1. TA Partnership SUSTAINABILITY: MEDICAID AND OTHER HEALTH INSURANCE MARY B. TIERNEY, M.D. September 25, 2003 MARY B. TIERNEY, M.D. September 25, 2003

2. TA Partnership OTHER FINANCING PROGRAMS State Children’s Health Insurance Program (CHIP) – Title XXI of the Social Security Act Maternal and Child Health Block Grant – Title V of the Social Security Act

3. TA Partnership CHIP Eligibility Services Trends

4. TA Partnership CHIP ELIGIBLITY Compared to Medicaid eligibility standards are very flexible States must submit plans to CMS for approval low-income children and: May not cover children with higher incomes than those who are already targeted May not deny eligibility based upon a pre-existing medical condition

5. TA Partnership ELIGIBILITY SCREENING AND COORDINATION WITH OTHER HEALTH COVERAGE Intake and follow-up screening assures that only the targeted children are enrolled Children found to be eligible for Medicaid are enrolled in that program Ensure that CHIP does not substitute for insurance provided by group commercial health plans Assure that there is coordination with other public and private programs

6. TA Partnership OTHER ELIGIBILITY ISSUES States must submit and obtain approval of plans to inform of the availability of this coverage Immigrant eligibility for CHIP including residency requirements and reasons for immigrating

7. TA Partnership COVERAGE REQUIREMENTS Medicaid Expansion Create or expand a new program Combination of both

8. TA Partnership COVERAGE OF BASIC SERVICES Inpatient and outpatient hospital services Physician surgical and medical services Laboratory and x- ray services Well child care including appropriate immunizations

9. TA Partnership COVERAGE OF ADDITIONAL SERVICES Prescription Drugs Mental Health Services Vision Services Hearing Services Any other additional Services that a state wishes to provide and is approved by HHS

10. TA Partnership MEDICAID EXPANSION If a state chooses to implement a Medicaid expansion, it must offer the newly eligible individuals the same Medicaid benefits 19 States have chosen to implement Medicaid expansions

11. TA Partnership CREATE OR EXPAND A STATE PROGRAM States choosing to implement a State program must choose from 5 basic options 19 States have chosen this option

12. TA Partnership CREATE OR EXPAND A STATE PROGRAM The Blue Cross/Blue Shield preferred provider option offered to Federal employees State employees health plan The HMO with the largest insured commercial enrollment Coverage that is actuarially equivalent to the previous 3 plans Another benefit package approved by the Secretary, HHS

13. TA Partnership COST SHARING States can impose cost sharing for adults receiving Medicaid under CHIP if they are at or above 150% FPL States can impose cost sharing for children at or above 150% FPL on a sliding scale but no more than 5% of the family income

14. TA Partnership STATE CHILD HEALTH INSURANCE PROGRAM PLAN ACTIVITY MAP

15. TA Partnership 26 states (including DC): < 200% FPL 12 states: > 100% but < 185% FPL 6 states: > 200% but < 250% FPL 7 states: > 250% FPL Note: Vermont and Nevada covered 18 year olds at lower income levels than younger adolescents. Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002 Medicaid and SCHIP Eligibility for Adolescents Under age 19, Highest Income Thresholds as a Percentage of FPL as of September 30, 2001

16. TA Partnership SCHIP Enrollees by Age Group and Program Type, FY 2001* * Reflects those ever-enrolled during FFY 2001. Source: CAHL analysis of data provided by CMS Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

17. TA Partnership Percent of Children and Adolescents Who Were Uninsured During 2001 Source: US Census Bureau, Sept. 2002 Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

18. TA Partnership Threats to Medicaid and SCHIP Increasing demand and need for public coverage  Poverty rate increased  High rates of unemployment  Rapidly rising health care costs  Reductions in private coverage States’ ability to meet current and increased demand is severely constrained Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

19. TA Partnership Federal Funding for SCHIP (in $Billions) Source: Balanced Budget Act of 1997 Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

20. TA Partnership OMB Projections for SCHIP Enrollment Source: Center on Budget and Policy Priorities, Aug. 2002 Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

21. TA Partnership MATERNAL AND CHILD HEALTH BLOCK GRANT Original grants authorized payments to States to reduce maternal mortality – in 1929 Title V of the Social Security Act signed by FDR in 1935 Title V included services for “maternal and child care,” “child welfare” and “crippled children”

22. TA Partnership MATERNAL AND CHILD HEALTH BLOCK GRANT In 1981and again in 1989, the legislation was amended to become a Block Grant to State Maternal and Child Health (MCH) agencies

23. TA Partnership MCH BLOCK GRANT MISSION  Provide access to prenatal care for low-income women  Provide preventive services including immunizations, health assessments, among others  Promote provision of family centered, community- based, culturally competent, coordinated care for children with special needs

24. TA Partnership ALLOTMENT OF FUNDS Funding for State MCH agencies for state- wide needs assessment, coordination and consultation with other family-serving agencies including Medicaid/CHIP, Mental Health, development and setting standards of care, care management Funding is not to be used for direct payment for health care services unless health insurance coverage is not available

25. TA Partnership SPECIAL PROJECTS Bright Future series including Bright Futures in Practice: Mental Health Collaborative grants with a new emphasis on mental health and early intervention as part of their children with special needs Potential collaboration between health and mental health

26. TA Partnership REFERENCES www.cms.gov www.aap.org www.aap.org/advocacy/schipsum.htm www.mchb.hrsa.gov www.kff.org http://www.kff.org/sections.cgi?section= kcmuhttp://www.kff.org/sections.cgi?section= kcmu

27. TA Partnership Mary B. Tierney, MD Primary Care Senior Advisor TA Partnership 202-298-2620 (office) 202-342-5007 (fax) mtierney@air.org (email)