1 Cindy Mann, JD Director Center for Medicaid and State Operations Centers for Medicare & Medicaid Services Institute of Medicine April 16, 2010 Cindy Mann, JD Director Center for Medicaid and State Operations Centers for Medicare & Medicaid Services Institute of Medicine April 16, 2010 Medicaid and HIV: New Opportunities in a Changing Landscape

Medicaid: An Overview Medicaid serves 60 million people each year  50 percent children, who account for less than 20 percent of the expenditures  Medicaid pays for nearly 50% of ALL births in the U.S. each year  25 percent disabled and elderly, who account for nearly 70 percent of the cost  40% of all Medicaid expenditures are for dual eligibles Medicaid serves 60 million people each year  50 percent children, who account for less than 20 percent of the expenditures  Medicaid pays for nearly 50% of ALL births in the U.S. each year  25 percent disabled and elderly, who account for nearly 70 percent of the cost  40% of all Medicaid expenditures are for dual eligibles

Medicaid Overview Before Reform:  Eligibility based on “categorical” and financial eligibility Categories: children, parents, people with disabilities, pregnant women, elderly Categories: children, parents, people with disabilities, pregnant women, elderly  Leaves a large gap Before Reform:  Eligibility based on “categorical” and financial eligibility Categories: children, parents, people with disabilities, pregnant women, elderly Categories: children, parents, people with disabilities, pregnant women, elderly  Leaves a large gap

Medicaid Overview  Major player in the health care system (15% of national health care expenditures in 2008)  Most people covered have lower incomes and are in poorer health than the general population  Expenditures highly skewed

Source: FY MSIS 2008, FY MSIS 2007 for AZ, NC, ND, HI, UT, VT, WI Source: FY MSIS 2008, FY MSIS 2007 for AZ, NC, ND, HI, UT, VT, WI

Medicaid is Performing Well  Medicaid covered an additional 3.3 million people from June 2008 – June 2009, as the economy worsened  Studies show that enrollment is directly correlated with improved access to care  Generally offers a package of benefits more geared to the needs of our beneficiaries than commercial products

Also Facing Many Challenges  States pay share of the cost State budget pressures State budget pressures Rising health care costs Rising health care costs  Generally high beneficiary satisfaction, but some access issues  Data needed to help guide the program is lacking  States pay share of the cost State budget pressures State budget pressures Rising health care costs Rising health care costs  Generally high beneficiary satisfaction, but some access issues  Data needed to help guide the program is lacking

Medicaid Expenditures by Population: Source: CMS Office of the Actuary, President’s FY 2011 Budget Disabled & Elderly Families & Children Disabled & Elderly Families & Children (in billions)

Medicaid and HIV  Medicaid is the largest single source of care and coverage for people with HIV $8 billion in combined federal/state spending in FY 2009 $8 billion in combined federal/state spending in FY 2009 Projected federal spending in FY 2011 $5.1 billion Projected federal spending in FY 2011 $5.1 billion  4 in 10 HIV/AIDS patients receive services through Medicaid  70% of people with HIV who qualify for Medicaid are low-income AND disabled. Source: Kaiser Family Foundation, “HIV/AIDS Policy Fact Sheet,” February 2009; available at  Medicaid is the largest single source of care and coverage for people with HIV $8 billion in combined federal/state spending in FY 2009 $8 billion in combined federal/state spending in FY 2009 Projected federal spending in FY 2011 $5.1 billion Projected federal spending in FY 2011 $5.1 billion  4 in 10 HIV/AIDS patients receive services through Medicaid  70% of people with HIV who qualify for Medicaid are low-income AND disabled. Source: Kaiser Family Foundation, “HIV/AIDS Policy Fact Sheet,” February 2009; available at

Federal Spending on HIV Care: FY 2008 Total $11.6 billion $4.5 $4.1 $2.2 $0.8

Medicaid and HIV  Medicaid covers: Medically necessary and routine HIV testing/screening required for children through EPSDT/well-child care Medically necessary and routine HIV testing/screening required for children through EPSDT/well-child care Testing for adults covered under mandatory lab benefit Testing for adults covered under mandatory lab benefit State option to cover testing as preventive benefit State option to cover testing as preventive benefit Prescription drugs Prescription drugs June 24, 2009 letter to SMDs June 24, 2009 letter to SMDs

Medicaid and HIV  14 States offer home and community-based waiver services specifically designed for individuals with HIV  2 States (DC and Maine) have section 1115 waivers in place  Ticket to Work demonstration  Prescription drug costs have shifted to Medicare but remain critical

Medicaid and HIV: Challenges  Being HIV positive does not automatically qualify as a disability  Provider participation/payment rates  Need to do more to ensure/promote testing  Prohibitions on payment for testing in prisons/other public institutions  Many uninsured are income eligible for Medicaid or CHIP but are not enrolled

Health Reform Is Here!!

Coverage Guarantees Rely on ESI, Exchange, Medicaid/CHIP Coverage Guarantees Rely on ESI, Exchange, Medicaid/CHIP Medicaid/CHIPMedicaid/CHIP ExchangeExchange ESIESI

Source: Congressional Budget Office, 3/11/2010 Projected Changes in Insurance Coverage (2019) Total new coverage = 31 million 24m24m 16m16m -4m -5m

Putting Medicaid into Reform: Eligibility Expansion  By January 2014, nonelderly individuals with incomes up to 133% of the FPL ($24,400 for a family of 3) will be eligible for Medicaid. Simplified rules-- ends the “categorical gap” Simplified rules-- ends the “categorical gap”  Significant increase in federal support for Medicaid/CHIP

Transition to a New Medicaid Program  Early option to receive FFP for covering low-income adults beginning April 1, See See  To avoid cost shifting and not lose coverage:  Medicaid eligibility MOE until 2014  Medicaid and CHIP eligibility for children is maintained through 2019

New Paradigm  Reform is predicated on the principle that everyone who is eligible is enrolled; and that coverage is stable Necessary for coverage, cost containment and quality Necessary for coverage, cost containment and quality  Essential to make a system out of different components  Clear focus on prevention  Reform is predicated on the principle that everyone who is eligible is enrolled; and that coverage is stable Necessary for coverage, cost containment and quality Necessary for coverage, cost containment and quality  Essential to make a system out of different components  Clear focus on prevention

Putting Reform into Medicaid  Creating a high performing Medicaid Program  Eligible means enrolled  Access issues  Systems upgrades and Data/Performance measures  Payment and delivery systems reform  Continuing to make progress “(re)balancing” long term- care service and supports  Assuring program integrity  Creating a high performing Medicaid Program  Eligible means enrolled  Access issues  Systems upgrades and Data/Performance measures  Payment and delivery systems reform  Continuing to make progress “(re)balancing” long term- care service and supports  Assuring program integrity

(Some) Next Steps  Promoting testing Identifying good models, eliminating barriers Identifying good models, eliminating barriers  Identifying and resolving access issues  Working with “early adopter” states  Establishing strong networks, outreach/enrollment mechanisms for 2014 eligibility changes