4 - DSS Presentation: Medical & Adult Services Thursday, January 22, 2015 9:56 AM Department of Social Services oss ~ Streng Families • Soudl Dalota's Foundation and Our F1ture Medical Services and Adult Services and Aging • Division of Medical Services • Division of Adult Services and Aging Page 63
Department of Social Services DSS {j Strang Families • South Dalata's Foundation and Our F1ture Division of Medical Services (MS) Page 64
Division of Medical Services Overview • What is Medicaid? • Who We Serve. • Services Provided. • Budget Development. Page 65
Division of Medical Services South Dakota Medicaid: • Medicaid is the nation's publicly financed health care coverage program for low-income people enacted in 1965 under Title XIX of the Social Security Act and Title XXI the Children's Health Insurance Program (CHIP) enacted in 1997. • lVIeclicaid is not Medicare. • Medicare is specific to the over 65 population and the disabled population who meet the federal disability criteria. • Medicare is a federally administered and funded program. • ~Iedicaid is an entitlement program- all people eligible must be served. • Federal - State partnership governed by l\tledicaid State Plan. Page 66
Division of Medical Services South Dakota Medicaid State Plan: Is a contract between the state and the federal government describing how South Dakota administers the state's Medicaid program. • A contract with the federal goven1ment outlining who is served and what services are covered. • States administer the Medicaid program. • Each state plan is different due to optional services provided making it difficult to compare states side-by-side. • When you've seen one Medicaid program, you've seen one Medicaid progrmn. Page 67
Division of Medical Services South Dakota Medicaid State Plan (cont.) • Department of Social Services is the designated Single State Agency fo r overall administration. • Amendments to the State Plan reflect federal and state changes in the Medicaid program. • There is a fonnal process for making changes to the State Plan. • An amendment must go through public notice and Tribal consultation prior to submission to the Regional Center for Medicare and Medicaid Se1vices (CNIS) for approval. • South Dakota State Plan can be found on the Departn1ent website at: • http://dss.sd. gov /medicalservices/medicaidstateplan/index. asp. • In addition, Medicaid Fee Schedules for Service (FFS) Reimbursement can be found at: • http://dss.sd. gov /sdmedx/includes/providers/feeschedules/ dss/index. aspx. • Annual South Dakota Medicaid Report can be found at: • http://dss.sd.gov/FY20l4SDMedicaidReport.pdf Page 68
Division of Medical Services Regulatory Structure: Federal Rules • • Code of Federal Regulations (CFR) • Defines the mandat01y Medicaid benefits and populations that the state is required to provide health care coverage for to receive federal funding. • Provides optional iv1edic aid benefits and populations a state can cover. • State Rules • Administrative Rules of South Dakota (ARSD ). • Implements federal and state le gislative mandates/changes. • Contains specific limits on the amount, duration and scope of services for South Dakota Medicaid providers and recipients. Page 69
Division of Medical Services Who We Serve: • Provide Healthcare Coverage: • Low income children pregnant women, adults and families • Elderly or di sabled • Chilch-en in foster care • Adult coverage is limited to: • Elderly or disabled • Parent/Caregiver/Relatives of Low Income Children - 53 % FPL (family of three $10,489 annual income) • 68 % chilch-en and 32% adults • SFY 2014 Average ~Ionthly Eligible South Dakotans: • Elderly - 7 078 • Disabled/Blind-18 ,914 • Pregnant Women (pregnancy only)- 1,844 • Low-income Adults - 11 ,897 • Children of Low-income Families - 63 ,076 • Children covered by CHIP - 12 ,519 • Total Average Ionthly - 115,328 Page 70
Division of Medical Services Medicaid Participation Medicaid Participation Age Eligibility Category SFY2014 SFY2014 Pregnant Low Women Elderly Income 1,844 7,078 Adults 11,897 Children of L ow Income Families 63,076 Page 71
Division of Medical Services South Dakota Medicaid Expenditures, SFY 2008-2014 (in Mi ll ions) • Sta te / Match • Federal $700.00 $6 00.00 $5 00.00 $4 00.00 $300.00 szoo.oo s1 00.oo SO .O D SFY 2008 SFY 200 9 SF Y 20 10 S FY 20 11 SFY 2012 SFY 2013 SFY 2014 * In cl u de s al l state agency Medic aid e xp e nd i ture s. Page 72
Division of Medical Services Majority of Expenses by Provider Type, SFY 2014 ( - SFV _ ~0~4 Expm,e -· i•rov"ider "of Total · (Millloni) Hospital $1 74.9 23.0% Nursin2 Homes/ Assisted Livi n~ Prov iders/Hospice $140 .7 18.5% Community Support Providers $114.4 15 .0% Ph y sic i ans, Indepe nd e nt Pr actitioners and Clinics $1 06.8 14.0% Indi an Health Services $72 .8 9.6% Pharmacies $32 _ 0 4.2% South Dakota Developmental Center and Human Services Center $34 .9 4.6% Substance Abuse, Mental Health and Other Community Support Providers $22 .1 2.9% Psychiatric Res idential Youth Ca re Providers $28 .0 3.7% - $17_2 Dentists 2.3% Dur able Medical EQuipment Providers $9.8 1.3% S In-Home Service Providers for the E l der ly and Skilled Home Health 8.3 1.1% Total for Ma'orit of Ex e'nses 7- 61 ~9 --' *Includes all state a gen cy Medicaid expe nd itures. Page 73
Division of Medical Services Med ical Seivices -Av erage Co st of Seiv i oe - SFY14: A1,g . El igib l es $1 , 986 Age d 7,078 Bl ind/D i sabled Mu l ls $7 , 266 15,740 $14,398 Bl ind/D i sabled Chil dr en 3,172 $2,460 Chi l dren of Lo w I ncome Fam ili es 63,077 Pre gnan W omen $8 ,522 2,612 L ow I ncom e Mu I ts $6 , 103 11,130 $1 ,884 Chi l dren 's Hea l th Ins ur ance 12,519 115,328 • Does n ot include Wedic are prem i ums , ad m in , drug rebates , & othe r non -dire ct se r.i ce costs Page 74
Division of Medical Services Service Delivery: • Medical Services Staff - 52.0 FTE • Provider Enrollment • Process Claims • Surveillance Utilization & Review • Electronic Health Records • Prior Authorizations for services • Manage State Plan • Staff located in Piene , Rapid City and Sioux Falls Page 75
Division of Medical Services Health Care Services: • Covered Healthcare Services must be medically necessaiy and physician ordered. • Recipients paiiicipate in cost sharing, but there are limits set federally and ce1tain groups are exempt from cost sharing. South Dakota Optional Services {examples) Medicaid Mandatory Services (examples} Inpatient hospital services Physician assistants Outpatient hospital services Psychologists and independent mental health Early and Periodic Screening, Diagnostic, and practitioners Treatment (EPSDT) services Intermediate Care Facilities for the Mentally All Medically Necessary care for eligible Retarded (ICFIMR) children under age 21 Podiatry Nursing facility services Prescription Drugs Home health serv i ces Optometry Physic i an services Chiropractic servi ces Rural health clinic services Durable medical equipment Federally qualified health center services Dental services Laboratory and X-ray services Physi ca l, occupational , speech therapy, Nurse Midwife services audiology Certified Pediatr ic and Family Nurse Prosthetic devices and eyeglasses Practitioner services Hospice care, nursing services Transportation to medical care Personal care services and home health Tobacco cessation counseling for pr egnant aides women Page 76
Division of Medical Services Medicaid Waivers: • States can only get waivers for specific areas of Nledicaid. • Cannot waive the basic tenants of Medicaid. • Ca nnot cap enrollment. • Must be cost/budget neutral. • Can only vary from existing federal Nledicaicl requirements in certain areas, e.g. • Level of care requirements, i .e. , serve people at home instead of institution s. • Services or Populations Covered - usually used to expand service s. • Specific process to obtain waivers. • Requires a series of detailed steps including an application and public notice. • South Dakota has four Home and Community Based Waivers . • Provide services outside of institutions. • DSS- aging and disabled waiver. • DH S- 2 ID/DD waivers, I waiver for people with quadriplegia . Page 77
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