Brian Sandoval Governor Richard Whitley Director State of Nevada Department of Health and Human Services MEDICAID 101 Dena Schmidt, Deputy Director, DHHS Marta Jensen, Acting Administrator, DHCFP Naomi Lewis, Deputy Administrator, DWSS February 8, 2017 Helping People. It s who we are and what we do.
Objectives Improve knowledge of Medicaid key features, terminology, and concepts; Understand Medicaid s eligibility process; Increase knowledge of Medicaid policy, budgets, and operational components; Understand the two delivery systems: Managed Care and Fee-for-Service. Helping People. It s who we are and what we do. 2
What is Medicaid? Medicaid is an optional medical coverage program that states elect to provide to their residents. Authorized by Congress under Title XIX of the Social Security Act in 1965. Publicly financed but not a Government Run Health Care Delivery System. States work in partnership with the federal Centers for Medicare and Medicaid Services (CMS) to assist in providing quality medical care for eligible individuals. Federal regulations define mandatory groups to be covered. Federal regulations define mandatory and optional services. Nevada generally covers mandatory services and some optional services if cost-effective. Nevada Check Up was authorized by Congress in 1997 as Title XXI of the Social Security Act, Reauthorized in February 2009 and renamed the Children s Health Insurance Program (CHIP). Families with income levels up to 205% of the Federal Poverty Level (FPL) may qualify. Medical coverage follows Medicaid policy with the exception of non-emergency transportation. Helping People. It s who we are and what we do. 3
March 1, 1965 Social Security Amendments of 1965 Establishing Medicaid to provide health insurance to low-income children, caretaker relatives, the elderly blind and individuals with disabilities. January 23, 1967 Early Periodic Screening, diagnosis, and Treatment (EPSDT) Mandates EPSDT services for children up to age 21. October 30, 1972 Social Security Amendments of 1972 Establishes the Supplemental Security Income (SSI) program of cash assistance for elderly and individuals with disabilities and enables states to link SSI and Medicaid eligibility. August 13, 1982 The Omnibus Reconciliation Act of 1981 Establishes Section 1915(b) Freedom-of-Choice Waivers and Section 1915(c) Home-and Community-Based Services waivers and allowed states to start making additional payments to hospitals serving a disproportionate share of Medicaid and low-income patients, known as DSH hospitals. July 18, 1984 Deficit Reduction Act of 1984 Extends Medicaid coverage to children in the Aid to Families with Dependent Children (AFDC) eligible families up to age 5, as well as AFDC-eligible first-time pregnant women and pregnant women in two-parent unemployed families December 22, 1987 Omnibus Budget Reconciliation Act of 1987 Gives states the option of extending coverage to pregnant women and infants with family income at or below 185% FPL. Imposes quality of care standards for Medicaid- certified nursing homes in response to well-documented problems facing seniors in nursing homes. December 19, 1989 Omnibus Budget Reconciliation Act of 1989 Requires states to provide coverage to pregnant women and children up to age 6 with income below 133% FPL. Expands EPSDT services to include needed diagnostic and treatment services even if not covered by Medicaid. Requires states to cover services provided by federally-qualified health centers (FQHCs). Helping People. It s who we are and what we do. 4
January 1, 1996 Block Grant Veto The U.S. Congress passes and President Bill Clinton vetoes legislation converting Medicaid to a block grant to states. August 22, 1996 Personal Responsibility and Work Opportunity Reconciliation Act of 1996 Repeals the AFDC individual entitlement to cash assistance and replaces it with the Temporary Assistance for Needy Families (TANF) block grant to states, removing link between welfare and Medicaid eligibility. June 22, 1999 Olmstead Case The U.S. Supreme Court rules in Olmstead v. L.C. the Americans with Disabilities Act (ADA) can, under certain circumstances, require states to provide community-based services to individuals for whom institutional care is inappropriate. October 24, 2000 Breast and Cervical Cancer Treatment and Prevention Act of 2000 Gives states the option to extend Medicaid coverage to uninsured women with breast or cervical cancer, regardless of income or resources. February 17, 2009 American Recovery and Reinvestment Act of 2009 Provided for $149 billion in new health spending, including a temporary increase in the federal matching rate for Medicaid, funding for health information technology, and funding for community health centers. March 23, 2010 The Patient Protection and Affordable Care Act of 2010 Reform the health care system and extend health coverage to uninsured individuals across the country. Expansion of coverage, new demonstration projects to control costs, investment in technology and data, increased CHIP matching through 2019. June 28, 2012 Supreme Court Decision on Constitutionality of the Affordable Care Act Supreme Court upholds the constitutionality of the ACA, but makes the Medicaid expansion effectively a state option. Helping People. It s who we are and what we do. 5
Medicare and Medicaid Helping People. It s who we are and what we do. 6
Medicaid has many Vital Roles in the National Health Care System Health care coverage for: Children and adults in low-income families Elderly and persons with disabilities Low income childless adults (if the State elected to enroll the expanded population) Assistance to Medicare beneficiaries: Premiums, co-pays and deductible coverage Long-Term care: Institutional and community based services Helping People. It s who we are and what we do. 7
Medicaid is Unique State to State If you ve seen one Medicaid program, you ve seen one Medicaid program. Services provided by one State may differ considerably in amount, duration, or scope from services provided in a similar or neighboring State. CATEGORICALLY NEEDY MEDICALLY NEEDY A person eligible in one State may not be eligible in another State. Medicaid eligibility, services, and/or reimbursement may change anytime during the year based upon state and federal regulations changes. Helping People. It s who we are and what we do. 8
Children Pregnant Women Mandatory Individuals Who is Eligible for Medicaid? Optional Individuals Women with breast or cervical cancer under 200% of the FPL Disabled children who require medical facility care, but can appropriately be cared for at home Katie Beckett eligibility group Parent/Caretaker and Childless Adults Health Insurance for Work Advancement (HIWA) is for individuals 16 to 64 who are disabled. It allows them to retain essential Medicaid benefits while working and earning income. SSI Recipients (Blind or Disabled) Certain Qualified Medicare Beneficiaries (QMB) Home and Community Based Waivers Helping People. It s who we are and what we do. 9
How to Apply for Medicaid Click in Come in Call in Individuals applying for assistance are provided service options via: Access Nevada the DWSS online application system Mail/Fax in applications Call Center (CCT) includes Automated Voice Response system for routine queries Visit one of the local area offices SNAP Outreach partners also accept applications at local food banks and community sites Helping People. It s who we are and what we do. 10
Single Application Medicaid Group Health Insurance Health Insurance Affordability Programs Child Health Insurance Program Advanced Premium Tax Credit Helping People. It s who we are and what we do. 11
Current Eligibility 250 200 200 150 165 138 165 138 138 F P L 100 50 0 Children 0-5 All Children 6-18 CHIP Pregnant Women Parent/Caretaker Childless Adults 19-65 Helping People. It s who we are and what we do. 12
Nevada Check Up Eligibility A child may qualify for Nevada Check Up if: They have income less than 200% (205%) FPL; The child is not eligible for Medicaid; The child is a U.S. citizen or legal resident. Federal Poverty Limit Effective 4/1/2016 Household Size AM limit 100% FPL 138% FPL 165% FPL 205% FPL 1 $319 $990 $1,366 $1,634 $2,030 2 $407 $1,335 $1,842 $2,203 $2,737 3 $495 $1,680 $2,318 $2,772 $3,444 4 $582 $2,025 $2,795 $3,341 $4,151 5 $670 $2,370 $3,271 $3,911 $4,859 6 $758 $2,715 $3,747 $4,480 $5,566 7 $846 $3,061 $4,224 $5,051 $6,275 8 $934 $3,408 $4,703 $5,623 $6,986 Helping People. It s who we are and what we do. 13
Recipients by Program SNAP 47,230 373,232 306 21,949 TANF 221 2,456 Medicaid 244,328 Note: October 2016 data is used in the diagram above. 689,722 unique individuals are in at least one of the three programs. Medicaid counts include retroactive cases. Helping People. It s who we are and what we do. 14
Comparability of Services Free Choice of Provider Statewide Coverage Utilization Control Medical Necessity Proper & efficient administration General Rules of Medicaid Payment for services furnished outside the State Assurance of Transportation (MTM) Early Periodic Screening and Diagnostic Treatment (EPSDT) States are required to provide all medically necessary services. This includes services that would otherwise be optional services but not part of the Nevada Medicaid State Plan. Helping People. It s who we are and what we do. 15
10 Essential Health Benefits Helping People. It s who we are and what we do. 16
Nevada s Mandatory & Optional Services Mandatory Services: Physician Services Laboratory and x-ray services Inpatient hospital services Outpatient hospital services Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under the age of 21 Family planning and supplies Federally-qualified health center (FQHC) services Rural health clinic services Nurse midwife services Certified nurse practitioner services Nursing facility (NF) services for individuals 21 or over Transportation Covered Optional Services: Prescription drugs Medical care or remedial care furnished by licensed practitioners (Limited) Diagnostic, screening, and preventive services Clinic services Dental services (only EPSDT), dentures Therapy (physical, occupational, speech, audiology) Prosthetic devices, eyeglasses Primary care case management ICF/MR services Inpatient/nursing facility services for individuals 65 and over in an institution for mental diseases (IMD) Inpatient psychiatric hospital services for individuals under age 21 Nursing Facility services for individuals under 21 Home health care services Respiratory care services for ventilator-dependent individuals Personal care services Private duty nursing services Hospice services Targeted case management (limited) Free-standing birthing centers Helping People. It s who we are and what we do. 17
Service Delivery Models Medicaid procures most services in the private health care market through purchasing services on a fee-for-service (FFS) basis or through paying premiums to one or more contracted managed care organizations (MCO). Title XIX (Medicaid) MCO in Nevada In urban Clark and Washoe counties except for the Medicaid Assistance for Aged, Blind and Disabled or Institutional Categories Disenrollment may occur for individuals that are severely emotionally disturbed (SED), in Child Protective Services (CPS) or severely mentally ill (SMI). Tribal Members may opt out Title XXI (Nevada Check Up) MCO in Nevada All children living in urban Clark and Washoe counties No disenrollment option except for tribal members Helping People. It s who we are and what we do. 18
700,000 Medicaid Caseload 600,000 500,000 400,000 300,000 200,000 100,000 0 Moms and Kids Aged, Blind, and Disabled Newly Eligible Parent-Caretakers Childless Adults Other Helping People. It s who we are and what we do. 19
Medicaid Caseload Breakdown Managed Care Breakdown Fee For Service 28% Health Plan of Nevada 59% AmeriGroup 41% Managed Care 72% Helping People. It s who we are and what we do. 20
Helping People. It s who we are and what we do. 21
Access to Care Centers for Medicare & Medicaid Medical Schools Licensing Boards Division of Insurance Provider Enrollment Graduate Medical Education Geography Health Care Quality & Comliance Rates Workforce Helping People. It s who we are and what we do. 22
How We ve Addressed This Expanded the use of telemedicine/telehealth Implemented Community Paramedicine Program Implemented the Applied Behavioral Analysis (ABA) Program Expanded the use of Advanced Practice Registered Nurses (APRN) Implementing the Certified Community Behavioral Health Clinics (CCBHC) program Increased Inpatient Psychiatric Rate Implemented the In Lieu of option for MCO Physician Forums with FFS and MCO Easing Administrative burdens by: Aligning Prior Authorization requirements between FFS and MCO Implementing online provider enrollment Requesting funds for: Registered dieticians to perform Medical Nutrition Therapy Adult Podiatry services. rate increases in community based services, skilled nursing facilities and pediatric surgeons. Helping People. It s who we are and what we do. 23
SFY16 Total Computable Spend by Type Operations $43,877,517 Fiscal Agent $43,755,813 Other $64,127,981 Medical $3,271,341,786 Total Computable Spend: $3,423,103,097 ADMIN OTHER $64,127,981 (Majority of these funds are pass through of federal dollars to sister & state agencies for administrative services) Medical (Medicaid and Nevada Check Up) $3,271,341,786 95.57% DHCFP Operations $43,877,517 1.28% DHCFP Fiscal Agent $43,755,813 1.28% Public and Behavioral Health $1,542,423 0.05% Division of Welfare and Supportive Services $49,956,597 1.46% Division of Aging and Disability Services Admin $10,449,053 0.31% Local Governments/Administrative Claiming $900,259 0.03% Division of Child and Family Services $1,026,342 0.03% Directors Office $204,410 0.01% Department of Administration $28,097 0.00% Transfer to Legislative Council Bureau $20,800 0.00% TOTAL $3,423,103,097 100.00% Helping People. It s who we are and what we do. 24
SFY16 Medicaid Cost by Budget Category Average Members per Month and Average Monthly Cost Per Eligible (CPE) Helping People. It s who we are and what we do. 25
Blended Federal Medical Assistance Percentage (FMAP) Updated September 2016 Helping People. It s who we are and what we do. 26
Maximizing Medicaid State and local Governments 100% State General Fund Medicaid Billable Service 40% State General Fund 50% Federal 100% State General Fund Medicaid Billable Service 5% State General Fund 95% Federal Helping People. It s who we are and what we do. 27
Insert BH savings chart from Ellen Helping People. It s who we are and what we do. 28
Appendix Helping People. It s who we are and what we do. 29
Acronyms ACA The Affordable Care Act ADA The Americans with Disabilities Act APTC Advanced Premium Tax Credit CMS Centers for Medicare and Medicaid EPSDT Early Periodic Screening, Diagnostic, and Treatment FMAP Federal Medical Assistance Percentage FPL Federal Poverty Level HCBS Home and Community-Based Services HHS U.S. Department of Health and Human Services LTSS Long-Term Supports and Services MCO Managed Care Organization MLTSS Managed LTSS Helping People. It s who we are and what we do. 30
Modified Adjusted Gross Income (MAGI) Medical Groups Medical Groups Income Limits Exceptions/Rules Parents & Caretakers 138% of Poverty Parent/Caretaker must have a dependent minor child in the home. Children under 19 Poverty Level Children Children 6-18: < 122% FPL Children under 6: < 165% FPL Pregnant Women < 165% FPL Childless Adult Non-Parents 19 64 years old < 138% FPL Cannot be pregnant; Cannot be Medicare eligible; Cannot be eligible in another Medical group. Nevada Check-Up State CHIP program for children under 19 Children under 6: 166%-205% Children 6-18: 139%-205% FPL Premium payment required; Cannot have other insurance; Cannot be Medicaid eligible. Helping People. It s who we are and what we do. 31
Specialized Medical Groups Aged Out of Foster Care No income or resource determination Under 26 years of age; were in foster care and enrolled in Medicaid at the time they turned 18 years of age. Children for Whom a Public Agency has Assumed Financial Responsibility No income or resource determination Public agency has assumed responsibility; Child cannot be in DCFS custody Title IV-E eligible foster children at Rite of Passage No income or resource determination Children under 18 years of age residing at Rite of Passage receiving IV-E foster care benefits Applications processed at Yerington D.O. Breast and Cervical Cancer No income or resource determination by DWSS. CDC screening includes income determination. Under age 65; Uninsured or under insured; Not eligible under any other medical assistance program; Screened by CDC and in need of treatment. Applications processed by Elko D.O. Helping People. It s who we are and what we do. 32
MAABD Medical Groups Definition Income Limits Exceptions/Rules Categorically eligible, income and resource Receiving SSI as a Nevada resident SSI Recipients determination made by SSI Public Law -Adult Disabled Child -Pickle Amendment -Widow/Widowers -Widow/Widowers and Surviving -Divorced Spouses -Suspension of SSI due to Income Had SSI, Lost SSI as a result of an event. (usually increase in RSDI) Institutional $30 SSI Institutional payment rate Residing in long term care HCBW Frail and Elderly Assisted Living Waiver Group Care Waiver for the aged or blind for the mentally impaired Disabled Waiver Over 65 years of age; Meets the level of care assessment; Over 65 years of age; Residing in approved assisted living facility in Las Vegas only; Over 65 years of age; Residing in approved assisted living facility in Las Vegas only; Mentally retarded; Living in a community setting; Meet Level of Care as approved by ADSD Living in a community setting Helping People. It s who we are and what we do. 33
MAABD Medical Groups (Continued) Definition Income Limits Exceptions/Rules Katie Beckett Disabled children not eligible for SSI Child under 19 years of age; Residing at home with parents; Denied SSI for excess income of parents; Meets level of care assessment and can be cared for at home for less cost than institutionalization; Prior medical for the Aged, Blind or Disabled Income < SSI payment level; Disability determination made by DHCFP Health Insurance for Working Disabled (HIWA) Gross earned 450% FPL; Unearned $699; Not eligible for Medicaid under any other category; Between 16-64 years of age; Employment related disregards allowed; Must be disabled or blind. Helping People. It s who we are and what we do. 34
Helping People. It s who we are and what we do. 35
Medicaid Caseload 700,000 700,000 687,515 676,885 600,000 600,000 567,952 500,000 500,000 400,000 400,000 300,000 300,000 200,000 200,000 100,000 100,000 0 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 Jan-18 Jul-18 Jan-19 0 Total Medicaid Leg. Approved Gov. Rec. January 2017 Projections Helping People. It s who we are and what we do. 36
Nevada Check Up Caseload 30,000 30,000 27,560 25,000 25,347 25,000 20,000 18,980 20,000 15,000 15,000 10,000 10,000 5,000 5,000 0 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 Jan-18 Jul-18 Jan-19 0 Nevada Check Up Leg. Approved Governor's Recommend. January 2017 Projection Helping People. It s who we are and what we do. 37
SFY16 FFS Top 10 Services by Expenditures Provider Type Sum of Net Payment % of Expenditures 011 - Inpatient Hospital $ 266,342,463.96 16% 028 - Pharmacy $ 258,129,046.94 16% 020 - Physician $ 174,672,277.26 11% 019 - Nursing Facility $ 141,130,587.78 9% 014 - Behavioral Health Outpatient $ 128,286,366.64 8% 038 - Intellectual Disability Waiver $ 96,409,603.88 6% 030 - Personal Care Aid Agency $ 88,926,190.74 5% 022 - Dental $ 49,528,587.79 3% 012 - Outpatient Hospital $ 43,871,730.07 3% 054 - Targeted Case Management $ 43,756,145.25 3% Helping People. It s who we are and what we do. 38
SFY16 MCO Top 10 Services by Expenditures Provider Type Sum of Net Payment % of Expenditures 020 - Physician $ 287,758,759.55 27.15% 028 - Pharmacy $ 226,022,619.20 21.32% 011 - Inpatient Hospital $ 149,730,850.67 14.12% 010 - Outpatient Surgery $ 125,488,044.10 11.84% 022 - Dental $ 33,561,244.08 3.17% 014 - Behavioral Health Outpatient $ 26,257,119.66 2.48% ~ Financial Transactions $ 24,102,805.23 2.27% 035 - Ambulance - Air or Ground $ 19,693,899.34 1.86% 013 - Inpatient Psychiatric Hospital $ 17,197,950.07 1.62% 012 - Outpatient Hospital $ 16,374,207.93 1.54% Helping People. It s who we are and what we do. 39
SFY16 FFS/MCO Top 10 Services by Expenditures Provider Type Sum of Net Payment % of Expenditures 028 - Pharmacy $ 484,151,666.14 18.09% 020 - Physician $ 462,431,036.81 17.27% 011 - Inpatient Hospital $ 416,073,314.63 15.54% 014 - Behavioral Health Outpatient $ 154,543,486.30 5.77% 019 - Nursing Facility $ 149,926,859.92 5.60% 010 - Outpatient Surgery $ 129,956,016.15 4.85% 038 - Intellectual Disability Waiver $ 96,409,603.88 3.60% 030 - Personal Care Aid Agency $ 89,831,535.19 3.36% 022 - Dental $ 83,089,831.87 3.10% 012 - Outpatient Hospital $ 60,245,938.00 2.25% Helping People. It s who we are and what we do. 40