FINANCING SYSTEMS OF CARE Part 1 Mary B. Tierney, MD Primary Care Senior Advisor TA Partnership August 7, 2003

Technical Assistance Partnership for Child and Family Mental Health BACKGROUND AND HISTORY Social Security Act Title I – Old Age AssistanceTitle I – Old Age Assistance Title IV – AFDC/TANF and Foster CareTitle IV – AFDC/TANF and Foster Care Title V – Maternal and Child Health Block GrantTitle V – Maternal and Child Health Block Grant Title XVI – SSI/Aged Blind and DisabledTitle XVI – SSI/Aged Blind and Disabled Title XVIII – MedicareTitle XVIII – Medicare Title XIX – MedicaidTitle XIX – Medicaid Title XXI - SCHIPTitle XXI - SCHIP

Technical Assistance Partnership for Child and Family Mental Health FEDERALLY FUNDED INSURANCE AND ELIGIBILITY REQUIREMENTS ELIGIBILITY –Title I of the Social Security Act/Social Security –TANF/Title IV –SSI/Title XVI –Pregnant women, children, and other categories –Flexible eligibility INSURANCEINSURANCE –Medical/Title XVIII of the Social Security Act –Medicaid/Title XIX –SCHIP/Title XXI

Technical Assistance Partnership for Child and Family Mental Health MEDICAID Federal/State PartnershipsFederal/State Partnerships State Agency RequirementsState Agency Requirements EligibilityEligibility ServicesServices Payment for ServicesPayment for Services

Technical Assistance Partnership for Child and Family Mental Health SCHIP Medicaid Expansion ModelMedicaid Expansion Model Separate ProgramSeparate Program Which States have What ModelWhich States have What Model

Technical Assistance Partnership for Child and Family Mental Health MEDICAID FEDERAL/STATE PARTNERSHIP Federal Statute and Regulations Govern Overall ProgramFederal Statute and Regulations Govern Overall Program State Plan RequirementsState Plan Requirements State Plan FlexibilityState Plan Flexibility Federal MatchFederal Match Federal Financial Participation (FFP) Federal Medical Assistance Percentage (FMAP)

Technical Assistance Partnership for Child and Family Mental Health STATUTORY, REGULATORY REQUIREMENTS There are stringent Federal requirements on Medicaid State agencies with regard to:There are stringent Federal requirements on Medicaid State agencies with regard to: Administration of the program, i.e., State PlanAdministration of the program, i.e., State Plan Hiring and subcontractingHiring and subcontracting Submitting correct and valid reportsSubmitting correct and valid reports [Sections 1902 (a) (4) – 1902 (a) (6)][Sections 1902 (a) (4) – 1902 (a) (6)]

Technical Assistance Partnership for Child and Family Mental Health States must meet all Federal mandates with regard to eligibility, services, administrationStates must meet all Federal mandates with regard to eligibility, services, administration States have flexibility to design their programs in those areas where the Federal statute and regulations gives them latitude in eligibility and servicesStates have flexibility to design their programs in those areas where the Federal statute and regulations gives them latitude in eligibility and services STATE PLAN REQUIREMENTS AND FLEXIBILITY

Technical Assistance Partnership for Child and Family Mental Health FEDERAL MATCH FFPFFP FMAPFMAP Generally at 50% 75% for Case Management, Maintenance of MIS Ranges from 50 – 83%

Technical Assistance Partnership for Child and Family Mental Health ELIGIBILITY OVERVIEW Financial StandardsFinancial Standards Categories of EligibilityCategories of Eligibility

Technical Assistance Partnership for Child and Family Mental Health FINANCIAL STANDARDS Income Standard – maximum amount of income a person can have and be eligible for Medicaid including wages, salary and unearned income such as social securityIncome Standard – maximum amount of income a person can have and be eligible for Medicaid including wages, salary and unearned income such as social security Resource Standard – anything a person owns that can be converted into cash including automobiles, real estateResource Standard – anything a person owns that can be converted into cash including automobiles, real estate

Technical Assistance Partnership for Child and Family Mental Health CATEGORIES OF ELIGIBILITY Mandatory CoverageMandatory Coverage Optional Groups with FFPOptional Groups with FFP Optional Groups without FFPOptional Groups without FFP

Technical Assistance Partnership for Child and Family Mental Health MANDATORY COVERAGE Categorically Needy Families and ChildrenCategorically Needy Families and Children Aged, Blind and DisabledAged, Blind and Disabled

Technical Assistance Partnership for Child and Family Mental Health FAMILIES AND CHILDREN HIGHLIGHTS Low Income Families with ChildrenLow Income Families with Children TANF/AFDC RecipientsTANF/AFDC Recipients Families that Lost TANF/AFDC because of EmploymentFamilies that Lost TANF/AFDC because of Employment Qualified Pregnant Women and ChildrenQualified Pregnant Women and Children Newborn Children of Medicaid Eligible Children Low Income Children under Age Six Low Income Children under Age Nineteen Foster Care and Adoption Assistance

Technical Assistance Partnership for Child and Family Mental Health AGED, BLIND & DISABLED SSI RecipientsSSI Recipients Disabled Adult ChildrenDisabled Adult Children Zebley v. Sullivan DecisionZebley v. Sullivan Decision

Technical Assistance Partnership for Child and Family Mental Health OPTIONAL GROUPS HIGHLIGHTS Infants to age 1 year and Pregnant Women below 185% FPLInfants to age 1 year and Pregnant Women below 185% FPL Individuals Eligible for assistance who are in institutionsIndividuals Eligible for assistance who are in institutions Individuals Receiving Home and Community Based ServicesIndividuals Receiving Home and Community Based Services Noninstitutionalized Disabled Children (Katie Beckett) Children under 21 years who meet income requirements but not eligible for TANF Ribicoff Kids

Technical Assistance Partnership for Child and Family Mental Health MEDICAID SERVICES CATEGORICALLY NEEDY Inpatient hospital servicesInpatient hospital services Outpatient hospital servicesOutpatient hospital services Rural Health Clinic ServicesRural Health Clinic Services Federally Qualified Health CentersFederally Qualified Health Centers Nursing Facilities other than IMD for over age 21 years EPSDT under age 21 years Family Planning Physician services

Technical Assistance Partnership for Child and Family Mental Health MEDICAID SERVICES CATEGORICALLY NEEDY Medical and dental surgical servicesMedical and dental surgical services Pediatric and Family Practice Nurse PractitionersPediatric and Family Practice Nurse Practitioners Nurse MidwivesNurse Midwives Health care by licensed practitioners (e.g. Psychologists) Laboratory and X-Ray Home Health

Technical Assistance Partnership for Child and Family Mental Health MEDICAID SERVICES MEDICALLY NEEDY Prenatal care and deliveryPrenatal care and delivery Ambulatory care for individuals under 18 years and those entitled to institutionsAmbulatory care for individuals under 18 years and those entitled to institutions ICF/MR and IMD provision Most States that cover the Medically Needy category provide preventive services and additional services outlined above for Categorically Needy

Technical Assistance Partnership for Child and Family Mental Health OPTIONAL SERVICES Physical and Occupational TherapyPhysical and Occupational Therapy Prescription drugsPrescription drugs Diagnostic, screening, preventive and rehabilitative servicesDiagnostic, screening, preventive and rehabilitative services Personal care servicesPersonal care services Any other medical or remedial care recognized under State law and specified by the Secretary of HHSAny other medical or remedial care recognized under State law and specified by the Secretary of HHS

Technical Assistance Partnership for Child and Family Mental Health Services must be sufficient in the amount duration and scope to reasonably achieve its purposeServices must be sufficient in the amount duration and scope to reasonably achieve its purpose EPSDT – health services determined to be necessary must be provided whether or not they are included in the State PlanEPSDT – health services determined to be necessary must be provided whether or not they are included in the State Plan Waivers can expand services to specific populationsWaivers can expand services to specific populations AMOUNT, DURATION AND SCOPE

Technical Assistance Partnership for Child and Family Mental Health PAYMENT FOR SERVICES Institutional services including inpatient and emergencyInstitutional services including inpatient and emergency Ambulatory servicesAmbulatory services Case Management and Wrap-AroundCase Management and Wrap-Around

Technical Assistance Partnership for Child and Family Mental Health REFERENCES

Technical Assistance Partnership for Child and Family Mental Health An Advocate's Guide to the Medicaid Program 2001 Edition – –An Advocate's Guide to the Medicaid Program (159 pages) is an essential resource for health advocates and lawyers working with the Medicaid program. –Price: $ for nonprofit advocacy organizations (Add $15.00 each for CD-ROM or online access) –$ for for-profit entities, government agencies, and educational institutions (Add $15.00 each for CD-ROM or online access) – Phone NHeLP's Los Angeles office at (310)

Technical Assistance Partnership for Child and Family Mental Health Mary B. Tierney, MD Primary Care Senior Advisor TA Partnership (office) (fax) ( )