SUSTAINABILITY: MEDICAID AND OTHER HEALTH INSURANCE

1. SUSTAINABILITY: MEDICAID AND OTHER HEALTH INSURANCE MARY B. TIERNEY, M.D. September 25, 2003

2. OTHER FINANCING PROGRAMS • State Children’s Health Insurance Program (CHIP) – Title XXI of the Social Security Act • Maternal and Child Health BlockGrant – Title V of the Social Security Act

3. CHIP • Eligibility • Services • Trends

4. CHIP ELIGIBLITY • Compared to Medicaid eligibility standards are very flexible • States must submit plans to CMS for approval low-income children and: • May not cover children with higher incomes than those who are already targeted • May not deny eligibility based upon a pre-existing medical condition

5. Intake and follow-up screening assures that only the targeted children are enrolled Children found to be eligible for Medicaid are enrolled in that program Ensure that CHIP does not substitute for insurance provided by group commercial health plans Assure that there is coordination with other public and private programs ELIGIBILITY SCREENING AND COORDINATION WITH OTHER HEALTH COVERAGE

6. OTHER ELIGIBILITY ISSUES • States must submit and obtain approval of plans to inform of the availability of this coverage • Immigrant eligibility for CHIP including residency requirements and reasons for immigrating

7. COVERAGE REQUIREMENTS • Medicaid Expansion • Create or expand a new program • Combination of both

8. Inpatient and outpatient hospital services Physician surgical and medical services Laboratory and x-ray services Well child care including appropriate immunizations COVERAGE OF BASIC SERVICES

9. Prescription Drugs Mental Health Services Vision Services Hearing Services Any other additional Services that a state wishes to provide and is approved by HHS COVERAGE OF ADDITIONAL SERVICES

10. MEDICAID EXPANSION • If a state chooses to implement a Medicaid expansion, it must offer the newly eligible individuals the same Medicaid benefits • 19 States have chosen to implement Medicaid expansions

11. CREATE OR EXPAND A STATE PROGRAM • States choosing to implement a State program must choose from 5 basic options • 19 States have chosen this option

12. The Blue Cross/Blue Shield preferred provider option offered to Federal employees State employees health plan The HMO with the largest insured commercial enrollment Coverage that is actuarially equivalent to the previous 3 plans Another benefit package approved by the Secretary, HHS CREATE OR EXPAND A STATE PROGRAM

13. COST SHARING • States can impose cost sharing for adults receiving Medicaid under CHIP if they are at or above 150% FPL • States can impose cost sharing for children at or above 150% FPL on a sliding scale but no more than 5% of the family income

14. STATE CHILD HEALTH INSURANCE PROGRAM PLAN ACTIVITY MAP

15. Medicaid and SCHIP Eligibility for Adolescents Under age 19, Highest Income Thresholds as a Percentage of FPL as of September 30, 2001 12 states: > 100% but < 185% FPL 26 states (including DC): < 200% FPL 6 states: > 200% but < 250% FPL 7 states: > 250% FPL Note: Vermont and Nevada covered 18 year olds at lower income levels than younger adolescents. Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

16. SCHIP Enrollees by Age Group and Program Type, FY 2001* * Reflects those ever-enrolled during FFY 2001. Source: CAHL analysis of data provided by CMS Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

17. Percent of Children and Adolescents Who Were Uninsured During 2001 Source: US Census Bureau, Sept. 2002 Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

18. Threats to Medicaid and SCHIP • Increasing demand and need for public coverage • Poverty rate increased • High rates of unemployment • Rapidly rising health care costs • Reductions in private coverage • States’ ability to meet current and increased demand is severely constrained Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

19. Federal Funding for SCHIP (in $Billions) Source: Balanced Budget Act of 1997 Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

20. OMB Projections for SCHIP Enrollment Source: Center on Budget and Policy Priorities, Aug. 2002 Morreale, M.C., Medicaid and SCHIP Policy Update, November 2002

21. MATERNAL AND CHILD HEALTH BLOCK GRANT • Original grants authorized payments to States to reduce maternal mortality – in 1929 • Title V of the Social Security Act signed by FDR in 1935 • Title V included services for “maternal and child care,” “child welfare” and “crippled children”

22. MATERNAL AND CHILD HEALTH BLOCK GRANT • In 1981and again in 1989, the legislation was amended to become a Block Grant to State Maternal and Child Health (MCH) agencies

23. MCH BLOCK GRANT • MISSION • Provide access to prenatal care for low-income women • Provide preventive services including immunizations, health assessments, among others • Promote provision of family centered, community-based, culturally competent, coordinated care for children with special needs

24. ALLOTMENT OF FUNDS • Funding for State MCH agencies for state-wide needs assessment, coordination and consultation with other family-serving agencies including Medicaid/CHIP, Mental Health, development and setting standards of care, care management • Funding is not to be used for direct payment for health care services unless health insurance coverage is not available

25. SPECIAL PROJECTS • Bright Future series including Bright Futures in Practice: Mental Health • Collaborative grants with a new emphasis on mental health and early intervention as part of their children with special needs • Potential collaboration between health and mental health

26. REFERENCES • www.cms.gov • www.aap.org • www.aap.org/advocacy/schipsum.htm • www.mchb.hrsa.gov • www.kff.org • http://www.kff.org/sections.cgi?section=kcmu

27. Mary B. Tierney, MD Primary Care Senior Advisor TA Partnership 202-298-2620 (office) 202-342-5007 (fax) mtierney@air.org (email)