1. Module 6 Medical and Dental Information Series
4/13/2017
Texas Medicaid
Medical and Dental Information Series
The goal of this 8-part series is to provide training for health care providers about Medicaid and to promote the availability of an adequate supply of health care providers who are engaged in the Texas Medicaid system and willing to provide services to Medicaid patients. This particular teaching series is directed at primary care medical residents, dental students, dental residents.
These Presentations may contain animations. To view the full effect for these slides, please view them in PowerPoint slideshow mode.
Module 6
2/22/2013
Texas Medicaid Curriculum

2. Medicaid Curriculum Overview
Module 6
4/13/2017
Module 6
Medicaid Curriculum Overview
Module 1: General Structure of the Texas Medicaid System
Module 2: Understanding Medicaid Clients and Health Literacy
Module 3: Texas Health Steps
Module 4: Navigating Insurance and Managed Care
Module 5: Interfacing with Medicaid as a Provider
Module 6: Special Medicaid Programs
Module 7: Special Medical Issues
Module 8: Special Dental Issues
The Presenter’s Notes that are included here are designed to augment and expand upon the content of each slide and are written to address the medical/ dental resident or dental student audience. For those slides that include primarily text, these Notes may include additional content but do not supplant the slide text. For those slides that include primarily charts, graphs or other visuals, these Notes will assist the presenter in addressing key points and highlights that are depicted in the visual content.
Additionally, these Notes may include notations that refer to content sources or additional resources.
Key to Abbreviations:
PB= Texas Medicaid and CHIP in Perspective, Ninth Edition - January 2013, commonly known as the "Pink Book”; the Pink Book is divided into 9 chapters, a Glossary and Appendices A-G; a reference to PB 3-10, for example, refers to Chapter 3, page 10. The full source is available here:
Additional references are included in these notes, as needed.
Texas Medicaid Curriculum 2

3. Special Medicaid Programs For Families, Children
Module 6
4/13/2017
Module 6
Special Medicaid Programs For Families, Children
and Women
You are viewing Module 6: Special Medicaid Programs for Families, Children and Women
Please note that the terms patients, clients, recipients and enrollees are all used to refer to the persons who are covered by Medicaid, with an effort to use the most appropriate term for the context in which the term is used.
Texas Medicaid Curriculum 3

4. Module 6
4/13/2017
Module 6
Module 6: Objectives After completing this module, you should be able to:
Review the structure and purpose of Texas Medicaid
Explain the purpose, goals, and eligible populations of special Medicaid programs for families
Explain the purpose, goals, and eligible populations of special Medicaid programs for children
Explain the purpose, goals, and eligible populations of special Medicaid programs for women
Describe the anticipated impact of the Affordable Care Act (health care reform) on women’s health care
Find Medicaid resources to support patients and providers
After you complete this module, you should have reviewed key details about the structure of Texas Medicaid. You should also be familiar with a number of programs conducted under the auspices of Texas Medicaid that serve special populations of families, children and women, including:
Family Programs:
Case Management for Children & Pregnant Women
Health Insurance Premium Payment (HIPP)
Children’s Programs:
Early Childhood (YES) Waiver)
Women’s Health Programs
Women’s Health Program (WHP)
Programs for Pregnant Women (Medicaid for Low-Income Women & CHIP Perinatal)
Nurse-Family Partnership
Breast and Cervical Cancer Programs (BCCS and MBCC)
Texas Medicaid Curriculum 4

5. Caring for Families Beyond Texas Health Steps
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Module 6
Caring for Families Beyond Texas Health Steps
Medicaid serves primarily low-income families, non- disabled children, related caretakers of dependent children, pregnant women, the elderly, and people with disabilities.
Texas chooses to extend Medicaid eligibility to pregnant women and infants up to 185% of the federal poverty level (FPL) as well as to the “medically needy,” including children and women whose income exceeds Medicaid eligibility limits, but who do not have the resources required to meet their medical expenses.
This module addresses special Medicaid programs for:
Families
Children
Women
This slide previews 3 overall themes for this Module:
Special programs for families
Special programs for children, including dental initiatives
Special programs for women, including pregnant women
Texas Medicaid Curriculum 5

6. Module 6
4/13/2017
Module 6
True or False? Test Your Knowledge about Special Medicaid Programs for Families, Children & Women
Case Management assists families with resources such as educational, financial, or housing needs.
ECI provides services to families of medically fragile children who keep their children at home instead of placing them in nursing facilities.
The Children with Special Health Care Needs program helps people of any age with cystic fibrosis.
One goal of a Caries Risk Assessment is to Identify the oral health status of the child and other family members.
The Nurse-Family Partnership provides post-natal home visits until the child is 1 year old.
These answers will be discussed in detail on Slide #50-51
Answers are:
1: True
2: False
3: True
4: True
5: False
Texas Medicaid Curriculum 6

7. Module 6
4/13/2017
Module 6
What is Medicaid?
Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments:
About one-third funded by the State of Texas
About two-thirds funded by the Federal Government
In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million).
Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967.
In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC).
Medicaid is an entitlement program, which means:
The number of eligible people who can enroll cannot be limited.
Any services covered under the program must be paid.
PB 1-1
Medicaid is jointly funded by the federal and state governments, with the actual percentages varying by state and across years. In 2011, the federal government funded about 66% of Medicaid, while the state of Texas funded about 34%. More than 14% of Texans received Medicaid services in 2011.
Texas Medicaid Curriculum

8. REVIEW: Medicaid Functions
Module 1
4/13/2017
Module 6
REVIEW: Medicaid Functions
Governor of Texas
Health & Human Services (HHSC) Executive Commissioner
Single State Agency (HHSC)
Department of State Health Services (DSHS)
Department of Assistive & Rehabilitative Services (DARS)
Department of Aging & Disability Services (DADS)
PB 2-12
Medicaid was created by Title XIX of the 1965 Social Security Act, and established in Texas in The Social Security Act requires that each state establish a state plan, which designates a single state agency to be responsible for administration and supervision of the Medicaid plan. In Texas, this agency is HHSC. This slide shows HHSC agencies that also have key Medicaid responsibilities. Further detail is available in Module 1.
Texas Medicaid Curriculum

9. REVIEW: Responsibilities
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REVIEW: Responsibilities
TMHP acts as the state's Medicaid fiscal agent and is responsible for paying acute care claims, while the state of Texas is responsible for covering the cost of claims.
Acts as the fee-for-service Medicaid claims administrator
Manages policy development
Collects HMO encounter data
Enrolls providers
Supplies provider relations representatives to enrolled providers
PB G-35
On a day-to-day basis, most providers who care for fee-for-service (FFS) patients will deal primarily with the Texas Medicaid and Healthcare Partnership (TMHP). TMHP was formed by ACS to administer Medicaid under a contractual relationship with HHSC.
TMHP serves as the claims administrator and enrolls providers for Texas Medicaid programs.
Texas Medicaid Curriculum

10. REVIEW: Texas Medicaid Recipients State Fiscal Year 2011
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REVIEW: Texas Medicaid Recipients State Fiscal Year 2011
Unduplicated Clients
SFY 2011 = 4,567,077
Hispanic
Caucasian
African- American
Other
0-5
6-14
15-20
21-64
65+
PB 5-13 and 5-14
This graph shows the breakdown of Medicaid patients in Texas, across 3 different demographic characteristics: ethnicity, age and gender.
Female
Male
Texas Medicaid Curriculum

11. Medicaid is a rigid, one size fits all program.
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Common Medicaid Myths
Myth
Medicaid is a rigid, one size fits all program.
Medicaid is designed with minimum federal standards, which require states to cover certain populations and provide certain benefits to key populations.
In many ways, Medicaid is a system that operates as 50 separate state coverage programs, with states having the choice to cover populations and services beyond minimum standards.
The Youth Empowerment Services (YES) and Medically Dependent Children Program (MDCP) are both examples of Medicaid waiver programs that allow coverage flexibility.
Fact
States have taken advantage of Medicaid’s flexibility to customize their program-about two-thirds of Medicaid spending is for “optional” services or populations.
All of the modules in this curriculum attempt to dispel myths about Medicaid. Additional information about Medicaid Myths & Facts is available form the Kaiser Commission on Medicaid and the Uninsured.
This slide addresses the states’ flexibility within federal guidelines.
Texas Medicaid Curriculum

12. Special Medicaid Programs for Families
Module 6
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Module 6
Special Medicaid Programs for Families
Case Management for Children and Pregnant Women
Health Insurance Premium Payment
Section Header Slide: Special Programs for Families
Texas Medicaid Curriculum

13. Module 6
4/13/2017
Module 6
Case Management (CM)
Case Management provides services that assist Medicaid patients in gaining access to needed medical, dental, mental health, social, educational and other services.
Case Managers (such as a nurse, social worker, or mental health professional) assess a patient’s needs and strengths, then develop and monitor an individualized care plan.
Case Management is available through such programs as Case Management for Children & Pregnant Women, Early Childhood Intervention (ECI), and local mental health/mental retardation services.
PB Glossary 3
Case Management is used increasingly across Medicaid Programs with a goal of giving patients and families more direct and hands-on navigation through the health care system and to obtain other needed services.
Texas Medicaid Curriculum 13

14. REVIEW: Case Management for Children and Pregnant Women
Module 3
4/13/2017
Module 6
REVIEW: Case Management for Children and Pregnant Women
Case managers assist children, women who are pregnant, and their families in getting help with:
Access to needed medical, dental, and mental health services, including transportation
Educational or school issues
Financial or housing problems
Medical supplies or equipment
What do case managers do?
Find out what families need
Make plans to meet those needs
Refer and teach families how to access community resources and services near where they live
Follow up regularly with families to make sure their needs have been met
Case Management is an important feature of Texas Health Steps. It helps patients to access specific types of services when and where they need them by linking patients and their families to health-related services and community resources.
Case management moves a patient through the continuum of health care, helping the patient to advance to the next step in medical care, such as referral to a specialist or preventive health-care services, and in actually getting to the specialist or preventive health care serviced per the referral. In also addressing the psychosocial and environmental issues, case management helps the family to find solutions to collateral problems that affect the patient’s health and well-being.
Referring patients in need of case management services relieves the burden of trying to provide services that are outside your usual scope of care. Case Management facilitates continuity of care for your patients by enabling them to receive proper follow-up, make it to scheduled appointments, and receive family support that optimizes the child’s health and well-being. It also allows you to be proactive in helping patients to avoid complications that may arise from not getting proper and timely care.
Texas Medicaid Curriculum 14

15. Case Management for Children & Pregnant Women Eligible Populations
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Case Management for Children & Pregnant Women Eligible Populations
To request CM for a patient or family:
Fax a referral form to Texas Health Steps
Call toll-free at THSTEPS
Contact a provider directly; providers are listed by Texas Health Regions on the Department of State Health Services website
Infants, children, teens and young adults from birth through age 20 can get case management if they:
Are eligible for Medicaid
Have or are at-risk for having a health problem that keeps them from doing things that other kids their age do
Need help accessing and getting services to keep health problems from getting worse
Women who are pregnant can get case management if they:
Have a high-risk pregnancy
Need the services to prevent more problems with pregnancy
Texas Medicaid Curriculum

16. Health Insurance Premium Payment (HIPP) Program
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Health Insurance Premium Payment (HIPP) Program
HIPP helps families pay for private health insurance. It is a program for families with at least one person who gets Medicaid.
Families may be eligible for HIPP if at least one family member receives Medicaid and if someone in the family can get health insurance at work.
HIPP reimburses families for private health insurance premiums that are paid to an employer-sponsored group plan.
Texas Medicaid Curriculum

17. ✓ What HIPP Pays for Family member who gets HIPP & Medicaid
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What HIPP Pays for
HIPP pays the premiums
Medicaid pays the co-pays when services are given by a Medicaid provider
Medicaid pays the deductibles when services are given by a Medicaid provider
Family member who gets HIPP & Medicaid ✓
Family member who gets HIPP but doesn’t get Medicaid
Texas Medicaid Curriculum

18. Special Medicaid Programs for Children
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Special Medicaid Programs for Children
Early Childhood Intervention
Medically Dependent Children Program
Children with Special Health Care Needs
YES Waiver
Oral Health and Fluoride Varnish in the Medical Home
Texas Medicaid Curriculum

19. Early Childhood Intervention (ECI)
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Early Childhood Intervention (ECI)
ECI serves babies and toddlers (birth to age 3) with developmental delays as well as those with medically diagnosed conditions such as autism, spina bifida, cerebral palsy and Down syndrome.
ECI providers create customized therapy programs for each child, using specialized teams of physical, occupational and speech therapists, social workers, dieticians and early intervention specialists.
ECI services are designed to enhance children’s long term development and ensure they reach their full potential.
The Department of Assistive and Rehabilitative Services (DARS) oversees the ECI program.
Texas Medicaid Curriculum

20. Module 6
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Module 6
ECI Cost and Access
The following services are provided at no cost regardless of income:
Evaluation/assessment
Development of the Individual Family Service Plan (IFSP)
Service coordination
Translation and interpretation services, if needed
Services for children with auditory and visual impairments who are eligible for services from ECI and local school districts
Services for children in foster care or in conservatorship of the state
Families with children enrolled in Medicaid or CHIP, or whose income is below 250% of the Federal Poverty Level, do not pay for any ECI services. Other families pay a cost-share determined by a sliding fee scale based on family size and net income after allowable deductions.
For ECI information, contact the DARS Inquiries Line:
Texas Medicaid Curriculum

21. ECI Services and Eligibility
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ECI Services and Eligibility
2009 ECI Patient Profile
Gender and Funding Source
Males 63%
Females 37%
Medicaid 61%
Referral Sources
Medical/ Health Services 32%
Parent/Family/Friends 27%
Social Services 32%
ECI Programs 7%
Educational 2%
Service Types
Developmental Services 86%
Speech-Language Therapy 51%
Occupational Therapy 29%
Physical Therapy 23%
Nutrition Services 13%
Family Training/ Counseling 9%
Behavioral Intervention 3%
Vision Services 2%
Audiology 2%
Psychology 2%
ECI Eligible Populations:
Children younger than 3 who are
Delayed or behind their peers in cognitive, motor, social- emotional, communication, or self-help skills
Have a medically diagnosed condition with a high probability of developmental delay
ECI determines eligibility for children birth to 36 months, but income is not a factor.
Texas Medicaid Curriculum

22. Medically Dependent Children Program (MDCP)
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Medically Dependent Children Program (MDCP)
MDCP is a Medicaid waiver that provides services to families of medically fragile children who choose to keep their children at home instead of placing them in nursing facilities.
To be eligible for MDCP, the child must:
Be under 21 years of age
Be eligible for Medicaid, based on the child’s
income and resources
Meet the medical necessity criteria for admission
into a nursing facility
Reside in Texas
Meet disability criteria
The Department of Aging and Disability Services (DADS) oversees the MDCP program.
DADs Reference Manual:
The MDCP provides a variety of services and supports for families caring for children who are medically dependent at home as an alternative to residing in a nursing facility. Specific services include adaptive aids, adjunct support services, minor home modifications, respite, financial management services, and transition assistance services. The Consumer Directed Services option is available for respite and adjunct support services.
Texas Medicaid Curriculum

23. MDCP Services Helpful Definitions
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MDCP Services Helpful Definitions
Respite: Direct care to an individual to provide a caregiver temporary relief from caregiving activities
Adjunct support services: Specific direct care services needed by the child to participate in child care, education or independent living when the caregiver is at work or school
Adaptive aids: A device that helps a child perform the activities of daily living or control the environment
Minor home modifications: A physical change to the family’s
residence that is needed to prevent institutionalization,
such as bathroom modifications, door widening, or ramp.
Transition Assistance Services: Services that support the
transition from a nursing home to the community
Financial Management Services: Services that assist an
individual or family with managing funds
Texas Medicaid Curriculum

24. Children with Special Health Care Needs (CSHCN) Services Program
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Children with Special Health Care Needs (CSHCN) Services Program
The CSHCN Services Program helps children with special health- care needs and people of any age with cystic fibrosis.
The program helps clients with their
Medical, dental and mental health care needs
Drugs and special therapies
Case management and family support services
Travel to health care visits
Insurance premiums
To be eligible for CSHCN, the child must be younger than 21 years of age and have chronic physical or developmental condition expected to last at least 12 months.
The Department of State Health Services (DSHS) oversees the CSHCN program.
Texas Medicaid Curriculum

25. CSHCN Services Program
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CSHCN Services Program
All CSHCN Services Program Health Benefits must be medically necessary for the care and treatment of an eligible person with a chronic physical or developmental condition.
Medicaid, CHIP, and commercial health insurance benefits, if any, must be used before using the CSHCN Services Program health benefits.
More information is available about CSHCN Services Program through the CSHCN Inquiry Line at
Texas Medicaid Curriculum

26. Youth Empowerment Services YES Waiver
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Youth Empowerment Services YES Waiver
A Medicaid waiver program for children with severe emotional disturbances whose parents feel they have reached or exceeded their financial, emotional or health care support resources and are unable to cover the costs of their child’s mental health treatment.
The YES program provides home and community-based services to youth who would otherwise need institutional care (e.g., psychiatric inpatient care) or whose parents would turn to state custody for care.
Allows Texas to cover youth who are not otherwise Medicaid-eligible when living in the community (parental income is not included in financial eligibility calculation).
The Department of State Health Services (DSHS) oversees the YES Waiver program, which is currently in place in Travis and Bexar counties and may be expanded to Tarrant and Harris counties.

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Goals of the YES Waiver
Provide a complete continuum of flexible community-based services and supports for children and adolescents with severe emotional disturbance and their families
Ensure access to other flexible non-traditional support services, including the parent partners
Develop individualized plans of care through a family-centered planning process
Prevent or reduce inpatient psychiatric admissions for children and adolescents with severe emotional disturbance
Reduce and prevent out-of-home placements by all child-serving agencies
Improve the clinical and functional outcomes of children and adolescents with severed emotional disturbances
Texas Medicaid Curriculum

28. YES Waiver Services and Eligibility
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YES Waiver Services and Eligibility
YES Waiver Eligibility
Age 3-18 years
Reside in Bexar or Travis County, in a non- institutional setting with the parent or legally authorized representative or in their own home or apartment, if legally emancipated
Be eligible for Medicaid; parental income is not included in financial eligibility determination
Meet DSHS clinical guidelines and qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines
Enrollment information is available on the DSHS website
YES Waiver Services
Respite
Community Living Supports
Family Supports
Transitional Services
Adaptive Aids & Support
Minor Home Modifications
Non-Medical Transportation
Paraprofessional Services
Professional services
Supportive Family Based Alternatives
Waiver recipients will still be able to receive Medicaid State Plan Services. Enrollment in the YES Waiver in Bexar and Travis counties is through an Interest List.
Interest List for YES Waiver Services Available in Bexar County (April 2010) – The Local Mental Health Authority in Bexar County, Center for Health Care Services, has begun an Interest List for youth and families interested in accessing services through the YES Waiver. To obtain more information or get registered on the Interest List for Bexar County, please call (210) extension 259.
Interest List for YES Waiver Services Available in Travis County (February 2010) – The Local Mental Health Authority in Travis County, Austin Travis County Integral Care, has begun an interest list for youth and families interested in accessing services through the YES Waiver. To obtain more information or to get registered on the Interest List for Travis County, please call (512) Information is also available online at

29. Oral Health Care: Recommendations for Physicians
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Oral Health Care: Recommendations for Physicians
Institute oral health risk assessments into well-child visits
Provide patient education regarding oral health
Provide appropriate prevention interventions (eg, feeding practices, hygiene)
Document findings and follow-up
Train office staff in oral health assessment
Identify dentists (pediatric/general) in your area who accept new patients/Medicaid patients
Take a dentist to lunch to establish a referral relationship
Investigate fluoride content in area water supply
Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals
Texas Medicaid Curriculum

30. First Dental Home Components
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First Dental Home Components
Caries Risk Assessment
Dental prophylaxis
Oral hygiene instructions with primary care giver
Dental anticipatory guidance
Establishment of a recall schedule
Texas Medicaid Curriculum

31. Oral Evaluation and Fluoride Varnish (OEFV) in the Medical Home
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Oral Evaluation and Fluoride Varnish (OEFV) in the Medical Home
The OEFV initiative is aimed at improving the oral health of children months of age.
The goal of the program is to allow medical and dental providers to work together to improve the oral health of children.
Providers include physicians, physician assistants and advanced practice nurses who have completed OEFV training.
Upon completion of training, dental providers are eligible to provide intermediate oral evaluation, apply fluoride varnish, and bill Texas Medicaid for enhanced reimbursement.
Texas Medicaid Curriculum

32. OEFV Visit Components During a Texas Health Steps Medical Checkup
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OEFV Visit Components During a Texas Health Steps Medical Checkup
Intermediate Oral Evaluation
varnish application
Fluoride
Anticipatory Guidance
Dental
Application of the fluoride varnish may be delegated to trained nurses or medical assistants.
Referral to
a dental home
Texas Medicaid Curriculum

33. Special Medicaid Programs for Women
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Special Medicaid Programs for Women
Texas Women’s Health Program
Programs for Pregnant Women
Nurse-Family Partnership
Breast and Cervical Cancer Programs
Texas Medicaid Curriculum

34. Texas Women’s Health Program
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Texas Women’s Health Program
The Texas Women’s Health Program (TWHP) provides low-income women with free family planning exams, related health screenings, and birth control through Texas Medicaid.
Patients pay no premiums or co-pays for services provided by the TWHP.
Applications are available to women at provider offices, local state eligibility offices, participating Women, Infant, and Children program (WIC) offices, through community-based organizations, and online.
The TWHP launched in January 2013, following a state district judge’s decision that cleared the way for HHSC to launch the program as a replacement to a previous Medicaid waiver program.
Women can apply for WHP by faxing a completed application and required verification documents toll-free to Applications can also be found at the following places:
Online in English and Spanish
DSHS family planning clinics (call for locations)
Local HHSC benefit offices
Participating WIC offices (call for locations)
Participating community-based organizations (call for locations)

35. TWHP Eligible Populations
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TWHP Eligible Populations
TWHP is for women who meet the following qualifications:
Ages 18 to 44
U.S. citizens and qualified immigrants
Reside in Texas
Do not currently receive full Medicaid benefits, including
Medicaid for pregnant women, CHIP, or Medicare Part A or B
Have a countable household income at or below 185% FPL
Are not pregnant, sterile, infertile, or unable to get pregnant due to medical reasons
Do not have private health insurance that covers family planning services, unless filing a claim through their health insurance would cause physical, emotional, or other harm from a spouse, parent, or other person
Providers who deliver family planning services, have completed the Medicaid-enrollment process through the Texas Medicaid & Healthcare Partnership (TMHP), and do not perform elective abortions are eligible to provide family planning services through the WHP.

36. TWHP Benefits One family planning exam each year, which might include:
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TWHP Benefits
One family planning exam each year, which might include:
Pap smear
Screening for breast and cervical cancers, diabetes, sexually transmitted diseases, and high blood pressure
Family planning counseling and education, which can include natural family planning and abstinence
Treatment of certain sexually transmitted diseases
Follow-up family planning visits related to the method of birth control.
Covered Birth Control:
Birth control pill
Vaginal ring
Hormone patch
Diaphragm
Male and female condoms
Spermicide
Intrauterine device (IUD)
Cervical cap
Depo-Provera
Devices placed under the skin, such as Implanon
Methods to permanently prevent pregnancy (tubal ligations or Essure)
Providers who have completed the Medicaid-enrollment process through the Texas Medicaid & Healthcare Partnership (TMHP), and do not perform elective abortions are eligible to provide family planning services through the WHP.

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Programs for Pregnant Women Percent of Births Paid by Medicaid,
Texas HHSC Medicaid and Health Babies Powerpoint Presentation, January 2011
Medicaid is the primary public coverage program providing prenatal
and perinatal care in Texas, and is the primary payor of all Texas
births.
• Texas spends over $2.2 billion per year in birth and delivery related
services (about 10% of total program services costs).
• More than 55% of all births in Texas are paid by Medicaid.
• Costs related to infant care are growing almost 10% per year.
• NICU utilization is growing faster than expected.
• Over 50% of costs are attributable to extremely premature infants, who
account for about 2% of births.
Texas Medicaid Curriculum

38. Pregnant Women Served by Texas Medicaid
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Pregnant Women Served by Texas Medicaid
PB 5-18
While private insurance companies can no longer exclude pregnant women seeking health insurance, young pregnant women may be unable to afford insurance. They may also work at low-level jobs that do not provide health coverage. The Texas Medicaid program extends pregnancy-related coverage to women with incomes up to 185 percent of FPL.
Texas Medicaid Curriculum

39. Programs for Pregnant Women
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Programs for Pregnant Women
Medicaid for Low-income Pregnant Women
A pregnant woman may receive Medicaid benefits during pregnancy and up to two months after birth if she meets certain income requirements.
Children’s Health Insurance Program (CHIP) Perinatal Coverage
CHIP perinatal coverage provides prenatal care for pregnant women who meet certain income requirements, who do not qualify for Medicaid and who do not have any other health coverage.
The Neonatal Care Management Program (NCMP)
NCMP provides help for low-birth- weight, medically complex, and high- risk infants in the neonatal intensive care unit (NICU). The program provides educational materials, care management nurses, and a 24-hour help line.
Medicaid Health Moms and Babies
Medicaid Healthy Moms and Babies is a program that provides OB risk assessment and educational services to expectant mothers and case management services to mothers who have high-risk pregnancies. The program provides educational materials, health assessments, and a help line for questions and concerns.
Texas Medicaid Curriculum

40. CHIP Perinatal Coverage Eligible Populations
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CHIP Perinatal Coverage Eligible Populations
Uninsured pregnant women who are Texas residents and:
Have a household income greater than 185% FPL but not greater than 200% FPL
Have a household income at or below 200% FPL, but do not qualify for Medicaid because of immigration status
An applicant is not eligible for CHIP perinatal services if she gives birth prior to an eligibility decision
The CHIP Perinate program extends prenatal care coverage to pregnant women with incomes up to 200% of FPL ($37,068 for a family of three in 2011) 40

41. CHIP Perinatal Benefits
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CHIP Perinatal Benefits
Up to 20 prenatal care visits
First 28 weeks of pregnancy – 1 visit every 4 weeks
28 to 36 weeks of pregnancy – 1 visit every 2-3 weeks
36 weeks to delivery – 1 visit per week
Additional visits allowed if medically necessary
Prescriptions based on CHIP formulary
Case management and care coordination
Ultrasound of the baby when medically indicated
Labor with delivery of child
2 postpartum visits for mother
Regular check-ups, immunizations, and prescriptions for baby after leaving the hospital 41

42. Medicaid Healthy Moms and Babies Program Benefits
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Medicaid Healthy Moms and Babies Program Benefits
Educational materials on pregnancy-related issues
Access to online program information
Access to the toll-free BabyLine®, which is answered by experienced obstetrical (OB) nurses, 24 hours a day, 7 days a week
The book, Your Journey Through Pregnancy, which has information about early pregnancy through the baby’s first weeks
Three assessments, before and after delivery
Referral to case management program
Reports for enrollees and their physicians
Texas Medicaid Curriculum

43. Neonatal Care Management Program (NCMP)
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Neonatal Care Management Program (NCMP)
The NCMP coordinates care for low birthweight, medically complex, and high-risk infants born to Texas Medicaid fee-for-service clients.
The program began in July 2012 for infants hospitalized in neonatal intensive care units (NICU) and specialty care nurseries.
NCMP serves only eligible Texas Medicaid fee-for-service clients who agree to participate in the program. Clients who are enrolled in a managed care organization are not eligible.
HHSC and TMHP are partnering with Alere Women’s & Children’s Health and its affiliates to implement NCMP.
HHSC and TMHP are partnering with Alere Women’s & Children’s Health and its affiliates to implement NCMP and the Medicaid Health Moms and Babies Program
Texas Medicaid Curriculum

44. Nurse-Family Partnership
Module 6
4/13/2017
Module 6
Nurse-Family Partnership
The Texas Nurse-Family Partnership (TNFP) pairs Bachelor’s prepared, registered nurses with low-income, first-time mothers to improve prenatal care and provide one-on-one child development education and counseling.
Women are enrolled in the program early in the second trimester of their pregnancy, when TNFP nurses begin home visits.
The visits continue throughout the woman’s pregnancy and until her child is 2 years old. The nurses provide support, education and counseling on health, parenting, developmental issues and life skills.
Texas Medicaid Curriculum

45. Module 6
4/13/2017
Module 6
NFP By the Numbers
NFP programs have existed for over 23 years and are currently operating in 31 states, serving over 20,000 mothers. Benefits to both children and mothers include:
56% reduction in emergency visits for accidents and poisonings
32% reduction in emergency visits in the second year of life
39% fewer injuries among children of low resource mothers
79% reduction in preterm delivery
23% fewer subsequent pregnancies PB
31% fewer closely-spaced (less than 6 months) subsequent pregnancies
20% reduction in welfare use
48% reduction in child abuse and neglect at child age 15
83% increase in mother’s labor force participation by child’s 4th birthday
67% reduction in behavioral/intellectual problems at child age 6
Texas Medicaid Curriculum

46. 7th most commonly diagnosed cancer among Texas women
Module 6
4/13/2017
Module 6
Breast & Cervical Cancer in Texas Expected New Cases & Death Rates in Texas Women, 2010
7th most commonly diagnosed cancer among Texas women
The most commonly diagnosed cancer among Texas women; an additional 100 Texas men are diagnosed with breast cancer annually
Breast cancer is the most common cancer diagnosed among women in Texas. Cervical cancer ranks seventh of the leading cancers diagnosed among Texas women. Surviving breast and cervical cancer depends on how early the cancer is detected. The best method to detect breast or cervical cancer in its early stages is through regular screening.
The Texas Cancer Registry also estimated that 100 Texas men would be diagnosed with breast cancer in 2010 and 24 Texas men would die of breast cancer in 2010.
Source:
Texas Medicaid Curriculum

47. Breast and Cervical Cancer Services (BCCS) Program
Module 6
4/13/2017
Module 6
Breast and Cervical Cancer Services (BCCS) Program
BCCS offers clinical breast examinations, mammograms, pelvic examinations, and Pap tests throughout Texas at no or low-cost to eligible women.
BCCS is partly funded by the Centers for Disease Control and Prevention (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP).
Since 1991, the BCCS program has screened 260,912 unduplicated women for breast or cervical cancer. Approximately 189,259 women received breast cancer screenings and
161,669 women received cervical cancer
screenings.
Breast and cervical cancer screening
services are available through health
care providers across Texas.
Locations of BCCS providers throughout Texas are available at this URL:
Texas Medicaid Curriculum

48. BCCS Eligible Populations
Module 6
4/13/2017
Module 6
BCCS Eligible Populations
Low-income women (at or below 200% of the Federal Poverty Income Guidelines)
Uninsured or underinsured
Age years for breast cancer screening and diagnostic services
Age years for cervical cancer screening services
Age years for cervical cancer diagnostic services
High Priority Populations:
Breast Cancer: Ages 50-64
Cervical Cancer: Ages years
Texas Medicaid Curriculum

49. Cervical Dysplasia Treatment Services:
Module 6
4/13/2017
Module 6
BCCS Services
Screening services:
Clinical breast examinations
Mammograms
Pap tests
Education
Diagnostic services:
Diagnostic Mammograms
Breast Ultrasounds
Breast biopsies
Colposcopies and biopsies
Cervical Dysplasia Treatment Services:
Loop Electrode Excision Procedure (LEEP)
Cryotherapy
Laser
Office visit in conjunction with treatment
Texas Medicaid Curriculum

50. Medicaid for Breast & Cervical Cancer (MBCC)
Module 6
4/13/2017
Module 6
Medicaid for Breast & Cervical Cancer (MBCC)
MBCC Eligible Population:
Diagnosed and in need of treatment for a biopsy-confirmed definitive breast or cervical diagnosis
Income at or below 200% FPL
No insurance for the treatment of the cancer
Under age 65
A Texas resident and a U.S. citizen or eligible immigrant.
MBCC is a special Medicaid program authorized by federal and state laws to provide access to cancer treatment services for qualified, low- income women.
The same agencies that provide screening services through BCCS assist women with receiving treatment for breast cancer through MBCC.
To ensure a successful referral and to facilitate prompt enrollment of qualified women into MBCC, health care providers should:
 Identify the nearest BCCS clinic;
 Ensure the pathology report has a definitive qualifying diagnosis (all diagnoses must be biopsy-confirmed);
 Use the “Medicaid for Breast and Cervical Cancer: Guidelines for Determination of Qualifying Diagnosis” as a reference tool:
 Provide the client with a copy of the pathology report or fax the pathology report to the referral BCCS clinic, to the attention of the agency’s MBCC Case Manager; and
 Contact the BCCS case manager about client and the necessary documents the client will need to bring to complete the eligibility and application process (financial documents, citizenship or alien status, pathology report, etc.).
Texas Medicaid Curriculum

51. The Face of Medicaid Anna’s Story
Module 6
4/13/2017
Module 6
The Face of Medicaid Anna’s Story
As a junior in college, Anna found herself pregnant and unemployed; even worse, Anna had no insurance
Among Anna’s limited options:
Terminate her parental rights
Take advantage of state assistance programs
How can Texas Medicaid help Anna?
Texas Medicaid Curriculum

52. The Face of Medicaid Anna’s Story
Module 6
4/13/2017
Module 6
The Face of Medicaid Anna’s Story
Anna was eligible for Medicaid for
Pregnant Women under the CHIP Perinatal Program
During her pregnancy, Anna received
Case Management for Children & Pregnant Women
Medicaid covered the hospital and doctor costs when Ryan was born
Until Ryan turned 2, a nurse from the Nurse-Family
Partnership made regular home visits
Throughout his Medicaid eligibility, Texas Health Steps paid for Ryan’s check-ups,
immunizations, labs and assessments, in his
medical and dental homes
Texas Medicaid Curriculum

53. The Face of Medicaid Anna’s Story
Module 6
4/13/2017
Module 6
The Face of Medicaid Anna’s Story
When she returned to school, Temporary Assistance for Needy Families (TANF) provided financial support to keep Ryan and Anna clothed and nourished.
When Ryan was 3, Anna completed her college degree and started to work, moving to private insurance.
Although she no longer needs Medicaid, Anna credits Texas Medicaid for giving her and her son a healthy start on their lives.
Texas Medicaid Curriculum

54. Impact of Health Reform on Women’s and Children’s Health Care
Module 6
4/13/2017
Module 6
Impact of Health Reform on Women’s and Children’s Health Care
Freestanding birthing centers are eligible for
Medicaid reimbursement
Tobacco cessation counseling added as a
Medicaid benefit for pregnant women
Children enrolled in Medicaid and CHIP can elect hospice care without waiving their rights to treatment
Extended dependent coverage to age 26
No lifetime limits or annual benefit restrictions
No pre-existing condition exclusions
No out-of-pocket expenses for preventive services
Source: Health Reform: Impact on Women’s Health Coverage and Access to Care, KaiserEDU Tutorial, The Henry J. Kaiser Family Foundation, November 2010,
Although the new law will not be fully operational until 2014, there are certain elements that have already gone into effect. These include the development of temporary high risk pools for individuals who don't qualify for coverage because they have pre-existing health conditions that make them uninusurable. The law also allows parents to extend dependent coverage to age The group of adults, men and women who are between 18 and 26, currently have among the highest uninsurance rates of all age groups.
In addition, the law eliminates lifetime limits on coverage and annual amounts that plans spend on non-clinical costs as well as eliminates recissions, which is when plans stop coverage because individuals become ill.
Pre-existing exclusion for children are no longer permitted, and qualified plans will need to cover certain preventive services without cost sharing. I'll discuss that more later.
In 2014, however, is when the major changes will take place. That is when individual coverage will become mandatory, when Medicaid will be broadly expanded and new avenues for purchasing private coverage will be available to the uninsured.

55. Module 6
4/13/2017
Module 6
True or False? Test Your Knowledge about Special Medicaid Programs for Families, Children & Women
Case Management assists families with resources such as educational, financial, or housing needs.
TRUE: Case Management assists Medicaid families in gaining access to needed medical, social, educational, and other services.
ECI provides services to families of medically fragile children who keep their children at home instead of placing them in nursing facilities.
FALSE: MDCP provides services to parents who choose to keep their medically fragile children at home. ECI serves babies and toddlers with developmental delays or atypical development.
The Children with Special Health Care Needs program helps people of any age with cystic fibrosis.
TRUE: CSHCN helps children with special health care needs and people of any age with CF.
It’s time to test what you’ve learned about Special Medicaid programs in Module 6.
Reference slides for each question:
Q1: Slide 13
Q2: Slides 20 & 22
Q3: Slide 24
Texas Medicaid Curriculum

56. Module 6
4/13/2017
Module 6
True or False? Test Your Knowledge about Special Medicaid Programs for Families, Children & Women
One goal of a Caries Risk Assessment is to Identify the oral health status of the child and other family members.
TRUE: Other goals include identifying potential bacterial transmission sources and determining a recall periodicity schedule for additional dental visits.
The Nurse-Family Partnership provides post-natal home visits until the child is 1 year old.
FALSE: Home visits to eligible families conducted through the Nurse-Family Partnership continue until the child is 2 years old.
Reference slides for each question:
Q4: Slide 33
Q5: Slide 48
Texas Medicaid Curriculum

57. Module 6
4/13/2017
Module 6
Medicaid Resources
Texas Health & Human Services Commission Texas Medicaid & Healthcare Partnership Texas Health Steps CHIP/ Children’s Medicaid
These web-based resources are available for more information on various aspects of Texas Medicaid.
Texas Medicaid Curriculum

58. This Texas Medicaid curriculum was prepared by
Module 6
4/13/2017
This Texas Medicaid curriculum was prepared by
Betsy Goebel Jones, EdD Project Director
Tim Hayes, MAM Project Designer
Authors: Module 6 Betsy Goebel Jones, EdD
David Trotter, MA
Module 6
Texas Medicaid Curriculum