Presentation Transcript

1. Module 4

   Texas Medicaid

   Medical and Dental Information Series Version 1.2 (6/22/2010) 2/22/2013
2. Module 4 Medicaid Curriculum Overview Module 1: General Structure of the Texas Medicaid System Module 2: Understanding Medicaid Clients and Health Literacy Module 4: 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

3. Module 4

   Navigating Insurance and Managed Care
4. Module 4 Module 4: ObjectivesAfter completing this module, you should be able to: Outline the history and current status of insurance and managed care in the U.S. List and define 3 umbrella types of insurance coverage List and define 3 models of managed care Describe the structure and overall function of Medicaid managed care Identify Medicaid managed care programs in Texas List key provisions of the Patient Protection and Affordability Care Act and describe its affect on Medicaid payments and benefits
5. Module 4 True or False?Test Your Knowledge about Insurance and Managed Care Blue Cross was created in the 1940s to provide health care for auto workers. Between 2007 and 2009, the number of uninsured Americans dropped by 5 million. Among families with no health insurance in 2009, more than 60% had at least one person who works full time. Capitation is a payment system in which a provider or health plan is paid a set amount of money per member patient per month to provide health care services. Patients’ enrollment in a Medicaid managed care plan in Texas is usually based on the service area of the state in which they live.
6. Module 4 A Brief History of Health Insurance in the U.S. The Development of insurance is the development of third-party payers, organizations other than the doctor or patient that participate in paying for health care services 1940s To compete for workers during wartime, companies began to offer health benefits 1930s Blue Cross, created in Dallas in 1929 to provide care for school teachers at Baylor University Hospital, begins offering private coverage for hospital care 1920s General Motors signs a contract with Metropolitan Life to insure 180,000 workers 1910s American Association for Labor Legislation organizes the first national conference on “social insurance” 1900s American Medical Association becomes a powerful national force, establishing the beginning of “organized medicine” Blue Cross, created in Dallas in 1929 to provide care for school teachers at Baylor University Hospital, begins offering private coverage for hospital care American Medical Association & American Dental Associations become powerful national forces, establishing the beginning of “organized medicine” American Association for Labor Legislation organizes the first national conference on “social insurance” General Motors signs a contract with Metropolitan Life to insure 180,000 workers 1900s 1910s 1920s 1930s 1940s
7. Module 4 A Brief History of Health Insurance in the U.S. Blue Cross, created in Dallas in 1929 to provide care for school teachers at Baylor University Hospital, begins offering private coverage for hospital care American Medical Association & American Dental Associations become powerful national forces, establishing the beginning of “organized medicine” American Association for Labor Legislation organizes the first national conference on “social insurance” To compete for workers during wartime, companies begin to offer health benefits General Motors signs a contract with Metropolitan Life to insure 180,000 workers 1900s 1910s 1920s 1930s 1940s
8. Module 4 A Brief History of Health Insurance in the U.S. American Medical Association & American Dental Associations become powerful national forces, establishing the beginning of “organized medicine” American Association for Labor Legislation organizes the first national conference on “social insurance” General Motors signs a contract with Metropolitan Life to insure 180,000 workers Blue Cross, created in Dallas in 1929 to provide care at Baylor University Hospital for school teachers, begins offering private coverage for hospital care To compete for workers during wartime, companies begin to offer health benefits 1950s Private insurance for those who can afford it and federal responsibility for the sick poor are firmly established 1900s 1910s 1920s 1930s 1940s 1950s
9. Module 4 A Brief History of Health Insurance in the U.S. American Medical Association & American Dental Associations become powerful national forces, establishing the beginning of “organized medicine” American Association for Labor Legislation organizes the first national conference on “social insurance” General Motors signs a contract with Metropolitan Life to insure 180,000 workers Blue Cross, created in Dallas in 1929 to provide care at Baylor University Hospital for school teachers, begins offering private coverage for hospital care To compete for workers during wartime, companies begin to offer health benefits 1960s President Johnson signs Medicare and Medicaid into law 2000-2010s 2000-2010s President George W. Bush signs the law authorizing Medicare Part D drug benefit; 1950s 1960s 1970-1980s 1990s Balanced Budget Act of 1997 created the State Children’s Health Insurance Program (CHIP) Private insurance for those who can afford it and federal responsibility for the sick poor are firmly established President Johnson signs Medicare and Medicaid into law Dental Insurance becomes available; President Nixon renames prepaid group health care plans as Health Maintenance Organizations (HMOs) 1990s Balanced Budget Act of 1997 created the State Children’s Health Insurance Program (CHIPn) 1970-1980s Dental Insurance becomes available; President Nixon renames prepaid group health care plans as Health Maintenance Organizations (HMOs) 1900s 1910s 1920s 1930s 1940s President Obama signs the Affordable Care Act 1950s
10. Module 4 A Brief History of Health Insurance in the U.S. American Medical Association & American Dental Associations become powerful national forces, establishing the beginning of “organized medicine” American Association for Labor Legislation organizes the first national conference on “social insurance” General Motors signs a contract with Metropolitan Life to insure 180,000 workers Blue Cross, created in Dallas in 1929 to provide care at Baylor University Hospital for school teachers, begins offering private coverage for hospital care To compete for workers during wartime, companies begin to offer health benefits 1950s 1960s 1970-1980s 2000-2010s 1990s Private insurance for those who can afford it and federal responsibility for the sick poor are firmly established President Johnson signs Medicare and Medicaid into law Dental Insurance becomes available; President Nixon renames prepaid group health care plans as Health Maintenance Organizations (HMOs) Balanced Budget Act of 1997 created the State Children’s Health Insurance Program (CHIP) President George W. Bush signs the law authorizing Medicare Part D drug benefit; President Obama signs the Affordable Care Act 1900s 1910s 1920s 1930s 1940s
11. Module 4 Medicare & Medicaid HighlightsDevelopments that have shaped health care 1965 Medicare and Medicaid enacted as Title XVIII and Title XIX of the Social Security Act, extending health coverage to Americans aged 65 or older, low-income children deprived of parental support and individuals with disabilities. 1965: Medicare and Medicaid enacted (Title XVIII and Title XIX) 1967 The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) comprehensive health services benefit for all Medicaid children under age 21 was established. 1967: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) established 1972 The newly enacted Federal Supplemental Security Income program (SSI) provided States the opportunity to link to Medicaid eligibility for elderly, blind, and disabled residents. 1972: Supplemental Security Income (SSI) enacted 1986 Medicaid coverage for pregnant women and infants to 100% of the Federal Poverty Level (FPL) was established as a state option and later mandated. 2010 Patient Protection and Affordable Care Act (P.L. 111-148) Requires most U.S. citizens and legal residents to have health insurance. Creates state-based American Health Benefit Exchanges through which individuals can purchase coverage. Requires employers to pay penalties for employees who receive tax credits for health insurance through an Exchange. Expands Medicaid to 133% of the federal poverty level. 1986: Medicaid coverage for pregnant women and infants established as state option (100% of FPL) 1996 Welfare Reform replaced the Aid to Families with Dependent Children (AFDC) entitlement program with the Temporary Assistance for Needy Families (TANF) block grant and severed the welfare link to Medicaid 1996: Welfare link to Medicaid severed 1997 Health Insurance Program (CHIP) and established new managed care options for Medicaid. 1997: State Children’s Health Insurance Program (CHIP) established 2006 The voluntary Medicare Part D outpatient prescription drug benefit became available to beneficiaries from private drug plans as well as Medicare Advantage plans. 2006:Medicare Advantage and private drug plans available for Medicare Part D 2009 Children’s Health Insurance Program Reauthorization Act is passed, financing CHIP through 2013 2009:Children’s Health Insurance Program Reauthorization Act finances CHIP through 2013 2010: Patient Protection and Affordable Care Act enacted
12. Module 4 Medicare & Medicaid HighlightsDevelopments that have shaped health care 1965: Medicare and Medicaid enacted (Title XVIII and Title XIX) 1967: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) established 1972: Supplemental Security Income (SSI) enacted 1986: Medicaid coverage for pregnant women and infants established as state option (100% of FPL) 1996: Welfare link to Medicaid severed 1997: State Children’s Health Insurance Program (CHIP) established 2006:Medicare Advantage and private drug plans available for Medicare Part D 2009:Children’s Health Insurance Program Reauthorization Act finances CHIP through 2013 2010: Patient Protection and Affordable Care Act enacted
13. Module 4 Development of Managed CareHistory of Health Insurance in the US Individuals credited as pioneers of managed care Dr. Michael Shadid, who started a rural farmers’ cooperative health plan in Elk City, OK in 1929 Henry Kaiser, who set up two medical programs on the West Coast to provide comprehensive health services to workers in his shipyards and steel mills during World War II, and later opened the plans to the public Dr. Paul Ellwood, who coined the term Health Maintenance Organization (HMO) in 1970 to refer to prepaid health plans that enrolled members and arranged for their care from a designated provider network Growth of managed care from the 1970s to the present 1973: President Nixon signed the HMO Act of 1973, which approved the use of federal funds and policy to promote HMOs 1982: California legislation allowed selective contracting for Medicaid and private insurance, paving the way for other states to enact similar laws facilitating Preferred Provider Organizations (PPOs) 1985: National total HMO enrollment reaches 19.1 million; 1990: National total HMO enrollment reaches 33.3 million 2006: National total HMO enrollment is 67.7, and national PPO enrollment is 108 million Shadid Kaiser Ellwood
14. Module 4 Health Insurance Coverage of the Total U.S. Population, 2011Current Status of Health Coverage Total = 307.9 million NOTE: Medicaid/Other Public includes Medicaid, CHIP, other state programs, and military-related coverage. Those enrolled in both Medicare and Medicaid (1.9% of total population) are shown as Medicare beneficiaries.
15. Module 4 Dental Coverage by Insurance SourceEmployment-based vs. Privately Purchased About 80% of people with employer-based insurance have dental coverage, compared with 30% of those with directly-purchased plans.
16. Module 4 Health Coverage, 2010-2011Texas, California, New York & the US
17. Module 4 Health Insurance Coverage of Workers, by Firm Size, 2007Current Status of Health Coverage
18. Module 4 Dental Coverage and Use AmongNon-Elderly Adults, 2005 Percent of Low-Income with Dental Check-Up in Last Year Percent with Dental Coverage Insured with Dental Coverage Uninsured Higher Income Low Income * Indicates statistically significant difference at the p<.05 level. Low-income is defined as living in families earning 200% of the federal poverty level (FPL) or less who live in high-poverty Census tracts. Adults are those age 19-64. Dental coverage includes both private and public sources. Source: 2005 Kaiser Low-Income Coverage and Access Survey.
19. Module 4 How Important is Insurance?Current Status of Health Coverage Adults who lack health insurance are unlikely to receive: Primary and preventive care Treatment for acute conditions Management of chronic illness The uninsured are three times more likely than the insured to be unable to pay for basic necessities because of medical bills
20. Module 4 Insurance and Health Care AccessCurrent Status of Health Coverage Between 2007 and 2009, the number of uninsured Americans increased by almost 6 million, driven by a decline in employer-sponsored coverage. Both the percentage and number of people without health insurance decreased between 2010 and 2011, driven by greater numbers of individuals covered by government health insurance, including Medicaid and Medicare
21. Module 4 Characteristics of Non-ElderlyUninsured, 2011Current Status of Health Coverage Total= 47.9 Million Uninsured
22. Module 4 Uninsured Rates for the Non-Elderly by Race/Ethnicity, 2011Current Status of Health Coverage
23. Module 4 Uninsured Rates Among Non-Elderly by State, 2007-2008Current Status of Health Coverage National Average Uninsured = 17%
24. Module 4 Diagnosis of Late-Stage CancerUninsured vs. Privately Insured Ratio of probability of diagnosis of late vs. early stage cancer (Uninsured/Private Insurance) Equal likelihood between Uninsured and Insured * NOTE: Odds ratios were adjusted for age, sex, race/ethnicity, facility type, region, and income and education on basis of postal code. They represent the odds of being diagnosed with stage III or stage IV cancer vs. stage I cancer; for oropharyngeal cancer, odds ratio represents stage III or IV vs. stage I or II. Analysis for oropharyngeal cancer based 1996-2003 cases; other sites based on cases occurring between 1998-2004.
25. Module 4 Three Umbrella Types of Private InsuranceInsurance Primer 101 Fee-for-Service plans, often called “indemnity plans,”pay fees to the hospital or provider for each health care service provided to the patient. Patients can see the doctor, dentist or provider of their choice and the claim is filed by either the provider or the patient. Consumer-Directed plans allow members to set up health savings funds or flexible spending accounts to pay for covered health expenses. These plans give consumers flexibility and control over their health benefits funds. Managed Care Plans provide coverage for comprehensive health services to their members and offer financial incentives in the form of lower out-of-pocket costs to patients who use providers participating in a network. Fee-for-Service Consumer-Directed Managed Care
26. Module 4 Fee for Service PlansInsurance Primer 101 Key Features of Fee-for-Service (FFS) Plans Patients can choose the doctors, dentists or other providers of their choice Members or employers pay a monthly premium and an annual deductible before the insurance company pays for covered costs Members usually “share” the cost of health care services with the insurance company; for example, a plan might pay 80% of the cost of services, while the patient or member pays 20% Types of Fee-for-Service Plans Basic: a cash reimbursement service that helps pay for hospitalization and “basic” health services Major Medical: plans that cover additional costs such as prescriptions, rehabilitation mental health, etc. Fee-for-Service plans, often called “indemnity plans,”pay fees to the hospital or provider for each health care service provided to the patient. Patients can see the doctor, dentist or provider of their choice and the claim is filed by either the provider or the patient. Fee-for-Service
27. Module 4 Dental Fee-for-Service PlansInsurance Primer 101 Common Fee-for-Service Dental Plans Direct Reimbursement (DR) Self-funded dental plans that allow patients to go to the dentist of their choice. The patient pays the dentist directly (or the benefit can be directly assigned to the dental office) and then submits a paid receipt for proof of treatment. The plan then reimburses the patient a percentage of the dental care costs. Indemnity Plans Sometimes called “traditional insurance” in which the insurance company pays claims based on the procedures performed, usually as a percentage of the charges. Fee-for-Service Dental Plans are typically freedom-of-choice arrangements under which a dentist is paid for each service rendered according to the fees established by the dentist. Dental Fee-for-Service
28. Module 4 Consumer-Directed PlansInsurance Primer 101 Key Features of Consumer-Directed Plans Patients have individual responsibility and ownership over their health care payments Members usually pay a high deductible (typically at least $1000) before the plan pays Types of Consumer-Directed Plans, all of which are tax-advantaged Health Savings Accounts (HSAs): accounts that are funded by individuals or employers to pay for qualified health expenses. HSAs belong to the individual, are portable, and can be rolled over from year to year. HSAs have contribution limits. Health Reimbursement Arrangements (HRAs): employer-established accounts that provide non-taxed funds that employees can use for health care expenses. HRAs are not portable. Flexible Spending Accounts (FSAs): employee-funded accounts that must be spent on qualified expenses within the year they are accrued and are not portable. Consumer-Directed plans allow members to set up health savings funds or flexible spending accounts to pay for covered health expenses. These plans give consumers flexibility and control over their health benefits funds. Consumer-Directed
29. Module 4 Managed Care PlansInsurance Primer 101 Key Features of Managed Care Plans Managed care plans have contracts with dentists, doctors, hospitals and other providers to provide health services to plan members Members pay a lower portion of their health care bills for agreeing to receive care from their plan’s network of providers Most plans require a Primary Care Provider (PCP) and PCP referral as well as prior authorization for some services Types of Managed Care Plans Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Point of Service (POS) Managed Care Plans provide coverage for comprehensive health services to their members and offer financial incentives in the form of lower out-of-pocket costs to patients who use providers participating in a network. Managed Care
30. Module 4 Additional Helpful Insurance TermsInsurance Primer 101 Co-Insurance The portion of the cost of covered health services paid by the patient under a health plan, after first meeting any applicable plan deductible. Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) A law that permits individuals to continue coverage temporarily under most employer health insurance plans when they would otherwise lose eligibility due to a loss of employment or a change in family status (such as divorce). Usual, Customary and Reasonable (UCR) The portion of fees that insurers or employers reimburse for health care costs; patients are usually obligated to pay out of pocket for a non-covered percentage of the UCR amount. Lifetime Maximum Limitation on the total amount of benefits or services that an individual may receive over the term of an insurance policy. Out-of-Pocket (OOP) Amounts such as copayments and deductibles that an individual is required to contribute toward the cost of health services covered by a health benefits plan. Self-Insurance or Self-Funded Health insurance funded by an employer who takes on the financial responsibility for paying the health benefits claims of its employees (versus a "fully insured" employer, who pays a health insurance company to take on financial responsibility for claims).
31. Module 4 Differences BetweenMedical and Dental Needs and Treatments
32. Module 4 HMOsHealth Maintenance OrganizationsSpotlight on Managed Care Key Features of HMOs Established by the HMO Act of 1973 as an affordable option to traditional health plans Provide health services to members for a fixed monthly premium (capitation, or per member per month, pmpm) May charge a co-payment for some services Usually require members in a medical plan to select a PCP within the plan’s “network” who manages their overall care As long as members use providers and hospitals within the HMO network, out-of-pocket costs remain limited Care from out-of-network providers is usually limited to services not available in the existing network Managed Care
33. Module 4 PPOsPreferred Provider Organizations Spotlight on Managed Care Key Features of PPOs A managed care health insurance plan that combines features of a fee-for-service plan and an HMO Provide health services to members for a fixed monthly premium, but the premiums are often higher than for HMOs Like HMOs, usually charge a co-payment for some services May not require members to select a PCP within the plan’s network As long as members use providers and hospitals within the network of participating (or “preferred”) provider organization, out-of-pocket costs are substantially lower than for out-of-network providers Managed Care
34. Module 4 POSPoint of Service PlansSpotlight on Managed Care Key Features of a POS A health benefits plan that provides coverage for care received from both participating providers and non-participating providers. Like HMOs and PPOs, provide health services to members for a fixed monthly premium, charge a co-payment for some services, and recognize network and non-network providers Require members to select a PCP within the plan’s network Allow members to choose providers and systems at the point of service Provide higher benefit levels to patients whose care is directed through referrals from their PCP and lower benefit levels when patients go directly to other providers or facilities Managed Care
35. Module 4 Distribution of Health Plan Enrollmentfor Covered Workers, by Plan Type, 1988-2011Spotlight on Managed Care * Distribution is statistically different from the previous year shown (p<.05).
36. Module 4 Managed Care Penetration Rate, 2011Texas, California, New York & the US * Data include all licensed HMOs and POS plans, which may include Medicaid and/or Medicare-only HMOs, group/commercial plans, the Federal Employees Health Benefits Program, direct pay plans and unidentified HMO products.
37. Module 4 Dental Managed CareSpotlight on Managed Care Common Dental Plans Dental Health Maintenance Organizations (DHMOs) Capitation plans in which contracted dentists are “pre-paid” a certain amount each month for each member patient. Dentists must then provide contracted services at no or low cost to member patients who may see only those dentists in the DHMO network. Dental Preferred Provider Organizations (DPPOs) Plans under which patients select a dentist from a network or list of providers who have contracted to discount their fees; patients who see non-contracted dentists may pay higher deductibles or co-payments Discount or Referral Dental Plans Not technically “insurance plans,” these contracted arrangements establish a network of dentists who agree to discount their fees; patients who buy these plans pay all of the costs of treatment at the contracted rate determined by the plan. Dental Managed Care
38. Module 4 Additional Helpful Managed Care TermsManaged Care Primer 101 Capitation A payment system in which a provider or health plan is paid a set dollar amount determined by a per member per month (pmpm) calculation to deliver health care services to a specified group of people. Carve-Out Health care services that are separated from a contract and paid under a different arrangement. Exclusive Provider Organization (EPO) A health plan that has the characteristics of an HMO or PPO plan, with a network of providers who have entered into written agreements with an insurer to provide health insurance to subscribers. Network A panel of physicians, dentists, hospitals and other providers who contract with a health benefits plan to provide services, typically at a negotiated rate of payment. With certain plans, an individual must access care from a network provider in order to receive the maximum level of benefits. Preauthorization/Precertification A requirement to receive advance authorization of particular health care services required in some plans. Value-Added Benefit Services covered by a health plan beyond what is available under Medicaid; examples are adult dental coverage and diapers for newborns.
39. Module 4 Three Umbrella Types of Public InsuranceInsurance Primer 101 Medicare is the national health insurance program for people aged 65 or older and under age 65 with certain disabilities. It includes Part A (hospital coverage), Part B (outpatient medical care), Part C (Medicare Advantage Plan) and Part D (prescription drug coverage). All but Part A are optional. Medicaid, the subject of this overall curriculum, provides health care to certain low-income individuals and families with limited resources. Medicaid is funded by both the federal government and the 50 states, each of whom define their own eligibility rules. CHIP is a joint state and federal program that provides insurance for children of qualifying families, usually families who make too much money to qualify for Medicaid but cannot afford private health insurance. State Children’s Health Program Medicaid Medicare
40. Module 4 REVIEW:What is Medicaid? 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 Texas About 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.
41. Texas Medicaid CHIP Module 4 REVIEW:Medicaid vs. CHIP(Children’s Health Insurance Program) Authorized by Social Security Act of 1965 Authorized by Balance Budget Act of 1997 Jointly Funded by State and Federal Government Entitlement program based on income, assets and/or disability Enrollment based on income (not an entitlement program) 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
42. Module 4 Enrollment ComparisonCHIP and Medicaid 2,192,055 Average monthly enrollment at a given point in time 1,834,137 1,573,975 533,213 455,713 304,214 2008 2006 2010 CHIP & CHIP Perinatal Medicaid
43. Module 4 CHIP Cost-Sharing Most families in CHIP pay an annual enrollment fee to cover all children in the family CHIP families also pay co-payments for doctor visits, prescription drugs, inpatient hospital care, and non-emergent care provided in an emergency room setting The co-pay amount and total out-of-pocket cost-sharing cap are based on the family’s income, such as these requirements, effective in March 2011:
44. Module 4 Assistance to Medicare Beneficiaries 8.8 million aged and disabled — 21% of Medicare beneficiaries Medicaid Today Long-Term Care Assistance 1 million nursing home residents; 2.8 million community-based residents Health Insurance Coverage 29 million children & 15 million adults in low-income families; 14 million elderly and persons with disabilities State Capacity for Health Coverage Federal share ranges 50% to 76%; 44% of all federal funds to states Support for Health Care System and Safety-net 16% of national health spending; 41% of long-term care services
45. Module 4 Medicaid andManaged Care The Balanced Budget Act of 1997 gave state Medicaid programs the authority to mandate managed care enrollment without a waiver, with some exceptions. Although Medicaid is publicly financed, the program purchases health services primarily in the private sector on a fee-for-service basis or by paying premiums to managed care plans under contracts In 2008, about 70% of Medicaid enrollees in the U.S. received some or all of their services through managed care arrangements, through: Managed Care Organizations (MCOs) are paid a fixed monthly fee per enrollee (capitation) and assume the financial risk for delivering services
46. Module 4 Medicaid Managed Care Penetration Rates by State, 2008 U.S. Average = 70% * NOTE: Unduplicated count. Includes managed care enrollees receiving comprehensive and limited benefits. Source: Medicaid Managed Care Enrollment as of December 31, 2008. Centers for Medicare and Medicaid Services.
47. Module 4 Share of US Medicaid Beneficiaries Enrolled in Managed Care, 1999-2008 *NOTE: In Texas, 71% of the state’s Medicaid population were enrolled in some form of managed care as of February 2010.
48. Module 4 Medicaid Managed Carein 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 preventive, primary, and acute care covered services STAR+PLUS Provides 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 Health A statewide program to provide coordinated care to children and youth in foster and kinship care
49. Module 4 The STAR ProgramMedicaid Managed Care in Texas The Texas STAR Program provides acute care medical assistance in a Medicaid managed care environment As of March 2012, the STAR program expanded to serve all Texas counties When they enroll, clients have a choice of health plans and PCPs. Each plan has a network of providers that includes PCPs that provide patients’ medical homes. STAR program clients receive all the benefits of traditional Medicaid. In addition, adults receive unlimited medically necessary prescriptions and hospital days. STAR plans also offer education classes and value-added services. Clients are allowed to change their PCP and health plan.
50. Module 4 The STAR+PLUS ProgramMedicaid Managed Care in Texas STAR+PLUS provides integrated acute and long-term services and supports in a Medicaid managed care environment for residents in the Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Nueces, Tarrant, and Travis service areas. Within each service area, patients have a choice of health plans or MCOs. Each plan’s network of providers includes PCPs. STAR+PLUS program clients’ acute, pharmacy, and long-term services and supports are coordinated and provided through a credentialed provider network contracted with MCOs. Many STAR+PLUS clients are eligible for Medicaid and Medicare (Dual-Eligibles); dual eligible members choose a STAR+PLUS health plan but not a PCP because they receive acute care from their Medicare providers. STAR+PLUS enrollment is required for those Medicaid clients who live in a STAR+PLUS service area and meet any of the following criteria: Age 21 or older who receive Supplemental Security Income (SSI) Age 21 or older and get both Medicaid and Medicare Age 21 or older who receive Medicaid through a Social Security Exclusion program Receive Community-Based Alternatives (CBA) services Voluntary enrollment for children age 20 and younger who receive SSI
51. Module 7 The NorthSTAR ProgramMedicaid Managed Care in Texas NorthSTAR is a behavioral health program that serves the seven counties within the Dallas service area. NorthSTAR provides integrated behavioral health services (mental health, chemical dependency, and substance abuse treatment) through a behavioral health organization (BHO), currently ValueOptions® NorthSTARis known as a behavioral health carve-out of the STAR and STAR+PLUS Medicaid Managed Care Programs in the Dallas service area. NorthSTARprogram's goal is to provide clinically necessary behavioral health services to enrollees, through a network of qualified and credentialed providers.
52. Module 4 The STAR Health ProgramMedicaid Managed Care in Texas STAR Health is a state-wide Medicaid managed care program that manages the health care for children and youth in foster care and kinship care STAR Health benefits include medical, dental, and behavioral health services, as well as service coordination and a web-based electronic medical record (known as the Health Passport). Managed care organizations for Star Health Medical: Superior Health Dental: MCNA Dental and DentaQuest
53. Module 4 Medicaid Managed CareService Areas Service Areas Effective March 1, 2012
54. Module 4 Texas Medicaid Benefits by Managed Care Program *Spell of Illness Waiver is the removal of a time-frame limitation on medically necessary care **Personal Care Services assist patients with “activities of daily living” in the patient’s home setting
55. Module 4 Medicaid Buy-In Medicaid Buy-In (MBI) is a program that allows people of any age who have a disability and are earning a paycheck to receive Medicaid by paying a monthly premium MBI has no age limit, but eligible clients must be disabled or age 65 or older  MBI clients must work & earn at least $1120/quarter but less than $2257/month (which is 250% FPL) and have countable resources ≤$5,000  Premiums range from $0-$40/month, depending on earned & unearned income Benefits include regular Medicaid adults services: Office visits Hospital stays X-rays Vision, hearing, and prescriptions MBI clients may also be eligible for home care & day care, depending on their level of function
56. Module 4 Medicaid Buy-In for Children Beginning January 1, 2011, the Medicaid Buy-In for Children (MBIC) program allows families who earn too much income to qualify for Medicaid to purchase Medicaid coverage for their children with disabilities by paying a monthly premium MBIC children must be 18 or younger and unmarried and meet disability criteria for Supplemental Security Income (SSI) Family income must not exceed 300% FPL  Premiums range from $0 to 7.5% of the family’s income, depending on family size and income Parents are required to enroll in employer-sponsored health insurance if the employer pays at least 50% of the total costs of premiums Benefits include regular Medicaid state plan services
57. Module 4 Medicaid Managed Care Enrollment Effective March 1, 2012, children’s Medicaid dental services are provided statewide through managed care for children birth through 20 years of age. Each member should have a main dental home provider who delivers all aspects of oral health care in a comprehensive, continuously accessible, coordinated, and family-centered way. Some Medicaid clients continue to receive dental services through existing delivery models and not through managed care: Medicaid recipients age 21 and over Medicaid recipients who reside in institutions STAR Health program recipients (foster children)
58. Module 4 Managed Care Dental Services Providers must contract and be credentialed with one of 3 dental plans to provide dental services. Rates are negotiated between the provider and the dental plan. Dental plans establish a network to include general, pediatric, and specialty care providers. Dental plans are responsible for authorizing, arranging, coordinating, and providing medically necessary covered services. Current Managed Care Dental Plans:
59. Module 4 Dental Managed Care vs.Fee-For-Service (FFS) Managed Care Fee-For-Service Client has to locate dental providers No member handbook No value-added services No mileage requirements Provider listings Includes main dentist and dental specialists Member handbook Value-added services (varies by dental plan) Member chooses main dentist and can change through the dental plan Dental plan must ensure access to dentists and dental specialists per contract requirements
60. Module 4 What’s Next for Insurance andManaged Care?Key Provisions of the Patient Protection and Affordable Care Act (ACA) On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA). The law puts in place comprehensive health insurance reforms that will roll out over four years and beyond, with most changes taking place by 2014 The ACA has 46 key provisions to be implemented between 2010 and 2015, which broadly include: Improved coverage for children up to age 26 or with pre-existing conditions New health insurance exchanges and premium subsidies Changes to private insurance rules Employer requirements and incentives Individual mandate to have health insurance On June 28, 2012, the U.S Supreme Court issued a decision on ACA provisions under consideration, ruling that the ACA is constitutional
61. Module 4 Expanding Medicaid: A Key Element in the Patient Protection and Affordable Care Act (ACA) Universal Coverage By 2019: 92% coverage Medicaid Coverage Up to 133% FPL(about $14,000 for an individual or $29,000 for a family of 4) Insurance Exchanges Subsidies for individuals 133-400% FPL Individual Mandate Health Insurance Market Reforms Employer-Sponsored Coverage
62. Module 4 Key Medicaid Coverage Provisions Expands Medicaid to individuals with incomes up to 133% of the federal poverty level (FPL) in 2014 Eligibility based on Modified Adjusted Gross Income for most groups Provides state option to expand Medicaid coverage to childless adults with regular match starting April 1, 2010 Provides enhanced federal funding for newly eligible individuals 100% covered by federal funds for 2014-2016, phases down to 90% by 2020 Phases in increased federal matching payment for states that have already extended coverage for childless adults Maintains Medicaid eligibility for adults > 133% FPL until 2014 and for children in Medicaid and CHIP until 2019 Simplifies enrollment processes and coordinates with exchanges
63. Module 4 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 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.
64. Module 4 Median U.S. Medicaid/CHIPIncome Eligibility Thresholds, 2009 Prior to enactment of health reform, state Medicaid programs were required to provide coverage only to certain categories of lower income individuals. Under ACA, by January 1, 2014, state Medicaid programs must extend Medicaid benefits to individuals who are: Under age 65 Not pregnant Not entitled to or enrolled in Medicare Part A or enrolled in Medicare Part B Not otherwise eligible for Medicaid under any other provision or category and have incomes at or below 133% of the federal poverty line Minimum Medicaid Eligibility under Health Reform = 133%FPL Current median FPL eligibility levels for Medicaid client categories
65. Module 4 Additional HelpfulHealth Care Reform TermsHealth Care Reform 101 Benchmark coverage Medicaid health plans that generally are less comprehensive than standard Medicaid coverage. Persons “newly eligible” for Medicaid (under ACA) are eligible for hospital and physician benchmark coverage. Co-ops Private, nonprofit health organizations, run in states or regionally, to compete with private insurance companies. Co-ops are a compromise proposal in the debate over greater government role in health reform. Exchanges A more competitive insurance marketplace, established by the government, where individuals and small firms would shop among health plans for coverage under overhaul proposals. Guaranteed access Reform provision that bars health insurers from rejecting applicants because of their pre-existing health conditions. Individual mandate Requirement that people purchase health insurance or pay a penalty.  The ACA provides subsidies to those with middle incomes and below to afford a policy. Pay or play Requirement that employers provide health insurance for their workers or pay a fee or penalty to the government. Also known as an employer mandate.
66. Module 4 US Health Insurance Coverage in 2019
67. Module 4 Common Insurance Myths Myth Medicaid covers too many people and crowds out private health insurance. Medicaid enrollment has swelled in recent years due to poor economic conditions and the loss of employer-sponsored insurance. Many studies of Medicaid eligibility expansions for women and children in the 1980s and early 1990s conclude that Medicaid growth had not replaced private coverage, as most people newly enrolled were previously uninsured. Medicaid addresses many of the private insurance market’s failures, acting as the “safety net” that covers populations and services that the private system excludes. Fact Most of the people who are covered by Medicaid do not have access to other insurance, because their employers do not offer them coverage, or they are ineligible for it or cannot afford it, or because they are priced out of the private market due to illness or disability.
68. Module 4 Test Your Knowledge about Insurance: True or False? Blue Cross was created in the 1940s to provide health care for auto workers. FALSE: Blue Cross was created in Dallas in 1929 to provide care for school teachers at Baylor University Hospital Between 2007 and 2009, the number of uninsured Americans dropped by 5 million. FALSE: Between 2007 and 2009, the number of uninsured Americans increased by 5 million, largely due to a decline in employer-sponsored coverage. Among families with no health insurance in 2009, more than 60% had at least one person who works full time. TRUE: Only 23% of families without insurance had no workers; an additional 16% had part-time workers, but 61% had one or more persons who worked full-time and still lacked health insurance.
69. Module 4 Test Your Knowledge about Insurance: True or False? Capitation is a payment system in which a provider or health plan is paid a set amount of money per member patient per month to provide health care services. TRUE: In a capitatedsystem, the provider or health plan is paid a contracted monthly rate for each member assigned (the pmpm rate), regardless of the number or nature of services provided. Patients’ enrollment in a Medicaid managed care plan in Texas is usually based on the service area of the state in which they live. TRUE: Texas Medicaid includes several managed care plans, many of which, such as STAR, are available to residents only in selected areas of the state.
70. Module 4 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.shtmwww.dshs.state.tx.us/dental/thsteps_dental.shtmwww.dshs.state.tx.us/thsteps/default.shtm CHIP/ Children’s Medicaidwww.chipmedicaid.org
71. Module 4

    This Texas Medicaid curriculumwas prepared by

    Betsy Goebel Jones, EdDProject Director Tim Hayes, MAMProject Designer Author: Module 4 Betsy Goebel Jones, EdD