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Medicaid 101

Stacey Shuman Native American Contact Region VI, Dallas Centers for Medicare & Medicaid Services. Medicaid 101. CMS Programs and AI/AN health. CMS/IHS partnership for Indian health care Working together to meet the challenge CMS revenue and Indian health programs

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Medicaid 101

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  1. Stacey Shuman Native American Contact Region VI, Dallas Centers for Medicare & Medicaid Services Medicaid 101

  2. CMS Programs and AI/AN health • CMS/IHS partnership for Indian health care • Working together to meet the challenge • CMS revenue and Indian health programs • Importance of enrolling AI/AN in Medicare, Medicaid and CHIP

  3. Medicaid Administration • States Determine: • Who is covered • How providers are paid • What services are covered • CMS Provides: • Oversight of Program • Technical Assistance • Federal Matching Funds

  4. Medicaid - Who is Covered? • Mandatory Categorically Needy Groups - Required by Statute • Children and Families • Pregnant Women • Disabled and Aged Individuals • Optional Categorically Needy Groups – States Select • Medically Needy – States Select • Tribal Documents must now be accepted as proof of citizenship and identity for Medicaid and CHIP

  5. Resource Exemptions for AI/AN • Exemptions from Resource tests include: • Property held in trust or under the supervision of the Secretary of Interior (BIA) • IIM Accounts - Restricted or unrestricted • Monies paid out from exempt resources are treated as exempt asset conversions, • NOT INCOME in the month of receipt

  6. Resource Exemptions for AI/AN • Exemptions from Resource tests include: • Property located on a reservation or within the most recent boundaries of a reservation • Real property and improvements • Ownership interest in: Rents, Leases, Royalties, Usage rights • For use of: Natural resources, Fish/shellfish, Harvesting animals, Harvesting plants or timber

  7. Resource Exemptions for AI/AN • Also excluded are items with religious, spiritual, traditional or cultural significance or used to support subsistence or a traditional lifestyle according to tribal law or custom. • Monies received for usage or ownership rights for excluded resources are • NOT income in the month of receipt • May be countable as a resource the first of the following month

  8. Medicaid - Who Can Determine Eligibility? • State Medicaid Agency Staff • TANF Agencies (State Agencies or County Agencies) • Tribes Who Administer TANF • The State must enter into interagency agreements with other State Agencies, County Agencies or TANF Tribes, if they are going to do eligibility determinations.

  9. Special Provisions in Medicaid States must provide outstationing opportunities to apply for family and children’s Medicaid at all Tribal 638 programs (FQHC authority) and Urban Indian Health programs or have an alternate plan approved by CMS.

  10. Enrollment Opportunities • CMS Support for Health Fairs, Local Outreach Events • Outreach Grants • General CHIP Outreach Grants • Outreach Grants for Indian Children • Future Outreach Opportunities

  11. Enrollment Opportunities • Outstationing • Tribal Eligibility Offices • CHIPRA Grantees • Online Applications • Develop Partnership with States and Local Offices

  12. Eligibility Requirements • State Program Web Sites • State Eligibility Manuals • Attend State Training Sessions if Possible • Enroll and Attend Training to be SHIPs (State Health Insurance Program) • Attend Area Training Sessions

  13. What Does Medicaid Cover? • Mandatory Services • Optional Services • All Medically Necessary Services for Children under 21, whether or not the State has elected the service • States also must assure Transportation to Medicaid covered appointments

  14. Maximize Utilization • Review Provider Manuals • Review State Plans for Coverage Groups and Covered Services • Become familiar with Covered Services • Review Eligibility Manuals

  15. Payment for Medicaid Services • States design payment methodology, within Federal upper limit and other regulatory requirements. • Medicaid is the payer of last resort, except • Indian Health Service is the payer of last resort after all CMS programs.

  16. I/T/U Enrollment as Providers • Obtain NPI • Enroll as a provider • States where program operates • Enroll as Primary Care Provider for programs operated in Managed Care environment • Make Sure ALL Tribal Programs are Enrolled

  17. Billing for Services Provided • Work with State Contacts, Managed Care Plans to determine trends, billing errors • Work with Coders • Provide training • Support Coders • Provide resources needed • Work with Medical professionals on charting, etc., to make sure everything is captured

  18. Cost Sharing in Medicaid • Nominal cost sharing for Medicaid services can be charged. • Children under 18 cannot be charged cost sharing • AI/AN who use I/T/Us and Contract Health Service (CHS) are exempt from cost sharing in certain circumstances.

  19. Cost Sharing Exemptions for AI/AN • AI/AN who utilize or are eligible to utilize I/T/Us are exempt from Premiums and Enrollment fees. • I/T/U should provide a letter or document for the individual to take to the State. • IHS provided a letter that can be used by I/T/Us to verify this exemption.

  20. Cost Sharing Exemptions for AI/AN • AI/AN who have ever received an I/T/U service are exempt from coinsurance, deductibles or copayments. • I/T/U can provide a letter or document for the individual to take to the State. • IHS provided a letter that can be used by I/T/Us to verify this exemption.

  21. Estate Recovery Protections for AI/AN • Properties exempt from Medicaid estate recovery action: • Property located on a reservation or within the most recent boundaries of a reservation • Real property and improvements • Ownership interest in: Rents, Leases, Royalties, Usage rights • For use of: Natural resources, Fish/shellfish, Harvesting animals, Harvesting plants or timber

  22. Estate Recovery Protections for AI/AN • Items with religious, spiritual, traditional or cultural significance or used to support subsistence or a traditional lifestyle according to tribal law or custom. • Ownership interests left as a remainder in an estate in rents, leases, royalties or usage rights in listed properties, as long as they can be clearly identified as such.

  23. Managed Care Protections for AI/AN and I/T/Us • An AI/AN enrolled in managed care can choose to utilize an I/T/U • Managed Care plan must pay the I/T/U a negotiated rate or not less than their normal payment for the service to a participating provider • State must assure the I/T/U receives payment up to the normal State Plan rate for that facility

  24. Consultation Requirements • Prior to submitting a proposed change to CMS, States must seek advice from I/T/Us for any Medicaid change likely to have a direct impact on an AI/AN person or an I/T/U • State Plan Changes • Demonstration Proposals • Waiver proposals, amendments, extensions, renewals

  25. Special Medicaid Provisions 100% Federal Financial Participation for services provided through IHS or Tribal 638 Clinics.

  26. Other Special Provisions in Medicaid • Urban & Tribal Indian Health Clinics can bill as FQHCs—(defined as FQHCs in the law) cost based reimbursement. • Tribes and Tribal Organizations can enter agreements with States to provide Medicaid Administrative Match to draw federal funds. • Any federal funds drawn by states based upon Tribal matching costs must be given to the Tribe or Tribal Organization.

  27. CHIP 101The Children’s Health Insurance ProgramThe Children’s Health Insurance Program Crystal Francis Native American Contact Region IV, Atlanta Centers for Medicare & Medicaid Services

  28. CHIP Administration • State – Federal Partnership • Broader State Flexibility than Medicaid • Can be Medicaid Expansion • Can be Separate Insurance Program • Can be Combination Medicaid and Separate Insurance • Can be 1115 Waiver • States receive higher (enhanced) Federal Matching Rate (FMAP)

  29. What Does CHIP Cover • Basic Medical Services • Inpatient/Outpatient • Preventive Services • Physician/Clinic • Immunizations • Can be modeled after private sector insurance plans—more options for coverage than Medicaid

  30. Special Provisions in CHIP • Managed care protections in Medicaid also apply to CHIP • Resource exclusions for Medicaid also apply to CHIP • Tribal Documents must now be accepted as proof of citizenship and identity for Medicaid and CHIP

  31. Special Provisions in CHIP • American Indian/Alaska Native Children are exempt from the cost sharing provisions of CHIP • States must seek advice from I/T/Us prior to submitting to CMS for State Plan Amendments, Demonstration proposals, Waiver proposals, waiver amendments, waiver extensions and waiver renewals if they are likely to have a direct impact on Indians or Indian health providers.

  32. Applicant Rights • Medicaid • Eligibility Decision in 45 days • Fair Hearing Process if Negative Decision • Appeal if payment or service is denied • CHIP • Eligibility Decision in 30-45 days • Fair Hearing Process if Negative Decision • Appeal if payment or service is denied

  33. Medicaid and Indian Health:Simplifying and Strengthening Eligibility under Health Care Reform Pamela Carson and Crystal Francis Centers for Medicare & Medicaid Services

  34. Key Components of Medicaid Eligibility Under Health Care Reform • Medicaid coverage for everyone • with household income under • 133 percent FPL • Eligibility based on “household • income” and “modified adjusted • gross income” - No asset tests - Disregards no longer apply • Alignment with Exchange and CHIP

  35. Guidance Available Patient Protection and Affordable Care Act (ACA) • Notice of Proposed Rule Making (NPRM) • Other Guidance on ACA has been issued: - State Health Official (SHO) Letters - State Medicaid Director (SMD) Letters - Final Rules - Informational Bulletins

  36. SMD 11-001:Tobacco Cessation Services http://www.cms.gov/smdl/downloads/SMD11-007.pdf • Guidance on Medicaid coverage of tobacco cessation services • Encourages States to provide tobacco cessation services for all Medicaid beneficiaries - Mandatory for Pregnant Females - Optional Service for all other Medicaid Beneficiaries • Clarifies that telephone “quit lines” will be coverable for the first time, as an option • Effective June 24, 2011

  37. SMD 11-004:Electronic Health Record (EHR) Incentive Programs http://www.cms.gov/smdl/downloads/SMD11004.pdf • ARRA established the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. • Expands on SMD Issued August 17, 2010 • Criteria for Health Information Exchange Promotion -Costs based on the fair share principle and appropriately allocated - Must leverage efficiencies with other Health Information Exchange funding - Activities must be developmental and time-limited.

  38. FQHCs for the Medicaid Electronic Health Record (EHR) Incentive Program http://questions.cms.hhs.gov/app/answers/detail/a_id/10417/kw/tribal/session/L3NpZC8xbVN1S0F3aw%3D%3D • Tribal Clinics were required to be paid as Federally Qualified Health Centers (FQHCs) for the Medicaid EHR Incentive Program • Guidance was corrected after stakeholder feedback. • Tribal clinics are eligible for Medicaid EHR Incentive Program • Eligible professionals in Tribal Clinics may be subject to the “needy individual patient volume threshold, rather than the “Medicaid patient volume threshold.”

  39. Guidance for Exchange and Medicaid Information Technology (IT) Systems http://www.cms.gov/Medicaid-Information-Technology-MIT/Downloads/exchangemedicaiditguidance.pdf • CMS released “Exchange/Medicaid IT Guidance 2.0” on May 31, 2011. • Support of Exchanges, Medicaid and Children's Health Insurance Programs for coverage under the Affordable Care Act. • Describes the data services hub supporting State systems.

  40. NPRM:Helping People with Disabilities Live in Their Communities http://edocket.access.gpo.gov/2011/pdf/2011-9116.pdf • Published in Federal Register February 25, 2011 • 1915(k) provides States the opportunity to cover HCBS attendant services and supports for Medicaid eligible individuals with incomes not exceeding 150% of the federal poverty level • Published in Federal Register April 15, 2011 • States would no longer need separate waivers to provide HCBS to the elderly, people with physical and intellectual disabilities, and those with mental illness (1915c waiver).

  41. Concurrent Hospice Care for Children in Medicaid and CHIP https://www.cms.gov/smdl/downloads/SMD10018.pdf • SMD Letter 10-018 released September 2010 • Guidance on implementation of Section 2301 of the Affordable Care Act - Hospice services are an optional benefit under Medicaid and CHIP - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provision requires Medicaid and CHIP programs operating as Medicaid expansions to provide all medically necessary services, including hospice services, to individuals under age 21.

  42. Dental Services in FQHCs • CHIPRA section 501(d) • States may not prevent a Federally-Qualified Health Center (FQHC) from entering into contractual relationships with private practice dental providers in the provision of FQHC services. • Dental services furnished off-site by private dental providers who contract with FQHCs will be covered by Medicaid and CHIP as FQHC services • Oral Health Strategy is available on the CMS website.

  43. NPRM:Access to Covered Medicaid Services http://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/2011-10681.pdf • Published in Federal Register May 6, 2011 • Create a standardized, transparent process to assure that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers • Affects only Medicaid Fee-for-Service Payments • Public notice to providers is required when changing Medicaid payment methods and standards.

  44. Model Interstate Coordination Process http://www.cms.gov/CHIPRA/Downloads/InterstateCoordination.pdf • CMS required to develop a model process to coordinate Medicaid and CHIP enrollment, retention and access to care for children who frequently change their address. • Secretary must submit a Report to Congress • CMS released a model process for interstate coordination in July 2010

  45. SMD 11-008:Financial Models Supporting Integrated Care • CMS is outlining two models for States pursuing integration of primary, acute, behavioral health and long term services and supports for their full benefit Medicare-Medicaid enrollees. • - Capitated approach to integration for Medicare-Medicaid enrollees • - Managed fee-for-service (FFS) approach to integration. • States need to submit a letter of intent by October 1, 2011 to initiate the process. • Target implementation December 31, 2012 http://www.cms.gov/smdl/downloads/Financial_Models_Supporting_Integrated_Care_SMD.pdf

  46. SMD 10-07 & SMD 11-003 :National Correct Coding Initiative (NCCI) Methodologies http://www.cms.gov/smdl/downloads/SMD11003.pdf • Clarifies the non-applicability of the appeals component of the five National Correct Coding Initiative (NCCI) methodologies • CMS Must Notify States: (1) Medicare NCCI methodologies “compatible” with claims filed with Medicaid (2) NCCI methodologies for claims filed with Medicaid for which no national correct coding methodology has been established for Medicare; and (3) How they must incorporate these methodologies for claims filed under Medicaid. • States are Not Obligated to Implement the Appeals Component

  47. SHO 11-001:CHIPRA Quality Measures http://www.cms.gov/smdl/downloads/SHO11001.pdf • Launched the “CHIPRA Technical Assistance and Analytic Support Program” to support child health care quality measurement, reporting, and improvement efforts. - Provide information and support to uniformly collect, calculate, and report the core measures; • Ensure that the data collected is used to inform decisions about policies, programs, and practices to improve quality of care; and • Share emerging best practices and lessons learned.

  48. Proposed Rule:Affordable Insurance Exchanges http://www.ofr.gov/OFRUpload/OFRData/2011-17610_PI.pdf • Framework to assist States in building Affordable Insurance Exchanges • Provides Guidance and Options on How to Structure Exchange: - Setting standards for establishing Exchanges, setting up a Small Business Health Options Program (SHOP), performing the basic functions of an Exchange, and certifying health plans for participation in the Exchange, and; - Ensuring premium stability for plans and enrollees in the Exchange • Comment period ends September 28, 2011 • Regional listening sessions and meetings will be established

  49. NPRM:Home Health Services http://www.gpo.gov/fdsys/pkg/FR-2011-07-12/pdf/2011-16937.pdf • Issued July 5, 2011 • Provides Guidance on Home Health Services - Physicians must document the face-to-face encounter with Medicaid Individual - Home health services cannot be restricted to the home - Includes a definition of medical supplies, equipment and appliances • Effective January 1, 2010

  50. Recent NPRMS • Issued August 12, 2011 • The Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010, CMS-2349-P; • Patient Protection and Affordable Care Act:  Establishment of Exchanges and Qualified Health Plans; proposed rule; CMS-9989-P; and • The IRS Health Insurance Premium Tax Credit, REG-131491-10

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