Medicaid and HIV: New Opportunities in a Changing Landscape

1. Cindy Mann, JDDirectorCenter for Medicaid and State OperationsCenters for Medicare & Medicaid ServicesInstitute of MedicineApril 16, 2010 Medicaid and HIV: New Opportunities in a Changing Landscape

2. Medicaid: An Overview Medicaid serves 60 million people each year • 50 percent children, who account for less than 20 percent of the expenditures • Medicaid pays for nearly 50% of ALL births in the U.S. each year • 25 percent disabled and elderly, who account for nearly 70 percent of the cost • 40% of all Medicaid expenditures are for dual eligibles

3. Medicaid Overview Before Reform: • Eligibility based on “categorical” and financial eligibility • Categories: children, parents, people with disabilities, pregnant women, elderly • Leaves a large gap

4. Medicaid Overview • Major player in the health care system (15% of national health care expenditures in 2008) • Most people covered have lower incomes and are in poorer health than the general population • Expenditures highly skewed

5. Source: FY MSIS 2008, FY MSIS 2007 for AZ, NC, ND, HI, UT, VT, WI

6. Medicaid is Performing Well Medicaid covered an additional 3.3 million people from June 2008 – June 2009, as the economy worsened Studies show that enrollment is directly correlated with improved access to care Generally offers a package of benefits more geared to the needs of our beneficiaries than commercial products

7. Also Facing Many Challenges • States pay share of the cost • State budget pressures • Rising health care costs • Generally high beneficiary satisfaction, but some access issues • Data needed to help guide the program is lacking

8. Medicaid Expenditures by Population: 2009-2020 (in billions) Disabled & Elderly Families & Children Source: CMS Office of the Actuary, President’s FY 2011 Budget

9. Medicaid and HIV Medicaid is the largest single source of care and coverage for people with HIV $8 billion in combined federal/state spending in FY 2009 Projected federal spending in FY 2011 $5.1 billion 4 in 10 HIV/AIDS patients receive services through Medicaid 70% of people with HIV who qualify for Medicaid are low-income AND disabled. Source: Kaiser Family Foundation, “HIV/AIDS Policy Fact Sheet,” February 2009; available at http://www.kff.org/hivaids/upload/7172_04.pdf

10. Federal Spending on HIV Care: FY 2008 $0.8 $2.2 $4.1 $4.5 Total $11.6 billion

11. Medicaid and HIV Medicaid covers: Medically necessary and routine HIV testing/screening required for children through EPSDT/well-child care Testing for adults covered under mandatory lab benefit State option to cover testing as preventive benefit Prescription drugs June 24, 2009 letter to SMDs http://www.cms.gov/SMDL/downloads/SHO062409.pdf

12. Medicaid and HIV 14 States offer home and community-based waiver services specifically designed for individuals with HIV 2 States (DC and Maine) have section 1115 waivers in place Ticket to Work demonstration Prescription drug costs have shifted to Medicare but remain critical

13. Medicaid and HIV: Challenges Being HIV positive does not automatically qualify as a disability Provider participation/payment rates Need to do more to ensure/promote testing Prohibitions on payment for testing in prisons/other public institutions Many uninsured are income eligible for Medicaid or CHIP but are not enrolled

14. Health Reform Is Here!!

15. Coverage Guarantees Rely on ESI, Exchange, Medicaid/CHIP Medicaid/ CHIP Exchange ESI

16. Source: Congressional Budget Office, 3/11/2010 Projected Changes in Insurance Coverage (2019) 24m 16m -4m -5m Total new coverage = 31 million

17. Putting Medicaid into Reform: Eligibility Expansion • By January 2014, nonelderly individuals with incomes up to 133% of the FPL ($24,400 for a family of 3) will be eligible for Medicaid. • Simplified rules-- ends the “categorical gap” • Significant increase in federal support for Medicaid/CHIP

18. Transition to a New Medicaid Program • Early option to receive FFP for covering low-income adults beginning April 1, 2010. • See http://www.cms.gov/smdl/downloads/SMD10005.PDF • To avoid cost shifting and not lose coverage: • Medicaid eligibility MOE until 2014 • Medicaid and CHIP eligibility for children is maintained through 2019

19. New Paradigm Reform is predicated on the principle that everyone who is eligible is enrolled; and that coverage is stable Necessary for coverage, cost containment and quality Essential to make a system out of different components Clear focus on prevention

20. Putting Reform into Medicaid • Creating a high performing Medicaid Program • Eligible means enrolled • Access issues • Systems upgrades and Data/Performance measures • Payment and delivery systems reform • Continuing to make progress “(re)balancing” long term-care service and supports • Assuring program integrity

21. (Some) Next Steps • Promoting testing • Identifying good models, eliminating barriers • Identifying and resolving access issues • Working with “early adopter” states • Establishing strong networks, outreach/enrollment mechanisms for 2014 eligibility changes