financing systems of care part 1 mary b. tierney, md primary care senior advisor ta partnership...

FINANCING SYSTEMS FINANCING SYSTEMS OF CAREOF CARE

Part 1Part 1

Mary B. Tierney, MDMary B. Tierney, MD

Primary Care Senior AdvisorPrimary Care Senior Advisor

TA PartnershipTA Partnership

August 7, 2003 August 7, 2003

Technical Assistance Partnership for Child and Family Mental Health

BACKGROUND AND HISTORYBACKGROUND AND HISTORY

Social Security ActSocial Security Act

• Title I – Old Age AssistanceTitle I – Old Age Assistance• Title IV – AFDC/TANF and Foster CareTitle IV – AFDC/TANF and Foster Care• Title V – Maternal and Child Health Block Title V – Maternal and Child Health Block

GrantGrant• Title XVI – SSI/Aged Blind and DisabledTitle XVI – SSI/Aged Blind and Disabled• Title XVIII – MedicareTitle XVIII – Medicare• Title XIX – MedicaidTitle XIX – Medicaid• Title XXI - SCHIPTitle XXI - SCHIP


FEDERALLY FUNDED INSURANCE FEDERALLY FUNDED INSURANCE AND ELIGIBILITY REQUIREMENTSAND ELIGIBILITY REQUIREMENTS

• ELIGIBILITYELIGIBILITY– Title I of the Social Title I of the Social

Security Act/Social Security Act/Social SecuritySecurity

– TANF/Title IVTANF/Title IV– SSI/Title XVISSI/Title XVI– Pregnant women, Pregnant women,

children, and other children, and other categories categories

– Flexible eligibilityFlexible eligibility

• INSURANCEINSURANCE– Medical/Title XVIII of Medical/Title XVIII of

the Social Security the Social Security ActAct

– Medicaid/Title XIXMedicaid/Title XIX

– SCHIP/Title XXISCHIP/Title XXI


MEDICAIDMEDICAID

• Federal/State PartnershipsFederal/State Partnerships• State Agency RequirementsState Agency Requirements• EligibilityEligibility• ServicesServices• Payment for Services Payment for Services


SCHIPSCHIP

• Medicaid Expansion ModelMedicaid Expansion Model

• Separate ProgramSeparate Program

• Which States have What Model Which States have What Model


MEDICAID FEDERAL/STATE MEDICAID FEDERAL/STATE PARTNERSHIPPARTNERSHIP

• Federal Statute and Regulations Federal Statute and Regulations Govern Overall ProgramGovern Overall Program

• State Plan Requirements State Plan Requirements • State Plan FlexibilityState Plan Flexibility• Federal Match Federal Match

Federal Financial Participation (FFP)Federal Financial Participation (FFP)Federal Medical Assistance Federal Medical Assistance Percentage (FMAP) Percentage (FMAP)


STATUTORY, REGULATORY STATUTORY, REGULATORY REQUIREMENTSREQUIREMENTS

• There are stringent Federal There are stringent Federal requirements on Medicaid State requirements on Medicaid State agencies with regard to:agencies with regard to:

• Administration of the program, i.e., Administration of the program, i.e., State PlanState Plan

• Hiring and subcontractingHiring and subcontracting• Submitting correct and valid reportsSubmitting correct and valid reports• [Sections 1902 (a) (4) – 1902 (a) (6)] [Sections 1902 (a) (4) – 1902 (a) (6)]


• States must meet all Federal mandates States must meet all Federal mandates with regard to eligibility, services, with regard to eligibility, services, administrationadministration

• States have flexibility to design their States have flexibility to design their programs in those areas where the programs in those areas where the Federal statute and regulations gives Federal statute and regulations gives them latitude in eligibility and servicesthem latitude in eligibility and services

STATE PLAN REQUIREMENTS STATE PLAN REQUIREMENTS AND FLEXIBILITYAND FLEXIBILITY


FEDERAL MATCHFEDERAL MATCH

• FFPFFP

• FMAPFMAP

• Generally at 50%Generally at 50%• 75% for Case 75% for Case

Management, Management, Maintenance of MISMaintenance of MIS

• Ranges from 50 – 83%Ranges from 50 – 83%


ELIGIBILITY OVERVIEWELIGIBILITY OVERVIEW

• Financial StandardsFinancial Standards

• Categories of EligibilityCategories of Eligibility


FINANCIAL STANDARDSFINANCIAL STANDARDS

• Income Standard – maximum amount of Income Standard – maximum amount of income a person can have and be income a person can have and be eligible for Medicaid including wages, eligible for Medicaid including wages, salary and unearned income such as salary and unearned income such as social securitysocial security

• Resource Standard – anything a person Resource Standard – anything a person owns that can be converted into cash owns that can be converted into cash including automobiles, real estate including automobiles, real estate


CATEGORIES OF ELIGIBILITYCATEGORIES OF ELIGIBILITY

• Mandatory CoverageMandatory Coverage

• Optional Groups with FFPOptional Groups with FFP

• Optional Groups without FFPOptional Groups without FFP


MANDATORY COVERAGEMANDATORY COVERAGE

• Categorically Needy Families and Categorically Needy Families and ChildrenChildren

• Aged, Blind and DisabledAged, Blind and Disabled


FAMILIES AND CHILDRENFAMILIES AND CHILDRENHIGHLIGHTSHIGHLIGHTS

• Low Income Families Low Income Families with Childrenwith Children

• TANF/AFDC TANF/AFDC RecipientsRecipients

• Families that Lost Families that Lost TANF/AFDC because TANF/AFDC because of Employmentof Employment

• Qualified Pregnant Qualified Pregnant Women and ChildrenWomen and Children

• Newborn Children of Newborn Children of Medicaid Eligible Medicaid Eligible ChildrenChildren

• Low Income Children Low Income Children under Age Sixunder Age Six

• Low Income Children Low Income Children under Age Nineteen under Age Nineteen

• Foster Care and Foster Care and Adoption AssistanceAdoption Assistance


AGED, BLIND & DISABLEDAGED, BLIND & DISABLED

• SSI RecipientsSSI Recipients

• Disabled Adult ChildrenDisabled Adult Children

• Zebley v. Sullivan DecisionZebley v. Sullivan Decision


OPTIONAL GROUPS OPTIONAL GROUPS HIGHLIGHTSHIGHLIGHTS

• Infants to age 1 year Infants to age 1 year and Pregnant Women and Pregnant Women below 185% FPLbelow 185% FPL

• Individuals Eligible Individuals Eligible for assistance who for assistance who are in institutionsare in institutions

• Individuals Receiving Individuals Receiving Home and Home and Community Based Community Based Services Services

• Noninstitutionalized Noninstitutionalized Disabled Children Disabled Children (Katie Beckett)(Katie Beckett)

• Children under 21 Children under 21 years who meet years who meet income requirements income requirements but not eligible for but not eligible for TANFTANF

• Ribicoff Kids Ribicoff Kids


MEDICAID SERVICES MEDICAID SERVICES CATEGORICALLY NEEDYCATEGORICALLY NEEDY

• Inpatient hospital Inpatient hospital servicesservices

• Outpatient Outpatient hospital serviceshospital services

• Rural Health Clinic Rural Health Clinic ServicesServices

• Federally Federally Qualified Health Qualified Health CentersCenters

• Nursing Facilities Nursing Facilities other than IMD for other than IMD for over age 21 yearsover age 21 years

• EPSDT under age EPSDT under age 21 years21 years

• Family PlanningFamily Planning• Physician servicesPhysician services


MEDICAID SERVICESMEDICAID SERVICESCATEGORICALLY NEEDYCATEGORICALLY NEEDY

• Medical and Medical and dental surgical dental surgical servicesservices

• Pediatric Pediatric and Family and Family Practice Nurse Practice Nurse PractitionersPractitioners

• Nurse MidwivesNurse Midwives

• Health care by licensed Health care by licensed practitioners (e.g. practitioners (e.g. Psychologists)Psychologists)

• Laboratory and X-RayLaboratory and X-Ray• Home Health Home Health


MEDICAID SERVICESMEDICAID SERVICESMEDICALLY NEEDYMEDICALLY NEEDY

• Prenatal care and Prenatal care and deliverydelivery

• Ambulatory Ambulatory care for care for individuals individuals under 18 years under 18 years and those entitled and those entitled to institutionsto institutions

• ICF/MR and IMD ICF/MR and IMD provisionprovision

• Most States that cover Most States that cover the Medically Needy the Medically Needy category provide category provide preventive services preventive services and additional and additional services outlined services outlined above for above for Categorically Needy Categorically Needy


OPTIONAL SERVICESOPTIONAL SERVICES

• Physical and Occupational TherapyPhysical and Occupational Therapy• Prescription drugsPrescription drugs• Diagnostic, screening, preventive and Diagnostic, screening, preventive and

rehabilitative servicesrehabilitative services• Personal care servicesPersonal care services• Any other medical or remedial care Any other medical or remedial care

recognized under State law and recognized under State law and specified by the Secretary of HHSspecified by the Secretary of HHS


• Services must be sufficient in the Services must be sufficient in the amount duration and scope to amount duration and scope to reasonably achieve its purposereasonably achieve its purpose

• EPSDT – health services determined to EPSDT – health services determined to be necessary must be provided whether be necessary must be provided whether or not they are included in the State or not they are included in the State PlanPlan

• Waivers can expand services to specific Waivers can expand services to specific populations populations

AMOUNT, DURATION AMOUNT, DURATION AND SCOPEAND SCOPE


PAYMENT FOR SERVICESPAYMENT FOR SERVICES

• Institutional services including inpatient Institutional services including inpatient and emergencyand emergency

• Ambulatory servicesAmbulatory services

• Case Management and Wrap-AroundCase Management and Wrap-Around


REFERENCESREFERENCES

• http://www.cms.gov/medicaidhttp://www.cms.gov/medicaid

• http://www.cdf.orghttp://www.cdf.org

• http://www.aap.orghttp://www.aap.org


An Advocate's Guide to the Medicaid An Advocate's Guide to the Medicaid Program 2001 Edition Program 2001 Edition

– http://www.healthlaw.org/advguide/index.shtmlhttp://www.healthlaw.org/advguide/index.shtml– An Advocate's Guide to the Medicaid ProgramAn Advocate's Guide to the Medicaid Program (159 (159

pages) is an essential resource for health pages) is an essential resource for health advocates and lawyers working with the Medicaid advocates and lawyers working with the Medicaid program.program.

– Price: $135.00 for nonprofit advocacy Price: $135.00 for nonprofit advocacy organizations (Add $15.00 each for CD-ROM or organizations (Add $15.00 each for CD-ROM or online access) online access)

– $235.00 for for-profit entities, government agencies, $235.00 for for-profit entities, government agencies, and educational institutions (Add $15.00 each for and educational institutions (Add $15.00 each for CD-ROM or online access)CD-ROM or online access)

– Phone NHeLP's Los Angeles office at (310) 204-Phone NHeLP's Los Angeles office at (310) 204-60106010


Mary B. Tierney, MDMary B. Tierney, MD

Primary Care Senior AdvisorPrimary Care Senior Advisor

TA PartnershipTA Partnership

202-298-2620 (office)202-298-2620 (office)

202-342-5007 (fax)202-342-5007 (fax)

[email protected] (email)[email protected] (email)

financing systems of care part 1 mary b. tierney, md primary care senior advisor ta partnership...

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