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Texas Medicaid

Texas Medicaid. Medical and Dental Information Series. Version 1.2 (6/22/2010). 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

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Texas Medicaid

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  1. Module 7 Texas Medicaid Medical and Dental Information Series Version 1.2 (6/22/2010) 2/22/2013

  2. Module 7 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 7 Special Medical Issues

  4. Module 7 Module 7: ObjectivesAfter completing this module, you should be able to: • Discuss additional Texas Medicaid programs that provide health services to children and adults including: • Behavioral health services • Prescription drug benefits • Benefits for “Dual Eligibles” (those eligible for both Medicare and Medicaid) • Long-term care programs • Review briefly the health topics discussed in previous modules

  5. Module 7 True or False? • Medicaid covers only behavioral health services provided by a psychiatrist. • Only medications listed on the Preferred Drug List (PDL) are reimbursable through Texas Medicaid. • Texas Medicaid must cover all medications for which a manufacturer offers a rebate. • PACE programs coordinate and provide preventive, primary, acute and long term care services for elderly individuals who live in the community. • Hospice is for all age groups, including children, during their final stages of life.

  6. Module 7 Behavioral Health Services Texas Medicaid defines Behavioral Health Services as: Services used to treat a mental, emotional, or substance use disorder. Medicaid makes behavioral health services available to Medicaid-eligible children and adults.

  7. Module 7 Behavioral Health Services:Basic Services • Screening, diagnosis, and referral to needed services • Freestanding psychiatric hospital services (for patients younger than 21 and older than 64 years of age) • Psychiatric hospitalization services in psychiatric unit within a general acute care hospital • Counseling and psychotherapy services • Medication services • Substance use disorder treatment services • Rehabilitation and case management services for people with severe and persistent mental illness and children with severe emotional disturbance

  8. Module 7 Behavioral Health Expenditures • Mental and behavioral health constitutes about 3% of all Texas health care expenditures • DSHS expenditures for mental health care in 2009 totaled $1.8 billion-- 26.3% more than in 2005.

  9. Module 7 Behavioral Health: Eligible Providers and Care Settings Providers • Psychiatrists • Primary Care Physicians • Psychologists • Licensed Clinical Social Workers • Licensed Professional Counselors • Licensed Marriage and Family Therapists • Advanced Practice Nurses and Physician Assistants Settings • Private practices • Private and public psychiatric and general hospitals • Community mental health centers (e.g. MHMR facilities) • Licensed substance use disorder treatment programs • Federally Qualified Health Centers (FQHCs)

  10. Module 4 Behavioral Health & Managed Care • Medicaid managed care, including STAR and STAR+PLUS, cover standard behavioral health services such as help for drug or alcohol problems and mental health services • Medicaid managed care plans can offer additional value-added services, such as: • Health psychology interventions to help manage chronic medical conditions • Intensive outpatient treatment/ day treatment • Inpatient substance abuse detoxification treatment

  11. Module 7 The NorthSTARProgram • 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.

  12. Module 7 PrescriptionDrug Coverage • In 1971, Texas Medicaid began providing optional coverage of outpatient medications. • Patients enrolled in fee-for-service Medicaid receive services through the Vendor Drug Program (VDP). • Patients enrolled in Medicaid managed care organizations receive services through their MCOs.

  13. Module 7 Medicaid Prescription Drug Coverage • Texas Medicaid covers prescription drugs that are dispensed through over 4,500 Texas pharmacies. • Medicaid reimburses pharmacy providers only for outpatient prescription drugs. • Over-the-counter drugs are covered for patients enrolled in Medicaid, Children with Special Health Care Needs and Kidney Health Care Programs, but not for patients in nursing facilities.

  14. Module 7 Limitations on Prescription Drugs, by Patient Group Unlimited Prescriptions Limited to Three Prescriptions/Month • Children under 21 years of age • Aged, blind, or disabled (ABD) nursing home clients • ABD adults in the community with waiver eligibility • Managed care clients (STAR, STAR Health, STAR+Plus) • TANF fee-for-service adults • ABD fee-for-service adults without waiver eligibility

  15. Module 7 Preferred Drug List (PDL) Program • The Medicaid PDL is a method to control growing medication costs, while also insuring that program recipients have access to medically necessary medications. • Medications on the PDL can be prescribed without prior authorization. • All “non-preferred” drugs require prior authorization. • Medications receive their “preferred” or “non-preferred” designations based on their safety, efficacy, and cost effectiveness. • HHSC saved approximately $245.8 million in general revenue during the 2008-2009 biennium as a result of the PDL, due to supplemental rebates and prescribing shifts. The PDL can be obtained from: www.txvendordrug.com/pdl

  16. Module 7 Prescription Drug Coverage: Federal Drug Rebate Program • The Omnibus Budget Reconciliation Act of 1990 requires that drug manufacturers pay medication rebates for drugs dispensed under state Medicaid programs. Additionally, this law mandates that: • States must cover all drugs for which the manufacturer provides a rebate. • States must maintain an open formulary for all drugs of manufacturers that have signed a federal rebate agreement. • States may require prior authorization to limit the use of drugs. • Approximately 36% of the VendorDrug Program’s budget is funded byrebates paid by pharmaceuticalmanufacturers

  17. Module 7 Texas Drug Code Formulary • The Texas Drug Code Formulary covers more than 32,000 drugs including single source and multi source (generic) products. • The Texas Medicaid formulary can be found at: www.txvendordrug.com/formulary/formulary-search.asp • The Texas Medicaid formulary and PDL are also available on the Epocrates drug information system.

  18. Module 7 Texas Drug Code Formulary Search Results PDL Prior Authorization = Yes…The drug is “non-preferred” and requires prior authorization before Medicaid will cover it Clinical PA Auth. Required = Yes…The drug is subject to clinical edits, requiring the pharmacy to first check a client’s Medicaid medical and drug claims histories for consistency with the edit criteria for that drug.

  19. Module 7 Non-PDL Prior Authorization Drug Search • Providers may also search specifically for drugs that do not require prior authorization. www.txvendordrug.com/formulary/PDLSearch.asp

  20. Module 7 Prescription Drug Prior Authorization • Prior authorization is necessary for any drug not on the PDL and can be obtained via two methods: • Telephone: 1-877-PA-TEXAS (1-877-728-3927) • Online: https://paxpress.txpa.hidinc.com

  21. Module 7 72-Hour Emergency Prescriptions • Both federal and Texas laws require that a 72-hour emergency supply of prescribed medications be provided when: • A medication is needed without delay • Prior authorization is not available (e.g. prescriber can not be contacted or is unable to request it) • Emergency prescriptions do not count towards the three-prescription limit for those subject to this limit.

  22. Module 7 The Vendor Drug Program (VDP) • The VDP provides prescription drug services to eligible Texas Medicaid recipients in these programs: • Texas Medicaid fee-for-service • Children with Special Health Care Needs • Kidney Health Care Programs • The VDP processes prescription drug claims from contracted pharmacies and reimburses pharmacies for the cost of the drugs

  23. Module 7 VDP ePrescribing • Medicaid prescriptions are now accepted via e-prescription (e-Rx), and all managed care plans are required to provide e-Rx services. • In order to submit an e-Rx that meets CMS requirements for “brand medically necessary” dispensing, the prescribing physician should do the following on the electronic prescription transaction that is sent to the pharmacy: • Select the option for “Dispense as Written” (DAW) on the electronic prescription pad. • Type “Brand Medically Necessary” in the “Notes to Pharmacy” free-text field.

  24. Module 7 Prescription Drugs for Medicaid Managed Care Clients • As of March 1, 2012 clients enrolled in Medicaid managed care (STAR, STAR+PLUS) obtain prescription drug benefits through their managed care organizations (MCOs).  • Each MCO will contract with a pharmacy benefits manager (PBM) that will process prescription claims and work with pharmacies that serve Medicaid managed care clients. • MCOs will use the state-approved formulary for pharmacy benefits.

  25. Module 7 Medicaid Managed CareService Areas Service Areas Effective March 1, 2012

  26. Module 7 What are the most prescribed drugs?Texas Medicaid Top 10 Drugs By Usage (Claims in 2010) By Expenditure (Paid in 2010) $90,402,420 1,482,930 $84,636,490 1,241,673 $69,095,046 868,965 $67,759,635 847,432 $46,187,032 635,844 $43,039,565 595,775 $38,744,539 567,929 $34,822,941 478,288 $29,646,374 469,244 $28,365,603 402,028

  27. Module 7 Dual Eligibility • Dual Eligiblesare individuals who qualify for Medicare and Medicaid benefits. • Medicare is a federally administered health insurance for: • People 65 years or older • People under age 65 with certain disabilities • People of any age with End-Stage Renal Disease

  28. Texas Medicaid Medicare Module 7 Review:Medicaid vs. MedicareWhat is the difference? Authorized by Social Security Act of 1965 Established in Texas – 1967 Jointly Funded by State and Federal Government, administered by State & regulated by CMS Funded by Federal Government & administered by CMS Entitlement program based on income Entitlement program based on age or disability Low income families, children, pregnant women, disabled, elderly People 65 years or older, or people with disabilities CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program. Eligibility and enrollment in both programs concurrently is possible

  29. Module 7 Common Medicaid Myths • Myth Medicaid pays the nursing home bill for all seniors. • Medicaid prohibits individuals from transferring savings to others in an attempt to qualify for nursing home care without exhausting their assets. Sixty percent of nursing home residents are not on Medicaid at the time of their admittance into a facility. • Even after individuals deplete their assets, they are still required to apply their income, including Social Security and pension checks, towards their care costs, except for an average monthly $30 personal needs allowance. • Fact Medicaid eligibility for seniors is limited to the very poor or those with large health expenses who have depleted their savings.

  30. Module 7 How Medicaid and Medicare Work Together • By federal law, Medicare coverage is primary to Medicaid • When a patient receives a service covered under both programs, Medicare pays first, and the remainder (if any) is payable by Medicaid. • Medicaid also serves dual eligibles by providing services not covered by Medicare, including: • Nursing home care beyond Medicare’s100-day limit • Some prescription drugs • Eye glasses • Hearing aids • For those who qualify, Medicaid may also coversome out-of-pocket Medicare expenses such as co-insurance, premiums, and deductibles

  31. Module 7 How Medicaid and MedicareWork Together to cover Nursing Home Care First 20 days: Medicare pays Next 80 days: Medicare pays + Medicaid covers co-insurance After 100 days: Medicaid pays

  32. Module 7 Full vs. Partial Eligibility for Medicaid Full Eligibility Partial Eligibility Medicaid pays for Part D (prescription drug coverage) premiums or deductibles Depending on income, Medicaid pays for Part A (hospital insurance) and/or Part B (medical insurance) • Medicaid pays deductibles and co-insurance for Medicare-covered services • Recipients may receive Medicaid services not covered by Medicare (e.g. long-term services and supports) • Medicare provides the majority of prescription coverage, while Medicaid covers those drugs not covered under Medicare Full vs. Partial Eligibility is based on income and eligibility for Supplemental Security Income (SSI)

  33. Module 7 Dual Eligibility: Special Considerations for Providers Enrollment • All physicians must be enrolled in Medicare before they can enroll in Medicaid. • Exceptions are gynecologists, pediatricians, pediatric psychiatrists, and providers performing only Texas Health Steps medical or dental checkups Prior Authorization • If a patient’s primary coverage is Medicare, providers must always confirm with Medicare whether a service is a Medicare benefit for the patient. • If Medicare denies this service, then Medicaid prior authorization is required. Billing • For those services covered by both Medicare and Medicaid, Medicare is the primary coverage and the claim must be filed with Medicare first.

  34. Module 7 Long-Term Services and Supports Nursing Facility Care Services Mental Retardation Services Primary Home Care Services (PHCS) Home and Community-based Waivers Day Activity and Health Services (DAHS) Hospice Care Services Program for All-inclusive Care for the Elderly (PACE) Consumer-Directed Services (CDS)

  35. Module 7 Nursing Facility Care Services • Nursing Facility Care provides 24-7 nursing care for people whose medical condition requires the skills of a licensed nurse on a regular basis. • The nursing facility must provide for the medical, nursing, and psychosocial needs of each recipient, including: • Room and board • Social services • Over-the-counter drugs (prescription drugs are covered through the Medicaid Vendor Drug program or Medicare Part D) • Medical supplies and equipment • Personal needs items • Rehabilitative therapies • Augmented Communication Device Systems • Power Wheelchairs • Emergency Dental Services

  36. Module 7 Services for Persons with Intellectual Disabilities • The Texas Department of Aging and Disability Services (DADS) administers several long-term services and support programs for individuals with intellectual disabilities. • Each of the DADS support programs for individuals with intellectual disabilities has different eligibility criteria; however, most criteria are based on: • Cognitive functioning levels • Adaptive behavior skills, which indicate the ability to care for oneself • Physical disability levels

  37. Module 7 DADS Programs & Services for Persons with Intellectual Disabilities Home and Community Based Services (HCS) • HCS provides individualized services and supports to persons with intellectual and developmental disabilities who are living with their family, in their own home or in other community settings, such as small group homes. • Intermediate Care Facilities for Persons with Intellectual Disabilities • This program provides residential and habilitation services to people with intellectual and developmental disabilities and/or a related condition. • In-Home and Family Support Program • This program provides direct grant benefits to people who have physical disabilities and or their families to help them purchase services that enable them to live in the community or in their own homes. • Texas Home Living Program • This program provides selected essential services and supports to people with intellectual and developmental disabilities who live in their family homes or their own homes.

  38. Module 7 DADS Programs & Services for Persons with Intellectual Disabilities Continued • State-Supported Living Centers • The state has 13 State-Supported Living Centers that provide 24-hour residential, treatment and training services for people with intellectual and developmental disabilities.

  39. Module 7 Primary Home Care • Primary Home Care (PHC) provides attendant services to people with an approved medical need for assistance with personal care tasks. • PHC is available to eligible adults whose health problems cause them to be functionally limited in performing activities of daily living according to a practitioner’s statement of medical need. • Services can include having in-home attendants who help recipients with activities of daily living including: • Bathing • Grooming • Meal preparation • Housekeeping

  40. Module 7 Home and Community-based Waivers • DADS waiver programs provide community-based services and supports for people who qualify for admission to institutional settings but have made the choice to receive receive services in the home or in a community setting as a cost effective alternative. • DADS administers seven waiver programs and maintains interest lists for most programs. • A person can be enrolled in only one waiver program at a time. Community-based Alternatives Community Living Assistance and Support Services Consolidated Waiver Program Deaf Blind Multiple Disabilities Medically Dependent Children Program Home and Community-based Services Texas Home Living Waiver

  41. Module 7 Day Activity and Health Services (DAHS) • DAHS licensed facilities provide daytime services Monday through Friday to clients residing in the community in order to provide an alternative to placement in nursing facilities or other institutions. • Eligibility Requirements: • Full Medicaid recipient • Medical diagnosis and physician’s orders requiring a licensed vocational nurse’s or a registered nurse’s care or have a functional disability related to the medical diagnosis • One or more personal care or restorative needs that can be stabilized, maintained or improved by participation in DAHS • Services can include nursing and personal care, noontime meal, snacks,transportation, social, educational,and recreational activities.

  42. Module 7 Hospice Care Services • Medicaid recipients who no longer choose curative treatment and who have a physician’s prognosis of six months or less to live are eligible for Medicaid Hospice services. • Service can be delivered in the following settings: • Home-based care • Community-based care • Long-term care facilities (e.g. nursing homes) • Eligibility Requirements: Hospice is for all age groups, including children, during their final stages of life. • Hospice services can include: physician and nursing care, medical social services, counseling, home health aide, personal care, homemaker and household services, physical, occupational, or speech language pathology services

  43. Module 7 Program for All-inclusive Care for the Elderly (PACE) • Program for All-inclusive Care for the Elderly (PACE) programs coordinate and provide all needed preventive, primary, acute and long term care services so older individuals can continue living in the community. • PACE utilizes interdisciplinary teams, including physicians, nurses, social workers, therapists, van drivers and aides, to exchange information and solve problems as the conditions and needs of PACE participants change. • PACE Eligible Populations: • Age 55 or older • Meet the medical necessity for nursing facility admission • Live in a PACE service area (Amarillo, El Paso, or Lubbock) • Have limited income and countable resources

  44. Module 7 PACE Services • PACE uses a comprehensive care approach, providing an array of services for a capitated monthly fee. • PACE provides all health-related services, including inpatient and outpatient medical care, and specialty services including: • Dentistry • Podiatry • Social services • In-home care • Meals • Transportation • Day activities • Housing assistance Nationally, the average age of PACE participants is 80 years old, and 93% live alone in the community. Seventy-five percent of participants are female. The average PACE participant has 7.9 medical conditions, many of which are chronic conditions including diabetes, dementia, coronary artery disease, and cerebrovascular disease

  45. Module 7 Consumer Directed Services (CDS) • The CDS option allows Medicaid clients or their legally authorized representatives to serve as an employer and assume responsibility for screening, hiring, training and dismissing providers. • Those who elect to use the CDS option must select a Consumer Directed Services Agency (CDSA) to conduct financial management services such as payroll and employer taxes. Benefits of Choosing CDS Control over who provides services and who comes into the home. Consumers train their own service providers and set their work schedule. Consumers set the pay and benefits within the funds allotted for their program. Most people who choose the CDS option do so because they want the independence that comes with employing the people who provide their services.

  46. Module 7 Texas Medicaid Series Summary Module 7 concludes the Texas Medicaid Medical and Dental Series for medical residents and students. The following slides provide a summary of the series.

  47. Module 7 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.

  48. Module 7 REVIEW: The Medicaid Team Providers: Medical, Dental and Other Services MCOs: Managed Care Organizations HHSC:Single State Agency TMHP: Claims Administrator DSHS DARS MAXIMUS: Medicaid and CHIP Enrollment Broker DADS ICHP: Quality Monitor

  49. Module 7 REVIEW: What Does Medicaid Cover? • Long-term services for elderly and individuals with disabilities • Mental health and substance abuse treatment • Acute and preventive health care for all ages • Physician visits • Inpatient and outpatient services • Pharmacy, lab, and radiology costs • Dental Services (for patients under the age of 21) • Preventive • Therapeutic

  50. Module 7 REVIEW: Who is Eligible to Deliver Medicaid Funded Services? • Individual Health Care Providers • Doctors, dentists, advanced practice registered nurses, physician assistants, physical therapists, optometrists, and psychologists • Outpatient Facilities • Rural health clinics, federally qualified health centers, school clinics, family planning agencies, and mental health centers • Inpatient Facilities • Hospitals and skilled nursing facilities • Providers of Goods & Services • Durable medical equipment, ambulance, pharmacies, radiology, and labs

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