Medicaid and Pediatric Health: What They Didn t Teach You In Medical School

1. Medicaid and Pediatric Health: What They Didn�t Teach You In Medical School October 3, 2003 Residency Training � Connecticut Children�s Medical Center By Robert Zavoski, M.D. & Jay E. Sicklick, Esq. Presented by the Medical-Legal Partnership Project, a medical-legal collaborative of Connecticut Children�s Medical Center, Saint Francis Hospital & Medical Center and the Center for Children�s Advocacy.

2. Presentation Goals Provide an Overview of the Medicaid Program for Children in Connecticut Explain Differences Between Government insurance programs � e.g. Medicaid vs. Medicare Demonstrate How Medicaid is Relevant to Pediatric Health Explain Eligibility and Physician Responsibility when treating a Medicaid Eligible Child

3. Testing The Waters:A Medicaid Quiz What is the Difference Between Medicaid & HUSKY? How Do you Know if Your Patient Is Covered by Medicaid or Medicare? Which Medicaid Patient will be insured by a Managed Care Company? When Your Patient is Denied a �Medically Necessary Service, What do you do?

4. Testing The Waters:A Medicaid Quiz (cont.) How much can physicians charge MA patients in co-pays for office visits? Is Medicaid a state or Federal program? Why is Medicaid so expensive to the taxpaying public? What is SCHIP?

5. What is Medicaid:A General Overview Title XIX of the Social Security Act for = Medical Assistance for the Poor Not Medicare - Title XVIII = Federal Health Insurance Linked to Social Security Categorical Eligibility = Elderly, Blind, Disabled, Pregnant women & Children Delinked from Cash Assistance & Resources

6. Source: 42 U.S.C. � 1396 et. seq. What is Medicaid:A General Overview (cont.) Vendor Payment System - hospitals, nursing homes, pharmacies, doctors & dentists are reimbursed Participation by provider voluntary No cost sharing allowed - theoretically

7. How Medicaid Works:The Federal-State Partnership

8. How The Partnership Works:The Federal Side Federal oversight through central agency = CMS Promulgates regulations, guidelines & statutes Issues waivers Reimburses from 50% to 83% of state costs Legal principles = due process

9. The Partnership:State Administration State Agency - Designated in Conn. As DSS The �Medicaid Plan� Must conform to federal law and apply statewide Medicaid Advisory Committee req�d

10. Managed Care: Medicaid�s Panacea State�s may contract with managed care entities to provide services: PCCM � case management w/monthly fee by M.D.�s, group practices, APRN�s, PA�s or nurse midwives MCO�s � contracts w/HMO�s, etc. w/capitation payment per enrollee State�s can r/q most individuals to enroll in managed care programs (need choice of at least 2 entities

11. Managed Care Requirements Specified Benefits Coverage of emergency services w/out PA No �gag� rules even if not covered Grievance procedure and fair hearings available Labor & Deliver = 48/96 hrs.

12. Medicaid�s Legal Requirements Medical Care Advisory Committee � in Conn. the Medicaid Managed Care Council Applications � through state social service agency (DSS in Conn.) Eligibility w/in 45 days Presumptive eligibility (oops!) EPSDT Services & Medical Necessity for Kids Continuing Eligibility (oops!) � notice and hearing requirement Notices & Hearings Court Enforcement

13. Connecticut�s HUSKY Plan Quiz What is HUSKY A? How is it different from HUSKY B? Which plan offers more Medicaid coverage - HUSKY A or Title XIX? Which family is eligible for HUSKY A: Family of 3 w/bank account of $452 Family of 3 w/bank account of $34,452 Pediatricians are required to accept HUSKY insurance � true or false? Baby born in HH � parents illegal immigrants: Is child eligible for HUSKY?

14. HUSKY Basics Connecticut�s Childrens� Medicaid Plan (�A�) Birth up to 19 y.o. Citizens & legal immigrants who applied b4 7/1/03 Income based (family or self) � no resource test 98% Insured through MCO�s (BCFP, Health Net & CHN) Straight Title XIX available

15. HUSKY Basics (cont.) No co-pays or premiums (YET) No presumptive eligibility No continuing eligibility �Medically necessary services� must be covered (now) EPSDT requires periodic screening, diagnosis & treatment Rights of appeal & legal challenges inviolate

16. Who is NOT eligible for HUSKY? Legal Immigrant children applying after 7/1/03 (must wait 5 years to apply) Children in U.S. on vicarious visas (e.g. parent work visas) Illegal Immigrant children Families $ > 185% FPL

17. What is EPSDT, or, why will it make me a better pediatrician? Early periodic screening, diagnosis, and treatment Federal mandates for screening at periodic intervals Medical, vision, hearing & dental, immunizations, lab tests (including PB), health education Mandate for coverage of treatment to �correct or ameliorate� physical/mental illness Outreach & transportation

18. SCHIP � Expanded Medicaid Affordable medical coverage � kids over 185% of FPL HUSKY B in Conn. Low cost & scaled expenses Loosely regulated Same access - (877) CT-HUSKY

19. Practice Quiz Child seen b/c persistent asthma exacerbating You believe specific medication is best bet for care Parent calls you � pharmacist won�t fill b/c not covered What do you do?

20. Practice Advocacy Tips for Pediatricians Know the players � MCO�s Know the language � prior authorization requests that are �medically necessary� Know that DSS is the ultimate authority � NOT the MCO Your patient has legal right to challenge and appeal denials Changes in HUSKY affect kids� health

21. HUSKY�s Future: The Winds of Change No legal immigrants No PE or CE Waiver R/Q for: No EPSDT Elimination of Min. benefits for HUSKY B Costs � office co- pays and premiums Pharmacy co-pays HUSKY B changes

22. What does it mean for kids at risk? Cost sharing � 23 states and counting Fewer meds. & services used by 44% w/cost sharing Cost sharing = poorer health Does no co-pay = no treatment? First waiver ever for kids & pregnancy Unable to pay � don�t seek treatment Doesn�t save money � pay now or later?

23. Medicaid Resources Children�s Health Council � www.childrenshealthcouncil.org State DSS � www.huskyhealth.com. 877-CT-HUSKY Federal Medicaid Office (CMS) - http://cms.hhs.gov/medicaid/default.asp National Health Law Program � An Advocates Guide to the Medicaid Program www.healthlaw.org Academy of Pediatrics � www.aap.org