1. + March 5, 2014 Session 2: Public Insurance

2. + Objectives Provide foundational background for learning Public Insurance Introduce key types of Public Insurance and their components related to Part C Display public insurance information from the 2012 ITCA Financial Survey and what forms of Public Insurance state Part C systems are accessing Highlight developments and directions in State Public Insurance programs and opportunities they may offer Part C systems 2

3. + Overview Medicaid Background Eligibility and Benefits Medicaid Waivers Early Periodic Screening Detection Treatment (EPSDT) Children’s Health Insurance Program (CHIP) Delivery systems and sources of State share National Part C uses of Medicaid and CHIP Recent Developments, future directions, and opportunities 3

4. + Medicaid Background State and Federal Financing Federal Medical Assistance Percentage (FMAP)* 50% - 76% 2014 ACA – 100% Federal 50% Administrative Claiming No Cap on Federal Dollars Waiver exception Entitlement Program State Eligible Individual 4

5. + Medicaid Background (continued) Covers nearly 1/3 of all children in the United States State administered program Eligibility standards Payment rates Benefits Packages Administration policies Medicaid State Plan serves as the contract between the State and CMS 5

6. + Medicaid Background (continued) Medicaid/CHIP Program Information http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-State/By-State.html http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-State/By-State.html State Plan Amendments http://www.medicaid.gov/Stat e-Resource-Center/Medicaid-State-Plan- Amendments/Medicaid-State-Plan- Amendments.html http://www.medicaid.gov/Stat e-Resource-Center/Medicaid-State-Plan- Amendments/Medicaid-State-Plan- Amendments.html 6

7. + Medicaid Eligibility General Eligibility Children in Foster Care Low Income Families with Children People receiving SSI due to disability People over 65 Optional Eligibility Higher Income Medically needy Other Groups 7

8. + Medicaid Background Eligibility and FMAP Under ACA Single Standard Under 65: income < 133% of federal poverty level ($25,390 for family of three) FMAP 100% from 2014-2016 Gradual decline to 90% by 2020 8

9. + Medicaid Eligibility (continued) Eligibility Criteria: Required for: children birth to 5 with family incomes below 133% of FPL children 6 through 18 with incomes below 100% of FPL Optional for: Children at higher income levels Children with severe disabilities who live at home but qualify for institutional care – Katie Beckett waiver Children who meet SSI disability criteria with income less that 300% - buy-in 9

10. + Medicaid Benefits Mandatory Benefits: Inpatient and Outpatient Hospital Services Physician Services Early Periodic Screening, Diagnosis and Treatment (EPSDT) Family Planning services and supplies Nursing Facilities Certified Pediatric and Family Nurse Practitioner services Laboratory and X-ray Services Tobacco cessation for pregnant women Transportation for non-emergency medical services Home Health services Rural health clinic services Federally qualified health center services Nurse Midwife services Freestanding Birth Center services (licensed or otherwise recognized by state) 10

11. + Medicaid Benefits (continued) Optional Benefits include: Prescription Drugs OT, PT and Speech Therapy Optometry Targeted case management Skilled Nursing Facilities for children under 21 Rehabilitative services Personal Care services Private Duty Nursing services Dental services Hospice services Inpatient psychiatric services for children under 21 Medical and remedial care from other licensed providers includes psychologists 11

12. + Medicaid Cost Participation In some situations states may require cost sharing. Children are exempt from : Copayments Deductibles Co-insurance Cost-sharing 12

13. + Medicaid Waivers Request to CMS to “waive” certain requirements Statewide availability Freedom of choice of providers Universal access to all benefits Must have cost neutrality Cannot cost the federal government no more than the amount projected if there was no waiver Caps for numbers served 13

14. + Medicaid Waivers 1115 Research and Demonstration 1915 (b) - Managed Care 1915 © Home and Community-based Services http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Waivers/Waivers.htmlervices 14

15. + EPSDT “The EPSDT program consists of two mutually supportive, operational components: assuring the availability and accessibility of required health care resources; and helping Medicaid recipients and their parents or guardians effectively use them.” 15

16. + EPSDT (continued) Benefits for children are guaranteed and are required to prevent as well as treat conditions. Treatment is defined as: Necessary health care diagnosis services, treatment, and other measures classified as medical assistance to correct or ameliorate defects and physical and mental health conditions discovered by screening services, whether or not such services are covered under the state medical assistance plan 16

17. + EPSDT (continued) EPSDT also requires states to do more than merely offer to cover services. States are obligated to actively arrange for treatment, either by providing the service itself or through referral to appropriate agencies, organizations or individual 17

18. + Early Periodic Screening Diagnosis Treatment (EPSDT) Benefits Screening through Comprehensive Well-Child Exams: Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations Laboratory tests Health Education Vision, hearing and dental screening in primary care Diagnosis Treatment Other Necessary Health Care 18

19. + Children’s Health Insurance Program (CHIP) Exclusively for Children If a state chooses, for pregnant women Also State/Federal Partnership Higher match rate Highest income level is 405% 14 states above 300% (5 additional with Medicaid) 10 states between 235-290% 20 states at 200 -235% 2 states < 200% 19

20. + 20 Notes: Eligibility levels are based on 2013 federal poverty levels. January 2014 income limits reflect MAGI converted income standards, and include a 5 percentage point of federal poverty level disregard. Eligibility standards include CHIP-funded Medicaid expansions. Eligibility levels are based on a family of three. Eligibility levels reflect state decisions on the Medicaid expansion as of September 30, 2013, available here. Per CMS guidance, there is no deadline for states to implement the Medicaid expansion. Eligibility limits for adults in Michigan, reflect levels effective April 2014, when the state plans to adopt the Medicaid expansion. This table does not include notations of states that have elected to provide CHIP coverage from conception to birth.Eligibility levels reflect state decisions on the Medicaid expansion as of September 30, 2013, available here. Per CMS guidance, there is no deadline for states to implement the Medicaid expansion. Eligibility limits for adults in Michigan, reflect levels effective April 2014, when the state plans to adopt the Medicaid expansion. Medicaid/ CHIP Income Eligibility Limits Children Birth to 5, Effective January 1, 2014 Data from Kaiser Family Foundation: http://kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for- children-at-application-effective-january-1-2014http://kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for- children-at-application-effective-january-1-2014

21. + CHIP (continued) Capped federal funds Increased flexibility Medicaid expansion Separate program Combination Benefits Link to the CMS Website with State by State and program wide information. http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Childrens-Health-Insurance- Program-CHIP/Childrens-Health-Insurance-Program- CHIP.htm http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Childrens-Health-Insurance- Program-CHIP/Childrens-Health-Insurance-Program- CHIP.htm 21

22. + CHIP Benefits Expansion – same as Medicaid Separate Program Benchmark Coverage Federal Employee Benefits State Employee Coverage HMO with largest commercial enrollment Benchmark Equivalent Coverage Coverage approved by HHS Comprehensive state-based coverage that existed when CHIP was enacted (FL, NY, PA) 22

23. + How Are Public Insurance Services Delivered? Managed Care Mandatory/Voluntary Prepaid/capitated (actuarially sound) Risk adjustment Some services may be carved out Fee for Service Combination Primary Care Case Management 23

24. + How do States fund their share of Medicaid ? CMS approved Medicaid State Plans include the source of the state share of Medicaid expenditures. CMS approved state plan amendments include the authorization of state funding sources as the federal financial participation (FFP) for the covered services. 24

25. + How do States fund their share of Medicaid ? Recognized sources of funding for the state share of Medicaid payments include: Legislative appropriations to the single state agency Inter-governmental transfers (IGTs) Certified public expenditures (CPEs) Permissible taxes and provider donations 25

26. + Part C Use of Public Insurance 26

27. + Public Insurance in Part C Systems FY 2012 ITCA Financial Survey States reported Public Insurance funding: $495,914,000 Federal Medicaid $335,900,000 State Medicaid Match $21,069,000 Managed Care (collected locally) $3,480,000 CHIP 27

28. + National Part C System Funding 28

29. + Assessing Factors Influencing Funding from Public Insurance What are the structures and relationships between your State’s Public Insurance and Part C systems? Are Part C services addressed in Medicaid State Plan? Under which sections? What types of providers deliver Part C services and does your Part C system, have a certification process? Has your state identified the sources for the state share? What percent of children in Part C are eligible and enrolled in Medicaid or CHIP? How do your Part C demographics and Medicaid and CHIP eligibility compare? Is the Part C system reaching families with Public Insurance eligible children? Is service coordination assisting families eligible for Public Insurance but not enrolled? 29

30. + FY 12 ITCA Finance Survey: 32 States and territories reported Medicaid as Part C system funding Part C System Funding States by Medicaid % of State Part C System Funding

31. + FY 12 ITCA Finance Survey: 34 States and territories reported using at least one type of Medicaid for Part C system funding Part C System Funding

32. + Infrastructure Number of States Funding Function with Medicaid /CHIP by Type AdminGenEPSDTRehab Managed Care WaiversCHIP State Administration 4331302 Local Administration 8031211 Eligibility Determination 4593736 IFSP Development 2592523 32

33. + Direct Services Number of States Funding Service with Medicaid/ CHIP by Type AdminGenEPSDTRehab Managed Care WaiversCHIP Assistive Technology111132936 Audiology2121431036 Family Train/ Counseling 25103525 Health211124917 Medical211124829 Nursing2111441037 Occupational Therapy2121461036 Physical Therapy2121461036 Psychology29133735 Respite1311101 Service Coordination5894532 Special Instruction24104432 Speech2121361036 Vision210114935 33

34. + Developments and Directions in Public Insurance 34

35. + Developments and Directions Nearly all states are developing and payment and delivery system reforms designed to: Improve quality Manage costs Better balance the delivery of long-term services and supports across institutional and community based settings Nearly all states developed at least one new policy to control Medicaid costs in the past two years. Most frequently states: Expanded Managed Care Initiated and Enhanced Care Coordination Strategies Increased Program Integrity Activities 35

36. + Directions: Managed Care The majority of states have expanded Medicaid Managed Care in recent years States are expanding both services (carved in) and populations covered Objectives of expanding Managed Care include: improvement in health plan performance increased health care quality improvement in health care outcomes 36

37. + Directions: Care Coordination All but six States reported new care coordination in FY 2012 and 2013 Care Coordination includes: Health Homes and Patient-Centered Medicaid Homes that focus on coordinating and integrating care for persons with chronic conditions and disabilities. Health/Medicaid Homes coordinate primary, acute, mental and behavioral health, and long term services and supports. 37

38. + Directions: Program Integrity Enhanced provider screening, use of various data bases for electronic verification, and advanced data analysis and predictive modeling Detailed utilization review of paid claims, access to other data including provider ownership and death records, increased targeted field audits Efforts to develop and increase collaborations across state agencies, private entities and CMS 38

39. + Medicaid Directors Top Issues and Challenges for FY 2014 and Beyond Development of new strategies to improve care, quality and outcomes which include: new requirements for MCOs and Health Homes coordination and integration of physical and behavioral health new quality improvement activities integrated with reimbursement methodologies Development of new systems of care for seniors and persons with disabilities including managed care and coordinated systems for dual eligibility beneficiaries 39

40. + Opportunities for Part C in changing public insurance systems State Plan Amendments negotiations are opportunities for the addition of Part C system services in State Plans Managed Care Contracts and Part C Systems State level system requirements for Part C providers and MCO relationships MCO facilitation of local level public awareness and child find activities including Physician / Health care referrals New waivers Part C systems accessing payments for services Waivers facilitating payment for populations and services within Part C systems 40

41. Thank you for your attention! This is the second of four webinars in a series on Part C Finance presented in 2014. Resources related to this call and other calls in the series are available at the following URL: http://ectacenter.org/~calls/2014/financepartc/financepartc.asp