Presentation is loading. Please wait.

Presentation is loading. Please wait.

Module 6 Medical and Dental Information Series

Similar presentations


Presentation on theme: "Module 6 Medical and Dental Information Series"— Presentation transcript:

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
Module 6 4/13/2017 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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.
Module 6 4/13/2017 Module 6 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 4/13/2017 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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. https://www.gethipptexas.com/ Texas Medicaid Curriculum

17 ✓ What HIPP Pays for Family member who gets HIPP & Medicaid
Module 6 4/13/2017 Module 6 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 https://www.gethipptexas.com/how-does-hipp-work.html Texas Medicaid Curriculum

18 Special Medicaid Programs for Children
Module 6 4/13/2017 Module 6 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)
Module 6 4/13/2017 Module 6 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 4/13/2017 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
Module 6 4/13/2017 Module 6 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)
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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.

27 Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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:
Module 6 4/13/2017 Module 6 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.

37 Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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
Module 6 4/13/2017 Module 6 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)
Module 6 4/13/2017 Module 6 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


Download ppt "Module 6 Medical and Dental Information Series"

Similar presentations


Ads by Google