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Module 7 Medical and Dental Information Series

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1 Module 7 Medical and Dental Information Series
4/15/2017 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, and dental residents These Presentations may contain animations. To view the full effect for these slides, please view them in PowerPoint slideshow mode. Version 1.2 (6/22/2010) Module 7 2/22/2013 Texas Medicaid Curriculum

2 Medicaid Curriculum Overview
Module 7 4/15/2017 Module 7 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 Notes: PB= Texas Medicaid and CHIP in Perspective, Eighth Edition - January 2011, commonly known as the "Pink Book”; the Pink Book is divided into 8 chapters, a Glossary and Appendices A-F; 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 Module 7 Special Medical Issues
4/15/2017 Module 7 Special Medical Issues You are viewing Module 7: Special Medical Issues Please note that the terms clients, patients, recipients, members and enrollees are all used to refer to the persons who are covered by Medicaid or insurance/ managed care plans, with an effort to use the most appropriate term for the context in which the term is used. Texas Medicaid Curriculum

4 Module 7 4/15/2017 Module 7 Module 7: Objectives After completing this module, you should be able to: Discuss additional Texas Medicaid programs that provide health services to children and adults including: Behavioral health services Prescription drug benefits Benefits for “Dual Eligibles” (those eligible for both Medicare and Medicaid) Long-term care programs Review briefly the health topics discussed in previous modules After you complete this module, you should be able to describe Texas Medicaid programs that support behavioral health, prescription drug benefits, and programs for the elderly and those in long-term care. You should also be have a review of previous modules in this series. Texas Medicaid Curriculum 4

5 Module 7 True or False? 4/15/2017 Module 7 Medicaid covers only behavioral health services provided by a psychiatrist. Only medications listed on the Preferred Drug List (PDL) are reimbursable through Texas Medicaid. Texas Medicaid must cover all medications for which a manufacturer offers a rebate. PACE programs coordinate and provide preventive, primary, acute and long term care services for elderly individuals who live in the community. Hospice is for all age groups, including children, during their final stages of life. These answers will be discussed in detail on Slides #63 & 64 Answers are: 1: False 2: False 3: True 4: True 5: True Texas Medicaid Curriculum 5

6 Behavioral Health Services
Module 7 4/15/2017 Module 7 Behavioral Health Services Texas Medicaid defines Behavioral Health Services as: Services used to treat a mental, emotional, or substance use disorder. Medicaid makes behavioral health services available to Medicaid-eligible children and adults. Texas Medicaid Curriculum

7 Behavioral Health Services: Basic Services
Module 7 4/15/2017 Module 7 Behavioral Health Services: Basic Services Screening, diagnosis, and referral to needed services Freestanding psychiatric hospital services (for patients younger than 21 and older than 64 years of age) Psychiatric hospitalization services in psychiatric unit within a general acute care hospital Counseling and psychotherapy services Medication services Substance use disorder treatment services Rehabilitation and case management services for people with severe and persistent mental illness and children with severe emotional disturbance All of these services are available through traditional Medicaid, although some have limits (such as psychotherapy and psychodiagnosis). Medicaid managed care, including STAR and STAR+Plus can offer value-added services (such as intensive outpatient treatment and forensic services) The substance use treatment service benefit previously covered only ambulatory services, but has been expanded to cover other substance use disorder services and is no longer limited to children. Texas Medicaid Curriculum

8 Behavioral Health Expenditures
Module 7 4/15/2017 Module 7 Behavioral Health Expenditures Mental and behavioral health constitutes about 3% of all Texas health care expenditures DSHS expenditures for mental health care in 2009 totaled $1.8 billion % more than in 2005. Texas Medicaid Curriculum

9 Behavioral Health: Eligible Providers and Care Settings
Module 7 4/15/2017 Module 7 Behavioral Health: Eligible Providers and Care Settings Providers Psychiatrists Primary Care Physicians Psychologists Licensed Clinical Social Workers Licensed Professional Counselors Licensed Marriage and Family Therapists Advanced Practice Nurses and Physician Assistants Settings Private practices Private and public psychiatric and general hospitals Community mental health centers (e.g. MHMR facilities) Licensed substance use disorder treatment programs Federally Qualified Health Centers (FQHCs) PB /15 Inpatient and outpatient care and treatment of behavioral health conditions by a Primary Care Physician Inpatient and outpatient treatment provided by a Psychologist; psychologists can also delegate to a licensed psychological associate Inpatient and outpatient treatment provided by a Psychiatrist Inpatient and outpatient treatment provided by a Licensed Professional Counselor Outpatient treatment by a Licensed Master Social Worker Texas Medicaid Curriculum

10 Behavioral Health & Managed Care
Module 7 4/15/2017 Module 4 Behavioral Health & Managed Care Medicaid managed care, including STAR and STAR+PLUS, cover standard behavioral health services such as help for drug or alcohol problems and mental health services Medicaid managed care plans can offer additional value-added services, such as: Health psychology interventions to help manage chronic medical conditions Intensive outpatient treatment/ day treatment Inpatient substance abuse detoxification treatment Medicaid managed care, including STAR and STAR+PLUS, can offer additional value added services (such as intensive outpatient treatment and forensic services). Texas Medicaid Curriculum

11 Module 7 4/15/2017 Module 7 The NorthSTAR Program NorthSTAR is a behavioral health program that serves the seven counties within the Dallas service area. NorthSTAR provides integrated behavioral health services (mental health, chemical dependency, and substance abuse treatment) through a behavioral health organization (BHO), currently ValueOptions® NorthSTAR is known as a behavioral health carve-out of the STAR and STAR+PLUS Medicaid Managed Care Programs in the Dallas service area. NorthSTAR program's goal is to provide clinically necessary behavioral health services to enrollees, through a network of qualified and credentialed providers. TMHP Provider Handbook Section 8.4 Medicaid managed care, including STAR and STAR+PLUS, can offer additional value added services (such as intensive outpatient treatment and forensic services). Texas Medicaid Curriculum

12 Prescription Drug Coverage
Module 7 4/15/2017 Module 7 Prescription Drug Coverage In 1971, Texas Medicaid began providing optional coverage of outpatient medications. Patients enrolled in fee-for- service Medicaid receive services through the Vendor Drug Program (VDP). Patients enrolled in Medicaid managed care organizations receive services through their MCOs. Effective March 1, 2012, Medicaid managed care expanded to new areas of the state and prescription drug benefits, previously administered statewide through VDP, are now delivered through MCOs or VDP, depending on whether a patient is enrolled in managed care or fee-for-service Medicaid. This section gives an overview of prescription drug policies for Medicaid, explains how prescription drugs are covered for MCO clients and describes the VDP. Texas Medicaid Curriculum

13 Medicaid Prescription Drug Coverage
Module 7 4/15/2017 Module 7 Medicaid Prescription Drug Coverage Texas Medicaid covers prescription drugs that are dispensed through over 4,500 Texas pharmacies. Medicaid reimburses pharmacy providers only for outpatient prescription drugs. Over-the-counter drugs are covered for patients enrolled in Medicaid, Children with Special Health Care Needs and Kidney Health Care Programs, but not for patients in nursing facilities. Drugs administered in the doctor's office, inpatient hospital, outpatient hospital, or any location other than the patient’s home, nursing facility, or extended care facility are not a covered Medicaid benefit. Texas Medicaid Curriculum

14 Limitations on Prescription Drugs, by Patient Group
Module 7 4/15/2017 Module 7 Limitations on Prescription Drugs, by Patient Group Unlimited Prescriptions Children under 21 years of age Aged, blind, or disabled (ABD) nursing home clients ABD adults in the community with waiver eligibility Managed care clients (STAR, STAR Health, STAR+Plus) Limited to Three Prescriptions/Month TANF fee-for-service adults ABD fee-for-service adults without waiver eligibility The Medicaid drug benefit is limited to 3 prescriptions per month with the exception of: • Most nursing facility residents (e.g. those in a non‐Medicare Bed) • Children under the age of 21 • Most managed care clients • Certain STAR+Plus clients • Waiver clients Other types of prescriptions that are not counted toward the limits are for family planning, diabetic supplies, and smoking cessation. KHC clients are limited to 4 prescriptions per month. CHIP and CSHCN clients have unlimited prescriptions. Texas Medicaid Curriculum

15 Preferred Drug List (PDL) Program
Module 7 4/15/2017 Module 7 Preferred Drug List (PDL) Program The Medicaid PDL is a method to control growing medication costs, while also insuring that program recipients have access to medically necessary medications. Medications on the PDL can be prescribed without prior authorization. All “non-preferred” drugs require prior authorization. Medications receive their “preferred” or “non-preferred” designations based on their safety, efficacy, and cost effectiveness. HHSC saved approximately $245.8 million in general revenue during the biennium as a result of the PDL, due to supplemental rebates and prescribing shifts. PB5-13 The Vendor Drug Program implemented the Medicaid Preferred Drug List (PDL) in 2004.  Preferred drugs are available without prior authorization, while non-preferred drugs require prior authorization The PDL can be obtained from: Texas Medicaid Curriculum

16 Prescription Drug Coverage: Federal Drug Rebate Program
Module 7 4/15/2017 Module 7 Prescription Drug Coverage: Federal Drug Rebate Program The Omnibus Budget Reconciliation Act of 1990 requires that drug manufacturers pay medication rebates for drugs dispensed under state Medicaid programs. Additionally, this law mandates that: States must cover all drugs for which the manufacturer provides a rebate. States must maintain an open formulary for all drugs of manufacturers that have signed a federal rebate agreement. States may require prior authorization to limit the use of drugs. Approximately 36% of the Vendor Drug Program’s budget is funded by rebates paid by pharmaceutical manufacturers PB5-13 In order for Texas Medicaid to receive federal funds for prescription claims, the drug must be made by a drug manufacturer that participates in the Centers for Medicare & Medicaid Services (CMS) drug rebate program. In return for having their drugs covered by state Medicaid programs, the manufacturer agrees to pay rebates according to their state and federal contracts. Rebate amounts per unit are determined by the Centers for Medicare & Medicaid Services. Texas Medicaid Curriculum

17 Texas Drug Code Formulary
Module 7 4/15/2017 Module 7 Texas Drug Code Formulary The Texas Drug Code Formulary covers more than 32,000 drugs including single source and multi source (generic) products. The Texas Medicaid formulary can be found at: The Texas Medicaid formulary and PDL are also available on the Epocrates drug information system. The Texas Drug Code formulary allows providers to determine which drugs are included in the Texas Medicaid/ CHIP formulary. Texas Medicaid Curriculum

18 Texas Drug Code Formulary Search Results
Module 7 4/15/2017 Module 7 Texas Drug Code Formulary Search Results PDL Prior Authorization = Yes… The drug is “non-preferred” and requires prior authorization before Medicaid will cover it Clinical PA Auth. Required = Yes… The drug is subject to clinical edits, requiring the pharmacy to first check a client’s Medicaid medical and drug claims histories for consistency with the edit criteria for that drug. The formulary may be searched by drug code, drug name/ description/ and therapeutic class. This slide shows the results of a search for the therapeutic class of NSAIDS, also showing whether the drug is subject to prior authorization. Additional details about each drug are also available, as show in the Details picture above. Clinical edits check a client’s Medicaid medical and drug claims histories to help determine whether the information on file indicates that the client’s medical condition matches the edit criteria for dispensing the requested drug without need of additional prior authorization. The edits are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. Texas Medicaid Curriculum

19 Non-PDL Prior Authorization Drug Search
Module 7 4/15/2017 Module 7 Non-PDL Prior Authorization Drug Search Providers may also search specifically for drugs that do not require prior authorization. The Non-PDL PA drug search includes only those drugs that do not require either PDL or clinical edits prior authorization. Texas Medicaid Curriculum

20 Prescription Drug Prior Authorization
Module 7 4/15/2017 Module 7 Prescription Drug Prior Authorization Prior authorization is necessary for any drug not on the PDL and can be obtained via two methods: Telephone: PA-TEXAS ( ) Online: https://paxpress.txpa.hidinc.com PB5-13 To obtain prior authorization for non‐preferred drugs and clinical edit failures, prescribing providers or their representatives should call the Texas Prior Authorization Hotline at 1‐877‐PA‐TEXAS. The hotline is available Monday through Friday, 7:30 a.m. to 6:30 p.m. (CST). Pharmacists cannot obtain prior authorization for medications. If the patient arrives at the pharmacy without a prior authorization for a non‐preferred drug, the pharmacist should alert the doctor’s office and ask the doctor to get the prior authorization. Texas Medicaid Curriculum

21 72-Hour Emergency Prescriptions
Module 7 4/15/2017 Module 7 72-Hour Emergency Prescriptions Both federal and Texas laws require that a 72-hour emergency supply of prescribed medications be provided when: A medication is needed without delay Prior authorization is not available (e.g. prescriber can not be contacted or is unable to request it) Emergency prescriptions do not count towards the three- prescription limit for those subject to this limit. A 72-hour emergency supply of prescribed medications can be dispensed any time a prior authorization is not available and a prescription must be filled without delay for a medical condition. If the prescribing provider can not be reached or is unable to request a prior authorization, the pharmacy can supply an emergency 72-hour prescription.  This procedure ca not be used for routine and continuous overrides. A 72-hour emergency prescription is paid in full to the prescribing pharmacy, and does not count toward the three-prescription limit for adults who have not already received their maximum prescriptions for the month (there is no prescription limit for children under 21). Texas Medicaid Curriculum

22 The Vendor Drug Program (VDP)
Module 7 4/15/2017 Module 7 The Vendor Drug Program (VDP) The VDP provides prescription drug services to eligible Texas Medicaid recipients in these programs: Texas Medicaid fee-for-service Children with Special Health Care Needs Kidney Health Care Programs The VDP processes prescription drug claims from contracted pharmacies and reimburses pharmacies for the cost of the drugs PB 4-7 and 5-12 (8th edition) In 2006, patients who were dually eligible for Medicare and Texas Medicaid began receiving most of their prescription medication coverage through Medicare Part D. Medicare prescription services are discussed later in this module, under the Dual Eligible section. Texas Medicaid Curriculum

23 Module 7 4/15/2017 Module 7 VDP ePrescribing Medicaid prescriptions are now accepted via e- prescription (e-Rx), and all managed care plans are required to provide e-Rx services. In order to submit an e-Rx that meets CMS requirements for “brand medically necessary” dispensing, the prescribing physician should do the following on the electronic prescription transaction that is sent to the pharmacy: Select the option for “Dispense as Written” (DAW) on the electronic prescription pad. Type “Brand Medically Necessary” in the “Notes to Pharmacy” free-text field. If an e-prescription is received by a pharmacy with DAW indicated but without the free text message or additional note, the pharmacist must contact the prescriber for a new prescription. Texas Medicaid Curriculum

24 Prescription Drugs for Medicaid Managed Care Clients
Module 7 4/15/2017 Module 7 Prescription Drugs for Medicaid Managed Care Clients As of March 1, 2012 clients enrolled in Medicaid managed care (STAR, STAR+PLUS) obtain prescription drug benefits through their managed care organizations (MCOs).  Each MCO will contract with a pharmacy benefits manager (PBM) that will process prescription claims and work with pharmacies that serve Medicaid managed care clients. MCOs will use the state-approved formulary for pharmacy benefits. A list of pharmacy benefits managers for each MCO is available from the Vendor Drug Program website: Texas Medicaid Curriculum

25 Medicaid Managed Care Service Areas
Module 7 4/15/2017 Module 7 Medicaid Managed Care Service Areas Service Areas Effective March 1, 2012 As of March 1, 2012, all areas of the state are included in a Medicaid Managed Care service area. Texas Medicaid Curriculum

26 What are the most prescribed drugs? Texas Medicaid Top 10 Drugs
Module 7 4/15/2017 Module 7 What are the most prescribed drugs? Texas Medicaid Top 10 Drugs By Usage (Claims in 2010) By Expenditure (Paid in 2010) 1,482,930 $90,402,420 1,241,673 $84,636,490 868,965 $69,095,046 847,432 $67,759,635 635,844 $46,187,032 595,775 $43,039,565 As this slide shows, the drugs that are most used for Texas Medicaid clients are not those with the greatest expenditures. 567,929 $38,744,539 478,288 $34,822,941 469,244 $29,646,374 402,028 $28,365,603 Texas Medicaid Curriculum

27 Module 7 4/15/2017 Module 7 Dual Eligibility Dual Eligibles are individuals who qualify for Medicare and Medicaid benefits. Medicare is a federally administered health insurance for: People 65 years or older People under age 65 with certain disabilities People of any age with End-Stage Renal Disease Texas Medicaid Curriculum

28 Review: Medicaid vs. Medicare What is the difference?
Module 7 4/15/2017 Module 7 Review: Medicaid vs. Medicare What is the difference? Texas Medicaid Medicare Authorized by Social Security Act of 1965 Established in Texas – 1967 Jointly Funded by State and Federal Government, administered by State & regulated by CMS Funded by Federal Government & administered by CMS Entitlement program based on income Entitlement program based on age or disability https://questions.medicare.gov/app/answers/detail/a_id/2038/~/what-is-the- difference-between-medicare-and-medicaid As a reminder, while Medicaid and Medicare both originate from the Social Security Act of 1965, their funding sources and eligibility criteria differ significantly. This slide reviews some of the key differences between these two programs. Research indicates that many health care trainees (including medical students) confuse the two programs. Medicare focuses on the elderly (age 65 and older), with some additional coverage for those with long-term disabilities, and is wholly funded by the federal government. Also important to note is the term “dual eligible's,” those elderly or SSI- disabled who are eligible to receive benefits from both programs. Medicaid also pays some deductibles, premiums, and coinsurance for dual eligible patients, and covers some categories of medications that Medicare doesn’t cover. Medicaid also covers long-term care for some patients through waiver programs, which Medicare does not (other than following a hospitalization). Medicaid also covers long-term institutional services and supports and thus covers the cost of nursing home care for dually eligible clients not paid for by Medicare. Low income families, children, pregnant women, disabled, elderly People 65 years or older, or people with disabilities Eligibility and enrollment in both programs concurrently is possible CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program. Texas Medicaid Curriculum

29 Medicaid pays the nursing home bill for all seniors.
Module 7 4/15/2017 Module 7 Common Medicaid Myths Myth Medicaid pays the nursing home bill for all seniors. Medicaid prohibits individuals from transferring savings to others in an attempt to qualify for nursing home care without exhausting their assets. Sixty percent of nursing home residents are not on Medicaid at the time of their admittance into a facility. Even after individuals deplete their assets, they are still required to apply their income, including Social Security and pension checks, towards their care costs, except for an average monthly $30 personal needs allowance. Fact Medicaid eligibility for seniors is limited to the very poor or those with large health expenses who have depleted their savings. 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 elderly patients whose nursing home costs are covered by Medicaid. With the average annual cost of nursing home care being $60,000, the longer an individual remains in a facility, the more likely they are to deplete their financial resources and qualify for Medicaid coverage. Texas Medicaid Curriculum

30 How Medicaid and Medicare Work Together
Module 7 4/15/2017 Module 7 How Medicaid and Medicare Work Together By federal law, Medicare coverage is primary to Medicaid When a patient receives a service covered under both programs, Medicare pays first, and the remainder (if any) is payable by Medicaid. Medicaid also serves dual eligibles by providing services not covered by Medicare, including: Nursing home care beyond Medicare’s 100-day limit Some prescription drugs Eye glasses Hearing aids For those who qualify, Medicaid may also cover some out-of-pocket Medicare expenses such as co-insurance, premiums, and deductibles Now that we have talked about Medicare, lets revisit the issue of Dual Eligibility. Remember, Dual Eligibles are those individuals who qualify for both Medicare and Medicaid based on age or disability and income status. Texas Medicaid Curriculum

31 How Medicaid and Medicare Work Together to cover Nursing Home Care
Module 7 4/15/2017 Module 7 How Medicaid and Medicare Work Together to cover Nursing Home Care First 20 days: Medicare pays Next 80 days: Medicare pays + Medicaid covers co-insurance After 100 days: Medicaid pays Texas Medicaid Curriculum

32 Full vs. Partial Eligibility for Medicaid
Module 7 4/15/2017 Module 7 Full vs. Partial Eligibility for Medicaid Full Eligibility Partial Eligibility Medicaid pays deductibles and co-insurance for Medicare-covered services Recipients may receive Medicaid services not covered by Medicare (e.g. long-term services and supports) Medicare provides the majority of prescription coverage, while Medicaid covers those drugs not covered under Medicare Medicaid pays for Part D (prescription drug coverage) premiums or deductibles Depending on income, Medicaid pays for Part A (hospital insurance) and/or Part B (medical insurance) PB4-3 2010 TMPPM 4-20 How Medicare and Medicaid interact for specific enrollees depends on what services they receive (e.g. SSI) and their income level. Partial Dual Eligibles do not qualify for full Medicaid services. There are 3 types of partial Dual Eligibles: Qualified Medicare Beneficiaries (QMB): Income no greater than 100% of FPL. Medicaid pays for Parts A and B, plus premiums, co-insurances and deductibles. Specified Low-Income Medicare Beneficiaries (SLMB): Income less than 120% of FPL. Medicaid pays for Part B premiums. Qualified Individuals (QI): Income less than 135% of FPL. With SLMB eligibility, Medicaid pays for Part B premiums. Full vs. Partial Eligibility is based on income and eligibility for Supplemental Security Income (SSI) Texas Medicaid Curriculum

33 Dual Eligibility: Special Considerations for Providers
Module 7 4/15/2017 Module 7 Dual Eligibility: Special Considerations for Providers Enrollment All physicians must be enrolled in Medicare before they can enroll in Medicaid. Exceptions are gynecologists, pediatricians, pediatric psychiatrists, and providers performing only Texas Health Steps medical or dental checkups Prior Authorization If a patient’s primary coverage is Medicare, providers must always confirm with Medicare whether a service is a Medicare benefit for the patient. If Medicare denies this service, then Medicaid prior authorization is required. Billing For those services covered by both Medicare and Medicaid, Medicare is the primary coverage and the claim must be filed with Medicare first. 2010 TMPPM 5-2, BH 2010 TMPPM 6-10 Enrollment All physicians (except gynecologists, pediatricians, pediatric psychiatrists, and providers performing only THSteps medical or dental checkups) must be enrolled in Medicare before they can enroll in Medicaid. This requirement can be also waived for physicians whose type of practice and service will never bill to Medicare. Prior Authorization If a client’s primary coverage is Medicare, providers must always confirm with Medicare whether a service is a benefit for the client. If a service that requires a prior authorization from Medicaid is a Medicare benefit and Medicare approves the service, prior authorization from TMHP is not required for reimbursement of the coinsurance or deductible. If Medicare denies the service, then Medicaid prior authorization is required. Texas Medicaid Curriculum

34 Long-Term Services and Supports
Module 7 4/15/2017 Module 7 Long-Term Services and Supports Nursing Facility Care Services Mental Retardation Services Primary Home Care Services (PHCS) Home and Community-based Waivers Day Activity and Health Services (DAHS) Hospice Care Services Program for All-inclusive Care for the Elderly (PACE) Consumer-Directed Services (CDS) Texas Medicaid Curriculum

35 Nursing Facility Care Services
Module 7 4/15/2017 Module 7 Nursing Facility Care Services Nursing Facility Care provides 24-7 nursing care for people whose medical condition requires the skills of a licensed nurse on a regular basis. The nursing facility must provide for the medical, nursing, and psychosocial needs of each recipient, including: Room and board Social services Over-the-counter drugs (prescription drugs are covered through the Medicaid Vendor Drug program or Medicare Part D) Medical supplies and equipment Personal needs items Rehabilitative therapies Augmented Communication Device Systems Power Wheelchairs Emergency Dental Services DADS Reference Guide page 67 Texas Medicaid Curriculum

36 Services for Persons with Intellectual Disabilities
Module 7 4/15/2017 Module 7 Services for Persons with Intellectual Disabilities The Texas Department of Aging and Disability Services (DADS) administers several long-term services and support programs for individuals with intellectual disabilities. Each of the DADS support programs for individuals with intellectual disabilities has different eligibility criteria; however, most criteria are based on: Cognitive functioning levels Adaptive behavior skills, which indicate the ability to care for oneself Physical disability levels In recent years, efforts have been made to use respectful language to refer persons challenged by developmental or mental disabilities and illnesses. In Texas, the term “persons with intellectual disabilities” rather than the term “mentally retarded” became part of state law in 2011 as a way to demonstrate the state’s respect and priority for persons with disabilities. Texas Medicaid Curriculum

37 DADS Programs & Services for Persons with Intellectual Disabilities
Module 7 4/15/2017 Module 7 DADS Programs & Services for Persons with Intellectual Disabilities Home and Community Based Services (HCS) HCS provides individualized services and supports to persons with intellectual and developmental disabilities who are living with their family, in their own home or in other community settings, such as small group homes. Intermediate Care Facilities for Persons with Intellectual Disabilities This program provides residential and habilitation services to people with intellectual and developmental disabilities and/or a related condition. In-Home and Family Support Program This program provides direct grant benefits to people who have physical disabilities and or their families to help them purchase services that enable them to live in the community or in their own homes. Home and Community-Based services include: Case management, adaptive aids, minor home modifications, counseling and therapies, dental treatment, nursing, residential assistance, respite care, day habilitation, supported employment Intermediate Care Facilities for Persons with Intellectual Disabilities services include: Residential care, habilitation care, medical care, skills training ,and adjunctive therapy In-Home and Family Support Program-eligible individuals direct grant benefits to purchase services that help them to remain in their own homes. Texas Home Living Program This program provides selected essential services and supports to people with intellectual and developmental disabilities who live in their family homes or their own homes. Texas Medicaid Curriculum

38 Module 7 4/15/2017 Module 7 DADS Programs & Services for Persons with Intellectual Disabilities Continued State-Supported Living Centers The state has 13 State-Supported Living Centers that provide 24-hour residential, treatment and training services for people with intellectual and developmental disabilities. Each State Supported Living Center (formerly known as state schools) is certified as an intermediate care facility for persons with intellectual disabilities (ICF/MR). Services include: 24-hour residential care, behavioral treatment series, health care services, PT, OT, speech therapy, skills training, vocational programs, services to maintain connection between residents and their families Texas Home Living Program services include: Adaptive aids, minor home modifications, specialized therapies, behavioral support, dental treatment, nursing, community support, respite care, day habilitation, employment assistance, supported employment Texas Medicaid Curriculum

39 Module 7 4/15/2017 Module 7 Primary Home Care Primary Home Care (PHC) provides attendant services to people with an approved medical need for assistance with personal care tasks. PHC is available to eligible adults whose health problems cause them to be functionally limited in performing activities of daily living according to a practitioner’s statement of medical need. Services can include having in-home attendants who help recipients with activities of daily living including: Bathing Grooming Meal preparation Housekeeping DADS Reference Guide page 25 On average, recipients are authorized to receive approximately 16.6 hours of assistance per week. They may use the traditional agency option or use the Consumer Directed Services (discussed later) option and in certain areas of the state. Eligibility Requirements. A recipient must: Be at least 21 years old. Be a full Medicaid recipient. Have a functional assessment score of 24 or greater. Have a functional limitation with at least one personal care task based on medical condition. Have a medical practitioner’s statement of medical need. Have an unmet need for purchased task(s). Texas Medicaid Curriculum

40 Home and Community-based Waivers
Module 7 4/15/2017 Module 7 Home and Community-based Waivers DADS waiver programs provide community- based services and supports for people who qualify for admission to institutional settings but have made the choice to receive receive services in the home or in a community setting as a cost effective alternative. DADS administers seven waiver programs and maintains interest lists for most programs. A person can be enrolled in only one waiver program at a time. Community-based Alternatives Community Living Assistance and Support Services Consolidated Waiver Program Deaf Blind Multiple Disabilities Medically Dependent Children Program Home and Community- based Services Texas Home Living Waiver DADS Reference Guide page 31 Most of these waiver programs are discussed elsewhere in this series. Because these are waiver programs, rather than entitlement programs, each is limited by capacity and funding, so enrollment is not guaranteed. Medicaid-eligible patients may be placed on interest lists pending space availability in these and other waiver programs. Texas Medicaid Curriculum

41 Day Activity and Health Services (DAHS)
Module 7 4/15/2017 Module 7 Day Activity and Health Services (DAHS) DAHS licensed facilities provide daytime services Monday through Friday to clients residing in the community in order to provide an alternative to placement in nursing facilities or other institutions. Eligibility Requirements: Full Medicaid recipient Medical diagnosis and physician’s orders requiring a licensed vocational nurse’s or a registered nurse’s care or have a functional disability related to the medical diagnosis One or more personal care or restorative needs that can be stabilized, maintained or improved by participation in DAHS Services can include nursing and personal care, noontime meal, snacks, transportation, social, educational, and recreational activities. DADS Reference Guide page 29 The DADS website includes a Long Term Care Reporting System (QRS) to allow clients and their families to find and evaluate long term care facilities in a particular geographic area. This website can be accessed at Texas Medicaid Curriculum

42 Hospice Care Services Medicaid recipients who no longer choose
Module 7 4/15/2017 Module 7 Hospice Care Services Medicaid recipients who no longer choose curative treatment and who have a physician’s prognosis of six months or less to live are eligible for Medicaid Hospice services. Service can be delivered in the following settings: Home-based care Community-based care Long-term care facilities (e.g. nursing homes) Eligibility Requirements: Hospice is for all age groups, including children, during their final stages of life. Hospice services can include: physician and nursing care, medical social services, counseling, home health aide, personal care, homemaker and household services, physical, occupational, or speech language pathology services DADS Reference Guide page 72 Additional services include bereavement counseling, medical appliances and supplies, drugs and biologicals, volunteer services, general inpatient care (short-term), respite care. Texas Medicaid Curriculum

43 Program for All-inclusive Care for the Elderly (PACE)
Module 7 4/15/2017 Module 7 Program for All-inclusive Care for the Elderly (PACE) Program for All-inclusive Care for the Elderly (PACE) programs coordinate and provide all needed preventive, primary, acute and long term care services so older individuals can continue living in the community. PACE utilizes interdisciplinary teams, including physicians, nurses, social workers, therapists, van drivers and aides, to exchange information and solve problems as the conditions and needs of PACE participants change. PACE Eligible Populations: Age 55 or older Meet the medical necessity for nursing facility admission Live in a PACE service area (Amarillo, El Paso, or Lubbock) Have limited income and countable resources DADS Reference Guide page 65 The facility shown here is La Paloma, the PACE facility in Lubbock. Texas Medicaid Curriculum

44 Module 7 4/15/2017 Module 7 PACE Services PACE uses a comprehensive care approach, providing an array of services for a capitated monthly fee. PACE provides all health-related services, including inpatient and outpatient medical care, and specialty services including: Dentistry Podiatry Social services In-home care Meals Transportation Day activities Housing assistance Nationally, the average age of PACE participants is 80 years old, and 93% live alone in the community. Seventy-five percent of participants are female. The average PACE participant has 7.9 medical conditions, many of which are chronic conditions including diabetes, dementia, coronary artery disease, and cerebrovascular disease DADS Reference Guide page 65 Texas Medicaid Curriculum

45 Consumer Directed Services (CDS)
Module 7 4/15/2017 Module 7 Consumer Directed Services (CDS) The CDS option allows Medicaid clients or their legally authorized representatives to serve as an employer and assume responsibility for screening, hiring, training and dismissing providers. Those who elect to use the CDS option must select a Consumer Directed Services Agency (CDSA) to conduct financial management services such as payroll and employer taxes. Benefits of Choosing CDS Control over who provides services and who comes into the home. Consumers train their own service providers and set their work schedule. Consumers set the pay and benefits within the funds allotted for their program. Most people who choose the CDS option do so because they want the independence that comes with employing the people who provide their services. CDS is the result of Senate Bill 1586, 76th Texas Legislature, which allows a voucher payment option that empowers consumers to make personal decisions related to the delivery of personal assistance and respite services within their current home and community-based program. Texas Medicaid Curriculum

46 Texas Medicaid Series Summary
Module 7 4/15/2017 Module 7 Texas Medicaid Series Summary Module 7 concludes the Texas Medicaid Medical and Dental Series for medical residents and students. The following slides provide a summary of the series. Texas Medicaid Curriculum

47 REVIEW: What is Medicaid?
Module 7 REVIEW: What is Medicaid? 4/15/2017 Module 7 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

48 REVIEW: The Medicaid Team
Module 7 4/15/2017 Module 7 HHSC: Single State Agency Providers: Medical, Dental and Other Services MCOs: Managed Care Organizations DSHS TMHP: Claims Administrator DARS DADS MAXIMUS: Medicaid and CHIP Enrollment Broker This slide was introduced in Module 1. Covering more than 3 million Texans requires a complex infrastructure, as shown above. ICHP: Quality Monitor Texas Medicaid Curriculum

49 REVIEW: What Does Medicaid Cover?
Module 7 4/15/2017 Module 7 REVIEW: What Does Medicaid Cover? Acute and preventive health care for all ages Physician visits Inpatient and outpatient services Pharmacy, lab, and radiology costs Long-term services for elderly and individuals with disabilities Mental health and substance abuse treatment PB 1-1 This slide was introduced in Module 1. In general, Medicaid covers acute health care for all ages. It also covers some long-term care for the elderly and disabled. Dental services are restricted to patients under age 21. Dental Services (for patients under the age of 21) Preventive Therapeutic Texas Medicaid Curriculum

50 REVIEW: Who is Eligible to Deliver Medicaid Funded Services?
Module 7 4/15/2017 Module 7 REVIEW: Who is Eligible to Deliver Medicaid Funded Services? Individual Health Care Providers Doctors, dentists, advanced practice registered nurses, physician assistants, physical therapists, optometrists, and psychologists Outpatient Facilities Rural health clinics, federally qualified health centers, school clinics, family planning agencies, and mental health centers Inpatient Facilities Hospitals and skilled nursing facilities Providers of Goods & Services Durable medical equipment, ambulance, pharmacies, radiology, and labs TMHP Provider Procedures Manual This slide was introduced in Module 1. TMHP is a contractual partnership that administers Medicaid claims and performs other services. The Texas Medicaid Providers Procedures Manual outlines policies and procedures relevant to participating providers. This manual can be found on the TMHP website by going to clinking on the “Providers” link, and then on the “Reference Material” link. You can also access the current manual from the web address provided below. The term “provider” is used extensively in Texas Medicaid, and includes a full range of individuals (doctors, dentists, advanced practice nurses), as well as facilities and groups. Provider enrollment is available online, through the TMHP website. Texas Medicaid Curriculum

51 REVIEW: How Many People Does Texas Medicaid Serve?
Module 7 4/15/2017 Module 7 REVIEW: How Many People Does Texas Medicaid Serve? How many individual Texans received Medicaid-funded services at some point in the year? About 4.57 million PB 5-3 This slide was introduced in Module 1. The “unduplicated count” is the number of Texans who received Medicaid-funded services at some point during the year. This number best answers the question of “How many individual Texans received Medicaid-funded services at some point in the year?” For SFY 2011, the unduplicated count was 4,567,077 patients, and includes all full benefit clients As a reminder the abbreviation SFY= State Fiscal Year, which is September 1 - August 31 (as opposed to FFY, Federal Fiscal Year). Texas Medicaid Curriculum

52 Texas Medicaid Spending The Major Categories
Module 1 Texas Medicaid Spending The Major Categories 4/15/2017 Module 7 By Services Type, State Fiscal Year 2011 House Appropriations Committee Presentation Source: Medicaid Management Information System (MMIS) Prepared by Strategic Decision Support, THHSC, April 2012 Note, due to rounding, totals may not add up exactly This slide, which was introduced in Module 1, shows the general categories of Medicaid Spending for FY 2011 Texas Medicaid Curriculum

53 REVIEW: What Does Medicaid Cost?
Module 7 4/15/2017 Module 7 REVIEW: What Does Medicaid Cost? In 1967, Texas Medicaid served fewer than 1 million people at a cost of less than $200 million In 2011, Texas Medicaid served more than 3 million people at a cost of $29.4 billion, representing about 26% of the total state budget Federal funds are based on the Federal Medicaid Assistance Percentage (FMAP) the matching rate that changes annually. For federal fiscal year (FFY) 2011, the Texas FMAP was 66.46%. PB 1-2 This slide was introduced in Module 1. Kaiser Commission on Medicaid Facts: The following slides take a look at Medicaid spending. The FMAP is derived from each state’s average per capita income, and is updated annually by the Centers for Medicare & Medicaid (CMS). Consequently, the percentage of total Medicaid spending that is paid with federal funds also changes annually. Because of the size of the Medicaid program, even small changes in the FMAP can result in federal funding fluctuations worth millions of dollars. Texas Medicaid Curriculum

54 REVIEW: What are Examples of Texas Medicaid Programs?
Module 7 4/15/2017 Module 7 REVIEW: What are Examples of Texas Medicaid Programs? Texas Health Steps Provides medical prevention and dental preventive/treatment services to eligible children Programs for Women and Children Programs for family planning and pregnant women, Medicaid Buy-In for Children, and women’s cancers Prescription Drugs Prescription medications through local pharmacies Behavioral Health Services Mental, emotional, and chemical dependency treatment for eligible patients This slide was introduced in Module 1. Long-Term Services and Supports Programs for those with physical, intellectual and developmental disabilities Texas Medicaid Curriculum

55 REVIEW: What is Texas Health Steps?
Module 7 4/15/2017 Module 7 REVIEW: What is Texas Health Steps? Perhaps the best known of Texas Medicaid programs is THSteps, which provides medial and dental preventive care and screening to eligible children. THSteps is the name for the federally-required Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in Texas. PB 6-3 This slide was introduced in Module 1. Module 3 deals extensively with Texas Health Steps. Perhaps the best known of Texas Medicaid programs is the support it provides to children for preventive care and screening. The EPSDT is part of the mandated coverage for children under 21, and therefore is included in the Medicaid coverage in all states. Module #3 will focus specifically on Texas Health Steps. Module 3 will focus specifically on Texas Health Steps. Texas Medicaid Curriculum

56 10 Myths About Medicaid Myths 1, 2 & 3
Module 7 4/15/2017 Module 7 10 Myths About Medicaid Myths 1, 2 & 3 MYTH 1: Medicaid is an antiquated program and needs to be modernized. MYTH 2: Medicaid is a rigid, one size fits all program. MYTH 3: Medicaid spending is out of control. FACT: Medicaid has demonstrated throughout its history that it is an innovative program and evolves with the changing American health care system. 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. FACT: The per enrollee cost growth in Medicaid (6.1 percent) is lower than the per enrollee cost growth in comparable coverage under Medicare (6.9), private health insurance (10.6), and monthly premiums for employer-sponsored insurance (12.6). Medicaid is a program that is most in demand when the country is experiencing economic difficulties. Because Medicaid has such a diverse set of obligations and is run jointly by federal and state governments, it is the subject of a number of myths and misunderstandings This list of Myths and Facts was prepared by the Kaiser Commission on Medicaid and the Uninsured. Texas Medicaid Curriculum

57 10 Myths About Medicaid Myths 4, 5, 6 & 7
Module 7 4/15/2017 Module 7 10 Myths About Medicaid Myths 4, 5, 6 & 7 MYTH 4: Medicaid provides “Cadillac” insurance coverage that is more than a person needs. MYTH 5: Medicaid covers too many people and crowds out private health insurance. MYTH 6: Medicaid is a welfare system for people who don’t work. FACT: The Medicaid program serves several populations that require services not readily available in standard health insurance plans. FACT: Most of the people covered by Medicaid do not have access to other insurance, because they can’t afford, their employers don’t offer coverage, or they are priced out of the private market due to illness or disability. FACT: Sixty-five percent of people who receive Medicaid are from working families. MYTH 7: Medicaid pays the nursing home bill for wealthy seniors. Because Medicaid has such a diverse set of obligations and is run jointly by federal and state governments, it is the subject of a number of myths and misunderstandings This list of Myths and Facts was prepared by the Kaiser Commission on Medicaid and the Uninsured. FACT: Medicaid eligibility is limited to the very poor or those with large health expenses who have depleted their savings. Texas Medicaid Curriculum

58 10 Myths About Medicaid Myths 8, 9 & 10
Module 7 4/15/2017 Module 7 10 Myths About Medicaid Myths 8, 9 & 10 MYTH 8: Medicaid’s open-ended federal financing encourages overspending. MYTH 9: The Medicaid program is inefficient. MYTH 10: Medicaid is a poor-quality program that has little impact on access to care or health and people on Medicaid dislike the program. FACT: During the most recent economic downturn, states worked hard to contain costs in their programs even as they served more people. FACT: Medicaid compares favorably to other parts of the American health system when measuring administrative efficiency and per enrollee costs. FACT: FACT: Medicaid has secured access to primary and preventive health care for its beneficiaries that is comparable to that of the privately insured and greatly exceeds that of the uninsured Because Medicaid has such a diverse set of obligations and is run jointly by federal and state governments, it is the subject of a number of myths and misunderstandings This list of Myths and Facts was prepared by the Kaiser Commission on Medicaid and the Uninsured. Texas Medicaid Curriculum

59 Why Take Medicaid Patients?
Module 7 4/15/2017 Module 8 Why Take Medicaid Patients? We treat patients based on need, not on their ability to pay cash. We take all comers. I love delivering babies and taking care of kids, and in Texas if you want to do OB and kids, its hard to do enough volume if you don't take Medicaid. The Texas Health Steps program through Texas Medicaid is such a good evidenced-based model for all well child checks, that we use the same guidelines and forms for all of our well child checks, Medicaid or not. Dr. K, Family Physician Why take Medicaid patients? Some thoughts from a practicing physician who chooses to include Medicaid patients in the patient panel. Texas Medicaid Curriculum

60 Test Your Knowledge about Insurance: True or False?
Module 7 4/15/2017 Module 7 Test Your Knowledge about Insurance: True or False? Medicaid covers only behavioral health services provided by a psychiatrist. FALSE: Medicaid covers mental health services provided by Psychiatrists, Primary Care Physicians, Psychologists, Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists Only medications listed on the Preferred Drug List (PDL) are reimbursable through Texas Medicaid. FALSE: Medications not on the PDL can be prescribed but require prior authorization. Medications on the PDL do not require prior authorization. Texas Medicaid must cover all medications for which a manufacturer offers a rebate. TRUE: The Omnibus Budget Reconciliation Act of 1990 requires that drug manufacturers pay medication rebates for drugs dispensed under state Medicaid programs. It’s time to test what you’ve learned about Texas Medicaid in Module 7. Reference slides for each question: Q1: Slide 8 Q2: Slide 21 Q3: Slide 19 Texas Medicaid Curriculum

61 Test Your Knowledge about Insurance: True or False?
Module 7 4/15/2017 Module 7 Test Your Knowledge about Insurance: True or False? PACE programs coordinate and provide preventive, primary, acute and long term care services for elderly individuals who live in the community. TRUE: Program for All-inclusive Care for the Elderly (PACE)utilizes interdisciplinary teams, including physicians, nurses, social workers, therapists, van drivers and aides, to exchange information and solve problems as the conditions and needs of PACE participants change. Hospice is for all age groups, including children, during their final stages of life. TRUE: All Medicaid recipients who no longer want curative treatment and who have a physician’s prognosis of six months or less to live are eligible for Medicaid Hospice services. Reference slides for each question: Q4: Slide 41 Q5: Slide 40 Texas Medicaid Curriculum

62 Module 7 4/15/2017 Module 7 Medicaid Resources Texas Health & Human Services Commission Texas Medicaid & Health Care Partnership Texas Medicaid Provider Procedures Manual Texas Health Steps CHIP/ Children’s Medicaid DADS Long-term Services and Supports: cfoweb.dads.state.tx.us/referenceguide/guides/FY11ReferenceGuide.pdf Medicare Information These web-based resources are available for more information on various aspects of Texas Medicaid. Texas Medicaid Curriculum

63 This Texas Medicaid curriculum was prepared by
Module 7 4/15/2017 This Texas Medicaid curriculum was prepared by Betsy Goebel Jones, EdD Project Director Tim Hayes, MAM Project Designer Authors: Module 7 Betsy Goebel Jones, EdD David RM Trotter, MA Module 7 Texas Medicaid Curriculum


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