Health Care Financing for Children and Youth This presentation may be shared. Please give credit as appropriate. Prepared by Kay Johnson, Johnson Group Consulting for CityMatCH Technical Assistance call March 18, MEDICAID 101

March, 2004 Medicaid 101: Basic facts vMedicaid is health care financing l It works like insurance but pays for many things most private insurance doesn’t cover. vMedicaid is a federal-state partnership l Some program rules are set by the federal government, others by the state. l Federal and state dollars pay for services.

Who is eligible for Medicaid? What special enrollment rules apply? MEDICAID ELIGIBILITY

March, 2004 Medicaid 101: Eligibility groups v Low income senior citizens v Low income children and pregnant women v Persons with physical and mental disabilities (including children) v Individuals receiving cash public assistance (welfare)

March, 2004 Eligibility for Children vChildren more likely than adults to be eligible. l Congress and states approved Medicaid expansions between  One main goal was to finance more prevention and early intervention. l Since 1996, the State Children’s Health Insurance Program (SCHIP) has covered more children.  In 21 other states SCHIP = Medicaid.  Medicaid-SCHIP expansions equalize benefits.

March, 2004 Eligibility for US Children l Federal law mandates:  Infants and children to age 6 up to 133% of poverty  Children ages 6-18 up to 100% of poverty l States have options to cover other children  Medicaid at any level  SCHIP up to 200% of poverty and above Birth to 6 Ages Mandated up to 100% of poverty Mandated up to 133% of poverty Optional Medicaid and/or SCHIP up to or above 200% of poverty

March, 2004 Benefits of Medicaid Expansion for Maternal & Child Health vMedicaid has: u Become an important source of insurance for working families. u Offset losses in employer coverage for dependents. u Provided comprehensive coverage for more children with special needs.

March, 2004 Medicaid Eligibility & Enrollment u Continued coverage once enrolled l guaranteed for pregnancy and 60 days after l guaranteed for infants through first year  Among those with birth financed by Medicaid most remain eligible throughout full 12 months. l optional 6 or 12 month continuous coverage for children older than age one  Instead of renewing coverage every month, family can renew for 6 or 12 month periods.

March, 2004 Medicaid Eligibility & Enrollment u Enrollment rules l Automatic enrollment for newborns required  All babies whose birth was paid for by Medicaid must be automatically enrolled.  Most babies qualify for first full year. l Expedited for children & pregnant women  Known as presumptive eligibility option  Means that some providers can “presume eligibility” based on income and certify temporary eligibility until the paperwork is done by the state.

What services are covered? What enhanced benefits are available to children under EPSDT? MEDICAID BENEFITS

March, 2004 Medicaid Benefits u Some federally mandated u Some optional selected by state u For children, more covered l all allowable under federal law l even if not in state plan u Kay says: “If its covered and approved for children in one state, it should be covered in all states.”

March, 2004 Medicaid Benefits States must cover: u Inpatient hospital services u Outpatient hospital services u Physician services u Nurse midwife and pediatric / family nurse practitioner services u Medical & surgical dental care u Laboratory & x-ray services u EPSDT services u Family planning services u Rural health clinic and federally- qualified health center services u Home health & nursing facilities Optional, covered for children as necessary u Prescription drugs u Dental services u Optometrist & eyeglasses u Mental health services u Prosthetic devices u Intermediate nursing facility / mental retardation services u Nursing facility for < age 21

March, 2004 EPSDT “We think of EPSDT as a set of requirements, not a specific service or benefit package.” Paul Wallace Brodeur Former Medicaid director, VT

March, 2004 EPSDT Framework v Follow the letters: E arly - starting before problems worsen P eriodic - at regular intervals & as needed S creening - comprehensive well child exams with developmental, physical, and mental, plus separate vision, hearing, dental D iagnosis - as appropriate T reatment - all services (covered under federal law) needed for diagnosed conditions

March, 2004 EPSDT offers unique benefit list vExamples of services covered for children, even if not included in state plan for adults l therapeutic child care, preschool, and school day treatment l case management l individual child care consultation l home visits/intensive home-based services l therapeutic behavioral health services l speech-language-hearing & physical therapy l eyeglasses, hearing aids, & assistive technology

March, 2004 EPSDT “Medical Necessity” “Medically necessary” services covered u EPSDT definition is broader than most private insurance plans u EPSDT purpose includes prevention & early intervention -- l if service will prevention condition l if service will improve health or ameliorate condition l if service will cure or restore health

March, 2004 Parent-Child Focus vMedicaid can support the family, even if only one child is eligible. u Examples: l Informing parents about coverage and available services l Parent health education & guidance l Parent-child mental health therapy l Foster parent support l Family-focused case management

March, 2004 Varieties of Case Management

How are Medicaid services financed? What are matching funds? MEDICAID FINANCING

March, 2004 Federal / State Matching vUnder a federal - state partnership u Federal financial participation (FFP) l Level set under federal law for each state. l FFP can vary by service. u States must provide matching funds. l States must come up with funds to “draw down” federal dollars. l Matching funds are generally state and local public dollars.

March, 2004 Medicaid Matching - CAUTIONS vTo match with Medicaid federal financial participation (FFP) u Cannot use other federal dollars u State dollars may be best source of match u Local dollars okay where available u Provider taxes and provider voluntary contributions not okay u Sometimes private funds okay l Tricky - needs state and federal approval

March, 2004 Federal / State Matching Rates

March, 2004 Medicaid & Private Insurance v. Dual coverage okay for some services. u Children who have private insurance can qualify for Medicaid, which may pay for services not covered in private and employer plans. u Dual coverage most valuable for children with special needs. u Medicaid pays last, after private coverage l known as “payer of last resort”

March, 2004 Medicaid Financing: State dollars vState must appropriate funds to match federal financial participation u general revenue dollars limited u legislature has to approve vMaximizing use of state dollars key u Use state general fund $ for matching u Use other federal program and private dollars for non-Medicaid activities

Who can be a provider and bill for Medicaid services? MEDICAID PROVIDERS

March, 2004 Medicaid Providers - who? vProviders must: u apply & be approved by the state u be licensed to practice in the state u be in a “qualified” category -- for example: l Physicians, nurses, dentists l Psychiatrists, psychologists, social workers l Hospitals, clinics, schools l Managed care plans l NOT professionals with education degrees only u be in state plan or subcontract with state

March, 2004 Medicaid Providers - special vA provider may be an individual or be an institution or facility. u Facilities may be reimbursed cover time of staff team, including some individuals who would not qualify as providers otherwise. l Hospital - physicians, nurses, nurses aides l Mental health center - therapists, aides l School - therapists, nurse, special ed. teachers l Managed care plans - medical & administrative staff

March, 2004 Medicaid Provider Payments v The state sets provider payment (fee) levels u Medicaid can pay fee-for-service or capitated. u Some federal rules apply u Under fee-for-service arrangements, Medicaid may pay at cost or usual fee for services l Except for federally qualified health centers (and some other types of clinics), no set way of assessing the cost of doing business l Facilities are more likely to be paid on cost basis

ligible child ligible service ligible provider MEDICAID Summary

March, 2004 Summary: Eligible children vNationally: u Over 40% of births nationally u 1 in 3 toddlers u 1 in 4 preschoolers u 1 in 5 school age and teen age vMillions of eligible children not enrolled. Yet we know: u Outreach methods that work u Enrollment/application assistance helps

March, 2004 Summary: Child benefits vAdditional child benefits under EPSDT u preventive care u early interventions u special needs care u dental care u family support services vService may address physical, mental, developmental, rehabilitation, or another category.

March, 2004 Summary: Two components u Direct health/ medical care services l immunizations l well child exam l doctor visit for illness l eyeglasses l mental health therapy l dental examination u Support services to give information or access to care l informing parents about preventive care l transportation aid l assistance in completing enrollment application PLUS Administrative services to operate state’s Medicaid program

March, 2004 Summary: Providers vIndividual or facility(group) vBe qualified type u Public agency u Licensed provider vApply and be approved by state vMay have limits u on types of services for which they can bill Medicaid u on their provider payment rates

March, 2004 Local Public Health agencies can -- vInform families about available coverage vAssist families in completing applications vAssist with transportation and appointment scheduling vProvide health services on site vLink with pediatric medical providers vProvide case management or care coordination

March, 2004 Public Health Core Functions Medicaid providers Assure appropriate access & use of coverage Assessment Policy Development Assurance surveillance access to providers contract is policy

March, 2004 Other Resources u u u u u (MCH Bureau webcast on EPSDT) WebcastDetail.asp?aeid=234