Medicaid Overview. Home and Community Based Services Conference

Transcription

1 Centers for Medicare & Medicaid Services Medicaid Overview Home and Community Based Services Conference September 11,

2 Overview of Presentation Basic facts about the Medicaid State Plan/program requirements Emphasis on those general Medicaid requirements that apply to 1915(c) HCBS waivers Subsequent presentations in the CMS Track will focus on the specific law and regulations that govern HCBS waivers - i.e. 1915(c) 2

3 Title XIX of the Social Security Act Established in 1965 as a companion program to Medicare Grants to States for Medical Assistance Programs ---- Medicaid Federal/State entitlement partnership program to individuals & States Emphasized dependent children and their mothers, older adults, & individuals with disabilities 3

4 The Beginning of Medicaid Initially mostly covered primary/acute health care services LTC limited to Skilled Nursing Facility (SNF) services e.g. nursing homes Institutional bias - eventual addition of community-based services---home health, personal care, home and community-based services (HCBS) in the 1980s 4

5 Medicaid in Brief States determine their own unique programs Each State develops and operates a State plan outlining the nature and scope of services; the State Plan and any amendments must be approved by CMS Medicaid mandates some services, States elect optional coverage States choose eligibility groups, services, payment levels, providers 5

6 Federal Medical Assistance Percentages (FMAP) & Enhanced Federal Assistance Percentages Calculated each year for Medicaid/SCHIP Reimbursement rate for services Based on average State income per person and the nation as a whole Minimum 50 percent match rate Highest 2007 FMAP: Mississippi, Arkansas, West Virginia, New Mexico (70%+) Enhanced FMAP for some programs/activities Indian Health Service facilities 100 % FMAP Additional information at: 6

7 The Single State Medicaid Agency Is responsible for the State s Medicaid program Assures accountability between the State and federal government May not delegate certain functions to another State agency, e.g. policy making or standard setting. May enter into a cooperative agreement with other state agencies to carry out specific functions or administrative tasks Relates to the 1915(c) HCBS waiver assurance for administrative accountability 7

8 Key State Plan Requirements States must follow the rules in the Act, the Code of Federal Regulations (generally 42 CFR), the State Medicaid Manual, and policies issued by CMS States must specify the services to be covered and the amount, duration, and scope of each covered service States may not place limits on services or deny/reduce coverage due to a particular illness or condition Services must be medically necessary Third party liability rules require Medicaid to be the payer of last resort 8

9 Additional State Plan Requirements Generally, services must be available Statewide Freedom of choice of providers Enrolled all willing and qualified providers Provider qualifications Payment for services (4.19-B pages) Reimbursement methodologies must include methods/procedures to assure payments are consistent with economy, efficiency, and quality of care principles 9

10 Why Change the State Plan? Mandated legislative changes (State/federal) Change in eligibility group or resource standards or covered service(s) Change/addition of managed care services Implementation of optional services Change in payment methodology 10

11 Medicaid Benefits in the Regular State Plan MANDATORY - Physician services - Laboratory & x-ray - Inpatient hospital - Outpatient hospital - EPSDT - Family planning - Rural and federallyqualified 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 11

12 Medicaid Administrative Activities Must be found necessary by the Secretary for the proper and efficient administration of the State plan Must conform to Office of Management and Budget (OMB) Circular A-87 Must be reasonable and necessary for the operation of the governmental unit or the performance of the federal award Are matched at a 50% FFP rate 12

13 Children s Health Insurance Program (CHIP) A child whose income is too high and is not eligible for Medicaid may be eligible for CHIP - Title XXI of the Act, an allotment program with fixed funding A child who does not have creditable health insurance coverage with income above Medicaid applicable levels may qualify for CHIP - income is usually at 200% of the Federal Poverty Line (FPL) Has been reauthorized and revised over time. 13

14 Medicaid Eligibility Individuals must be in a group covered by the State s Medicaid program Some groups are mandatory, others are optional Almost all groups include people who are: - aged, blind, or disabled - under 21 - pregnant - parent/caretaker of a child 14

15 Basic Eligibility Requirements Financial - Income and resources Non-financial: - State resident - Citizen or qualified alien - Social Security Number - Assignment of rights to medical support & payment 15

16 State Flexibility in Eligibility Cover optional groups Cover medically needy individuals (those with incomes slightly higher than the categorically needy) Raise income and/or resource levels States may not expand eligibility by changing non-financial eligibility requirements 16

17 Changes in Eligibility The Affordable Care Act implemented substantial changes to the way eligibility for Medicaid is determined. January 1, 2014 will bring millions of newly eligible individuals into Medicaid, based on MAGI. CMS published a regulation to implement these changes. 17

18 Benchmark Benefit Packages Section 1937 of the Act Permit States to provide alternative benefit coverage to specified groups Must include: inpatient/outpatient hospital services, physician s surgical/medical services, lab/x-ray, well-baby & child care, family planning and may include other preventive services as approved by the Secretary States cannot require some groups to enroll (disabled, special needs, children in foster care or adoption assistance, other groups) Coverage vehicle for newly eligibles in

19 More on Benchmark Expansion eligibles will receive coverage through Medicaid benchmark provisions in Upcoming guidance will be issued to provide assistance to States in using the benchmark provisions. Individual technical assistance available to States through SOTA process. 19

20 Waivers Title XIX permits the Secretary of Health & Human Services - through CMS - to waive certain provisions required through the regular State plan process: - Comparability (amount, duration, & scope) - Statewideness - Income and resource requirements - Freedom of choice of all willing and qualified providers 20

21 Waiver Authorities Under the Act Section 1915(a) voluntary contract with organization that agrees to provide care Section 1915(b) managed care that restricts providers, selective contracting, locality as central broker, additional services generated through savings 1915(c) home and community-based services 1115 demonstrations managed care, expand eligibility, impose cost-sharing, provide different benefits, budget neutral 21

22 Home & Community-Based Services Available through the regular State plan: - Personal Care - Home Health (nursing, medical supplies & equipment, appliances for home use, optional PT/OT/Speech/Audiology - Rehabilitative Services - Targeted Case Management - Self-directed Personal Care - HCBS for the Elderly & Disabled 22

23 Participant Direction of Services Available through the State plan [Sections 1915(i) and (j)] Available in 1915(c) waivers Permits beneficiaries to exercise decision-making authority over some/all waiver/state plan services and accept the responsibly for taking a direct role in managing them May allow for recruiting/hiring/firing staff Employer Authority and Budget Authority Supports Information/Assistance and Financial Management Services 23

24 Medicaid Institutional LTC Nursing facility (NF) Intermediate Care Facilities For The Mentally Retarded (ICFs/MR) Institution For Mental Disease (IMD) Over 65: NF or Hospital Under 21: Hospital or psychiatric residential treatment facility (PRTF) 24

25 Institutional issues for HCBS Costs HCBS must cost less than institutional services, on average LOC Institutional levels of care define waiver level of care and the populations that may be targeted Choice HCBS participants must have the option to choose the institutional service PASRR Preadmission Screening and Resident Review 25

26 PASRR Pre Admission Screening & Resident Review Purpose: To ensure that Nursing Facility (NF) applicants and residents with Serious Mental Illness and/or Mental Retardation are: Identified Placed Appropriately (least restrictively) Admitted or allowed to remain in a NF only if they can be appropriately served in a NF Provided with the MI/MR services they need, including Specialized Services (SS) 26

27 CMS QUALITY DRIVERS - National Quality Strategy: ACA CMS Vision: Three Part Aim

28 CMS Challenge Develop policies and provide guidance that furthers the uptake of these new opportunities in a way that increases access, individual choice and control, quality and experience of care, and more efficient ways to delivery services Building the System for the Future The Three Part Aim

29 The Three Part Aim Population Health Experience Of Care Per Capita Cost

30 CMCS Quality Initiatives Underway Integrated care models and quality Measures coordination and development Increased work on quality outcome measures Managed long term services and supports quality guidance to states Integrated quality strategies across all HCBS authorities, including new programs CFC, health homes National Balancing Indicators Project (NBIP) TEFT - Testing HCBS national measure sets & e- health Coordinated research agenda - integration with policy

31 The CMS-64 Illustrates how the State expended its grant funds for the reported quarter, plus adjustments for previous quarters Summarizes actual expenditures from invoices, cost reports, and eligibility records in specified categories States submit quarterly Medicaid expenditure reports through the Medicaid and SCHIP Budget and Expenditure System (MBES) 31