Update: Children

1
Update Childrens Health Care and More
900 Lydia Street - Austin, Texas 78702 Phone
[phone] fax [phone] - www.cppp.org

• The University of Texas at Austin
• LBJ School of Public Affairs
• February 14, 2006
• Anne Dunkelberg, Assistant Director
  (dunkelberg_at_cppp.org)

2
Texas Health Insurance System

• US Census Bureau Statistics
• Approximately 5.6 million Texans uninsured in
  2004
• 25.1 of Texans of all ages were uninsured
• 27.6 of Texans under age of 65 were uninsured
• Another three million Texans covered by Medicaid
  or CHIP
• Why are so many Texans uninsured?
• Low percentage of employer-sponsored
  insurance (ESI)
• 9 below national average for lt 65 (54.2, vs.
  63.2)
• 9.3 below national average for lt18
• Approximately 83 of Texas Medicaid recipients
  are below poverty
• Only 14.5 of Americans below poverty have ESI

3
Texas Health Insurance System

• In other words, 2/3 of uninsured Texas children
  are below 200 FPL, despite public coverage
  options.
• Texas is home to an estimated 230,000
  undocumented kids and another 160,000 legal
  immigrant (LPR) children under age 18 (Pew
  Hispanic Center).
• The LPR kids can participate in CHIP.
• Clearly, undocumented children are just a small
  part of our uninsured problem
• About 700,000 (half) of our uninsured kids could
  enroll in Medicaid or CHIP!
• Kids Count 3-year average 6.493 million aged
  0-18 6. 23 million aged 0-17

4
Medicaid in Texas Who it Helps

• Medicaid
• As of December 2005, 2.7 million Texans were
  enrolled in Medicaid
• 1.8 million were children
• about 89,700 of these children, or 5, were
  receiving disability-related Medicaid (98 of
  these on SSI)
• about 12,500 were pregnant teens (0.7 of the
  kids 0.5 of all Medicaid)
• 141,700 in TANF cash assistance families (5.2 of
  total caseload)
• OTHER 1.6 MILLION predominantly in WORKING POOR
  FAMILIES
• (about 1.3 million worker-headed families,
• Other 20 are headed by disabled parents or
  living on child support from non-custodial
  parent)
• 898,500 were adults
• 691,000 (77 of the adults) were elderly or
  disabled. Adults on SSI account for 60 of the
  aged and disabled recipients
• Other adults 91,500 maternity coverage 31,000
  TANF parents (1.1 of total caseload)
• NOTE there are fewer than 95,000 poor parents on
  Texas Medicaid- see next slide. 63,000 either
  TMA (Transitional Medicaid Assistance) or parents
  who are at or below TANF income, but not
  receiving TANF cash assistance
• Childrens Health Insurance Program (CHIP)
• as of September 1, 2003 507,259 children
• as of December 1, 2005 322,898 (drop of
  184,361, or 36)

5
Why Very Few Poor Parents are Enrolled in Texas
Medicaid

• Texas Medicaid income cap for poor parents has
  not been increased by our Legislature for 20
  years.
• Working poor parents in Texas can get Medicaid
  now ONLY if they earn less than the
  legislatively-imposed income cap of 188 per
  month for a family of 3 (308 if one parent is
  working).
• This fixed dollar amount cap, does not increase
  from year to year with inflation. In 2006 this
  income cap denies Medicaid to parents with
  incomes above 13.6 of the federal poverty
  income.
• Forces poor parents with high medical needs to
  choose between work and health care 15 hours of
  work per week at minimum wage (5.15 per hour)
  makes them too well off to get Medicaid.
• Texas can increase the Medicaid income limit for
  parents to any level it chooses, without any
  special federal approval. The only limiting
  factor is our willingness to put up our states
  share (about 40) of the costs.
• Today, fewer than 95,000 poor Texas parents get
  Medicaid, though
• there are about 836,000 poor parents in the state
  
• 61 of adult Texans 18-64 below poverty are
  uninsured
• 1.8 million Texas children have Medicaid coverage

6
Texas Medicaid Who it Helps
December 2005, HHSC data.
Total enrolled 12/1/2005 2,707,681
7
Medicaid Cuts What was Reversed by 2005
Legislature

• Adults Medicaid Services Restored (eff. 10/05)
• Podiatrists
• Eyeglasses and Hearing Aids
• Mental health services (eff. 12/05) by social
  workers, psychologists, licensed professional
  counselors, and licensed marriage and family
  therapists. There was complication with the
  funding for this benefit, but it appears services
  by all 4 mental health provider types were
  restored December 1, 2005.
• http//www.hhsc.state.tx.us/medicaid/cs/Medicaid_B
  enefitsUpdate.html

Center for Public Policy Priorities www.cppp.o
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8
Medicaid Cuts What was Reversedby 2005
Legislature

• Might be restored (but no action yet!)
• The Personal Needs Allowance of Medicaid nursing
  home residents (the monthly amount that Medicaid
  nursing home residents may keep from SSI, Social
  Security or other pension income the rest goes
  to the nursing home)
• was cut in 2003 from 60 to 45.
• Not restored by the budget or other 2005 bill,
  but Gov. Perry and Senator Zaffirini have pledged
  to ask LBB for budget execution to allocate the
  13 million in state dollars needed to restore
  this.
• Scheduled LBB meeting (9/05) delayed due to
  hurricanes Katrina and Rita none scheduled
  since, STAY TUNED!

Center for Public Policy Priorities www.cppp.o
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9
Medicaid Cuts What was Reversed by 2005
Legislature

• Not exactly restored
• Medically Needy Spend-Down Program for Parents
  (Temporary Coverage for Poor Families with
  Catastrophic Medical Bills)
• HHSC estimated that full restoration of MN would
  cost 175 million GR for 2006-2007 SB1
  authorizes just 35 million for partial
  restoration AND assumes this will be funded
  entirely by voluntary contributions of local tax
  dollars (IGT) from the big urban hospital
  districts
• Also says 20 million GR could be added to this
  IF the local funds are provided first (the 20
  million would come from savings achieved due to
  the Womens Health and Family Planning Waiver,
  more later on this)
• No action so far to restore, and no indications
  it is likely to happen. STAY TUNED!

Center for Public Policy Priorities www.cppp.o
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10
Medicaid Cuts that Remain

• Medicaid and CHIP provider rate cuts
• Most Medicaid and CHIP providers had rates cut in
  2003 hospitals and doctors had a rate cut of
  2.5 nursing homes 1.75, and community care
  providers 1.1.
• In August 2004, HHSC proposed and LBB approved
  keeping most the cuts at the same level for 2005
  (i.e., not making deeper cuts) but hospitals
  took a deeper 5 cut.
• 2005 legislature restored rates to 2003 levels
  for Community Care services and Waivers, and for
  ICF-MR (all at DADS), but not for doctors, other
  professionals, hospitals, or CHIP.
• All other rate cuts remain. Rate cuts were the
  largest HHS cut made in 2003 much larger than
  the CHIP cuts.

Center for Public Policy Priorities www.cppp.o
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11
Income Caps for Texas Medicaid and CHIP, 2006
21,708
33,200
30,710/yr
30,710/yr
22,078/yr
222
200
16,600
7,236
185
185
2,256
3,696
133
100
74
13.6
22.3
Income Limit as Percentage of Federal Poverty
Income Annual Income is for a family of 3,
except Individual Incomes shown for SSI and Long
Term Care
12
Community Care and Waiting Listsfunding for
enrollment increases

• 2003 Legislature reduced numbers and/or levels of
  services in capped Community Care and Health
  programs
• 2006-2007 budget provides funds to increase a
  number of non-entitlement programs enrollment
• For children
• MDCP increased from 977 in 03, 983 in 05, to
  1,993 in 2007.
• CSHCN increased from 1,463 in 03, 2,114 in 05,
  to 2,293 in 07
• Most Medicaid waivers, HIV Meds increased
• Exceptions
• CBA was 30,279 in 03 26,100 in 05 to 28,401
  in 07,
• Kidney Health Program 22,834 in 03 21,247 in
  05 to 20,415 in 07
• In-Home and Family Support for aged disabled,
  MR still below 03 levels (MH IHFS program
  eliminated in 03 and not restored)

13
Center for Public Policy Priorities www.cppp.o
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14

• HHSC projected in 11/05 Medicaid expenditures v.
  appropriations shortfall of 559.4 million GR for
  2006-2007
• Lions share is due to assumed expenditure of
  444.2 million GR projected for Texas Part D
  claw-back payment. (Gov. Perry line-item vetoed
  this funding).

15
CHIP Cuts, 2004-05 Budget

• Summary of 2003 CHIP changes
• Benefits eliminated dental vision (eyeglasses
  and exams) hospice skilled nursing facilities
  tobacco cessation chiropractic services. Mental
  health coverage was reduced to about half of the
  coverage provided in 2003
• Premiums and co-payments increased
• Coverage period reduced from 12 months to six
• New coverage delayed for 90 days
• Income deductions eliminated (gross income
  determines eligibility)
• Asset test (limit) added for those above 150 of
  the poverty Line (took effect August 2004)
• Outreach and marketing reduced
• Underlined Items Restored by 2005 Legislature

16
How CHIP Fared in 2005 Session

• Restored Dental, vision, hospice and mental
  health benefits restored to 2003 levels. Dental
  delayed HHSC says will begin April 2006.
• Funding to replace monthly premiums with more
  affordable and convenient enrollment fees. To be
  applied beginning 1/06
• No enrollment fee below 133 of the federal
  poverty level (FPL) (lt2,145/ family of 4)
• 25 per family (per 6-month period) from 133-150
  FPL (2,145-2,419/family of 4)
• 35 per family (per 6-month period) from
  151-185 FPL (2,420-2,983/family of 4) and
• 50 per family (per 6-month period) from
  186-200 FPL (2,984-3,225/family of 4)

17
How CHIP Fared in 2005 Session

• None of the CHIP restoration bills ever had a
  public hearing, not even Senator Averitts SB 59.
  Restorations made were all done via the budget.
• These 2003 Changes Remain
• Coverage period reduced from 12 months to six.
  Language in law now makes this permanent, rather
  than planning for a return to 12 month coverage
  at a future date.
• New coverage delayed for 90 days. (New perinatal
  coverage could eliminate this for many newborns.)
• Income deductions eliminated (gross income
  determines eligibility).
• Asset test (limit) added for those above 150 of
  the poverty line (took effect August 2004).
• Outreach and marketing were reduced in 04-05,
  important to monitor and push for strong
  investment in both in 06-07.

18
Texas Child Medicaid and CHIP Combined
Enrollment (January 2002-December 2005)
Source All figures from Texas Health and Human
Services Commission Compares most recent month
with September 2003
Center for Public Policy Priorities www.cppp.o
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19
CHIP Caseloads Now and Projected
Rider 57 HHSC (SB 1) requires agency to request
more for CHIP from LBB if needed for
enrollment and benefits.
20
New CHIP Perinatal Coverage Planned

• Last-minute addition to the budget bill
  authorized this (Rider 70 HHSC). No previous
  bill or public discussion, but agency had done
  significant lead work behind the scenes.
• HHSC plans start-up 9/2006. The benefit and
  eligibility belong to the perinate, not the
  mother. Will provide prenatal care and delivery
  to women 186-200 FPL (who make too much for
  Medicaid).
• ALSO will pick up mothers 0-200 FPL who do not
  qualify for Medicaid maternity coverage because
  they are either a legal immigrant or an
  undocumented resident. This means that many of
  the covered perinates would already have been
  eligible for Medicaid at birth, i.e. all those
  with incomes below 185 FPL.

Center for Public Policy Priorities www.cppp.o
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21
New CHIP Perinatal Coverage Planned

• At some point before or at the first birthday,
  Medicaid-eligible children will be switched back
  to that program.
• Of the nearly 48,000 perinates per month
  projected in FY 2007, over 39,000 are infants who
  would have been enrolled in Medicaid under
  current rules, and about 8,300 are perinates who
  would not have been covered without this option.
• 7 states have these programs (AR, IL, MA, MN, MI,
  RI, WA) all but AR provided prenatal care to
  immigrants with state dollars before the CHIP
  program.
• Some controversy because (1) created under
  federal rule (not law) and (2) gives person
  status to the unborn.

Center for Public Policy Priorities www.cppp.o
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22
Womens Health and Family Planning Medicaid
Waiver

• SB 747 by Senator John Carona,.
• Texas Medicaid will provide basic medical
  check-ups and birth control services to adult
  Texas women (ages 18 and older) up to 185 of the
  poverty line (thats 2,481 per month pre-tax
  income for a family of 3 in 2005).
• Currently in Texas, working mothers must live at
  or below 23 of the FPL to qualify for Medicaid
  (23 of poverty is less than 308 per month for a
  family of 3) and childless women cant qualify at
  all so the waiver could help many thousands of
  women who cant get full Medicaid benefits.
• Texas has the highest of uninsured women aged
  18 to 64 (28.3) in the nation (the U.S. average
  is 17.7)
• About 40 of all Texas women live below 200 of
  poverty, and 50 of them are uninsured.
• HHSC still negotiating details with CMS,
  tentative September 2006 start-up .

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Womens Health and Family Planning Medicaid Waiver

• Services covered will include
• well-woman exams,
• counseling and education on contraceptive
  methods,
• provision of contraception,
• screenings for diabetes, breast and cervical
  cancer, sexually transmitted diseases,
  hypertension, cholesterol and tuberculosis,
• risk assessment and referral of medical problems
  to appropriate providers.
• It is against federal and state law to use
  Medicaid funds for abortion, and SB 747
  specifically excludes abortion providers.
• The bill also excludes coverage of emergency
  contraceptives.
• Outreach will be critical once the program
  starts, so STAY TUNED!!

24
Medicaid Buy-in Program for Working Disabled
MBI

• SB 566 by Deuell
• Directs HHSC to develop/start program to allow
  working individuals who earn too much to qualify
  for Medicaid, but less than 250 FPL
  (23,925/year for a single person) to pay
  premiums to get Medicaid coverage.
• Premiums amounts will depend on income level, and
  have 2 parts
• one is based on unearned income (like
  disability benefits) and
• the other part on earned income (like wages from
  a job)
• Latest HHSC information gives September 2006 as
  earliest start-up. Projected to serve about 2,300
  in 2007.

25
Universal Services Card Medicaid Biometric
Finger Imaging

• Universal Services card authorized (SB 46, by
  Nelson)
• HHSC can develop a single smart card for use
  both as an ID for benefits like Medicaid, Food
  Stamps, and TANF, as well as an EBT card (like
  the Lone Star card)
• CAN include finger imaging
• MUST protect client privacy
• Statewide Expansion of Medicaid Finger Imaging
  authorized (SB 563 by Janek)
• HHSC can proceed to mandatory statewide use of
  finger image cards
• Would be done in stages, and HHSC must adopt a
  plan for how to deal with lost and forgotten
  cards, who to exempt, and how to deal with no
  match situations BEFORE expanding
• Project must be found cost-effective, but not
  clear how this will be evaluated.
• HHSC plans to test mandatory finger imaging in
  Travis, Cameron, Hidalgo in April 2006.

26
Medicaid Managed Care Statewide Expansion (PCCM,
STARPlus, ICM)

• Primary Care Case Management
• PCCM expanded to 197 additional Texas counties on
  September 1, 2005
• Some Medicaid clients who do not live in a PCCM
  expansion county were enrolled in PCCM by mistake
  (should be fixed by now).
• Date for clients to pick a PCP was extended to
  November 11.
• a referral from the client's PCP was not required
  until December. To keep up with ongoing issues
  with PCP assignment selection, a Primary Care
  Provider Change List is updated daily on the TMHP
  website.
• PCCM Client Helpline 1-888-302-6688

27
Medicaid Managed Care Statewide Expansion (PCCM,
STARPlus, ICM)

• STARPLUS
• The STARPLUS managed long term care HMO model
  serves aged and disabled Medicaid clients in the
  Houston area.
• New state laws and the state budget assumed
  savings from greater management of care for aged,
  blind and disabled Medicaid clients, via three
  models of care
• a modified STARPLUS HMO model, a new Integrated
  Care Management approach, or primary care case
  management
• reduces Medicaid funding by 109.5 million GR
• A new enhanced PCCM-type Integrated Care
  Management (ICM) model will be implemented in
  the Dallas-Tarrant service area
• Where an HMO-style STARPLUS model is used, the
  state will modify the model to protect federal
  UPL payments to local public hospitals.
• Savings are guaranteed by allowing HHSC to cut
  provider rates if the new model does not produce
  the required savings. There are specific
  targets for each service area e.g., 23.1
  million for Bexar in 2006-2007.

28
Integrated Eligibility and Enrollment

• June 30, HHSC announced 5-year, 899 million
  contract with Accenture (Texas Access Alliance
  or TAA), to take over operation of the state's
  eligibility and enrollment systems for Medicaid,
  CHIP, Food Stamps, and TANF cash assistance.
• Local offices will drop from 381 DHS offices to
  167 full-service offices and 44 satellite
  offices open on certain days only the state will
  close 99 eligibility offices.
• Four call centers will provide assistance from 8
  a.m. to 8 p.m., will receive and process
  applications, and consumers will be able to track
  their applications through an automated phone
  system.
• The primary number for assistance will be 2-1-1
  calls for eligibility services will be routed to
  TAA (not the 211 call centers).

Center for Public Policy Priorities www.cppp.o
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Integrated Eligibility and Enrollment

• Eventually will be able to apply through the
  Internet, over the phone and by fax or mail.
• Over 10,000 DHS state eligibility workers in
  1997 reduced to 2,900 in IEE (counting the 600
  out-stationed workers)
• Call centers will employ about 2,500 (total
  system about 5,400)
• The transition to the new office structure began
  in January and will be phased in over a 10-month
  period.
• First step was takeover of CHIP enrollment in
  November (from current contractor, ACS)
• New child Medicaid and CHIP apps all going to
  TAA
• RGV will be last (September 2006, if on
  schedule).
• Many computer, training, staffing problems are
  troubling the transition so far child Medicaid
  enrollment dropped by 29,000 from November to
  December.
• http//www.hhs.state.tx.us/consolidation/IE/Projec
  ted_RolloutSchedule.shtml
• http//www.hhs.state.tx.us/consolidation/IE/IE.sht
  ml

30
Katrina and Health Care Texas So far

• Texas waiver allows simplified Medicaid or CHIP
  eligibility for Katrina evacuees.
• Covers, for a one-time period of 5 months,
  evacuees who meet Texas current Medicaid or CHIP
  categories and income limits.
• A major exception is that the disaster coverage
  is available to parents (with dependent children)
  who have incomes as high as the federal poverty
  line (FPL 1,341 per month for a family of 3 in
  2005), compared to regular Texas Medicaid, which
  only covers parents up to 23 FPL (about 308 per
  month for a family of 3, or even less if the
  parent is not working).
• Childless adults are not included in this
  Medicaid coverage, but costs for such adults were
  paid for under an uncompensated care pool, thru
  1/31/06.

31
Katrina and Health Care Texas So far

• Evacuees (except the childless adults) can get
  their 5 months of Medicaid coverage any time
  between September 1, 2005 and June 30, 2006, as
  long as they apply by January 31, 2006.
• There are no asset limits, and no premiums or
  co-payments required.
• Benefits include what Texas Medicaid and CHIP now
  cover including mental health services.
• HHSC says the pool will pay for care to all
  evacuees (if not covered by Medicaid) up to 200
  FPL, for services delivered between 8/24/05 and
  1/31/06.
• HHSC reported only 9,028 waiver enrollees as of
  10/21?? but that number should increase.
• After 5 months, these folks can apply for regular
  Texas Medicaid (most working parents will not
  qualify). HHSC projects about 135,000 new
  Medicaid clients in FY 2006 may result.

32
Congress passes Medicaid Cuts, Changes in FY 2006
Budget Reconciliation

• Cuts do NOT reduce deficit, as tax cuts that are
  part of the Budget Reconciliation package
  EXCEED the spending cuts
• Senate and House had VERY different budget cut
  bills House dominated final bill on HHS issues.
• Cut Medicaid by 4.7 billion over 5 years (26.4
  billion over 10 years)
• Mandatory Provisions
• Requirement to verify citizenship Beginning July
  1, 2006, all citizens applying for Medicaid have
  to submit passports or naturalization papers or
  birth certificates and other proof of identity to
  prove that they are citizens.
• Changes in the treatment of asset transfers by
  individuals needing Medicaid coverage for
  long-term care services.
• Optional provisions
• New state authority to impose co-payments and
  premiums
• prescription drugs and non-emergency use of the
  emergency room for all groups, all incomes
• allows states to implement co-payments up to 10
  of the cost of the service to clients with
  incomes 100-150 above 150 FPL can be charged
  up to 20 of the cost of the service. Children,
  pregnant women, BCCTP exempt.

33
Congress passes Medicaid Cuts, Changes in FY 2006
Budget Reconciliation

• New state authority to provide scaled back
  benefit packages for some groups of beneficiaries
• Children lt 133 FPL must get the full EPSDT
  benefits, tho some worry about wrap-around
  approach
• states may amend their state Medicaid plans to
  establish new benefit packages modeled on
  commercial health insurance coverage for
  higher-income, non-disabled, non-elderly adults
  (probably no one in current Texas program)
• New state authority to establish Health
  Opportunity Accounts (HOAs??!) for some
  beneficiaries
• up to 10 states
• Clients can be responsible for up to 10 of
  deductible
• COSTS the bill 261 million/10 years

34
Congress passes Medicaid Cuts, Changes in FY 2006
Budget Reconciliation

• CBO
• 80 percent of the budget cuts that result from
  Medicaid co-payment increases would come from
  enrollees who do not receive the health care they
  need because they can't afford the co-payments--
  not from the collection of increased co-payments
• 65,000 individuals would lose Medicaid coverage
  entirely because they will be unable to afford
  new premiums. Children will account for 60
  percent of the individuals who are unable to pay
  their premiums and are therefore denied Medicaid
  coverage.
• Around 15 percent of new Medicaid nursing home
  coverage recipients each year would ultimately
  face delays of up to one year in obtaining
  coverage as a result of the new rules.

35
Ways to Be Informed and Involved

• Go to www.cppp.org and subscribe to CPPPs e-mail
  publication, the Policy Page.
• Go to www.texaschip.org to get on Texas CHIP
  Coalition listserve (be sure to read the
  minutes!)
• for National information about Congress, the
  President, Medicaid and CHIP www.familiesusa.org
  
• for more technical and detailed information about
  Congress, the President, Medicaid CHIP, and the
  federal budget taxes www.cbpp.org