Texas Medicaid

Medical and Dental Information Series

1Module 1Version 1.2 (6/22/2010)

2/22/2013

Medicaid Curriculum Overview

Module 1: General Structure of the Texas Medicaid SystemModule 2: Understanding Medicaid Clients and Health Literacy

Module 3: Texas Health Steps

Module 4: Navigating Insurance and Managed Care

Module 5: Interfacing with Medicaid as a Provider

Module 6: Special Medicaid Programs

Module 7: Special Medical Issues

Module 8: Special Dental Issues

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Module 1

General Structure of the Texas Medicaid Program

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Module 1: ObjectivesAfter completing this module, you should be able to:

Describe the purpose and background of Medicaid

Identify who benefits from services supported by Texas Medicaid

Contrast Medicaid with other major health programs

Describe the organization of Medicaid in Texas

List features of Medicaid Managed Care

Identify examples of Texas Medicaid programs

Outline advantages to serving as a Medicaid provider

Find Medicaid resources

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True or False?Test Your Knowledge about Texas Medicaid:

Medicaid is funded solely by the federal government.Medicaid is an entitlement program based solely on age.Medicaid benefits include many optional services that a state can choose to provide. Non-disabled children account for more than half of Texas Medicaid spending.Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.

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What is Medicaid?

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Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments:

About one-third funded by the State of TexasAbout two-thirds funded by the Federal Government

In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million).Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967.

In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC).

Medicaid is an entitlement program, which means:

The number of eligible people who can enroll cannot be limited.Any services covered under the program must be paid.

What Does Medicaid Cover?

Long-term services for elderly and disabled clients

Mental health and substance abuse treatment

Acute and preventive health care for all ages

Physician visits

Inpatient and outpatient services

Pharmacy, lab, and radiology costs

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Dental Services (for patients under the age of 21)

Preventive

Therapeutic

Basic Principles of MedicaidSocial Security Act

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Statewideness

All services must be available statewide.

Comparability

The same level of services must be

available to all clients or patients (e.g., those with

similar disabilities).

Freedom of Choice

With certain exceptions, including for

managed care, the States must allow

Medicaid recipients freedom of choice

among participating providers of health

care services.

Amount, Duration and Scope

States must cover each service in an amount, duration, and scope that is

“reasonably sufficient” and may

impose limits on services for adult

clients. A state may not arbitrarily limit services for any

specific illness or condition.

Medicaid Benefits

The Social Security Act specifies…

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Required Benefits Optional Benefits

States may define their own amount, duration, and scopeof (or limitations on) Medicaid benefits

Example: Limitations on prescription drugs

Limits on coverage, for both required and optional services, may not be imposed for children under 21 if there

is a medical necessity.

Mandated ServicesCovered by Texas Medicaid, 2013

EPSDT (Texas Health Steps) medical and dental check-ups and treatments for persons under 21

Physician services

Dental services

Family planning services

Inpatient & outpatient hospital

Lab and radiology

Nursing facility care

Home health care

Services by:

Federally Qualified Health Centers

Rural Health Clinics

Certified Nurse Midwives

Clinical nurse specialists and nurse practitioners10

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Examples of Optional Services Covered by Texas Medicaid, 2013

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Hospice servicesMaternity service clinicsPrescription drugsPodiatryOptometry, including glassesHearing instrumentsRenal dialysisRehabilitation services

Medical or remedial care provided by:

Physician extendersMental health providersChiropractorsPhysical therapistsOccupational therapistsSpeech therapists

All services are required for children under 21 years of age if medically necessary; restrictions apply for many services to adults.

Rehabilitative services for mental illnessIn-home respiratory careAttendant servicesProgram for All-Inclusive Care for the Elderly (PACE)

Who is Eligible for Medicaid Benefits?

Medicaid primarily serves:Low-income families

Foster children

Pregnant women

The elderly

People with disabilities

Babies born to mothers receiving benefits at time of delivery(Services available for one year)

Caseload Costs0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aged & Disability Re-lated30%

Aged & Disability Re-lated58%

Non-Disabled Adults 9%

Non-Disabled Adults 10%Non-Disabled Children

61%

Non-Disabled Children32%

Texas Medicaid 2011

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Who is Eligible to Deliver Medicaid Funded Services?

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Individual Health Care ProvidersDoctors, dentists, advanced practice registered nurses, physician assistants, physical therapists, optometrists, and psychologists

Outpatient Facilities Rural health clinics, federally qualified

health centers, school clinics, family planning agencies, and mental health

centers

Inpatient FacilitiesHospitals and skilled nursing facilities

Providers of Goods & ServicesDurable medical equipment, ambulance,

pharmacies, radiology, and labs

Choosing a Provider:Patient Options

Although the Social Security Act requires freedom of choice in selecting Medicaid providers, it also allows states to set specific guidelines, especially for managed care organizations

Medicaid fee-for-service patients may choose any Medicaid provider

Patients enrolled in Health Maintenance Organizations (HMOs) have a primary care provider (or PCP) in a medical home

Patients in an HMO may choose any Medicaid primary care provider or specialist within the HMO network

In most cases, a referral for specialty care from the PCP is required for HMO patients

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Medicaid vs. MedicareWhat is the difference?

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Texas Medicaid Medicare

Eligibility and enrollment in both programs concurrently is possible

CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program.

Authorized by Social Security Act of 1965Established in Texas – 1967

Jointly Funded by State and Federal Government, administered by State &

regulated by CMS

Funded by Federal Government & administered by CMS

Entitlement programbased on income

Entitlement programbased on age or disability

Low income families, children, pregnant women, disabled, elderly

People 65 years or older, or people with disabilities

Medicaid vs. CHIPWhat is the difference?

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Texas MedicaidChildren’s Health

Insurance Program(CHIP)

Authorized by Social Security Actof 1965

Jointly Funded by State and Federal Government

Entitlement program based on income, assets and/or disability

Low income families, children, pregnant women, disabled, elderly

Children in families with too much income or too many assets to qualify for Medicaid and who meet the CHIP

income requirements

Authorized by Balance Budget Actof 1997

Enrollment based on income(not an entitlement program)

Who can receive FullMedicaid Benefits?Categories of Eligibility

Low income families, pregnant women, and children

Based on income level, age, caring for a related Medicaid eligible dependent child or pregnancy

Cash assistance recipients

Based on receipt of Supplemental Security Income (SSI)

People age 65 and older and those with disabilities

Based on income level, age, and physical or mental disability

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Who can receive Limited Medicaid Benefits?Categories of Eligibility

Medicare Beneficiaries

Based on income level and age

Non-Citizens

Legal permanent residents and undocumented persons who are not eligible for Medicaid based on citizenship status may receive emergency services.

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How Many People DoesTexas Medicaid Serve?

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

1.872.10

2.492.68

2.88 2.79 2.83 2.88 3.003.30

3.54

Texas Average Monthly Medicaid Enrollment

SFYs 2001-2011

Mill

ions

At any one time, how many individuals are enrolled in Medicaid? About 3.54 million

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How Many People DoesTexas Medicaid Serve?

2001 2002 2003 2004 2005 2006 2007 2008 20090.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2.612.96

3.363.63 3.73 3.81 3.83 3.85 4.02

Texas Annual Unduplicated Medicaid EnrollmentSFYs 2001-2011

Mill

ions

How many individual Texans received Medicaid-funded services at some point in the year? About 4.57 million

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Distribution of Medicaid Enrollees

State Total = 3,098,169As of: August 2010

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Texas Medicaid Recipients State Fiscal Year 2011

Gender

Age

Ethnicity

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

55%

36%

54%

45%

30%

22%

11%

17%

17%

8%

6%

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Female Male

0-5 6-14 15-20 21-64 65+

Hispanic Caucasian African-American

Other

Unduplicated ClientsSFY 2011 = 4,567,077

How does Texas enroll Medicaid participants?

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Fee for Service

Traditional arrangement in which a provider is paid for each individual service that

a patient receives

Managed Care

Structured clinical, financial, and

organizational activities designed to improve

continuity and access to health care services,

promote appropriate use of services, and contain

costs.

MCO: Managed Care Organization, a health organization that finances and delivers health care through a specific provider network and

defined services and products

The Medical HomeKey Feature of Medicaid Managed Care

Serves as a source for continuity of care from a primary care provider (PCPs)

Provides comprehensive preventive and primary acute care

Provides specialty referrals and other services offered by a managed care organization and coordinates all levels of patient care

Texas Medicaid PCPs:Family physicians PediatriciansGeneral internistsObstetricians/gynecologistsPhysicians’ assistantsAdvanced practice registered nursesCommunity clinics including federally qualified health centers (FQHCs) and rural health centers

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Medicaid Managed Care in TexasOverview of Plans

STAR (Originally an acronym for State of Texas Access Reform)A statewide managed care program in which HHSC contracts with MCOs to provide, arrange for, and coordinate preventative, primary, and acute care covered services

STAR+PLUSProvides integrated acute and long-term services and supports to people with disabilities and the elderly

NorthSTAR A capitated program in Dallas and surrounding counties that provides behavioral health (mental health and substance abuse) services to Medicaid and medically indigent patients

STAR HealthA statewide program to provide coordinated care to children and youth in foster and kinship care

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Percentage of Medicaid Clients by Delivery Type, State Fiscal Year 2011

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Fee-for-

service24%

Star PCCM25%

STAR MCO43%

STAR+PLUS6%

Star Health1%

Service Delivery Types

What are Examples of Texas Medicaid Programs?

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Texas Health Steps Provides medical prevention and dental preventive/treatment services to eligible children

Programs for Women and ChildrenPrograms for family planning and pregnant women, Medicaid Buy-In for Children, and women’s cancers

Prescription Drugs Prescription medications through local pharmacies

Behavioral Health Services Mental, emotional, and chemical dependency treatment for eligible patients

Long-Term Services and Supports Programs for those with physical, intellectual and developmental disabilities

Texas Health Steps

Perhaps the best known of Texas Medicaid programs is THSteps, which provides medial and dental preventive care and screening to eligible children.

THSteps is the name for the federally-required Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in Texas.

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Module 3 will focus specifically on Texas Health

Steps.

Components of THSteps Medical Checkups

Medical history

A complete physical examination

Screening of nutritional, developmental, and mental-health needs

Age appropriate laboratory tests (including lead screening)

Routine immunizations

Health education

Vision and hearing screening

Oral health screening and referral to a dental home

Referrals to other health care providers as needed

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Components of THSteps Dental Checkups and Services

Preventive servicesDental examinations, cleanings, oral health education, topical fluoride applications, application of sealants, maintenance of space

Treatment servicesRestorations (fillings and crowns), endodontic treatment, periodontic treatment, prosthodontics, oral surgery, implant services and maxillofacial prosthetics

Emergency treatmentProcedures to control and treat bleeding, pain, acute infection, immediate tooth loss, and injury to teeth or supporting structures

Health Related Orthodontic Services (prior authorization needed)Correction of cleft palate, crossbite therapy, treatment of severe malocclusion, and treatment of facial accidents involving severe traumatic deviation

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MCOs: Managed Care Organizations

Providers: Medical, Dental and Other Services

ICHP: Quality Monitor

MAXIMUS: Medicaid andCHIP Enrollment Broker

TMHP: Claims Administrator

DARS

DADS

DSHS

The Medicaid Team

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HHSC: Single State Agency charged with the administration & supervision of the Medicaid plan

Texas MedicaidOperating Departments

Governor of Texas

Health & Human Services (HHSC) Executive CommissionerSingle State

Agency (HHSC)Department of State Health Services

(DSHS)

Department of Assistive & Rehabilitative Services (DARS)

Department of Aging & Disability Services (DADS)

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Medicaid Functions

Operates as the single state agency responsible for Medicaid

Serves as primary contact point for the federal government

Administers the state Medicaid plan

Contracts with other state agencies to carryout certain Medicaid functions

Determines Medicaid eligibility

Operates the state’s acute care, prescription drug, and most managed care programs

Develops Medicaid policies, rules, and reimbursement rates

Organizes and coordinates initiatives to maximize federal funding

Manages the Medical Care Advisory Committee (MCAC)

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Medicaid Functions

Texas Health Steps

Case Management for pregnant women and children

Newborn metabolic screening, newborn hearing screening

Family planning

Targeted case management and rehabilitation

Services for people diagnosed with a mental health condition

NorthSTAR Administrator

YES Waiver program for children with severe emotional disturbance

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Medicaid Functions

Early childhood intervention

Targeted case management for Blind Children’s Vocational Discover and Developmental Program (BCVDDP)

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Medicaid Functions

Nursing facility programs and services

Long-term care licensing and certification

Program of All-Inclusive Care for the Elderly (PACE)

Hospice

Nursing home Preadmission Screening and Resident Review (PASRR)

Intermediate Care Facilities and Mental Retardation Facilities, including State Supported Living Centers.

Targeted case management for people with intellectual disabilities

Home and community-based services for people with developmental disabilities and those who would otherwise require nursing facility level of care

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TMHP acts as the state's Medicaid fiscal agent and is responsible for paying acute care claims, while the state of Texas is responsible for covering the cost of claims.

Affiliated Computer Services, Inc. (ACS) meets consolidated contractual Medicaid responsibilities with a team of subcontractors under the name of TMHP (Texas Medicaid & Healthcare Partnership).

ResponsibilitiesAdministers fee-for-service Medicaid claims

Manages policy development

Collects HMO encounter data

Enrolls providers

Supplies provider relations representatives to enrolled providers

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What Does Medicaid Cost?

In 1967, Texas Medicaid served fewer than 1 million people at a cost of less than $200 million

In 2011, Texas Medicaid served more than 3 million people at a cost of $29.4 billion, representing about 26% of the total state budget

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Federal funds are based on the Federal Medicaid

Assistance Percentage (FMAP) the matching rate

that changes annually.For federal fiscal year (FFY) 2011, the Texas FMAP was 66.46%.

*Note: Percentages do not reflect temporary increases in FMAP provided by the American Recovery and Reinvestment Act of 2009.

Federal Medical Assistance Percentages (FMAP), Fiscal Year 2011

Texas66.46%

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Texas Medicaid SpendingThe Big Picture

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By Services Type, State Fiscal Year 2010

Texas Medicaid SpendingThe Major Categories

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Prescription Drugs $2.6 billion9%

Long Term Services & Supports $6.3 billion

23%

Dental $1.8 billion5%

Physician & Professional $5.1 billion18%

Clinic & Hospital Outpa-tient $2.9 billion

10%

Hospital Inpatient $3.5 billion13%

Medicare Parts A, B & D $1.5B

Disproportionate Share Hospital Program $1.6B

Upper Payment Limit $2.8B

By Services Type, State Fiscal Year 2011

Average Monthly Medicaid Spendingby Type of Eligibility, State Fiscal Year 2011

Non-disabled children Aged, blind & disabled Non-disabled adults, including pregnant women

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$259

$1,350

$640

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Federal Health Care Reform and Texas Medicaid

The federal health care reform Affordable Care Act (ACA) will impact Texas Medicaid, the Texas HHSC and other agencies. Examples of ACA changes include:

Benefit changes:Concurrent hospice care and treatment services for children enrolled in Medicaid and CHIP

Birthing centers as a Medicaid provider

Expanded Medicaid formulary

New provisions to address fraud and abuseIncreased use of the National Provider Identifier (NPI) on claims and applications

Requiring face-to-face encounters with patients for the certification of home health services and durable medical equipment

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ACA Medicaid Eligibility Expansion

Effective January 1, 2014, ACA expands Medicaid to the following groups:

Former foster care youth through age 25

Children ages 6-18 whose families have an income 100%-133% of the FPL; this is the population of children currently eligible for CHIP

The “individual mandate” for health insurance could lead to the enrollment of about 130,000 people who are currently eligible for Medicaid or CHIP, but are not currently enrolled

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If a Medicaid expansion is pursued by the state, income eligibility could be expanded to adults ages 19 to 64 who are not currently

eligible for Medicaid, and have incomes ≤133% of the FPL.

With this option Texas could expect to experience a caseload growth in 2014 of approximately 340,976.

Texas Healthcare Transformationand Quality Improvement Program 1115 Waiver

In December 2011, Texas was granted a waiver of certain federal Medicaid requirements under Section 1115 of the Social Security Act; the waiver:

Expands Medicaid managed care to the entire state, including managed care for dental and prescription drug services

Creates 2 new funding pools, one to reimbursehospitals for Uncompensated Care (UC) forMedicaid and uninsured patients and one forDelivery System Reform Incentive Payment(DSRIP) to provide financial incentives toencourage hospitals and other providers toachieve quality health outcomes

What is being “waived”?Certain aspects of the Statewideness,Comparability of Services and Freedom ofChoice requirements of the Social Security Act

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Regional HealthcarePartnership Regions

The Face of Medicaid:The Patient’s Perspective

Amy and her husband Josh havea 4-year old son, Ian, and anotherchild due in 6 months.

Josh’s work hours at a locallumberyard have recently beenreduced. Amy is a full-timecosmetology student anddoes not currently work.

The family income is currently about $1,900 per month, which is less than 120% of the current federal poverty level for a family of 3.

What services and support can Amy’s family expect from Texas Medicaid this year?

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How Can Texas Medicaid HelpAmy’s Family?

Medicaid for Ian and the new baby (when it is born)Medicaid: Treatment and prescriptions for any of the children's acute illnesses or chronic conditions that are medically necessary

THSteps

Medical check-ups, including routine immunizations, physical examinations, and anticipatory guidance/health education

Dental check-ups, including preventive services and treatment

AmyMedicaid: Pre-natal and pregnancy services for Amy, including the delivery of her baby, and post-partum care

Women’s Health Program: Family planning after the baby is born

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The Face of Medicaid:The Provider’s Perspective

Lauren will graduate from dental school inTexas this year, and she plans to establisha general practice in her hometown in theTexas Panhandle, in a county consideredto be “dental lagging.”

She’s looking forward to buildinga practice and taking care of a wide rangeof patients, including those with Medicaid.

What services and support can Lauren expect from Texas Medicaid when she enrolls as a Texas Health Steps Provider?

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How Can Texas Medicaid Help Lauren Build Her Practice?

Payment to establish a dental home for her patients as young as 6 months of age. The first dental home visit can include (but is not limited to) an oral exam, oral hygiene instruction, dental prophylaxis, topical fluoride application, and caries risk assessment.

Payment for dental services for her child patients, 6 months to 21 years, to cover dental visits every 6 months for diagnostic, preventive, and routine therapeutic care.

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How Does Texas Medicaid Remain Dynamic & Progressive?

Medicaid adjusts and grows to meet Texas’ changing health care needs of its recipients and providers:

Legislation has led to expanded services and populations covered

Professional organizations provide feedback, medical recommendations, and suggestions about practice guidelines

Provider feedback is actively sought

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www.improvetxmedicaid.com

The Interactive Medicaid Provider Voice System allows

providers to submit concerns & suggestions to share with the

HHSC Medicaid Staff

Common Medicaid Myths

Medicaid is designed with minimum federal standards, which require states to cover certain populations and provide certain benefits to key populations.

In many ways it is a system that operates as 50 separate state coverage programs, with states having the choice to cover populations and services beyond minimum standards.

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MythMedicaid is a rigid, one-size-fits-

all program.

FactStates have taken advantage of

Medicaid’s flexibility to customize their programs—about 2/3 of

Medicaid spending is for “optional” services or populations.

Common Medicaid Myths

Research supports Medicaid’s role in improving access to care for the people it serves.

Medicaid beneficiaries value their coverage, are grateful for the assistance it provides, and often report satisfaction with their coverage at the same levels as those with commercial insurance coverage.

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MythMedicaid is a poor-quality

program that has little impact on access to care or health and Medicaid patients dislike the

program.

FactMedicaid offers access to primary and preventive health care for its patients that is comparable to that

of commercial coverage and greatly exceeds that of the

uninsured.

Test Your Knowledge about Texas Medicaid: True or False?

Medicaid is funded by the federal government.FALSE: Medicaid is jointly funded by the federal and state governments. In 2011, the state funded more than 33% of Medicaid costs.

Medicaid is an entitlement program based on age.FALSE: Medicaid is an entitlement program, but one based on income, assets, and disability/age.

Medicaid benefits include many optional services that a state can choose to provide.

TRUE: About 2/3 of the services provided under Texas Medicaid are considered optional for adults, rather than mandatory. Optional benefits in Texas include durable medical equipment, optometry, and prescription drugs. All federally allowable and medically necessary services are provided to children under 21 years of age.

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Test Your Knowledge about Texas Medicaid: True or False?

Non-disabled children account for more than half of Texas Medicaid spending.

FALSE: Although non-disabled children account for about 66% of the Medicaid caseload, they account for only about 33% of the costs

Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.

TRUE: Medicaid covers all such acute care costs.

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TMHP Provider Manual

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www.tmhp.com Providers > Reference Manual

Medicaid Resources

Texas Health & Human Services Commissionwww.hhsc.state.tx.us/medicaid

Texas Medicaid & Healthcare Partnershipwww.tmhp.com

Texas Health Stepswww.dshs.state.tx.us/thsteps/providers.shtm

www.dshs.state.tx.us/dental/thsteps_dental.shtmwww.dshs.state.tx.us/thsteps/default.shtm

CHIP/Children’s Medicaidwww.chipmedicaid.org

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This Texas Medicaid curriculumwas prepared by

Betsy Goebel Jones, EdDProject Director

Tim Hayes, MAMProject Designer

Authors: Module 1 Betsy Goebel Jones, EdD

David Trotter, MADepartment of Family & Community Medicine

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