A Strong Foundation for System Transformation
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1 A Strong Foundation for System Transformation Suzanne Bosstick Deputy Director Disabled and Elderly Health Programs Group Center for Medicaid, CHIP and Survey & Certification Centers for Medicare & Medicaid Services
2 Some Medicaid Basics Medicaid is a State/Federal Partnership Within broad requirements, States may receive Federal matching dollars for certain health (including mental health) and long term services and supports provided to eligible individuals. There are some services States must provide: Mandatory Services There are additional services that States may choose to cover: Optional Services
3 Medicaid Basics, Cont d Medicaid Benefits MANDATORY - Physician services - Laboratory & x-ray - Inpatient hospital - Outpatient hospital - EPSDT - Family planning - Rural and federally-qualified health centers - Nurse-midwife services - NF services for adults - Home health OPTIONAL - Dental services - Therapies PT/OT/Speech/Audiology - Prosthetic devices, glasses - Case management - Clinic services - Personal care, self-directed personal care - Hospice - ICF/MR - PRTF for <21 - Rehabilitative services - Home and Community Based Services 3
4 Medicaid Basics, Cont d Since its enactment in 1965, the Medicaid statute has been amended a number of times most recently by the Affordable Care Act. To understand these important changes, it is important to have the Medicaid basics in mind
5 Affordable Care Act Focus on expanding coverage Continue role of employer-based coverage Expand Medicaid to 133% FPL Subsidize private coverage through Stateoperated exchanges
6 2014 Health Insurance Subsidies Simplified eligibility rules apply to most people qualifying for Medicaid/CHIP Income only; no assets for adults up to 133% of FPL Exchange subsidies available up to 400% of FPL for adults For most people, eligibility is no longer tied to category In most cases, the same income rules apply to Medicaid/CHIP/Premium Tax Credit ( MAGI )
7 Traditional Medicaid Continues for Seniors, and Individuals who are Blind or Have Other Disabilities Challenges, opportunities and questions: Overlap with new MAGI-based mandatory population Benchmark benefit design for newly eligible population Medicaid-Exchange interface
8 Beyond Coverage to Delivery System Reform Payment reform to drive improved value Innovate system designs Quality Workforce Health Information Technology
9 Provisions of The Affordable Care Act Supports most integrated setting appropriate Offers new option for integrating and linking services for complex, high cost populations Offers new or improved HCBS State Plan options Offers enhanced FMAP to help states modify delivery systems Creates special focus on dual eligibles The newly available provisions in Medicaid are in addition to the tools (noted earlier).
10 Section 2703: Health Homes for Individuals with Chronic Conditions Option for individuals with multiple chronic conditions or serious mental illness effective January 1, 2011 Coordinated, person-centered care Primary, acute, behavioral, long term care, social services = whole person Enhanced FMAP (90%) is available for the health home services (first 8 quarters)
11 Health Home Services Health home services include: Comprehensive care management; Care coordination and health promotion; Comprehensive transitional care from inpatient to other settings; Individual and family support; Referral to community and social support services; Use of health information technology, as feasible and appropriate. 11
12 Designated Provider Types and Functions States have flexibility to define health home providers Providers must address several functions: Assure health home services are quality-driven, costeffective, culturally appropriate, person/family-centered Coordinate and provide access to high-quality health care services informed by evidence-based guidelines Coordinate and provide access to full range of services: primary, acute, behavioral, long-term care 12
13 Section 2403: Money Follows the Person Extends and expands MFP through 2016 Offers States substantial resources and additional program flexibilities to remove barriers Enhanced FMAP for community services for first year following transition from facility 43 States and the District of Columbia now participating in the demonstration
14 Section 2402: Removing Barriers to HCBS Section 1915(i) established by DRA of 2005 State option to offer waiver-like HCBS under state plan; breaks eligibility link between HCBS and institutional level of care under 1915(c) 1915(i) was modified through the ACA with the changes becoming effective October 1, 2010 Allows waiver of comparability, expands service definitions Eliminates ability to cap enrollment or waive statewideness 14
15 Section 2401: Community First Choice Option Adds Section 1915(k) Optional State Plan benefit to offer Attendant Care and related supports in community settings, providing opportunities for self-direction Does not require institutional Level of Care under 150% Federal Poverty Line Includes 6% enhanced FMAP
16 Section 10202: Balancing Incentive Program Effective October 1, 2011 Enhanced FMAP to increase diversions and access to Home and Community Based Services 2% if less than 50% Long-term Services and Supports (LTSS) spending in non-institutional settings 5% if less than 25% LTSS spending in noninstitutional settings CMS Guidance and Application targeted for mid-2011
17 Federal Coordinated Health Care Office Section 2602 of the Affordable Care Act (ACA) Duals Office Purpose: Improve quality, reduce costs, and improve the beneficiary experience. Ensure individuals have full access to services Improve the coordination between federal-state government Develop innovative care coordination and integration models. Eliminate financial misalignments that lead to poor quality and cost shifting 17
18 The Foundation for a Redesigned Service System for Individuals with Chronic Conditions Person Centered Integration Individual Control Quality
19 State Medicaid Directors Letters and Regulations Medicaid Prescription Drug Rebates: SMD 10006,SMD Community Living Initiative (Olmstead Tool Kit): SMD Money Follows The Person Extension: SMD (i): SMD Concurrent Hospice Care for Children: SMD yr Approval/Renewal Period: SMD Health Homes for Enrollees w/ Chronic Conditions: SMD Code of Regulations Rx AMP Withdrawal: CMS-2238-P2 NPRM Community First Choice: CMS-2337-P NPRM 1915 (c) Waivers: CMS-2346-F
20 Additional Information CMS: Community Services and Long-Term Supports State Medicaid Director Letters MFP Technical Assistance Website CFC NPRM (c) NPRM After April 19, 2011, the regulation can be accessed at
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