MEDICAID 101 The National Safety Net

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MEDICAID 101The National Safety Net
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Brief History
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1965

• Medicare is Born (Title XVIII)- dominant
• Coverage for Seniors and People with Disabilities
  and some dependents
• Passed Medicaid (Title XIX) too
• Coverage for poor families, seniors and some
  individuals with disabilities

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Points of Interest

• Medicare was a compromise struck between the AHA,
  the AMA and Congress
• The benefits are what these powerful lobbies
  wanted in 1965
• The benefits havent changed much since
• But the healthcare industry has!
• Congress starting to add more contemporary
  benefits (preventative services)

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More Points of Interest

• Medicare is a federal program and is not means
  tested
• Medicare has high co-pays and deductibles
• Medicaid is a federal/state partnership, is
  means-tested and prohibits high co-pays and
  deductibles
• Medicaid grew up in the welfare world ergo
  stigma

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Of note

• Since 1965 the private sector has shifted the
  high cost populations to the public sector
• The public sector (Medicaid) became the only real
  insurer of long term care

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No One Designed Medicaid

• It developed incrementally

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THERE IS NO MEDICAID PROGRAM

• IF YOUVE SEEN ONE MEDICAID PROGRAM, YOUVE SEEN
  ONE MEDICAID PROGRAM
• Every state has a different program

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Federal-State Partnership

• Federal government matches state dollars
• Based on state per capita earnings
• States decide what to cover but certain services
  are mandatory
• This includes nursing facilities

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CMS, the Federal Partner

• Centers for Medicare and Medicaid (CMS)
• Formerly Health Care Financing Administration
• (HCFA)

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Medicaid State Plans
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CMS Approves Each State Plan

• No approval, no match
• Time consuming process
• Start/Stop the Clock

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Basic Rules for State Plan Services

• Amount, Duration and Scope must be same statewide
• Deficit Reduction Act changes this for some
  options

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WHAT DOES THE STATUTE START WITH?
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Medicaid Section 190142 USC 1396

• State, to furnish (1) medical assistance on
  behalf of families with dependent children and of
  aged, blind or disabled individuals whose income
  and resources are insufficient to meet the costs
  of necessary medical services, and

• (2) rehabilitation and other services to help
  such families and individuals attain or retain
  capability for independence of self-care.

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TWO BROAD CATEGORIES OF SERVICES

• BASIC HEALTH INSURANCE
• Medical model
• Standardized services
• Doctor, hospital, lab, home health (short
  term), medical equipment, etc.
• For all who have a card

• LONG TERM SUPPORTS
• Non-Medical Model
• Individualized Services
• Nursing Facility/ICF-MR
• Home and Community-Based Waivers
• Personal Care Services
• Only for Subset of Medicaid eligible persons

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Mandatory Services

• Inpatient Hospital
• Outpatient Hospital
• Lab and X-ray
• Physician and services Nurse Practitioner
  services
• Rural Health Clinic and Federally Qualified
  Health Center Services
• Home Health (short term)
• EPSDT

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EPSDT

• Early Periodic Screening Diagnosis and Treatment
• Omnibus Budget Reconciliation Act of 1989 (OBRA
  89)
• All children up to age 21
• Must screen and must treat any anomalies you find
• Very Broad Definition of Medically Necessary

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EPSDT Screens

• Comprehensive Health and Developmental History
• Comprehensive Unclothed Physical Exam
• Immunizations and Lead Screens
• Lab Tests
• Vision, Dental, Hearing
• Other Necessary Health Care to correct or
  ameliorate defects, and physical and mental
  illnesses and conditions discovered by the
  screening services

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SCHIP

• Title XXI
• Lets Do Healthcare for all the children
• Can be Medicaid Expansion or Stand- Alone or
  Hybrid
• 65 federal Match
• Very successful but millions of children still
  uninsured

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Optional Services

• Pharmacy
• Waivers
• Hospice
• Personal Care Services
• Adult Dental
• Medical Supplies
• Rehab services

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Rehab Option Services

• Psychosocial Rehabilitation
• In-home services
• Therapeutic Foster Care
• Early Intervention Services
• Crisis Programs
• Home and Community-based services for people with
  mental illness
• And others

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THE OTHER MEDICAIDLONG TERM SUPPORTS

• Medicaid is the only act in town
• Personal Care Services State Plan Option
• Habilitation/Rehabilitation Services
• Home and Community-Based Waiver Services
• Increasingly Consumer-Directed
• Great Opportunity for creativity
• New DRA options

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Home and Community-based Waiver Services

• States must receive Federal approval to provide
  these services
• Services are designed as an alternative to
  institutional care
• Services can be targeted to a specific group and
  do not need to be provided statewide

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Home and Community-based Waiver Services

• Services can include
• Personal Care and Assistance
• Case Management/Care Coordination
• Habilitation
• Supported Employment
• Adult Day Health
• Skilled Nursing
• Home Adaptations, Assistive Devices
• Personal Emergency Response Systems
• Transportation
• Other

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Home and Community-based Waiver Services

• Medicaid does not pay for room and board for
  non-institutionalized participants

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• Nursing Home is Entitlement
• Home and Community-Based is optional

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Medicaid Eligibility

• One must be a member of a group which shares
  common characteristics and meet specific
  requirements such as
• Aged, blind or disabled with incomes below 100
  of the Federal Poverty Level
• People receiving Supplemental Security Income
  (SSI)
• Medically Needy

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Medicaid State Plan Eligibility

• Must meet both categorical (group) and financial
  requirements
• Categorical eligibility requires that a person be
  a member of an eligible group
• Aged, blind or disabled
• Child or caretaker of a child
• Pregnant woman

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State Plan Financial Eligibility

• Financial eligibility means that a person must
  meet certain income and resource standards

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State Flexibility in Counting Income and Resources

• Section 1902(r)(2) allows states to use less
  restrictive income and resource methodologies
  than SSI for aged, blind or disabled groups
• States can expand eligibility by disregarding
  certain types or amounts of income or resources

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Medically Needy Option

• States can cover people with too much income to
  otherwise qualify resource standard remains the
  same
• People must meet categorical eligibility
• States must first cover pregnant women and
  children before extending it to aged, blind or
  disabled
• States must use a single income and resource
  standard for all medically needy groups

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Medically Needy Option

• Persons who qualify must spend-down to the
  states regular income standard before becoming
  eligible for Medicaid benefits that is, incur
  expenses on a periodic basis that brings their
  income below the standard
• States can offer the option of paying the
  spend-down amount directly to the State in
  exchange for immediate coverage

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Home and Community-based Waiver Eligibility

• To be eligible for waiver services, people must
  be eligible for Medicaid
• Services can be targeted to a specific group
  and/or specific geographic area
• States can disregard parents or spouses income
  and resources
• States can design program for people up to 300
  of SSI standard

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Eligibility

• Very complicated with multiple avenues to become
  eligible
• Just remember there are many ways to get the card
  

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Who or What is Katie Beckett?

• Allows states to cover children with severe
  disabilities as a family of one, thereby
  disregarding family income

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Other Eligibility

• QMB Qualified Medicare Beneficiary
• Medicaid pays Part B premium and co-pays and
  deductibles for Medicare for low income persons
  with limited assets
• Income Below poverty level

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Other Eligibility

• SLMB Specified Low Income Medicare Beneficiary
• Medicaid pays the Part B premium for Medicare for
  certain low income Medicare beneficiaries with
  limited assets
• Up to 20 above poverty limit
• There are QDWIs too (Qualified Disabled Working
  Individual)
• These are the groups getting Medicare Part D
  subsidies under the new prescription drug program

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Medicaid the Only game in town forLong Term
Supports

• Children and Adults with Major Disabilities who
  need supports to live in the community
• Elders who need supports to live in the community

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Evolution of Medicaid Program Design Process
the beginning

• Pinnacle of the medical model
• Institutional Bias

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Phase Two

• Some Medicaid employees start talking to
  individuals and families that use the services
• Partnership brings needed changes - more choices,
  less institutions, more customization
• Families with children with developmental
  disabilities lead the pack

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Enter Major Change

• Disability Rights Movements
• Americans with Disabilities Act (ADA)
• Olmstead
• Ticket To Work and Work Incentives Improvement
  Act (TWIIA)
• Consumer-Direction and Self-Determination
• Cash and Counseling

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TWWIIA

• Ticket to Work and Work Incentives Improvement
  Act of 1999
• Changes the Paradigm - separates poverty and
  disability

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Medicaid Buy-Ins and Grants

• People can return to work without losing
  Medicaid, their only source of long term supports
• Can buy into the program and keep benefits
• Created 11 years of funding for states

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Other TWWIIA Provisions

• Social Security Administration grants for
  Benefits Planning
• Department of Labor grants for making one-stop
  employment centers accessible

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New Goals

• Equal Opportunity
• Full Participation
• Independence
• Financial Security

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Lois and Elaine

• Olmstead plaintiffs
• Supreme Court case that says the ADA is a civil
  rights statute and acknowledged that Congress
  found that discrimination against people with
  disabilities includes segregation, isolation and
  institutionalization

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Consumer-Direction

• Choice and Control
• Choice What do you want, is it out there, can
  you have it?
• Who Has the Power? The payer, the provider, or
  the user of services?

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Cash and Counseling
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Phase Three -

• The Model Community

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Must Engage the Larger Community

• Right Thing to Do
• Solutions, like Politics, are Local
• Public coffers cannot sustain the whole burden
• Costs will exceed the wealth of the nation
• Only viable path to inclusion
• Makes Economic Sense for each community to
  invest in all of itself

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Inclusion means Everyone

• Chief of Police
• Religious Institutions
• Superintendent of Schools
• Zoning Board

• Main Street Proprietors
• Kiwanis
• Rotary
• Buildings
• Meetings

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Look What Happens

• New Relationships Form -Personal relationships
  diminish our ability to sustain incorrect ideas
  and superstitions
• Solutions help everyone - ever wheel a stroller
  over a curb cut?
• Success breeds Success
• Everyone contributes, everyone gains

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In The Model Community

• Everyone lives in the generic community with its
  network of informal and formal supports
• They only reach in to Medicaid when they need
  additional services and they bring them back to
  the community to spend

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ADA PRINCIPLES

• Opportunity
• Meaningful Participation
• Independence
• Financial Security

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Opportunity

• Do individuals have the opportunity to
  participate in the community in meaningful ways?

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Meaningful Participation

• Do individuals with disabilities participate in
  decisions affecting their lives? Are they
  consulted about changes in policy?

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Independence

• Are individuals able to make decisions affecting
  their lives in the community?

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Financial Security

• Do programs assure that participants have enough
  money/resources to support themselves?
• Are participants able to feel secure in their
  communities?