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Medicaid Reimbursement for TB Services Carol J. Pozsik, RN MPH Executive Director National TB Controllers Assn.

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Presentation on theme: "Medicaid Reimbursement for TB Services Carol J. Pozsik, RN MPH Executive Director National TB Controllers Assn."— Presentation transcript:

1 Medicaid Reimbursement for TB Services Carol J. Pozsik, RN MPH Executive Director National TB Controllers Assn.

2 History of TB Funding  Prior to 1982 states were dependent on State or local funds for program operation  1982 Federal Cooperative Agreements for TB began providing staff and travel  Today, State and local funds still provide some financial support for patient diagnosis, treatment, prevention and surveillance.  In general, funding for TB from both state and federal sources has been on the decline for several years.

3 Background Many TB programs still provide free outpatient services to clients using state and local funds.  Because TB is a communicable disease, if patient doesn’t have to pay for clinic visits and medications they will be more likely seek and complete treatment.

4 Background  Majority of TB clients are low income  Majority of TB clients are male and do not qualify for traditional Medicaid services  Females are more likely to be Medicaid eligible because they can be enrolled in Maternity, Family Planning and the WIC Program

5 Background  Some Medicaid programs cover limited TB services if the client is already eligible and if there is an existing billing system in place.  Most TB programs do not collect income information unless they are trying to bill traditional Medicaid.

6 Background  Some TB programs provide funding for inpatient hospitalization for complicated diagnosis and treatment that is beyond the scope of regular outpatient services  CDC Cooperative Agreement funds do not pay for drugs, x-rays and other direct treatment services

7 What is Medicaid?  Federal-State matching entitlement program  Title XIX of the Social Security Act  Provides medical assistance for certain individuals and families who have low incomes and resources  Largest program providing medical and health related services to America’s poorest people

8 Implementation  Federal govt. sets broad guidelines  States:  Establish their own eligibility standards  Determine type, amount, duration and scope of services  Set rates of payment for services  Administer their own programs  Programs vary from state to state

9 Basis of Eligibility  Medicaid does not provide medical assistance for all poor persons even under the broadest provision of Federal statute  To qualify must be in Mandatory Eligibility group  Low income is only one test of established thresholds for eligibility (determined by each state within the Federal guidelines)  States generally have broad discretion in determining which groups Medicaid will cover

10 Examples of Mandatory Eligible Groups  Recipients of AFDC (Aid to Families with Dependent Children)  SSI Recipients (Supplemental Security Income (aged, blind, disabled) who qualify in states with more restrictive eligibility requirements  Pregnant women whose family income is below 133% of poverty level

11 Examples of State Options  Infants up to age one and pregnant women not covered under the mandatory rules  Persons receiving care under home or community based waivers are eligible.  TB-infected persons who would be financially eligible for Medicaid at the SSI income level (only for TB-related ambulatory services and for TB drugs)

12 The TB Medicaid Option  1993 Medicaid Act was amended to allow states to extend eligibility for Medicaid to TB infected persons  Must meet State income eligibility criteria  Covers both TB infection and disease, including suspected cases  Coverage limited to treatment period  Does not qualify client for other Medicaid services

13 Federal – State Match  Match is determined at Federal level by a Committee  Federal “matches” State cost of services  Example: May be 50% State and 50% Federal  Match differs from state to state.

14 Eligibility  Medicaid policies for eligibility and services are complex, and vary considerably among similar sized and/or adjacent states  A person eligible for Medicaid in one State might not be eligible in another state.  Services within a State may change from year to year

15 Medicaid TB Option Coverage (State dependent)  Outpatient Clinic visits  Medications  DOT (Directly Observed Therapy) visits  X-rays (Diagnostic and Follow-up)  Laboratory tests

16 Major Limitations of Medicaid TB Option  Does not pay for: Contact Investigation (rules vary) Hospitalization

17 Payment for Services  Operates as a Vendor System  State pays providers directly (includes health departments)  Providers must accept reimbursement as payment in full  State generally has broad discretion to implement reimbursement methodology and rate for services (There is a Federally imposed upper limit and specific restrictions.)

18 Payment for Services  Some states impose nominal deductibles or co-payments from clients

19 Medicaid Option Sounded Good 1993 - 2007  NTCA survey about the Medicaid Option done in 2006 – 2007  All fifty states surveyed

20 Who has the TB Medicaid Option? Only five states: ArkansasCaliforniaMaine South Dakota Wisconsin

21 Why Other Programs Don’t Have The Medicaid Option?  State covers the costs of treatment: drugs, clinic operations (Some pay for hospitalization)  Medicaid agency does not have funds for the TB Option  Public health administration will not support applying for the Option  Administrative set-up too difficult for TB program – few clerical staff to do the work  Bill Medicaid, then must bill all clients – not enough staff  Match is too large up front – funds taken from TB Program’s State monies causing deficits in funding required services  Two states did not know about Medicaid Option

22 Why Don’t Other Programs Have The Medicaid Option?  Too time consuming to apply (2 years)  Sufficient funding from Medicaid eligible pts.  State has the Option – not all counties use it  Indian Health Service covers most clients  Gaps in coverage – drugs, hospitalization, no field DOT  Has expanded coverage for Medicaid eligibles  Medicaid reimburses for lab, diagnostic tests, xrays and private M.D. visits

23 Problems for States with Immigrants  Undocumented cannot qualify for Medicaid programs  Path to Citizenship and Guest Relations programs require 5 years in US even after becoming citizens to become eligible for Medicaid  Refugees are only eligible for 6 – 9 months  Financial burden is great upon TB programs who have large population of foreign born clients

24 Information About Medicaid Option  Institute of Medicine Report, “Ending Neglect”, 2000, pages 68 – 70, California Case Study pages 72-73.  Wisconsin TB Program Website:

25 “All That Glitters Is Not Gold” Some things will have to change

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