Impact of the Deficit Reduction Act (DRA) on Maternal and Child Health (MCH) Programs and Populations

1
Impact of the Deficit Reduction Act (DRA) on
Maternal and Child Health (MCH) Programs and
Populations

• James A. Resnick, MHS
• Public Health Analyst
• Health Resources and Services Administration
• Maternal and Child Health Bureau/
• Office of Data and Program Development

2
Title V Maternal and Child Health Services Block
Grant
SEC. 501. 42 U.S.C. 701 (a) To improve the
health of all mothers and children consistent
with the applicable health status goals and
national health objectives established by the
Secretary under the Public Health Service Act .
3
Percentage of Individuals Served by Title V, by
Source of Coverage
National Summary  Title V Total Served 32,121,402 Primary Source of Coverage   Primary Source of Coverage   Primary Source of Coverage   Primary Source of Coverage   Primary Source of Coverage  
National Summary  Title V Total Served 32,121,402 Title XIX Title XXI Private/Other None Unknown
Pregnant Women 2,327,892 42.4 0.1 22.4 7.5 11.9
Infants lt 1 year old 3,822,746 37.6 0.5 28.6 12.4 9.5
Children 1 to 22 years old 22,050,122 34.4 1.1 21.9 9.9 7.5
CSHCN 963,634 54.5 5.2 21.7 6.8 11.8
Others 2,957,008 26.5 0.4 22.9 24.4 11.1
As reported by States in their Title V Block
Grant FY 2004 Annual Report and FY 2006
Application
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DRA Impact on Maternal and Child Health Programs
and Populations

• (Clear) ?? (Not-So-Clear)

5
Deficit Reduction Act of 2005

• Eligibility
• Premiums and cost-sharing
• Benchmark coverage
• Targeted case management
• Citizen Requirements

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2007 HHS Poverty Guidelines
Personsin Family or Household 48 ContiguousStates and D.C. Alaska Hawaii
1 10,210 12,770 11,750
2 13,690 17,120 15,750
3 17,170 21,470 19,750
4 20,650 25,820 23,750
5 24,130 30,170 27,750
6 27,610 34,520 31,750
7 31,090 38,870 35,750
8 34,570 43,220 39,750
For each additionalperson, add  3,480  4,350  4,000
SOURCE  Federal Register, Vol. 72, No. 15,
January 24, 2007, pp. 31473148
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A Quick Analysis Premiums, Cost Sharing and
Flexibility

• DRA Provides Protections for Pregnant Women and
  Low-Income Children

  Pregnant Women Mandatory Populations Children 100-150 FPL Children Above 150
Premiums None allowed None allowed None allowed Not to exceed 5 of family income
Cost sharing None allowed None allowed Individual Services limited to 10 Individual Services limited to 20
Cost sharing None allowed None allowed Total not to exceed 5 of family income Total not to exceed 5 of family income
Benefits Flexibility Excluded Allowed Allowed Allowed
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Overview Protected Services for Women and
Children

• Exempted Cost-Sharing Services
• Emergency
• Family Planning
• Services to Mandatory Medicaid Women

• Benchmark Plans Must Include
• Well-baby and well-child care, including age
  appropriate immunizations
• Secretary approved preventative services
• EPSDT Wrap-around

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Eligibility

• 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

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Family Opportunity Act

• Provides an option to States to allow families of
  disabled children (SSI definition for severity of
  disability but meet income) to buy into Medicaid

• Eligibility
• Child is defined as disabled
• Income does not exceed 300 FPL
• Incomes above 300 FPL must only use State
  funds

• Premiums and Cost Sharing
• (lt200 FPL) Not to exceed 5 of family income
• (200 - 300 FPL) Not to exceed 7.5 of family
  income

? Supports Family-to-Family Health Information
Centers
Effective Date January 1, 2007
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Insurance by Income Level
  CSHCN w/ private or employer-based ins only CSHCN w/ private or employer-based ins only   CSHCN w/ Medicaid, SCHIP, Title V or other public ins only CSHCN w/ Medicaid, SCHIP, Title V or other public ins only
  Weighted popl. estimate ()   Weighted popl. estimate ()
0 to 99 FPL 137,767 2.5   852,148 47.1
100 to 149 FPL 293,609 5.3   456,203 25.2
150 to 299 FPL 1,649,746 29.7   397,536 22.0
300 FPL or above 3,472,014 62.5   105,194 5.8
Total 5,553,136 100.0   1,811,081 100.0
Source The Child and Adolescent Health
Measurement Initiative, Data Resource Center for
Child and Adolescent Health (www.childhealthdata.o
rg), Special Analysis Produced by CAHMI/DRC
Staff for James Resnick, HRSA (November 28, 2006)
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Impact of Cost Sharing
Research Report Conducted by Kaiser Commission
on Medicaid and the Uninsured, May 2005

• New or increased premiums served as a barrier to
  obtaining and/or maintaining public coverage
• Premiums disproportionately impacted those with
  lower incomes, but also led disenrollment among
  those with incomes about 150 of poverty
• While some disenrollees obtained other coverage,
  many became uninsured

• Cost sharing led to unmet medical need and
  financial stress, even when amounts were nominal
  or modest
• Coverage losses and affordability problems
  stemming from increased out-of-pocket costs let
  to increased pressures on providers and the
  health are safety-net
• Increases in beneficiary costs may have created
  savings for States, but they may accrue more from
  reduced coverage and utilization rather than
  increased revenue.

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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 need for waiver State Plan Amendment suffices
• This is similar to what is used for State
  (non-Medicaid) SCHIP programs
• EPSDT wraparound required

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Benchmark Plans

• Federal Employee Health Benefits Program (FEHBP)
• Standard Blue Cross/Blue Shield (preferred
  provider option)
• State Employee Coverage
• Coverage Offered Through HMO
• Largest insured commercial, non-Medicaid plan in
  State
• Secretary-Approved Coverage

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Benchmark Plans

• Additional services must have an actuarial
  value that is equal to at least 75 of the
  actuarial value of the coverage of that category
  of services in such package. (DRA)
• Coverage of prescription drugs
• Mental health services
• Vision services
• Hearing Services

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Impact of Benefits Flexibility-Unclear

• Family Planning
• Duration and scope of services
• Hearing, Vision, Mental/Behavioral Services
• Services for Children with Special Health Care
  Needs (CSHCN)
• Physical therapy/Occupational therapy
• Durable medical equipment
• Supplies (Asthma, trach, hearing aids,
  eyeglasses)
• Medical necessity (No baseline for kids)
• Prescription Drugs (Generic versus Brand)
• EPSDT
• Coordination of wrap-around services
• Families need to promote EPSDT

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Citizen Requirements

• States required to obtain documentation of
  citizenship. Declaration of citizenship no
  longer allowed.
• Dear State Medicaid Level Identified various
  levels and degrees of documentation.
• Examples include
• U.S. passport, certificate of naturalization,
  certificate of citizenship, valid drivers
  licenses, birth certificates
• Children born in the U.S. to illegal immigrants
  with low incomes are no longer automatically
  entitled to Medicaid (New York Times Article)

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Citizen Requirements

• Update
• December 20, 2006 Tax Relief and Health Care
  Act of 2006 (TRHCA)
• Exempted Groups from Citizen Requirements
• Citizens receiving Social Security Disability
  Insurance (SSDI)
• Children receiving foster care
• March 20, 2007 CMS News Release
• All babies born in the United States whose
  deliveries are covered by Medicaid may remain
  eligible under certain circumstances for Medicaid
  for up to a year after their birth

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Case Management PRIOR DRA
Source Johnson K. Prepared for HRSA Managed
Care TA Project. May 2005.
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Case Management
DRA Defined Services which will assist
individuals eligible under the plan in gaining
access to needed medical, social, educational and
other services.
21
Targeted Case Management
DRA Defined Furnished without regard to the
requirements of section 1902(a)(1) and section
1902(a)(10)(B) to specific classes of individuals
or to individuals who reside in specific areas.
K Johnson Defined For specific categories of
beneficiaries, specific geographic areas, or
specific sets of services.

• Allowable
• DRA directly related to the management of the
  eligible individuals care

• Not Allowable
• DRA relate directly to the identification and
  management of the noneligible or nontargeted
  individuals needs and care
• DRA Defined FMAP is Available Only if there
  are no other third parties liable to pay for such
  services, including as reimbursement under a
  medical, social, educational, or other program.

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Impact of Medicaid Case Management Changes

• Examples of Title V MCH case management services
• Outreach for pregnant women
• Home visiting programs for CSHCN
• Prenatal education services
• Medical coordination for individuals with severe
  medical conditions
• Care coordination to support the medical home
• It is unclear if changes to Medicaid law will
  impact reimbursement of services performed by MCH
  programs

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Examples of Targeted C.M.

• Utah A "targeted case management" protocol will
  be developed for use with home health nurses that
  identify infants who missed or failed initial
  newborn hearing screening.
• Utah with the targeted case management staff in
  local health departments to help improve
  coordination between health care providers and
  families and to ensure that families have
  information about their Medicaid benefits and
  know how to access care.
• Utah The local health departments also provide
  targeted case management services for Medicaid
  families that include education about the
  importance of the well child visits, especially
  for children under age one year, and assistance
  with referrals to needed health care services
  when appropriate.
• Alaska the Title V program is working in
  collaboration with the Medicaid program, and
  Behavioral health to offer targeted case
  management services as part of the Medicaid
  program for children with special health care
  needs who do not qualify for one of the waiver
  programs.

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Examples of Targeted C.M.

• Kentucky Medicaid reimbursement for targeted
  case management for Medicaid patients (including
  children in custody or at risk of being in
  custody of the state and adults in need of
  protective services) and for rehabilitative
  services for Medicaid-eligible children in
  custody or at risk of being in custody of the
  state.
• Colorado The Children, Adolescent and School
  Health Section, Nurse-Family Partnership Program
  is working with the Colorado Department of Health
  Care Policy and Financing to secure Medicaid
  reimbursement for targeted case management
  services, which will lead to an increase in the
  number of clients served.
• North Carolina CSC services are available in
  each county through LHDs or other providers to
  offer case management/care coordination for
  families of children at risk for or diagnosed
  with developmental delays, chronic illness, or
  social/emotional disorders. The CSC Program works
  with DMA to develop new policy, revise risk
  indicators, and address other programmatic
  components based on CMS restrictions on targeted
  case management.

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Conclusion Increased flexibility

• States have multiple options to change Medicaid
  programs.
• Impact will only be known once changes are
  implemented by States
• Many policy decisions affecting MCH populations
  and programs will be made in the near future
• Update of Medicaid regulation
• Revision of Medicaid manual
• Review of CMS approved Medicaid State Plan
  Amendments

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Conclusion Monitoring Role

• Monitoring the impact of these changes on public
  health/ MCH programs at the national, state and
  local levels
• Does the number of individuals requesting
  services and assistance from MCH public health
  programs increase?
• Do higher co-payments/premiums cause individuals
  to seek care from safety-net providers?
• Will costs shift to public health programs?
• Analysis of TVIS data to determine if States have
  shifted funds from Infrastructure, Enabling and
  Population services to Direct health services

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Conclusion Title V Coordination

• Title V MCH programs lead in coordination,
  infrastructure, and enabling services
• How can you provide information to families when
  benefit, cost-sharing, and case management rules
  change?
• Toll-free hotline updates
• Outreach informational materials
• Engage families, providers, and other agency
  partners in designing approaches to continue care
  coordination for children with special health
  care needs (CSHCN).
• Study impact on systems of care (perinatal, early
  childhood, CSHCN, genetics, mental health, etc.)

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For More InformationVisit the EPSDT Web-Based
Modulewww.hrsa.gov/epsdt

• James A. Resnick MHS
• [phone]
• JResnick_at_hrsa.gov