Medicaid 101

1. Medicaid 101 Just the Basics

2. Medicare Vs Medicaid • Medicare: • Over 65, or Disabled • Federally Managed program • Medicaid • Resource & Need Based • State – Federal • Payer of last resort (except Indian Health Services) • SSI Recipient

3. Social Security Act • 1965 – Amended to include the authority for both Medicare and Medicaid • Provides authority for states to administer their Medicaid program within Federal Guidelines • Medicaid programs vary considerably across the country

4. Federal Government Centers for Medicare & Medicaid Services (CMS) Provides guidelines Beginning July 1, 2009 state participation is 23.57 State Government DPHHS Manages Medicaid programs based on ARMs and Legislative Authority State’s Financial Participation FY09 it is $ 23.57 Federal – State Partnership For every $100 of Medicaid claims, $ 76.43 is Federal money.

5. Medicaid Eligibility • Categorical – An individual or couple who meet all non financial eligibility criterion and whose incomes does not exceed the categorically needy limits. • Blind, Aged, FAIM, SSA Disabled • Determined by Office of Public Assistance • CSB 202

6. Medically Needy • For individuals & families whose income exceeds program standards • Difference between countable income and Medically Needy Income Level is paid toward medical expenses each month & Medicaid pays the balance • Income can be ‘spent down’ or incurment met by cash payment, medical bills/obligations or a combination • This can also be done with a “cash option” • CSB 202

7. CSB 202

9. Some Fundamentals of Medicaid (Part I) • Freedom of Choice: each Medicaid client can choose amongst any Medicaid provider • Service Definitions:Medicaid recipients have a right to know the details of the services they are receiving • Comparability:service provided to a Medicaid recipient should be of the same quality as that provided to a non-Medicaid recipient • State-wideness:Medicaid services should be available in any part of the state (in reality, this isn’t always the case due to limited providers in some areas) CSB 202

10. Some Fundamentals of Medicaid(Part II) • Payment in Full:No partial payments. No co-pays for PAS services. No outstanding balance will be due by a Medicaid recipient for a covered service. • Recipient Confidentiality: Right to privacy for Medicaid recipients and their information (within legal limits) • Right to Fair Hearing on Adverse Actions: Any Medicaid client can appeal an adverse action; must be given appeal process procedures if asked • “Equally effective least costly service” CSB 202

11. Medicaid Services • States participating in Medicaid are required to provide specific services. • MANDATORY • States have the option to provide others. • OPTIONAL • A state plan service is available to all Medicaid individuals who need the service. Entitlement Program • A waiver program has received permission from CMS to do something different. CSB 203

12. Mandatory State Plan Services • Inpatient Hospital Outpatient Hospital • Physician Nurse Midwife • Nurse Practitioner Laboratory & X-ray • Nursing Facility Care – for 21 yrs and older • Early & Periodic Screening, Diagnosis and Treatment (EPSDT) • Includes: outpatient chemical dependency treatment, chiropractic, dietitian, residential treatment facilities, private duty nursing, respiratory therapy, school based services, therapeutic group and foster care for those under the age of 21. • Family Planning • Home Health • Rural Health clinics • Medical and Surgical Services of a Dentist • Transportation • CSB 203

13. Ambulatory Surgical Centers Dental/Denturist Services Audiology/Hearing Aids Eyeglasses/Optometric Community Mental Health Home Dialysis Attendant Psychology Licensed Professional Counselors Freestanding Dialysis Clinic Diagnostic Clinic Targeted Case Management Mid-Level Practitioners Prescribed Drugs ICF/MR DME/Medical Supplies SP/PT/OT Personal Assistance Podiatry Social Work Nurse Specialist Hospice Home Infusion Therapy CSB 203 Optional State Plan Services

15. More on State Plan Eligibility • Must be needing some hands-on personal care in order to qualify for hours (this includes cooking) • Limited homemaker tasks can be authorized, but no more than 3 hours a week (or one-third of the total hours authorized) • Must be eligible for full Medicaid not just basic coverage (OPA determines this) • No more than 40 hours of state plan services can be authorized (in most instances) • Hours are authorized independent of what the consumer’s physician may order

16. State Plan Services in CSB • Personal Assistance Services (optional) • Self-Directed Personal Assistance Services (optional) • Home Health (mandatory) • Hospice (optional) • Home Dialysis (optional) CSB 203

17. Service Definitions • Personal Assistance Services – Assistance with ADLs, some homemaker tasks, in the recipient’s home. • Self-Direct Personal Assistance Services- Self managed PAS services plus some health maintenance activities. • Home Health – Skilled nursing or therapy services for individuals who need home based care or can’t get care elsewhere (i.e. – PT/OT/ST) • Hospice – Palliative care program for recipients with terminal illness; can be provided at home or a NH or assisted living • Home Dialysis – In home dialysis provided by a nurse. No one is currently on this service CSB 104

18. Home and Community Based Services • Community Based Alternative to Nursing Facility or Hospital Services • Waiver: Specific CMS regulations have been “waived” for the purpose of the HCBS program. • Comparability: due to variations throughout the state • Service Definitions: PAS service under waiver; socialization is added as a service • Resource and income: spousal impoverishment and waiver of deeming Guidelines CSB 104, 105, 106 PAS/SDPAS 709

19. Why Have Waivers • Federal (CMS) • Response to Need for Alternative Care System • Respond to Rising Costs of Institutional Care • Allow States Flexibility in Developing Alternative Care System • Administrative • Provide Options in Long Term Care Continuum • Cost Containment • Provide Customized Care • Consumer • Provide Choice • Maintain/Increase Independence • Encourage use of Informal Support Systems • Allow Consumer to Use Own Funds Longer

20. Who Can be Served • People with Physical Disabilities (SSI/SSA Determination) (PD HCBS waiver) (All ages) This includes people with multiple disabilities (T.B.I., M.S., A.L.S., ventilator dependent, etc.) • People who are Elderly - Age 65 or Older (Elderly HCBS waiver) • Financially Eligible for Medicaid • Meet Level of Care (LOC) Criteria (authorized through the M-PQH by calling 1-800-219-7035) • Can be Served in Community at Reasonable Cost PAS/SDPAS 709

21. Relationship between Case Management Teams and PAS Providers • Case Management team develops and monitors HCBS plans of care • Referral is sent to the PAS/SDPAS provider • HCBS personal assistance services may include socialization, supervision for health and safety reasons, specially trained attendants for consumer’s with extensive needs or extended state plan services • Doesn’t require action by M-PQH • PAS provider is the employer.

22. Other HCBS services which can be provided by a PAS/SDPAS agency if enrolled as an HCBS provider • Homemaker • Habilitation training • Home Chores • Respite • Social transportation • Private Duty Nursing

23. In relation to others… • Consumers of services managed by the Community Services Bureau – may be in other service systems • Disability Services Division (Developmental Disabilities) & Addictive/Mental Disorders Divisions (Mental Health) are two good examples

24. Disability Services Division Manages services for individuals with mental retardation (MR), whether Medicaid eligible or not Manages Medicaid DD/HCBS waiver Addictive and Mental Disorders Division Manages state institutions Manages Services for individuals with mental illness, whether Medicaid eligible or not program in specific pilot states around the state Other Services

25. Questions? It’s break time, Yippee!!