of State Health
    Services and the populations it serves will
    likely be altered.
  • Public hospitals will have less uncompensated
    care.
  • The role of city and county health departments
    may need to be redefined.
  • Unknown impact to Local Mental Health
    Authorities.

47
The Affordable Care Act
  • Impact to Texas Workforce Planning
  • Demand for primary care providers and specialists
    will increase as more Texans are insured.
  • State will need to examine this increased demand
    as it relates to the supply of healthcare
    providers.
  • Strategies for meeting increased demand will need
    to be explored.
  • Telemedicine
  • Additional use of ancillary service providers

48
The Affordable Care Act Texas Uninsured
Demographics Current
49
The Affordable Care Act Texas Uninsured
Demographics Post-Implementation
50
  • Questions?
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