Update: Texas Medicaid and CHIP

1
Update Texas Medicaid and CHIP
900 Lydia Street - Austin, Texas 78702 Phone
[phone] fax [phone] - www.cppp.org

• Texas Health Care Access Conference
• Texas Association of Community Health
  Centers/Covering Kids and Families/Texas CHIP
  Coalition
• February 28, 2006
• Anne Dunkelberg, Assistant Director
  (dunkelberg_at_cppp.org)

2
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)

3
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

4
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

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5
Medicaid Cuts What was Reversedby 2005
Legislature

• Soon to be restored
• 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 pledged to
  ask LBB for budget execution to allocate the
  13 million in state dollars needed to restore
  this.
• Lt. Gov. and Speaker directed HHSC 2/16/06 to
  restore how soon?

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6
Medicaid Cuts What was Reversed by 2005
Legislature

• Not REALLY restored
• Medically Needy Spend-Down Program for Parents
  (Temporary Coverage for Poor Families with
  Catastrophic Medical Bills)
• SB1 authorizes just 35 million for partial
  restoration (full restoration would cost 175
  million GR for 2006-2007)
• AND assumes these funds DONATED by big urban
  hospital districts (from local tax dollars, or
  IGT)
• Urban counties unlikely to do 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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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 of 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. Lt. Gov.
  Speaker directed HHSC 2/16/06 to restore/increase
  nursing home rates (when?).
• All other rate cuts remain. Rate cuts were the
  largest HHS cut made in 2003 even larger than
  the CHIP cuts.
• TMA surveys of Texas doctors show that the
  percentage of doctors taking new Medicaid
  patients dropped from 75 in 1996 to 45 on 2004.
  

Center for Public Policy Priorities www.cppp.o
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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)

9
Medicaid Caseloads Actual and Projected Medicaid Caseloads Actual and Projected Medicaid Caseloads Actual and Projected
Actual Medicaid enrollment, December 2005 (Final recipient months enrollment averages 109 of point-in-time) 2,707,681 (final will be about 2.95 million) 2,707,681 (final will be about 2.95 million)
2006 2007
What HHSC estimated in 2/05 when budget process began 3,124,110 3,356,597
What the LBB assumed when the budget bill was introduced (lower caseload AND cost per client) REDUCES BUDGET 930 MILLION GR 2,987,578 3,137,045
Medicaid Buy-In (New Clients) 2,273 2,273
Waiting List (New Clients) 1,078 3,196
CHIP Perinatal Subtractions (i.e., moved to CHIP) (14,386) (39,214)
Medically Needy 10,118 10,918
Final Budget for 2006-2007 2,986,661 3,114,218
Difference, HHSC projected and budgeted in SB 1 -137,449 -242,379
Center for Public Policy Priorities www.cppp.o
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WHY is she Telling Us This??

• 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 Medicare
  Part D claw-back payment. (Gov. Perry line-item
  vetoed this funding).
• Conservative (low) assumptions of caseload and
  cost-per-person in budget create strong
  likelihood that there will be a Medicaid
  shortfall in 2007.

11
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

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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.
  Applied beginning 1/06
• No enrollment fee below 133 of the federal
  poverty level (FPL) (lt2,217/ family of 4 for
  2006)
• 25 per family (per 6-month period) from 133-150
  FPL (2,217-2,500/family of 4)
• 35 per family (per 6-month period) from
  151-185 FPL (2,500-3,084/family of 4) and
• 50 per family (per 6-month period) from
  186-200 FPL (3,084-3,334/family of 4)
• HHSC will use 2006 FPL figures staring 4/1/06

13
How CHIP Fared in 2005 Session

• No CHIP restoration bill 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.

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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
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CHIP Caseloads Now and Projected
2006 2007
September 2003 actual caseload 507,259
December 2005 actual caseload 322,898
decline, 9/03 to 12/05 (36) (-184,361)
HHSC 2/05 enrollment projection, if 12-month eligibility restored 386,110 467,404
HHSC 2/05 enrollment projection (6 month renewal) 360,786 388,920
SB 1 funded caseload, traditional CHIP (6 month renewal) 344,750 351,132
Additional caseload, perinatal coverage 17,425 47,498
Total, SB 1 projected CHIP caseload, traditional perinatal CHIP 362,175 398,630
Rider 57 HHSC (SB 1) requires agency to request
more for CHIP from LBB if needed for
enrollment and benefits.
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New CHIP Perinatal Coverage Planned

• Last-minute addition to the budget bill
  authorized this (Rider 70 HHSC). No bill,
  hearings, or public discussion, but HHSC 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 U.S
  citizen women 186-200 FPL (not quite low enough
  to qualify 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.
• over 39,000 will be infants who would have been
  enrolled in Medicaid at birth under current
  rules, and
• about 8,300 are perinates whose prenatal care
  would not have been covered without this option
  (but would have qualified for CHIP after birth).
• MORE DETAILS LATER TODAY!

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17
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 2,559 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
  (22 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 .
• MORE DETAILS THIS AFTERNOON!

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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.

19
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
• No time line announced by HHSC
• 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.

20
Medicaid Managed Care Statewide Expansion (PCCM,
STARPlus, ICM)

• Since 1993, Texas Medicaid has enrolled growing
  numbers of clients in managed care programs.
• Larger cities use Health Maintenance
  Organizations (HMOs), while more rural areas use
  Primary Care Case Management (PCCM), a non-HMO
  managed care system that assigns every person to
  a primary care doctor.
• 2003 and 2005 Legislatures expanded Medicaid
  Managed Care.
• All of Texas rural counties and many smaller
  cities now use PCCM (expanded to 197 additional
  Texas counties on September 1, 2005), and
• Austin, Dallas, El Paso, Fort Worth, Lubbock,
  Houston, and San Antonio offer HMO-based care.
  HMO care will begin in Corpus Christi/Nueces
  County later in 2006.

21
Medicaid Managed Care Statewide Expansion (PCCM,
STARPlus, ICM)

• These urban areas that now have HMO-based
  Medicaid Managed Care will begin to also manage
  long term and community care services for their
  aged or disabled clients (through the STARPLUS
  and Integrated Care Management or ICM models).
  2007 is earliest this is roll out.
• The STARPLUS managed long term care HMO model
  currently serves aged and disabled Medicaid
  clients in the Houston area.
• A new enhanced PCCM-type Integrated Care
  Management (ICM) model will be implemented in
  the Dallas-Tarrant service area
• 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.

22
Integrated Eligibility and Enrollment

• HHSC 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.
• TAA has begun processing CHIP and childrens
  Medicaid applications, all programs in 4 Travis
  and Hays offices, and is scheduled to roll out
  Call Center and internet operations in phases
  over the next year.
• Stay Tuned for More at the 1015 session!
• http//www.hhs.state.tx.us/consolidation/IE/IE.sh
  tml

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23
Katrina and Health Care

• 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 plus parents (with
  dependent children) who have incomes as high as
  the federal poverty line.
• After 5 months, these folks can apply for regular
  Texas Medicaid (but most working parents will not
  qualify). HHSC projects about 135,000 new
  Medicaid clients in FY 2006 may result.
• Childless adults care thru 1/31/06 was funded
  from an uncompensated care pool , so some of
  these folks got less than 5 months of help.

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Ways to Be Informed and Involved

• Go to www.texaschip.org to get on Texas CHIP
  Coalition listserve (be sure to read the
  minutes!)
• Go to www.cppp.org and subscribe to CPPPs e-mail
  publication, the Policy Page.
• 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