1. Securing the Future of Medicaid Toolkit Companion Prepared by Harvard Law School & Treatment Access Expansion Project in collaboration with Bristol-Myers Squibb VIUS10UBMU32303 10/10

2. Acknowledgments – Action Toolkit Action Toolkit Developed by the Harvard Law School (HLS) Health Law and Policy Clinic and the Treatment Access Expansion Project (TAEP) as part of a public education initiative to encourage informed and active participation in state and federal Medicaid reform The views expressed in the action toolkit document are solely those of the HLS Health Law and Policy Clinic and TAEP Development and production of the action toolkit funded by BMS with limited editorial review and discretion for layout and design purposes only. The content of the toolkit does not reflect the views or opinions of BMS HLS, Harvard Law School; TAEP, Treatment Access Expansion Project; BMS, Bristol-Myers Squibb. 2

3. Acknowledgments – Action Toolkit Informational Companion Materials Companion materials to informational portions of action toolkit (including this slide deck) Developed by the HLS Health Law and Policy Clinic and TAEP to support advocacy community and public education function of action toolkit Companion materials for the informational portions of the toolkit developed and produced in collaboration with BMS. The content of this companion slide deck does not reflect the beliefs or opinions of BMS. Reasonable effort has been made to accurately and objectively present issues surrounding Medicaid, the current economic landscape, and healthcare reform implementation. Any opinions or views expressed in the slide deck and speaker notes are solely those of the Health Law & Policy Clinic and TAEP. Medicaid has neither reviewed nor endorsed this program or materials 3

4. Presentation Outline Part 1: Medicaid and the Current Economic Landscape Part 2: Medicaid – The Basics and Impact of Healthcare Reform Part 3: Example Case Studies Part 4: Challenges for Medicaid at the Federal and State Levels Part 5: Beyond Medicaid: Healthcare for Those Who Need It Most 4

5. Part 1: Medicaid and the Current Economic Landscape 5

6. Impact of Unemployment on State Revenues Dark shading indicates states with shortfalls in fiscal 2010. Center on Budget and Policy Priorities. 2010. Survey: 46 States Have Faced Budget Shortfalls This Year. Garrett B, Holahan J. 2009. Kaiser Commission on Medicaid and the Uninsured. Rising Unemployment, Medicaid, and the Uninsured. Increase in national unemployment rate Decrease in state revenues 1% 46 States Faced Budget Shortfalls in 2010 3-4% 6

7. High National and State Unemployment Rates and Increased Need for Medicaid National unemployment rate (June 2010): 9.5% State unemployment rates (including District of Columbia): Bureau of Labor Statistics. State Unemployment Rates. www.bls.gov/lau/. Accessed June 2010. 1% Increase in National Unemployment Rate = → 1.0 million increase in Medicaid and CHIP enrollment → 1.1 million increase in uninsured Bowen Garrett and John Holahan, 2009. 7 ≥10% unemployment rate 3% - 5.9% unemployment rate 6% - 9.9% unemployment rate

8. What Is Medicaid Who Is Eligible? What Does Medicaid Cover? Who Pays for Medicaid? What Is Medicaid Required to Provide? How Does Healthcare Reform Affect Medicaid? Part 2: Medicaid – The Basics 8

9. What Is Medicaid? State-administered and funded by both federal and state governments Means-tested entitlement program –Means tested: strict income requirements –Entitlement: funding and enrollment are uncapped Largest funder of health services for the nation’s poorest residents Medicaid State and federally funded $$$ Administered by states Centers for Medicare and Medicaid Services. Medicaid Overview. www.cms.gov/MedicaidGenInfo.. 9

10. Who Is Eligible? Before reform Mandatory “categorically needy” beneficiaries Optional beneficiaries Medically needy Special eligibility groups Waiver beneficiaries Eligibility before and after 2010 reform law After reform Already eligible beneficiaries: States must maintain rules in place at time reform law went into effect Newly eligible beneficiaries: Beginning in 2014 (and immediately if states choose to expand early), Medicaid will cover individuals with income up to 133% of the federal poverty level (FPL) Already eligible beneficiaries = those eligible for or enrolled in Medicaid at the time healthcare reform law went into effect Newly eligible beneficiaries = those not eligible for Medicaid under pre-reform law Centers for Medicare and Medicaid Services. Medicaid Overview. www.cms.gov/MedicaidGenInfo. Kaiser Family Foundation. 2010. Focus on Health Reform: Medicaid and Children’s Health Insurance Program. Provisions in the New Health Reform Law. 10

11. What Does Medicaid Cover? Already eligible beneficiaries Varies state-to-state Mandatory services that states must provide include: Physicians’ services Hospital services (inpatient and outpatient) Laboratory and x-ray services Optional services that states may provide include: Prescription drug coverage Dental services Newly eligible beneficiaries National, federally mandated benefits package, which must include: Prescription drugs Preventive and wellness services and chronic disease management Mental health and substance use disorder services, including behavioral health treatment Health Resources and Services Administration, Department of Health and Human Services. 2010. Opportunities to Use Medicaid in Support of Access to Health Care Services: Basic Description of the Medicaid Program. www.hrsa.gov/medicaidprimer/. Patient Protection and Affordability Act of 2010, §§ 2001(c), 1302(b)(1). 11

12. Who Pays for Medicaid? Already eligible Federal government and states share costs based on Federal Medical Assistance Percentage (FMAP), which varies by state No change Newly eligible Current FMAP rates if states choose to expand early 100% FMAP (fed gov’t) Gradual reduction in FMAP to 90%* 90% (fed gov’t)* Present - 2013 2014 - 2016 2017 - 2018 Kaiser Family Foundation. 2010. Focus on Health Reform: Medicaid and Children’s Health Insurance Program. Provisions in the New Health Reform Law. Beneficiaries in both groups have some cost sharing under Medicaid 2019 + BENEFICIARIES GOVERNMENT 12 *Under the healthcare reform law, states will be eligible for an increased FMAP rate if they provide prevention services (eg, immunizations and smoking cessation programs) with no cost sharing (free to beneficiary)

13. What Is Medicaid Required to Provide? Already eligible Pre- Reform Law States have discretion, but with federal requirements (see below) Post- Reform Law No change Newly eligible N/A Less flexibility through essential health benefits package Federal Requirements –States must provide a sufficient level of services to achieve purpose of benefits –States cannot discriminate among beneficiaries based on medical diagnosis or condition –Benefits must be comparable among specific groups of Medicaid recipients –Benefits must be available to all eligible individuals, no matter where they reside in the state, with certain exceptions State Flexibility and Choices Kaiser Family Foundation. 2009. Medicaid: A Primer. 13

14. Summary of Healthcare Reform Changes Eligibility expansion (by 2014): o Elimination of categorical eligibility requirement o Income eligibility standard at 133% FPL o Maintenance of eligibility requirement New income formula: modified adjusted gross income without assets test New essential health benefits package Increased federal funding: o 100% federal matching rate (FMAP) for cost of services for newly eligible beneficiaries in 2014-2016 o Enhanced FMAP for newly eligible beneficiaries in subsequent years o Increased federal funding for Medicaid programs in Puerto Rico and the territories starting in 2011 Provider reimbursement rates: o Increased reimbursement for primary care providers in 2013-2014 only Streamlining Medicaid enrollment and aligning with state exchanges 14

15. Part 3: Example Case Studies 15

16. PROFILE Age 41 Single, no children Unemployed/uninsured HIV+ symptomatic Case Study: Sylvia (hypothetical) Pre-Reform Eligibility Denied SSI disability claim Income – $240 per month state emergency assistance Healthcare through Ryan White Program public health clinic and ADAP Post-Reform Eligibility Eligible for Medicaid Eligibility based on income alone – 133% FPL Will still need Ryan White Program support for care and support services not covered under Medicaid 16

17. PROFILE Age: 29 Nondisabled Seasonally employed Case Study: Glen (hypothetical) Pre-Reform Eligibility Earning approximately $12,000/year Untreated panic attacks and depression Post-Reform Eligibility Eligible for Medicaid starting in 2014, or earlier if his state chooses early expansion As newly eligible beneficiary, will receive benchmark benefit package, which must include mental health services 17

18. PROFILE Ages: Marie 51 and son Sam 12 Undocumented immigration status AIDS/Disabled Uninsured, employed part-time earning 15K Case Study: Marie and Sam (hypothetical) Pre-Reform Eligibility Undocumented immigration status means ineligible for Medicaid/CHIP Healthcare through Ryan White Program public health clinic and ADAP Post-Reform Eligibility Ineligible for Medicaid/CHIP Ineligible for private insurance coverage subsidies and protections Will still need Ryan White Program support for care and support services 18

19. PROFILE Age: 53 Disabled and unemployed Receiving long-term disability benefits Case Study: Joe (hypothetical) Pre-Reform Eligibility Income totals $10,830/year (100% FPL in 2010) Family history of heart disease and prostate cancer Post-Reform Eligibility Already eligible beneficiary (as opposed to newly eligible) Eligible for benefits offered by state at the time healthcare reform law was enacted 19

20. Part 4: Challenges for Medicaid at the Federal and State Levels 20

21. Challenge: Insufficient Federal and State Medicaid Support in Times of Economic Crisis Federal –States are dependent on federal action in times of crisis and need enhanced FMAP rates to avoid making cuts to their Medicaid programs –Enhanced FMAPs under ARRA are set to expire by July 2011 –Full federal funding for 2014 expansion is limited and temporary: 100% FMAP in 2014-2016 FMAPs vary by state in 2017-2019 90% FMAP after 2019 Enhanced FMAP applies only to services for newly eligible beneficiaries States –In times of economic crisis, states look to curb ballooning budget deficits by making cuts to their Medicaid programs –In the current economic climate, some states may be unable to fund expansion Kaiser Family Foundation. 2010. State Medicaid Agencies Prepare for Health Care Reform. Kaiser Family Foundation. 2010. Financing New Medicaid Coverage Under Health Reform. 21

22. What Are Communities Doing to Ensure Adequate Funding? Federal –Considering automatic FMAP increase in times of economic crisis States –Confronting the true costs of Medicaid cuts States lose federal matching funds when they cut Medicaid spending Medicaid expenditures stimulate local economies and provide jobs in the medical sector Medicaid cuts will increase other medical expenditures, such as emergency care Miller V. 2007. Georgetown University Health Policy Institute, Strengthening Medicaid: Stabilizing Financing During Economic Downturns. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. 22

23. Challenge: Restrictions on Enrollment for Optional Beneficiaries Cuts in services to optional beneficiaries or reduction of income eligibility levels hurt low-income beneficiaries States have reduced access to care through: –Eligibility restrictions –Enrollment caps –Procedural barriers –Reduction of outreach efforts –Citizenship requirements The maintenance of eligibility requirements in the healthcare reform law is limited Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Families USA. Frequently Asked Questions about Medicaid Waivers. www.familiesusa.org. Wilson J, et al. 2009. Are State Medicaid Application Forms Readable? J. Health Care for the Poor and Underserved. 20; 423-31. Hoadley J, et al. 2003. Popular Medicaid programs do battle with state budget pressures: perspectives from twelve states. Health Affairs. Vol. 23:1453-54. National Immigration Law Center. 2010. How Are Immigrants Included in Health Care Reform? Families USA. 2010. Maintenance of Effort Requirements Under Health Reform. 23

24. What Are Communities Doing to Address Restrictions on Enrollment? Already eligible beneficiaries –Maintaining eligibility rules as required by ARRA and healthcare reform law –Examining use of waivers to impose enrollment caps and identifying what the actual cost savings would be from enrollment restrictions –Confronting assertions of fraud –Increasing access to Medicaid prior to healthcare reform expansion through Section 1115 waivers Newly eligible beneficiaries –Expanding Medicaid before 2014 National Alliance of State &Territorial ADAP Directors. August 2010. HIV/Hepatitis Health Reform Watch. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Center on Budget and Policy Priorities. 2009. Mississippi’s “Face-to-Face” Rule Blocks Coverage of Eligible People, Not Fraud. 24

25. Challenge: Premiums and Cost Sharing in Medicaid Charging monthly premiums for coverage lowers enrollment for low-income people Cost sharing disproportionately burdens poor and disabled people –Beneficiaries who are unable to meet cost-sharing obligations cannot access life-saving care and treatment National Association of State Budget Officers. 2010. The Fiscal Survey of States. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. 25

26. What Are Communities Doing to Address Premium and Cost-Sharing Provisions? Joining coalitions with healthcare providers Considering: –Premiums and cost sharing prevent the people who need care the most from accessing that care –Poor and disabled people bear the biggest burden of premiums and cost sharing –Premiums and cost sharing do not generate significant savings in the long run –States can get increased federal funding by providing prevention services without cost sharing Immunizations Smoking cessation Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Center on Budget and Policy Priorities. 2005. The Effect of Increased Cost-sharing in Medicaid: A Summary of Research Findings. Kaiser Family Foundation. 2010. Focus on Health Reform: Medicaid and Children’s Health Insurance Program. Provisions in the New Health Reform Law. 26

27. Challenge: State Cuts to Optional Benefits States can cut coverage of optional benefits even for mandatory beneficiaries States can limit mandatory and optional services States can require prior authorization States can use waivers to cut benefits Healthcare reform considerations –Potential for different benefits provided to already eligible beneficiaries vs newly eligible beneficiaries Existing state Medicaid benefits for already eligible beneficiaries Essential health benefits package for newly eligible beneficiaries National Association of State Budget Officers. 2010. The Fiscal Survey of States. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Families USA. 2010. Five Good Reasons Why States Shouldn’t Cut Home- and Community-Based Services in Medicaid. 27

28. What Are Communities Doing to Address Benefit Cuts? At the federal level, considering waiver policies that better support healthcare providers and beneficiaries Increase transparency Relax budget neutrality rules Emphasizing Medicaid’s role –Medicaid only pays for medically necessary services –Medicaid is the “payer of last resort” Keeping an eye on responses to healthcare reform –Cuts to benefits for already eligible beneficiaries in order to fund mandated Medicaid expansion –Essential health benefits package for newly eligible beneficiaries Families USA. Waiver Tool Box. www.familiesusa.org Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. National Association of State Budget Officers. 2010. The Fiscal Survey of States. Treatment Access Expansion Project. 2010. AIDS Watch 2010: Advocacy After Health Care Reform. 28

29. Challenge: Limits on Access to Prescription Drugs To save money, states often create barriers to access to life-saving medications, including: –Increased consumer drug copayment obligations –Increased limits on monthly prescriptions –Increased provider restrictions and regulations Preferred drug lists & prior authorization requirements Mandated “fail first” schemes National Association of State Budget Officers. 2010. The Fiscal Survey of States. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Center on Budget and Policy Priorities. 2007. Cost-sharing and Premiums in Medicaid: What Rules Apply?. National Alliance on Mental Illness. 2003. Medicaid Access to Effective Medications: Prior Authorization Threatens Consumers’ Health. Hoadley J, Alker J. 2007. Georgetown University Health Policy Institute. Uncertain Access to Needed Drugs: Florida's Medicaid Reform Creates Challenges for Patients. Gencarelli D. 2003. George Washington University National Health Policy Forum. Medicaid Prescription Drug Coverage: State Efforts to Control Costs. 29

30. What Are Communities Doing to Address Limits on Access to Prescription Drugs? Working with healthcare providers to build coalitions Educating clients, pharmacists, and healthcare providers about Medicaid law requirements Securing provider authority to override generic substitution requirements Ensuring protection of beneficiary rights Focusing on real cost considerations –Administrative costs –Increased medical costs associated with delayed treatment National Alliance on Mental Illness. 2010. Access to Medication Task Force Report and Recommendations. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Saint Petersburg Times. Health Agency Settles Suit Over Denied Prescriptions. June 12, 2003. 30

31. Challenge: Inadequate Provider Reimbursement Rates One of the most common types of Medicaid budget cuts Medicaid provider reimbursement rates already too low to cover cost of care in many instances Low reimbursement rates mean not enough providers to meet service needs of Medicaid enrollees Healthcare reform provided limited reimbursement increase, only for primary care providers and only for 2013- 2014 Cunningham P, Nichols L. The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: a community perspective. Med Care Res Rev. 2005;62:676-696. National Association of State Budget Officers. 2010. The Fiscal Survey of States. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Nash D. April 7, 2010. The Impact of Medicaid Underfunding: From the Trenches. Medpage Today. 31

32. What Are Communities Doing to Address Inadequate Provider Reimbursement Rates? Working with healthcare providers to make sure that reimbursement rates are adequate Highlighting Medicaid access difficulties Emphasizing that it is the poorest and most vulnerable Medicaid recipients who will be hurt Focusing on the importance of access to specialized care Considering the costs: –Long-term costs of delays in treatment –Money spent on healthcare goes toward stable jobs in your state Kaiser Family Foundation. 2008. Filling an Urgent Need: Improving Children’s Access to Dental Care in Medicaid and SCHIP. Cunningham P, Nichols L. The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: a community perspective. Med Care Res Rev. 2005;62:676-696. Nash D. April 7, 2010. The Impact of Medicaid Underfunding: From the Trenches. Medpage Today. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. 32

33. Part 5: Beyond Medicaid – Healthcare for Those Who Need It Most 33

34. Beyond Medicaid – Healthcare for Those Who Need It Most Federal and state healthcare reform implementation Issues not fixed in healthcare reform –Provider reimbursement rates –5-year waiting period for legal immigrants –Comprehensive benefits package for already eligible Medicaid beneficiaries Government Health Care Reform Website, www.healthcare.gov/center/regulations/index.html. Miller V. 2007. Georgetown University Health Policy Institute, Strengthening Medicaid: Stabilizing Financing During Economic Downturns. Zuckerman S, et al. April 2009. Trends in Medicaid Physician Fees, 2003-2008. Health Affairs. National Immigration Law Center. 2010. How Are Immigrants Included in Health Care Reform? Center on Budget and Policy Priorities. 2010. Childless Adults Who Become Eligible for Medicaid in 2014 Should Receive Standard Benefits Package. 34

35. Beyond Medicaid – Healthcare for Those Who Need It Most (cont) Securing an access-to-care bridge to 2014 and beyond: –Federal level Early Treatment for HIV Act (ETHA) Emergency supplemental ADAP funding Full funding of all Ryan White programs –State level Medicaid Section 1115 waiver to expand access to needed Medicaid services immediately Treatment Access Expansion Project. ETHA Overview. www.taepusa.org. The AIDS Institute. 2010. FY 2011 Appropriations for Federal HIV/AIDS Programs, AIDS Budget and Appropriations Coalition. National Alliance of State &Territorial ADAP Directors. August 2010. HIV/Hepatitis Health Reform Watch. 35

36. Action-based Toolkit Medicaid Basics Talking Points Power Tools www.withinsightinitiative.org 36

37. References The AIDS Institute. 2010. FY 2011 Appropriations for Federal HIV/AIDS Programs, AIDS Budget and Appropriations Coalition. Bureau of Labor Statistics. State Unemployment Rates. www.bls.gov/lau/. Accessed June 2010. Center on Budget and Policy Priorities. 2010. Childless Adults Who Become Eligible for Medicaid in 2014 Should Receive Standard Benefits Package. Center on Budget and Policy Priorities. 2007. Cost-sharing and Premiums in Medicaid: What Rules Apply?. Center on Budget and Policy Priorities. 2009. Mississippi’s “Face-to-Face” Rule Blocks Coverage of Eligible People, Not Fraud. Centers for Medicare and Medicaid Services. Medicaid Overview. www.cms.gov/MedicaidGenInfo. Center on Budget and Policy Priorities. 2010. Survey: 46 States Have Faced Budget Shortfalls This Year. Center on Budget and Policy Priorities. 2005. The Effect of Increased Cost-sharing in Medicaid: A Summary of Research Findings. Cunningham P, Nichols L. The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: a community perspective. Med Care Res Rev. 2005;62:676-696. Department of Health & Human Services Centers for Medicare & Medicaid Services. 2008. Actuarial Report on the Financial Outlook for Medicaid. Families USA. 2008. A Painful Recession: States Cut Health Care Safety Net Programs. Families USA. 2010. Five Good Reasons Why States Shouldn’t Cut Home- and Community-Based Services in Medicaid. Families USA. 2010. Maintenance of Effort Requirements Under Health Reform. Families USA. Frequently Asked Questions about Medicaid Waivers. www.familiesusa.org. Families USA. Waiver Tool Box. www.familiesusa.org. Garrett B, Holahan J. 2009. Kaiser Commission on Medicaid and the Uninsured. Rising Unemployment, Medicaid, and the Uninsured. Gencarelli D. 2003. George Washington University National Health Policy Forum. Medicaid Prescription Drug Coverage: State Efforts to Control Costs. Government Health Care Reform Website, www.healthcare.gov/center/regulations/index. Health Resources and Services Administration, Department of Health and Human Services. 2010. Opportunities to Use Medicaid in Support of Access to Health Care Services: Basic Description of the Medicaid Program. www.hrsa.gov/medicaidprimer/. Hoadley J, et al. 2003. Popular Medicaid programs do battle with state budget pressures: perspectives from twelve states. Health Affairs. Vol. 23:1453-54. Hoadley J, Alker J. 2007. Georgetown University Health Policy Institute. Uncertain Access to Needed Drugs: Florida's Medicaid Reform Creates Challenges for Patients. 37

38. References (cont) Kaiser Family Foundation. 2008. Filling an Urgent Need: Improving Children’s Access to Dental Care in Medicaid and SCHIP. Kaiser Family Foundation. 2009. Medicaid: A Primer. Kaiser Family Foundation. 2010. Financing New Medicaid Coverage Under Health Reform. Kaiser Family Foundation. 2010. Focus on Health Reform: Medicaid and Children’s Health Insurance Program. Provisions in the New Health Reform Law. Kaiser Family Foundation. 2010. State Medicaid Agencies Prepare for Health Care Reform. Miller V. 2007. Georgetown University Health Policy Institute, Strengthening Medicaid: Stabilizing Financing During Economic Downturns. Nash D. April 7, 2010. The Impact of Medicaid Underfunding: From the Trenches. Medpage Today. National Alliance on Mental Illness. 2003. Medicaid Access to Effective Medications: Prior Authorization Threatens Consumers’ Health. National Alliance on Mental Illness. 2010. Access to Medication Task Force Report and Recommendations. National Alliance of State &Territorial ADAP Directors. August 2010. HIV/Hepatitis Health Reform Watch. National Alliance of State &Territorial ADAP Directors. ADAP Watch. www.nastad.org. National Association of State Budget Officers. 2010. The Fiscal Survey of States. National Immigration Law Center. 2010. How Are Immigrants Included in Health Care Reform? Patient Protection and Affordability Act of 2010. §§ 2001(c), 1302(b)(1). Saint Petersburg Times. Health Agency Settles Suit Over Denied Prescriptions. June 12, 2003. Treatment Access Expansion Project. 2010. AIDS Watch 2010: Advocacy After Health Care Reform. Treatment Access Expansion Project. ETHA Overview. www.taepusa.org. Wilson J, et al. 2009. Are State Medicaid Application Forms Readable? J. Health Care for the Poor and Underserved. 20; 423-31. Zuckerman S, et al. April 2009. Trends in Medicaid Physician Fees, 2003-2008. Health Affairs. 38 VIUS10UBMU32303 10/10