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Texas Medicaid

Texas Medicaid. Medical and Dental Information Series. 2/22/2013. Medicaid Curriculum Overview. Module 1: General Structure of the Texas Medicaid System Module 2: Understanding Medicaid Clients and Health Literacy Module 3: Texas Health Steps Module 4: Navigating Insurance and Managed Care

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Texas Medicaid

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  1. Module 6 Texas Medicaid Medical and Dental Information Series 2/22/2013

  2. Module 6 Medicaid Curriculum Overview Module 1: General Structure of the Texas Medicaid System Module 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

  3. Module 6 Special Medicaid ProgramsFor Families, Children and Women

  4. Module 6 Module 6: ObjectivesAfter completing this module, you should be able to: Review the structure and purpose of Texas Medicaid Explain the purpose, goals, and eligible populations of special Medicaid programs for families Explain the purpose, goals, and eligible populations of special Medicaid programs for children Explain the purpose, goals, and eligible populations of special Medicaid programs for women Describe the anticipated impact of the Affordable Care Act (health care reform) on women’s health care Find Medicaid resources to support patients and providers

  5. Module 6 Caring for FamiliesBeyond Texas Health Steps • Medicaid serves primarily low-income families, non-disabled children, related caretakers of dependent children, pregnant women, the elderly, and people with disabilities. • Texas chooses to extend Medicaid eligibility to pregnant women and infants up to 185% of the federal poverty level (FPL) as well as to the “medically needy,” including children and women whose income exceeds Medicaid eligibility limits, but who do not have the resources required to meet their medical expenses. • This module addresses special Medicaid programs for: • Families • Children • Women

  6. Module 6 True or False?Test Your Knowledge about Special Medicaid Programs for Families, Children & Women Case Management assists families with resources such as educational, financial, or housing needs. ECI provides services to families of medically fragile children who keep their children at home instead of placing them in nursing facilities. The Children with Special Health Care Needs program helps people of any age with cystic fibrosis. One goal of a Caries Risk Assessment is to Identify the oral health status of the child and other family members. The Nurse-Family Partnership provides post-natal home visits until the child is 1 year old.

  7. Module 6 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.

  8. Module 6 REVIEW: Medicaid Functions

  9. Module 6 REVIEW:Responsibilities • 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. • Acts as the fee-for-service Medicaid claims administrator • Manages policy development • Collects HMO encounter data • Enrolls providers • Supplies provider relations representatives to enrolled providers

  10. Module 6 REVIEW:Texas Medicaid Recipients State Fiscal Year 2011 Unduplicated Clients SFY 2011 = 4,567,077 Hispanic Caucasian African-American Other 0-5 6-14 15-20 21-64 65+ Female Male

  11. Module 6 Common Medicaid Myths • Myth Medicaid is a rigid, one size fits all program. • Fact States have taken advantage of Medicaid’s flexibility to customize their program-about two-thirds of Medicaid spending is for “optional” services or populations. Medicaid is designed with minimum federal standards, which require states to cover certain populations and provide certain benefits to key populations. In many ways, Medicaid is a system that operates as 50 separate state coverage programs, with states having the choice to cover populations and services beyond minimum standards. The Youth Empowerment Services (YES) and Medically Dependent Children Program (MDCP) are both examples of Medicaid waiver programs that allow coverage flexibility.

  12. Module 6 Special Medicaid Programs for Families Case Management for Children and Pregnant Women Health Insurance Premium Payment

  13. Module 6 Case Management (CM) Case Management provides services that assist Medicaid patients in gaining access to needed medical, dental, mental health, social, educational and other services. Case Managers (such as a nurse, social worker, or mental health professional) assess a patient’s needs and strengths, then develop and monitor an individualized care plan. Case Management is available through such programs as Case Management for Children & Pregnant Women, Early Childhood Intervention (ECI), and local mental health/mental retardation services.

  14. Module 6 REVIEW:Case Management for Children and Pregnant Women Case managers assist children, women who are pregnant, and their families in getting help with: • Access to needed medical, dental, and mental health services, including transportation • Educational or school issues • Financial or housing problems • Medical supplies or equipment What do case managers do? • Find out what families need • Make plans to meet those needs • Refer and teach families how to access community resources and services near where they live • Follow up regularly with families to make sure their needs have been met

  15. Module 6 Case Management for Children & Pregnant Women Eligible Populations • To request CM for a patient or family: • Fax a referral form to Texas Health Steps • Call toll-free at 1-877-THSTEPS • Contact a provider directly; providers are listed by Texas Health Regions on the Department of State Health Services website • Infants, children, teens and young adults from birth through age 20 can get case management if they: • Are eligible for Medicaid • Have or are at-risk for having a health problem that keeps them from doing things that other kids their age do • Need help accessing and getting services to keep health problems from getting worse • Women who are pregnant can get case management if they: • Are eligible for Medicaid • Have a high-risk pregnancy • Need the services to prevent more problems with pregnancy

  16. Module 6 Health Insurance Premium Payment (HIPP) Program HIPP helps families pay for private health insurance. It is a program for families with at least one person who gets Medicaid. Families may be eligible for HIPP if at least one family member receives Medicaid and if someone in the family can get health insurance at work. HIPP reimburses families for private health insurance premiums that are paid to an employer-sponsored group plan.

  17. Module 6 What HIPP Pays for

  18. Early Childhood Intervention Medically Dependent Children Program Children with Special Health Care Needs YES Waiver Oral Health and Fluoride Varnish in the Medical Home Module 6 Special Medicaid Programs for Children

  19. Module 6 Early Childhood Intervention (ECI) ECI serves babies and toddlers (birth to age 3) with developmental delays as well as those with medically diagnosed conditions such as autism, spina bifida, cerebral palsy and Down syndrome. ECI providers create customized therapy programs for each child, using specialized teams of physical, occupational and speech therapists, social workers, dieticians and early intervention specialists. ECI services are designed to enhance children’s long term development and ensure they reach their full potential. The Department of Assistive and Rehabilitative Services (DARS) oversees the ECI program.

  20. Module 6 ECI Cost and Access • The following services are provided at no cost regardless of income: • Evaluation/assessment • Development of the Individual Family Service Plan (IFSP) • Service coordination • Translation and interpretation services, if needed • Services for children with auditory and visual impairments who are eligible for services from ECI and local school districts • Services for children in foster care or in conservatorship of the state • Families with children enrolled in Medicaid or CHIP, or whose income is below 250% of the Federal Poverty Level, do not pay for any ECI services. Other families pay a cost-share determined by a sliding fee scale based on family size and net income after allowable deductions. • For ECI information, contact the DARS Inquiries Line: 1-800-628-5115

  21. Module 6 ECI Services and Eligibility 2009 ECI Patient Profile Gender and Funding Source • Males 63% • Females 37% • Medicaid 61% Referral Sources • Medical/ Health Services 32% • Parent/Family/Friends 27% • Social Services 32% • ECI Programs 7% • Educational 2% Service Types • Developmental Services 86% • Speech-Language Therapy 51% • Occupational Therapy 29% • Physical Therapy 23% • Nutrition Services 13% • Family Training/ Counseling 9% • Behavioral Intervention 3% • Vision Services 2% • Audiology 2% • Psychology 2% ECI Eligible Populations: • Children younger than 3 who are • Delayed or behind their peers in cognitive, motor, social-emotional, communication, or self-help skills • Have a medically diagnosed condition with a high probability of developmental delay • ECI determines eligibility for children birth to 36 months, but income is not a factor.

  22. Module 6 Medically Dependent Children Program (MDCP) • MDCP is a Medicaid waiver that provides services to families of medically fragile children who choose to keep their children at home instead of placing them in nursing facilities. • To be eligible for MDCP, the child must: • Be under 21 years of age • Be eligible for Medicaid, based on the child’s income and resources • Meet the medical necessity criteria for admission into a nursing facility • Reside in Texas • Meet disability criteria • The Department of Aging and Disability Services (DADS) oversees the MDCP program.

  23. Module 6 MDCP Services Helpful Definitions Respite: Direct care to an individual to provide a caregiver temporary relief from caregiving activities Adjunct support services: Specific direct care services needed by the child to participate in child care, education or independent living when the caregiver is at work or school Adaptive aids: A device that helps a child perform the activities of daily living or control the environment Minor home modifications: A physical change to the family’s residence that is needed to prevent institutionalization, such as bathroom modifications, door widening, or ramp. Transition Assistance Services: Services that support the transition from a nursing home to the community Financial Management Services: Services that assist an individual or family with managing funds

  24. Module 6 Children with Special Health Care Needs (CSHCN) Services Program • The CSHCN Services Program helps children with special health-care needs and people of any age with cystic fibrosis. • The program helps clients with their • Medical, dental and mental health care needs • Drugs and special therapies • Case management and family support services • Travel to health care visits • Insurance premiums • To be eligible for CSHCN, the child must be younger than 21 years of age and have chronic physical or developmental condition expected to last at least 12 months. • The Department of State Health Services (DSHS) oversees the CSHCN program.

  25. Module 6 CSHCN Services Program All CSHCN Services Program Health Benefits must be medically necessary for the care and treatment of an eligible person with a chronic physical or developmental condition. Medicaid, CHIP, and commercial health insurance benefits, if any, must be used before using the CSHCN Services Program health benefits. More information is available about CSHCN Services Program through the CSHCN Inquiry Line at 1-800-252-8023.

  26. Module 6 Youth Empowerment ServicesYES Waiver A Medicaid waiver program for children with severe emotional disturbances whose parents feel they have reached or exceeded their financial, emotional or health care support resources and are unable to cover the costs of their child’s mental health treatment. The YES program provides home and community-based services to youth who would otherwise need institutional care (e.g., psychiatric inpatient care) or whose parents would turn to state custody for care. Allows Texas to cover youth who are not otherwise Medicaid-eligible when living in the community (parental income is not included in financial eligibility calculation). The Department of State Health Services (DSHS) oversees the YES Waiver program, which is currently in place in Travis and Bexar counties and may be expanded to Tarrant and Harris counties.

  27. Module 6 Goals of the YES Waiver Provide a complete continuum of flexible community-based services and supports for children and adolescents with severe emotional disturbance and their families Ensure access to other flexible non-traditional support services, including the parent partners Develop individualized plans of care through a family-centered planning process Prevent or reduce inpatient psychiatric admissions for children and adolescents with severe emotional disturbance Reduce and prevent out-of-home placements by all child-serving agencies Improve the clinical and functional outcomes of children and adolescents with severed emotional disturbances

  28. Module 6 YES Waiver Services and Eligibility YES Waiver Services • Respite • Community Living Supports • Family Supports • Transitional Services • Adaptive Aids & Support • Minor Home Modifications • Non-Medical Transportation • Paraprofessional Services • Professional services • Supportive Family Based Alternatives YES Waiver Eligibility • Age 3-18 years • Reside in Bexar or Travis County, in a non-institutional setting with the parent or legally authorized representative or in their own home or apartment, if legally emancipated • Be eligible for Medicaid; parental income is not included in financial eligibility determination • Meet DSHS clinical guidelines and qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines • Enrollment information is available on the DSHS website

  29. Module 6 Oral Health Care: Recommendations for Physicians Institute oral health risk assessments into well-child visits Provide patient education regarding oral health Provide appropriate prevention interventions (eg, feeding practices, hygiene) Document findings and follow-up Train office staff in oral health assessment Identify dentists (pediatric/general) in your area who accept new patients/Medicaid patients Take a dentist to lunch to establish a referral relationship Investigate fluoride content in area water supply

  30. Module 6 First Dental Home Components Caries Risk Assessment Dental prophylaxis Oral hygiene instructions with primary care giver Dental anticipatory guidance Establishment of a recall schedule

  31. Module 6 Oral Evaluation and Fluoride Varnish (OEFV) in the Medical Home The OEFV initiative is aimed at improving the oral health of children 6-35 months of age. The goal of the program is to allow medical and dental providers to work together to improve the oral health of children. Providers include physicians, physician assistants and advanced practice nurses who have completed OEFV training. Upon completion of training, dental providers are eligible to provide intermediate oral evaluation, apply fluoride varnish, and bill Texas Medicaid for enhanced reimbursement.

  32. Module 6 OEFV Visit ComponentsDuring a Texas Health Steps Medical Checkup Intermediate Oral Evaluation Fluoride varnish application Dental Anticipatory Guidance Referral to a dental home

  33. Texas Women’s Health Program Programs for Pregnant Women Nurse-Family Partnership Breast and Cervical Cancer Programs Module 6 Special Medicaid Programs for Women

  34. Module 6 Texas Women’s Health Program • The Texas Women’s Health Program (TWHP) provides low-income women with free family planningexams, related health screenings, and birthcontrol through Texas Medicaid. • Patients pay no premiums or co-pays for services provided by the TWHP. • Applications are available to women at provider offices, local state eligibility offices, participating Women, Infant, and Children program (WIC) offices, through community-based organizations, and online. • The TWHP launched in January 2013, following a state district judge’s decision that cleared the way for HHSC to launch the program as a replacement to a previous Medicaid waiver program.

  35. Module 6 TWHP Eligible Populations TWHP is for women who meet the following qualifications: Ages 18 to 44 U.S. citizens and qualified immigrants Reside in Texas Do not currently receive full Medicaid benefits, including Medicaid for pregnant women, CHIP, or Medicare Part A or B Have a countable household income at or below 185% FPL Are not pregnant, sterile, infertile, or unable to get pregnant due to medical reasons Do not have private health insurance that covers family planning services, unless filing a claim through their health insurance would cause physical, emotional, or other harm from a spouse, parent, or other person

  36. Module 6 TWHP Benefits • One family planning exam each year, which might include: • Pap smear • Screening for breast and cervical cancers, diabetes, sexually transmitted diseases, and high blood pressure • Family planning counseling and education, which can include natural family planning and abstinence • Treatment of certain sexually transmitted diseases • Follow-up family planning visits related to the method of birth control. Covered Birth Control: • Birth control pill • Vaginal ring • Hormone patch • Diaphragm • Male and female condoms • Spermicide • Intrauterine device (IUD) • Cervical cap • Depo-Provera • Devices placed under the skin, such as Implanon • Methods to permanently prevent pregnancy (tubal ligations or Essure)

  37. Module 6 Programs for Pregnant WomenPercent of Births Paid by Medicaid, 2001-2008

  38. Module 6 Pregnant Women Served by Texas Medicaid

  39. Module 6 Programs for Pregnant Women • Medicaid for Low-income Pregnant Women A pregnant woman may receive Medicaid benefits during pregnancy and up to two months after birth if she meets certain income requirements. • Children’s Health Insurance Program (CHIP) Perinatal Coverage CHIP perinatal coverage provides prenatal care for pregnant women who meet certain income requirements, who do not qualify for Medicaid and who do not have any other health coverage. • The Neonatal Care Management Program (NCMP) NCMP provides help for low-birth-weight, medically complex, and high-risk infants in the neonatal intensive care unit (NICU). The program provides educational materials, care management nurses, and a 24-hour help line. • Medicaid Health Moms and Babies Medicaid Healthy Moms and Babies is a program that provides OB risk assessment and educational services to expectant mothers and case management services to mothers who have high-risk pregnancies. The program provides educational materials, health assessments, and a help line for questions and concerns.

  40. Module 6 CHIP Perinatal Coverage Eligible Populations • Uninsured pregnant women who are Texas residents and: • Have a household income greater than 185% FPL but not greater than 200% FPL • Have a household income at or below 200% FPL, but do not qualify for Medicaid because of immigration status • An applicant is not eligible for CHIP perinatal services if she gives birth prior to an eligibility decision

  41. Module 6 CHIP Perinatal Benefits • Up to 20 prenatal care visits • First 28 weeks of pregnancy – 1 visit every 4 weeks • 28 to 36 weeks of pregnancy – 1 visit every 2-3 weeks • 36 weeks to delivery – 1 visit per week • Additional visits allowed if medically necessary • Prescriptions based on CHIP formulary • Case management and care coordination • Ultrasound of the baby when medically indicated • Labor with delivery of child • 2 postpartum visits for mother • Regular check-ups, immunizations, and prescriptions for baby after leaving the hospital

  42. Module 6 Medicaid Healthy Moms and Babies Program Benefits Educational materials on pregnancy-related issues Access to online program information Access to the toll-free BabyLine®, which is answered by experienced obstetrical (OB) nurses, 24 hours a day, 7 days a week The book, Your Journey Through Pregnancy, which has information about early pregnancy through the baby’s first weeks Three assessments, before and after delivery Referral to case management program Reports for enrollees and their physicians

  43. Module 6 Neonatal Care Management Program (NCMP) HHSC and TMHP are partnering with Alere Women’s & Children’s Health and its affiliates to implement NCMP and the Medicaid Health Moms and Babies Program The NCMP coordinates care for low birthweight, medically complex, and high-risk infants born to Texas Medicaid fee-for-service clients. The program began in July 2012 for infants hospitalized in neonatal intensive care units (NICU) and specialty care nurseries. NCMP serves only eligible Texas Medicaid fee-for-service clients who agree to participate in the program. Clients who are enrolled in a managed care organization are not eligible. HHSC and TMHP are partnering with AlereWomen’s & Children’s Health and its affiliates to implement NCMP.

  44. Module 6 Nurse-Family Partnership The Texas Nurse-Family Partnership (TNFP) pairs Bachelor’s prepared, registered nurses with low-income, first-time mothers to improve prenatal care and provide one-on-one child development education and counseling. Women are enrolled in the program early in the second trimester of their pregnancy, when TNFP nurses begin home visits. The visits continue throughout the woman’s pregnancy and until her child is 2 years old. The nurses provide support, education and counseling on health, parenting, developmental issues and life skills.

  45. Module 6 NFP By the Numbers • 56% reduction in emergency visits for accidents and poisonings • 32% reduction in emergency visits in the second year of life • 39% fewer injuries among children of low resource mothers • 79% reduction in preterm delivery • 23% fewer subsequent pregnancies • 31% fewer closely-spaced (less than 6 months) subsequent pregnancies • 20% reduction in welfare use • 48% reduction in child abuse and neglect at child age 15 • 83% increase in mother’s labor force participation by child’s 4th birthday • 67% reduction in behavioral/intellectual problems at child age 6 NFP programs have existed for over 23 years and are currently operating in 31 states, serving over 20,000 mothers. Benefits to both children and mothers include:

  46. Module 6 Breast & Cervical Cancer in TexasExpected New Cases & Death Rates in Texas Women, 2010 7th most commonly diagnosed cancer among Texas women The most commonly diagnosed cancer among Texas women; an additional 100 Texas men are diagnosed with breast cancer annually Source: www.texascancer.info

  47. Module 6 Breast and Cervical Cancer Services (BCCS) Program http://batchgeo.com/map/bccstexascliniclocator BCCS offers clinical breast examinations, mammograms, pelvic examinations, and Pap tests throughout Texas at no or low-cost to eligible women. BCCS is partly funded by the Centers for Disease Control and Prevention (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Since 1991, the BCCS program has screened 260,912 unduplicated women for breast or cervical cancer. Approximately 189,259 women received breast cancer screenings and 161,669 women received cervical cancer screenings. Breast and cervical cancer screening services are available through health care providers across Texas.

  48. Module 6 BCCS Eligible Populations • Low-income women (at or below 200% of the Federal Poverty Income Guidelines) • Uninsured or underinsured • Age 40-64 years for breast cancer screening and diagnostic services • Age 21-64 years for cervical cancer screening services • Age 18-64 years for cervical cancer diagnostic services • High Priority Populations: • Breast Cancer: Ages 50-64 • Cervical Cancer: Ages 21-64 years

  49. Module 6 BCCS Services • Screening services: • Clinical breast examinations • Mammograms • Pap tests • Education • Diagnostic services: • Diagnostic Mammograms • Breast Ultrasounds • Breast biopsies • Colposcopies and biopsies • Cervical Dysplasia Treatment Services: • Loop Electrode Excision Procedure (LEEP) • Cryotherapy • Laser • Office visit in conjunction with treatment

  50. Module 6 Medicaid for Breast & Cervical Cancer (MBCC) • MBCC is a special Medicaid program authorized by federal and state laws to provide access to cancer treatment services for qualified, low-income women. • The same agencies that provide screening services through BCCS assist women with receiving treatment for breast cancer through MBCC. MBCC Eligible Population: • Diagnosed and in need of treatment for abiopsy-confirmed definitive breast or cervical diagnosis • Income at or below 200% FPL • No insurance for the treatment of the cancer • Under age 65 • A Texas resident and a U.S. citizen or eligible immigrant.

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