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

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10/2/19 1 Medicaid Overview and Impacts on Case Management: Past, Present, and Future

Rhys W. Jones, MPH

Vice President, Medicaid Policy and Advocacy, AHIP October 2, 2019 CMSNE Conference Southbridge, MA

America’s Health Insurance Plans (AHIP) is the national association whose members provide coverage and health-related services that improve and protect the health and financial security of consumers, families, businesses, communities and the nation.

Who is AHIP?

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America’s Health Insurance Plans and its members create and accelerate positive change and innovation across the health care system for consumers through market-based solutions and public-private partnerships that advance affordability, value, access, and well-being.

Our Mission

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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.

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Agenda

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Medicaid Overview
Medicaid Financing
Eligibility/Enrollment
Populations
Medicaid Benefits
Medicaid Managed Care
Long Term Services and

Supports (LTSS)

Case/Care Management
Challenges in Medicaid

Medicaid Overview –

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56 million managed care enrollees in 40 states and territories Federal/State partnership with shared funding Health coverage for 74 million Americans

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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

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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

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Overview – Financing of Medicaid

Medicaid cost $592 billion in 2017
Federal government funds at least 50% of state costs
FMAP – “federal medical assistance percentage”
Averages 62% across all 56 programs
Current FMAP range from 50% (e.g., California) to

76.4% (e.g., Mississippi)

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

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Federal $367 B State $225 B $0 $100 $200 $300 $400 Federal State State & Federal Medicaid Expenditures

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Who Does Medicaid Cover?

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1/3 of all kids 7 out of 10 kids at poverty level Half of all births 2/3 of nursing home residents 1 in 5 people with Medicare 45% of adults with disabilities

Overview – Medicaid Eligibility

Several factors determine eligibility
Meet income eligibility requirements

⎻ Tied to Federal Poverty Level (FPL), vary by state

Be in a categorically eligible population; or

⎻ Children, pregnant women ⎻ Adults in families with dependent children, ⎻ People with disabilities, adults over age 65

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

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In 2019, FPL is an annual income of

$12,140 for
ne person or
$25,100 for a

family of four

37 States Have Expanded Medicaid

12 Source: Kaiser Family Foundation; August 2019

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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

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Total Medicaid Enrollment 2017

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Source: Kaiser Family Foundation’s State Health Facts

Overview – Mandatory Medicaid Benefits

Inpatient hospital services
Outpatient hospital services
EPSDT: Early and Periodic Screening,

Diagnostic, and Treatment Services

Nursing facility services
Home health services
Physician services
Rural health clinic services
Federally qualified health center

services

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Laboratory and X ray services
Family planning services
Nurse midwife services
Certified pediatric/ family nurse

practitioner services

Freestanding birth center services

(when licensed or otherwise recognized by the state)

Transportation to medical care
Tobacco cessation counseling for

pregnant women

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Overview – Optional Medicaid Benefits

Prescription drugs
Clinic services
Physical therapy
Occupational therapy
Speech, hearing and

language disorder services

Respiratory care services
Other diagnostic, screening,

preventive and rehabilitative services

Podiatry services
Optometry services

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Other practitioner services
Private duty nursing services
Personal Care
Hospice
Case management
Dental services and dentures
Prosthetics
Eyeglasses
Chiropractic services
TB related services
Health homes for enrollees

with chronic conditions

Services for Individuals Age 65 or Older in

an Institution for Mental Disease (IMD)

Services in an intermediate care facility for

Individuals with Intellectual Disability

State Plan Home and Community Based

Services 1915(i)

Self-Directed Personal Assistance

Services 1915(j)

Community First Choice Option 1915(k)
Inpatient psychiatric services for

individuals under age 21

Other services approved by the Secretary

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

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States with Medicaid Managed Care

18 Source: CMS; States Contracting with MCOs, 2017

42 Medicaid programs use managed care for some or all of their enrollees

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Range of Medicaid Managed Care Options

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Fee for Service Primary Care Case Management (PCCM) Accountable Care Organizations (ACOs) Managed Care Organizations (MCOs)

Non-capitated, non-risk

model

No care coordination or

case management

Limited quality

incentives

No budget predictability
Strong incentives for
ver-utilization and

inappropriate use

Few reporting

requirements

Few fraud waste and

abuse (FWA) protections

Primary Care Providers

(PCPs) receive a per- member-per-month (PMPM) fee to coordinate care for patient panel

Do not share risk with the

state

Limited quality incentives
No budget predictability
Strong incentives for over-

utilization, inappropriate use

Limited reporting

requirements

Few FWA protections
Groups of hospitals, doctors, and

care providers who organize to coordinate care for their patients

Limited risk sharing with the

state

Quality and value incentives
Large up-front infrastructure

costs

No budget predictability
Limited control over utilization.

inappropriate use due to open provider networks

Strict reporting requirements
Few FWA obligations
Capitated, risk-based

contracting with a single

rganization for all covered

services.

Quality and value incentives
No infrastructure outlay
Budget predictability
Control over utilization and

inappropriate

Strong oversight of network

adequacy

Strict reporting requirements
Extensive FWA obligations

Less Risk More Risk

Long Term Services and Supports – LTSS

Assistance in performing routine activities of daily living (ADLs) like

bathing, grooming, dressing, meal preparation, eating, and medication assistance, provided to people of any age.

ADL impairments result from functional limitations, chronic illnesses,

physical disabilities, intellectual/developmental disabilities

Non-medical, non-curative; supports and services that help people carry
ut their daily activities
Services can be provided in a range of settings, including nursing homes,

assisted living facilities, convalescent homes, and home and community settings

Eligibility: require assistance with ADLs, meet state income requirements

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Rebalancing Long Term Care

Nursing home care is a mandatory Medicaid benefit; creates a bias

toward institutional care

HCBS are optional benefits; must be added through state plan

amendment (SPA) or Medicaid waiver

⎻ Personal Care ⎻ Home and Community Based Services 1915(c) ⎻ State Plan Home and Community Based Services 1915(i) ⎻ Self-Directed Personal Assistance Services 1915(j) ⎻ Community First Choice Option 1915(k)

Progress toward “rebalancing”

⎻ Increasing HCBS, reducing institutional care ⎻ Consistency with ADA, Olmstead decision

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LTSS System Performance – New England States

State Rank Access Choice Support Quality Transitions VT 3 1 1 1 2 1 CT 10 1 2 1 2 3 MA 11 1 1 2 3 2 NH 16 2 3 1 1 2 ME 18 4 2 2 3 1 RI 32 3 3 2 2 3

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Access: access and affordability
Support: support for family caregivers
Transitions: effective transitions

Source: LTSS State Scorecard 2017; AARP

Choice: choice of setting and provider
Quality: quality of life and quality of care

LTSS by the Numbers

$581.0 $167.0 $71.8 $95.2 $- $100.0 $200.0 $300.0 $400.0 $500.0 $600.0 Total MCD Total LTSS Nsg Home HCBS

Medicaid Expenditures

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4.6 million people receive

LTSS through Medicaid

1.7 million people (37%)

receive LTSS through Medicaid MCOs in 24 states

LTSS spending accounts for

29% of total Medicaid spending

($ billions; CMS 2016 data)

States with Managed LTSS

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Source: Kaiser Family Foundation’s State Health Facts

24 states have MLTSS programs as

f 2017

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Medicaid Case Management

Services that help beneficiaries access needed medical, social, educational,

and other services.

Targeted CM services focus specifically on special enrollee groups, e.g.

people with developmental disabilities, people in certain geographic areas

CM services must be comprehensive and coordinated, include an

assessment of an eligible individual; development of a specific care plan; referral to services; and monitoring and follow-up activities.

States can cover in three ways

⎻ Targeted case management ⎻ HCBS waiver programs ⎻ Administrative claiming

Not risk based; services typically paid fee-for-service plus a monthly case

management fee

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Medicaid MCO Care Management

MCO uses predictive analytics to identify at-risk members
Care manager/service coordinator – nurse, MSW, BH specialist
Initial comprehensive assessment (typically in-home)
Medical/ behavioral/ functional/ social/ environmental dimensions
Develop integrated care and service plan
May involve formal interdisciplinary care team led by care manager
Implement care and service plan, track progress
Reassess at least annually or following changes in enrollee’s condition
Care management service covered under capitation agreement

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Challenges in Medicaid – Providers

Provider dynamics

⎻ Providers must enroll in state Medicaid program, accept rates ⎻ Geographic limitations, underserved areas – can’t create infrastructure ⎻ State-line access issues in multi-state metropolitan areas ⎻ Communications challenges

Confirming scheduled/completed care
Transitions in care or settings
Changes in enrollee condition
Referral follow-up

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Challenges in Medicaid – Technology

Electronic visit verification (EVV)

⎻ State Medicaid implementation dates required by federal law

Jan 1 2020 for personal care services
Jan 1 2023 for home health services

⎻ Program integrity, quality of care rationale ⎻ State determines single vendor or delegates vendor selection to MCOs ⎻ Capabilities and features not standardized ⎻ Some advocates have concerns with requirements

Privacy concerns, monitoring their activities
Applies to caregivers accompanying them outside the home
CMS has clarified applies only to services in home

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Challenges in Medicaid – Care Settings

HCBS Settings Rule issued by CMS in 2014

⎻ Requirements for federal funding of services provided in home and community settings ⎻ Characteristics of home/community settings vs. settings presumed to be institutional (especially provider-owned) ⎻ Supports choice and independence of individuals, their right to receive care in the most integrated setting possible ⎻ Test criteria for beneficiary independence in questionable settings

States must submit transition plans to CMS, complete transition of their

HCBS programs by March 2022

Potential implications for HCBS infrastructure, esp. in rural areas

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Challenges in Medicaid – MFP

“Money Follows the Person” (aka “Consumer-Directed”)

⎻ Supports transition of enrollees from nursing homes to the community ⎻ Nearly 90,000 people transitioned since 2005 ⎻ Programs in 43 states and DC for many enrollee categories ⎻ Congress considering funding reauthorization ⎻ Medicaid enrollee is the client and employer ⎻ Enrollee hires the caregiver, may include family members ⎻ Problem areas complicate care management

Language barriers
Caregiver skill levels, client manipulation
Enrollee assertiveness, experience, cognitive levels

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Challenges in Medicaid – State Constraints

State contract requirements can present challenges in many areas

⎻ Guaranteed minimum provider rates ⎻ Program carve-outs – mental health, prescription drugs ⎻ Grandfathered populations ⎻ Care and service plans provider sign-off ⎻ Interdisciplinary care team scheduled meetings (not asynchronous) ⎻ Unreasonable turnaround times – service/auth requests, claims payment ⎻ Prescription drug formulary / PDL constraints ⎻ Restrictions on coverage of physical and BH services on same day

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Challenges in Medicaid – SDOH

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Housing

Medicaid will pay for housing in a nursing home but not otherwise
Certain home modifications covered – wheelchair ramp, widen doorways, bathroom safety equipment

Transportation

NEMT is an optional benefit; transportation not covered for other non-medical activities
Covered by many Medicaid MCOs

Food security

Home-delivered meals for certain groups
Medicaid MCOs partner with food banks, supermarkets

Employment

No Medicaid benefits
Some Medicaid plans sponsor GED programs, job training

Challenges in Medicaid – Workforce

Medicaid is primary payer of LTSS and HCBS
As baby boomers age, need for direct care workers (DCWs) will increase
4.3 million DCWs in 2017

⎻ Estimated 1 million are immigrants

BLS estimates workforce will increase by 1.6 million by 2026 but…
7.8 million DCWs will be needed – gap of 1.9 million?
Future supply of DCWs uncertain due to several factors

⎻ High average age of current workforce ⎻ Low wages – $11-12 per hour ⎻ Anti-immigrant policies ⎻ High rates of turnover – 40-50%

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Looking Ahead

Partial expansion (100% FPL)
Block grant waivers
Work requirements

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Texas v. U.S. (two cases)
CMS Medicaid Managed Care Rule
Medicare for All/ Medicaid Buy-In
Outlook for case management

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