Health Care Reform: What’s in it for

Homeless Families and Youth?

Presented by: Martha Knisley

Technical Assistance Collaborative, Inc. National Conference on Ending Family and Youth Homelessness

February 18, 2014

Overview

Health Care Reform: What’s In it For

Homeless Families and Youth?

Core Medicaid Concepts with HCF Updates

Medicaid Managed Care

Introduction: Louisiana’s PSH Program

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What’s in Healthcare Reform

for Families and Youth

An opportunity to extend Medicaid coverage for youth;

For families, it reduces potential burden of crippling

healthcare costs;

If a parent gets sick, they can go to a doctor, miss fewer

days of work and address potential complications from

chronic disease; and

Eliminates denial for pre-existing conditions.

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What’s in Healthcare Reform

for Families and Youth Coverage Details:

• ACA increases mandatory eligibility for youth ages 6 to 19 to

133% from 100% of FPL; children 0-5 already at 133% although

some states are up to 185% for this age group (state option);

• The ACA imposed MOE: states cannot reduce child eligibility for

Medicaid or CHIP until after September 30, 2019;

• Potential eligibility issues for some parents in states not

expanding;

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What’s in Healthcare Reform

for Families and Youth • States must provide Medicaid for youth through their 19th birthday and

some states are taking option to provide coverage up through age 21;

• Under ACA states may not enroll parents and caretaker relatives in

Medicaid unless the child(ren) that live with them are enrolled in

Medicaid, CHIP, or other minimum essential coverage;

• If child was enrolled in Title IV-E foster care at age 18, then they can

stay on Medicaid until age 26;

• Thirty-three states have continuous eligibility option (“churn”) that allows

youth to stay on Medicaid/CHIP for a full year before renewal.

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What’s in Healthcare Reform

for Families and Youth

• Providers can assist families and youth by providing enrollment

information and assistance, helping gather documentation and

providing assistance to make choices and better understanding

options and categorical programs;

• For providers serving youth this includes understanding EPSDT

benefits, optional benefits and the CHIP (Children’s Health

Insurance Program) in their state.

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Core Concepts of

Medicaid Coverage • Medicaid is first and foremost an Insurance Plan

• Established through a Medicaid State Plan

Key issues:

• Contrast between Medicaid and Medicare

• Eligibility and coverage groups

• Means for covering services

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Medicaid: Insurance Plan and More

• Medicaid is a major payor of health care services in this

country—over $500 billion annually with 55 million people

enrolled;

• Regardless of your state’s position on expansion, states

cover a portion of Medicaid costs and the federal

government pays a portion (FMAP);

• The Medicaid “insurance plan” includes both mandatory

and optional services; CMS and state Medicaid agencies

also shape health policy;

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Medicaid State Plan

• The Medicaid State Plan is a written plan between a State

and the Federal Government that outlines Medicaid:

– eligibility standards;

– provider requirements;

– payment methods; and

– health benefit packages;

• A Medicaid State Plan is submitted by each State

(continuously) and approved by the Centers for Medicare

and Medicaid Services (CMS).

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Medicaid State Plan

States must, among other requirements:

• ensure that services are provided in all parts of the state (the

“statewideness” requirement);

• establish or designate a single State agency to administer the plan;

• require the State health agency to establish health standards for

medical providers;

• provide coverage to certain categorically eligible individuals;

• provide services for all recipients in the same amount, duration and

scope (the “comparability” requirement);

• provide individualized plans of care for recipients.

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Contrasting Medicaid and Medicare

• The Medicaid program is a medical welfare program

based on financial and functional need;

• Applicants must meet income and asset eligibility

requirements, or must demonstrate a qualifying disability or

functional need for services;

• Eligibility for Medicare is not based on financial need;

• Medicare provides a standard benefit that provides partial

coverage

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Eligibility and Coverage Groups

• Federal law and the state Plan establish:

– eligibility rules, which include income, asset, citizenship, and

residency requirements;

– Mandatory and optional groups;

– There are many requirements—and new options with ACA;

• There are many “means” for covering services;

• Regardless of target population, category of service or

means, providers must meet state specific requirements and

enroll in the state Medicaid program.

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Eligibility and Coverage Groups

• Optional coverage varies by type service and is

influenced by categorical and mandatory requirements;

• States analyze their costs

• The ACA presents many new options and expanded

FMAP for newly eligible beneficiaries, for Health Homes,

other increases in expansion states.

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Mandatory Benefits Optional Benefits Essential Benefits

• Inpatient hospital services • Outpatient hospital services • EPSDT • Nursing Facility Services • Home health services • Physician services • Rural health clinic services • Federally qualified health center services • Laboratory and X-ray services • Family planning services • Nurse Midwife services • Certified Pediatric and Family Nurse Practitioner services • Freestanding Birth Center services (when licensed or otherwise recognized by the state) • Transportation to medical care • Tobacco cessation counseling for pregnant women

• Prescription Drugs • Clinic services • Physical therapy; occupational therapy • Speech, hearing and language disorder services • Respiratory care services • Other diagnostic, screening, preventive and rehabilitative services • Podiatry services; Optometry • Dental Service; Dentures • Prosthetics; eyeglasses • Other practitioner services • Private duty nursing services; personal care • Hospice • Case management • Inpatient psychiatric services for individuals under age 21

Market Place (10 essential services): 1. ambulatory patient services 2. emergency services 3. Hospitalization 4. maternity and newborn care 5. mental health and substance

use disorder services, including behavioral health treatment;

6. prescription drugs 7. rehabilitative and habilitative

services and devices 8. laboratory services 9. preventive and wellness

services and chronic disease management

10. pediatric services, including oral and vision care

Coverages

Means for Covering Services

• Medicaid is an individual benefit—thus costs for care vary

by individual based on their use and need;

• CMS and State Medicaid programs are continuously

analyzing and creating options and costs: costs incurred

and costs avoided;

• CMS offers different “means” to states for flexibility---

including managing care through waivers and options;

• State plan options

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Health Care Reform:

Medicaid Costs

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Basic and preventive services —for all

Extensive Use/ Chronic care

Deep End

Coverages

• The Early and Periodic Screening, Diagnostic and Treatment

(EPSDT) benefit provides comprehensive and preventive

health care services for children under age 21 who are

enrolled in Medicaid;

• Under EPSDT, states are required to provide comprehensive

services and furnish all Medicaid coverable, appropriate, and

medically necessary services needed to correct and

ameliorate health conditions, based on certain federal

guidelines.

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Coverages

EPSDT is made up of the following screening, diagnostic,

and treatment services:

– Screening Services

– Vision Services

– Dental Services

– Hearing Services

– Other Necessary Health Care Services

– Diagnostic Services

– Treatment

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Coverages

• Another means of covering services is through “waivers”;

• Waivers permit states to be excused from one or more of

the Medicaid State Plan requirements – an example of

this is the “statewideness” requirement;

• The Affordable Care Act also provides some new options

for coverage through State Plan Amendments;

• One word on HCBS.

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Homeless Service

Provider Options

• Many organizations serving homeless families and youth

are also Medicaid providers;

• And/ or organizations can assist with enrollment and

helping families and youth gain access to needed

services;

• How do you decide what works for your organization?

– There is a role for every organization, healthcare matters

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Three Steps for Providers to

Examine Options • Crosswalk your services, provider qualifications, mgmt.

capacity with requirements for specific Medicaid programs/

services;

• “Map” the Medicaid system for persons who you serve from:

enrollment referral assessment individualized plan

service delivery (may need to authorized or approved at

several points) and then repeated with re-evaluations and

redeterminations.

• Establish an agency business plan with multiple options.

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Basics: Medicaid Managed Care

• States “manage” care by enrolling people into managed care

plans; either on a voluntary or mandatory basis;

• States can implement a managed care delivery system using

three basic types of federal authorities:

• State plan authority [Section 1932(a)]

• Waiver authority [Section 1915 (a) and (b)]

• Waiver authority [Section 1115]

• Regardless of the authority, states must comply with the

federal regulations that govern managed care delivery

systems.

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Basics: Medicaid Managed Care

• All three types of authorities give states the flexibility to not

comply with statewideness, comparability and freedom of

choice requirements;

• States also have options types of approaches and for paying

managed care organizations:

– MCOs through a fully capitated model or

– Primary Care Case Management arrangements.

• There are literally dozens of models and hundreds of

organizations managing Medicaid benefits across the country.

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What’s In It: Medicaid Managed Care

• Components (established with a mix of federal and state

requirements) :

– Establish networks;

– Qualify providers;

– Establish medical or clinical homes;

– Pay providers negotiated or fixed fees for services, per diems or

per episode;

– Authorize and/or approve services;

– Assure access---to programs and services;

– Manage utilization and care; manage formulary;

– Meet quality standards.

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Louisiana PSH

• A strong coalition of advocates, state leaders,

providers and political leaders created the

Louisiana PSH program as part of the state’s

recovery hurricane effort in 2006;

• This effort grew to include 3000 subsidies

including 2000 PBV and 1000 S+C subsidies

and $69 million for “start up” services; and

• a significant change in Louisiana’s Medicaid

program five years later;

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Single family units in

Jefferson Parish

Louisiana PSH

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• PSH model is permanent, cross

disability largely scattered site with

families and single adults holding their

own leases and getting assistance from

local service providers;

• Early efforts created nearly 1,000 units

as set asides in LIHTC programs—today

tenants in those units get Section 8 PBV

The Preserve in New Orleans

• Over 60% of participants were homeless at time they entered

the program

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Good Luck!!

Resources:

http://www.nationaldisabilitynavigator.org/

http://www.enrollamerica.org

TAC Website: www.tacinc.org

Contact Info: mknisley@tacinc.org