10/2/19 Medicaid Overview and Impacts on Case Management: Past, - PDF document

10/2/19 Medicaid Overview and Impacts on Case Management: Past, Present, and Future Rhys W. Jones, MPH October 2, 2019 CMSNE Conference Vice President, Medicaid Policy and Advocacy, AHIP Southbridge, MA America’s Health Insurance Plans (AHIP) is the national association whose members Who is AHIP? provide coverage and health-related services that improve and protect the health and financial security of consumers, families, businesses, communities and the nation . 2 America’s Health Insurance Plans and its members create and accelerate positive change and innovation across the health Our Mission care system for consumers through market-based solutions and public-private partnerships that advance affordability, value, access, and well-being. 3 1

10/2/19 Medicaid Overview and Impacts on Case Management: Past, Present, and Future Session Objective Medicaid is one of America’s largest government health programs, covering more than 70 million people. This session will explore the Medicaid program’s unique state/federal partnership structure, the range of people it serves, its diversity of covered services and supports, and the challenges it presents to care and case managers. 4 • Medicaid Overview • Medicaid Financing • Eligibility/Enrollment Agenda • Populations • Medicaid Benefits • Medicaid Managed Care • Long Term Services and Supports (LTSS) • Case/Care Management • Challenges in Medicaid 5 Medicaid Overview – Health coverage Federal/State 56 million managed for 74 million partnership with care enrollees in Americans shared funding 40 states and territories 6 2

10/2/19 History of Medicaid • Means-tested program for low income individuals • Signed into law along with Medicare in 1965 • Title XIX of the Social Security Act • HCBS waivers introduced in 1981 • All states were participating by 1982 • Medicaid managed care introduced in 1980s • Medicare prescription drug rebate program in 1990 • ACA Medicaid expansion in 2010, with first enrollment 2014 7 Overview – State / Federal Partnership • Medicaid is a state/federal partnership • 56 Medicaid programs – 50 states, 5 territories, and DC • Lead federal agency is CMS (Centers for Medicare and Medicaid Services) • Designated state agencies provide state administration • States design and operate programs within a federal framework • Federal framework sets core benefits, eligibility standards, eligible populations • State may cover additional services, populations, expand eligibility • States decide on delivery system – fee-for-service (FFS), managed care, or a combination or the two; provider rates • CMS reimburses states the federal share of Medicaid program expenses 8 Overview – Financing of Medicaid • Medicaid cost $592 billion in 2017 State & Federal Medicaid Expenditures • Federal government funds at least 50% of state costs State $225 B • FMAP – “federal medical assistance percentage” Federal $367 B • Averages 62% across all 56 programs • Current FMAP range from 50% (e.g., California) to $0 $100 $200 $300 $400 76.4% (e.g., Mississippi) Federal State • Calculated for each state based on its per capita income • FMAP for territories is set at 55% under federal law • ACA provides enhanced FMAP to encourage Medicaid expansion; now at 90% • With limited exceptions, federal funding is open-ended/uncapped 9 3

10/2/19 Who Does Medicaid Cover? 1/3 of all kids Half of all births 7 out of 10 kids at poverty level 2/3 of nursing 45% of adults 1 in 5 people home residents with Medicare with disabilities 10 Overview – Medicaid Eligibility • Several factors determine eligibility • Meet income eligibility requirements In 2019, FPL is an ⎻ Tied to Federal Poverty Level (FPL), vary by state annual income of • Be in a categorically eligible population; or • $12,140 for ⎻ Children, pregnant women one person or ⎻ Adults in families with dependent children, • $25,100 for a ⎻ People with disabilities, adults over age 65 family of four • Be in an optional coverage population ⎻ Medicaid expansion: adults with incomes up to 138% of FPL ⎻ Determined by state • Eligibility is determined at the individual level, not family • Meet other criteria set by the state 11 37 States Have Expanded Medicaid Source: Kaiser Family Foundation; August 2019 12 4

10/2/19 Overview – Medicaid Enrollment • Person applies to state, county or enrollment facilitator • Agency verifies person meets criteria: residence, income, eligibility category • Person is enrolled in FFS Medicaid or is asked to choose a managed care plan • If no choice, may be auto-assigned to managed care plan • Managed care enrollment may be mandatory or voluntary; determined by state, may vary with eligibility group • Certain groups often excluded from managed care; e.g. dual eligibles, I/DD 13 Total Medicaid Enrollment 2017 Source: Kaiser Family Foundation’s State Health Facts 14 Overview – Mandatory Medicaid Benefits • Inpatient hospital services • Laboratory and X ray services • Outpatient hospital services • Family planning services • EPSDT: Early and Periodic Screening, • Nurse midwife services Diagnostic, and Treatment Services • Certified pediatric/ family nurse • Nursing facility services practitioner services • Home health services • Freestanding birth center services (when licensed or otherwise • Physician services recognized by the state) • Rural health clinic services • Transportation to medical care • Federally qualified health center • Tobacco cessation counseling for services pregnant women 15 5

10/2/19 Overview – Optional Medicaid Benefits • Services for Individuals Age 65 or Older in • Prescription drugs • Other practitioner services an Institution for Mental Disease (IMD) • Clinic services • Private duty nursing services • Services in an intermediate care facility for • Physical therapy • Personal Care Individuals with Intellectual Disability • Occupational therapy • Hospice • State Plan Home and Community Based Services 1915(i) • Speech, hearing and • Case management language disorder services • Self-Directed Personal Assistance • Dental services and dentures Services 1915(j) • Respiratory care services • Prosthetics • Community First Choice Option 1915(k) • Other diagnostic, screening, • Eyeglasses preventive and rehabilitative • Inpatient psychiatric services for services individuals under age 21 • Chiropractic services • Podiatry services • Other services approved by the Secretary • TB related services • Optometry services • Health homes for enrollees with chronic conditions 16 Medicaid Managed Care • 38 states, Washington DC, and Puerto Rico use managed care to serve some or all of their Medicaid enrollees • Managed care plans serve over 56 million enrollees, approximately 75% of total • States contract with several Medicaid MCOs, paying a fixed per-person monthly amount (capitation payment) to provide benefits to each Medicaid enrollee ⎻ Financial risk and administrative responsibilities shifted to MCOs • MCOs use those funds to pay for all of their enrollees’ covered Medicaid services and supports; the MCO is at risk for any costs exceeding the capitation payment • Managed care provides states with budget predictability, improved care management, ensures services are appropriate and necessary • Contracting with multiple MCOs ensures enrollee choice • State contracts include comprehensive requirements for MCO payment, performance, and administration 17 States with Medicaid Managed Care 42 Medicaid programs use managed care for some or all of their enrollees Source: CMS; States Contracting with MCOs, 2017 18 6