Partners In Policymaking Medicaid

1. PartnersIn PolicymakingMedicaid August 18, 2012 Tara Larson, Division of Medical Assistance

2. What is Medicaid Today • Title XIX of the Social Security Act (Medicaid) is a federal entitlement program that pays for medical assistance for certain individuals with low income and resources. • Funding is made up of dollars from the federal government and state resources. • It is very complex and has many, many rules and guidelines • The federal agency that administers Medicaid is CMS The Center for Medicaid and Medicare Services • Medicaid and Medicare are not the same.

3. What is NC Health Choice • NC Health Choice is North Carolina’s child health insurance program - SCHIP. It is funded by the state and federal governments. Similar to Medicaid but under a different part of the federal regulations. • Who is eligible for NC Health Choice? • Children under age 19 whose family income is too high to qualify for Medicaid but less than 200% FPL. • In North Carolina, children from birth through age 5 qualify for Medicaid with incomes up to 200% FPL. Children ages 6 through 18 qualify for Medicaid with incomes up to 100% FPL, and for NC Health Choice with incomes between 100-200% FPL. • Currently serves 148,849 children through Health Choice • Operates very similar to Medicaid in process that will be discussed in subsequent slides

4. What is NC Health Choice (cont’d) • The federal government establishes very broad rules and then allows each state to: • Establish its own recipient eligibility standards • Determine type, amount, duration and scope of services (what, • how much and what conditions) • Set the rate and payment for the services • Administer the program. • As a result, a person who is eligible in one state may not be eligible in another or services offered in one state may not be the same in another state. • As part of the broad rules, the federal government must approve what a state pays for, how a person is determined to be eligible, how rates are set and other aspects of the administration of the program.

5. How It Works Today • Must be determined to be eligible for Medicaid or Health Choice • NC uses the County Department of Social Services to determine Medicaid/Health Choice eligibility. • An application is completed and the local DSS worker determines eligibility for Medicaid/Health Choice benefits based upon policies established by the federal and state government. • This will change with NCFAST full implementation • This is an automation process for eligibility – will interface with requirements of the Affordable Care Act (National Health Care Reform) • The DSS will use a single application process to determine if the person is eligible for various kinds of financial assistance. • If a person receives Supplemental Security Income (SSI), then the person is automatically covered by Medicaid in NC. There is still a process that has to be followed. SSI does NOT make you eligible for Health Choice

6. How It Works Today (Cont’d) • If determined to be eligible, the person is issued a Medicaid/Health Choice card annually. If card is lost or other changes occur, then new cards can be issued. • The card also has various information on it which informs the provider, doctor, dentist, etc what the person can receive. • Important because just because a person is on Medicaid doesn’t mean they can get any and all services covered under Medicaid – special rules for certain programs or services • ALWAYS take your card and picture ID. Guard your card and DO NOT allow others to use your card.

7. How It Works Today (cont’d) • It is important that the person takes the card with them when they get service. • Do not let other people use your card!!!! (handout for reporting fraud/abuse or misuse) • The provider will probably ask to see the card before providing the service or at least once a month to make sure that the person is still eligible. They also may ask for picture ID • Person has to be reviewed periodically to make sure they are still eligible – the time varies depending on the kind of Medicaid a person gets. • There are about 1.9 million people who get Medicaid in NC. • Eligibility is one of the MOST complicated parts of Medicaid. Always call the local DSS if there are questions about eligibility or call the State at 1-800-662-7030 and tell the person you want to talk to someone about getting Medicaid or Health Choice.

8. Medicaid Covered Services • The federal government requires every state to pay for certain services such as (not an exhaustive list). These services are called Mandatory Services. Although every state covers mandatory services, they don’t look the same in every state. • Going to the hospital either for overnight visits or outpatient • Going to the doctor’s office and other kinds of clinics • Certain kinds of mental health treatment – NOT ALL • Living in a nursing home • Certain kinds of medical equipment • EPSDT – a special funding program for children under 21 • Health Choice is different in what is considered mandatory

9. Other Medicaid Services • NC may choose to offer other services such as: • Waivers such as CAP-MR/DD • ICF-MR Group Homes • Dental • Eyeglasses • Case management • Prescription Drugs • Mental Health • Certain kinds of doctors such as Podiatrists (foot) • Therapies such as Speech, OT, PT • Many others • These are called Optional Services – it is totally up to each state to decide if they will cover optional services.

10. WHAT IS COVERED TODAY by Medicaid? Mandatory Services Optional Services • Ambulance • Children’s Dental • Durable Medical Equipment • Family Planning • Early Periodic Diagnosis Screening and Treatment (EPDST) • Children’s Hearing Aids • Clinics • Home Health • Hospital Services • Midwife and Nurse Practitioner • Nursing Facility • Other Lab and X-ray • Physician • Psychiatric Residential Treatment Facilities (PRTFS) • Routine Eye Examinations and Visual Aids for Children • Case Management • Chiropractor • Podiatry • CAP Programs • Adult Dental and Dentures • HMO Membership • Home Infusion Therapy • Hospice • ICF-MR • Mental Health • Personal Care • Orthotics and Prosthetics • Prescription Drugs • PT, OT and Speech Therapy • Private Duty Nursing • Respiratory Therapy • Transportation

11. Health Choice Services • Established by the General Assembly • Is capped on number of people that can be served and dollars spent • Mirrors Medicaid in benefits except for: • No non-emergency transportation • No Long term care • No Maternity benefits • Modified dental • Not EPSDT

12. Health Choice Services • NC writes the rules about getting the services and sends to CMS for approval. • Before we send the paperwork to CMS, we have to follow all the NC rules and laws • Figure out how much it will cost to add the service • Get permission from the General Assembly if necessary • Make sure we have rules or requirements written so people on Medicaid/Health Choice or providers who get paid by DMA know what the rules are.

13. How Does Medicaid Pay for Services to People with Disabilities • There are special rules for getting Medicaid if the person has a disability – it is easier to get Medicaid than for other people – Will be referred to as ABD (age/blind/disabled) • Services • http://www.dhhs.state.nc.us/dma/services/services.html • Regular Medicaid (Doctor visits, hospitals, dentists, therapies) • CAP-MR/DD (Community Alternative Program for People with mental retardation/development disabilities) and other CAP programs such as CAP-DA (people who don’t want to live in nursing homes), CAP-C (children who have a lot of medical conditions and require lots of medical help) • EPSDT (Early, Periodic, Screening, Diagnostic and Treatment Services) – Handout • http://www.dhhs.state.nc.us/dma/EPSDTconsumer.htm • http://www.dhhs.state.nc.us/dma/EPSDTprovider.htm • MFP (Money Follows the Person) – Handout • http://www.dhhs.state.nc.us/dma/MoneyFollows/MoneyFollowsPerson.html

14. The Services – Medicaid or Health Choice • Depending on the Services, there are more rules. For example: • How often you can go • Once a year for a physical, every 6 months to the dentist • How much or how many • So many hours a week for a person to come to your house • How many prescriptions you may get • Special permission to get certain services before the service gets provided • Referred to as prior approval • If the rules don’t get followed, then the provider doesn’t get paid • If you have appointments and don’t show, then the provider doesn’t get paid but has assumed cost – your part is to be responsible • You can be charged for the service if you’re told first if the provider provides outside the service definition. Providers usually will take care of making sure the paperwork is completed correctly. But if they don’t, they can’t pass the cost of the problem to you, unless you gave them false information. • The rules are determined through Physician Advisory Group or Legislative authority

15. People with Disabilities • Regular Medicaid/Health Choice • Doctor visits, dentists, medications, equipment like wheelchairs, walkers, special beds or lifts, supplies like diapers, bandages, special feeding equipment, personal care workers, speech therapy, occupational therapy, physical therapy • 1915 b/C Medicaid Waiver • CAP Medicaid Programs • Special services under the programs and regular Medicaid services • Other Funding Sources • Contact the Local Management Entity in your community to help you • http://www.ncdhhs.gov/mhddsas/index.htm

16. How to Advocate • Know your rights to appeal decisions about eligibility or services. • Use others to help you such as attorneys, advocates, clinical staff • Help each other • http://www.dhhs.state.nc.us/dma/consinfo.htm • Not all providers are good – you have the right to choose providers but they must be enrolled with Medicaid/Health Choice. You have the right to fire your provider and ask for another provider. • You have the right to review documentation submitted to Medicaid/Health Choice by the provider. This is a good way to make sure that Medicaid/Health Choice is only getting billed for services that you know about or are actually received. • This is a way you can help fight fraud and abuse • You have the right to see your medical record but the clinicians also have obligations before they turn it all over to you. • Working with the legislators or state officials • What programs are needed • Getting more money to start new programs or expand programs • Serve on committees and groups to help write the rules

17. Important Numbers or Resources • Customer Service Line (formerly the CARELINE) • 1-800-662-7030 , 919-855-4400 (Voice, Spanish) 1-877-452-2514 or 919-733-4851 (TTY Dedicated) • Tell the operator you want to talk to someone about Medicaid or any other topic and the operator will transfer you to the right department. • Hearings and Appeals • Phone (919) 647- 8200 • NC Division of Medical Assistance - Phone - (919) 855-4100 http://www.ncdhhs.gov/dma/index.htm • Division of Mental Health, Developmental Disabilities and Substance Abuse Services • Advocacy and Customer Service Section: 919-715-3197 • Local County of Department of Social Services • Local Management Entities For State employees in DHHS: Email addresses are first name.last name@dhhs.nc.gov

18. Overview of Affordable Care ActThe Future – HIGHLEVEL Review • By January 1, 2014, the bill requires most people to have health insurance and most employers to provide affordable health insurance or pay a penalty. • Most low-income people will be eligible for Medicaid. • Most low- and moderate-income individuals and families will be eligible for subsidies to help pay for private insurance, unless they have employer or governmental insurance. • Employers with 50 or more employees will be required to offer affordable insurance coverage or pay a penalty. • Small employers will be exempt from mandates, but some will be eligible for tax credits if they offer insurance to their workers. • Supreme Court Ruling did not change this

19. Overview of Health Reform 19 • The legislation expands health insurance coverage by: • Covering more people and making it more affordable to many. • Covering preventive services and essential health benefits. • The legislation provides new funding for: • Health promotion and wellness initiatives. • Expansion of the safety net. • Health professions education and workforce. • The legislation includes an emphasis on improving quality and efforts to reduce unnecessary health care costs.

20. Medicaid (cont’d) 20 • Will I qualify for Medicaid under health reform? • If you qualify for Medicaid now, you should be able to qualify in 2014 (assuming your income stays about the same). • Beginning in 2014, the bill expands Medicaid to cover all low-income people under age 65 with incomes up to 133% of the federal poverty level (FPL), based on modified gross income. • This was changed by the Supreme Court Decision • States do NOT have to cover the 133% population • Currently being reviewed by NC • Will need legislation to enact coverage for this population since now optional and not mandatory • Undocumented immigrants will not be eligible for regular Medicaid coverage, regardless of how poor.

21. NC Health Choice 21 • Will my children still be eligible for NC Health Choice after health reform? • If your children qualify for NC Health Choice now, they should be able to qualify in 2014 (assuming your income stays about the same). • However, the federal government has only authorized and provided funding to support the children’s health insurance program through 2019. After that time, children will remain on Medicaid if still eligible or buy insurance through their parent’s policy.

22. Medicaid Income Eligibility Limits/Year (2012) Note: This example is based on the 2012 Federal Poverty Levels. These income limits will be increased by 2014. 22

23. Insurance Reform 23 • Will health reform make it easier for me to get health insurance in the private market? • Yes, especially if you have a health problem that has made it hard for you to buy health insurance. Beginning in 2014, health insurers cannot charge more, exclude people, or rescind policies because of a person’s pre-existing conditions. • Health reform includes other changes in the insurance laws. Some of these changes will occur in the next 12-18 months.

24. Insurance Reform (cont’d) 24 • Some of the more immediate changes begin for health insurance plans that are issued after September 23, 2010.* • Insurers must extend coverage for young people up to their 26th birthday through a parent’s coverage. • Insurers will no longer be able to deny coverage to children under age 19 with pre-existing conditions. • Insurers may not include annual or lifetime limits for essential health benefits (defined later). • Insurers must submit premium rate increases to state Commissioners of Insurance for review to determine reasonableness. * Some of the protections do not apply in the same way to “grandfathered” plans or to some employer-sponsored plans.

25. Essential Benefits Package 25 • What health care services will be covered by private insurance? • The Secretary of US Department of Health and Human Services will define the “essential” health benefit package. • In general, health plans will be required to offer: hospital services; services by doctors and other health professionals; prescription drugs; rehabilitation and **habilitative services; mental health and substance abuse services; and maternity care. • Plans must also cover well-baby, well-child care, oral health, and vision and hearing services for children under age 21. • Plans are also required to cover all preventive services and immunizations (recommended by the Centers for Disease Control and Prevention) with no cost sharing.

26. Health Insurance Exchange (HIE) 26 • What are health insurance exchanges? • States will create marketplaces, or “exchanges,” in which individuals and small businesses may purchase health insurance coverage. • Exchanges will provide standardized information on quality and costs to help consumers choose between health insurance plans. • Exchanges will determine an individual’s or family’s eligibility for the health insurance premium tax credit (see next slides). • Exchanges will be limited to citizens and lawful residents who do not have access to employer-sponsored or governmental-supported health insurance and to small businesses with 100 or fewer employees.

27. What Plans Will be Available in the HIE? 27 • What kinds of health insurance plans will be available to purchase in the Health Insurance Exchanges? • All of the plans offered through the Health Insurance Exchanges (HIEs) will include the essential health benefits. • Insurers will offer bronze, silver, gold, and platinum plans through the HIE with varying levels of coverage. For example “silver” plans will pay, on average, 70% of the covered health care costs. You will be responsible for paying the remaining 30% of covered health care costs out of pocket. • In general, the higher the level of plan, the more a person will pay in premiums but the less they will pay in out-of-pocket costs.

28. Individual Mandate 28 • Am I required to buy health insurance under health reform? • No. However beginning in 2014, you may be required to a pay penalty if you do not have qualified health insurance (if you are not exempt). • Is anyone exempt from the individual mandate? • Yes. Some examples include those who aren’t required to pay taxes, those for whom the lowest cost plan would exceed 8% of their income, and those with religious exemptions. 28

29. Help Buying Private Coverage 29 • Can I qualify for a subsidy to purchase private coverage if I qualify for Medicaid or other governmental insurance? • No. Individuals with health insurance coverage through TRICARE, the VA, Medicaid, NC Health Choice, or Medicare are generally not eligible for subsidies. • Can I qualify for a subsidy if I have employer-sponsored insurance? • Generally no, unless the employer-sponsored insurance is unaffordable. The legislation considers employer-sponsored health insurance to be unaffordable if your share of the premiums exceeds 9.5% of your annual family income.

30. Example of Sliding Scale Subsidies 30 *Out-of-pocket cost sharing includes deductibles, coinsurance, copays. **Out of pocket limits do not include premium costs. Annual cost sharing limited to: $5,950 per individual and $11,900 family in 2010 (HSA limits) (Sec. 1302(c), 1401, 1402, as amended by Sec. 1001 of Reconciliation)

31. Provider Supply 31 • I have limited income and resources to pay for health care services. Aside from a hospital emergency room, is there anywhere else I can obtain care if I need it? • Yes. Many communities have “safety net” providers that provide services for free or on a reduced cost basis. • The legislation expanded funding for community and migrant health centers. In addition, health reform included new funding to build more school-based health centers.

32. Other Provisions 32 • What other provisions does health reform include? • The legislation provides more funding to support prevention and health promotion efforts at national, state and local levels. • The legislation requires providers and payers to report health data to measure quality of care. Over the next few years, more of the quality information about insurers, hospitals, nursing homes, physicians, and other providers will be made available to the public. • The legislation promotes efforts to test new models of care to improve health care delivery, quality, and efficiency. • Increase review and focus on preventing and targeting fraud and abuse by providers.

33. Useful Resources Related to the Affordable Care Act 33 • Patient Protection and Affordable Care Act(HR 3590 signed into law March 23, 2010) http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf • Health Care and Education Reconciliation Act of 2010 (HR 4872 signed into law March 30, 2010) http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h4872eh.txt.pdf • Kaiser Family Foundation http://www.kff.org/healthreform/upload/8061.pdf • Congressional Budget Office http://www.cbo.gov/ftpdocs/113xx/doc11379/Manager'sAmendmenttoReconciliationProposal.pdfhttp://www.cbo.gov/ftpdocs/114xx/doc11490/LewisLtr_HR3590.pdfhttp://www.cbo.gov/ftpdocs/114xx/doc11493/Additional_Information_PPACA_Discretionary.pdf 33