Understanding Medicaid and EPSDT/Health Tracks for Children in North Dakota

1. Understanding Medicaid and EPSDT/Health Tracks for Children in North Dakota Sponsored by: US Dept of Health & Human Services / Centers for Medicare and Medicaid Services – Grant # 11-P-92506/8-01 & Department of Human Services/Medical Services Division /CSHS Family Voices of North Dakota Health Information and Education Center

2. Whatis Medicaid? Title XIX of the Social Security Act is a program which provides medical assistance for certain individuals and families with low incomes and resources

3. What is Medicaid? The program, known as Medicaid, became law in 1965 as a jointly funded cooperative venture between the Federal and State governments to assist States in the provision of adequate medical care to eligible needy persons.

4. What is Medicaid? • Physician care • Hospital care • Skilled nursing care • Family planning • DME • EPSDT services, including dental and care coordination • Lab and X-ray • Transportation • Prescription Drugs • Vision Care

5. HOW IS MEDICAID DIFFERENT FROM MEDICARE? Medicaid mainly serves low-income families, while Medicare covers elderly and disabled people who receive Social Security, regardless of their income.

6. HOW IS MEDICAID DIFFERENT FROM MEDICARE? Medicaid also covers many services for low-income elderly and disabled people that Medicare does not pay for. Both programs are individual entitlements, which means that you qualify if you meet certaincriteria.

7. HOW IS MEDICAID DIFFERENT FROM MEDICARE? Medicaid is a joint program with costs shared by both federal and state governments, while Medicare is paid for entirely by the federal government

8. Medicaid Funding Currently, the federal government will pick up more than 50% of the cost, but not more than 75%. North Dakota’s current federal match is 67.49%

9. Medicaid Funding In other words, for every $100,000 that the state budgets for Medicaid services, the Federal government also contributes $100,000 resulting in $200,000 available for services.

10. Medicaid Within broad national guidelines, which the Federal government provides…

11. Each State: • establishes its own eligibility standards; • determines the type, amount, duration, and scope of services; • sets the rate of payment for services; and • administers its own program.

12. Medicaid Thus, the Medicaid program varies considerably from State to State, as well as within each State over time.

13. However, Children Are Different! (Because of EPSDT/Health Tracks)

14. What Is EPSDT? Early and Periodic Screening, Diagnosis & Treatment or in North Dakota Health Tracks

15. Why is HEALTH TRACKS so Important? • About HALF of all births in the U.S. are paid for by Medicaid. • Over 22% of all children in the country under age 6 are covered by Medicaid. • In 1999 16 % of American children 6 to 17 had no health care visits. • HEALTH TRACKS is designed to enhance primary care with emphasis on prevention, diagnosis and timely treatment.

16. What Is EPSDT? The federally mandated health care benefit package, administered in partnership with each state, for essentially ALL Medicaid enrolled children, ages birth through 20 years

17. What is HEALTH TRACKS? • Early and Periodic Screening, Diagnosis & Treatment • The federally mandated health care benefit package, administered in partnership with each state, for essentially ALL Medicaid enrolled children, ages birth through 20 years.

18. What is HEALTH TRACKS? • Medicaid is required to cover any medically necessary health care service listed in the Social Security Act, even if the service is not available to adults receiving Medicaid benefits. It emphasizes preventive care and complete early treatments. It does not include: • Experimental treatments • Services or items not generally accepted as effective

19. Is EPSDT Different From Medicaid? Through EPSDT, each state’s Medicaid plan must provide to any EPSDT recipient any medically necessary health care service, even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population.

20. EPSDT/Health Tracks Coverage does not include: • Experimental treatments • Services or items not generally accepted as effective • Services for the caregiver’s convenience

21. The EPSDT Benefit Consists of: • Assuring availability and accessibility of required health care services and items;

22. Why is EPSDT so Important? • More than HALF of all Medicaid enrollees across the country are children. • EPSDTis designed to enhance primary care of children with emphasis on prevention, early diagnosis and timely treatment.

23. Why is EPSDT so Important? • Children in ND who are enrolled in SCHIP or Healthy Steps are not entitled to the comprehensive benefits as offered through Medicaid via EPSDT

24. The EPSDT Benefit Consists of: Helping Medicaid clients and their parents or guardians effectively use these resources (through provider staff and EPSDT Coordinators).

25. EPSDT StaffFREE Resources for Families • Notify every enrolled family of the scope of EPSDT benefits and support services.

26. EPSDT StaffFREE Resources for Families • Guide families to appropriately use their Medicaid benefits with emphasis on education, prevention, diagnosis and timely treatment;

27. EPSDT StaffFREE Resources for Families • Maintain a Medicaid provider database for patient referrals, including dental care, vision care,hearing services, mental/behavioral health,and other services.

28. EPSDT StaffFREE Resources for Families Share extensive knowledge of Medicaid benefits and services, including those provided through HMOs;

29. EPSDT StaffFREE Resources for Providers • Assist families with Medicaid-enrolled children and youth tocontact your offices to schedule appointments;

30. EPSDT Staffalso………. • Assists providers in reducing the incidence of multiple appointments missed by Medicaid enrolled children and youth;

31. EPSDT Staffalso………. • Identify and refer families to other community resources such as Early Intervention Services (Part C); housing; food banks; the Women, Infants and Children food program (WIC); Prenatal Plus; and Head Start.

32. Whom to contact Medical Services Division, North Dakota Department of Human Services Telephone:(701) 328-2321Toll-free: 1-800-755-2604 or your County Social Services Office

33. Who is Eligible for Health Tracks/EPSDT? • Infants born to Medicaid-enrolled women, until the child’s first birthday. • Children from birth through age 5 • If family income is below 133% FPL*

34. Who is Eligible for Health Tracks/EPSDT? • Children from age 6 through age 18 at 100% FPL • Children age 19 through 20 at 60% FPL • Pregnant teenagers and women • If family income is below 133% FPL * FPL stands for Federal Poverty Level. Levels change April 1st of every year. North Dakota Medicaid covers the following citizens and qualified non-citizens through age

35. And…. • Children who would have been eligible for the now discontinued AFDC cash grant program, OR lost eligibility in that group due to increased wages or child support,

36. And…. If family income is up to the state-established income level • Children who are in foster care, subsidized adoption under Title IV-E OR receive Supplemental Security Income (SSI)

37. Healthy Steps This is the State Child Health Insurance Plan or SCHIP

38. Healthy Steps Healthy Steps is health insurance coverage for low-income children (21 years of age and under and whose families earn <140% of FPL) .

39. Healthy Steps Healthy Steps provides medical benefits including inpatient and outpatient hospital, physician, prescription drugs, dental and mental health care, of which some have a set benefit.

40. Medicaid eligibility Depending on the amount of net income, individuals may be eligible for full Medicaid benefits or may be responsible for a portion of their medical bills which is called their recipient liability. Children who are not eligible for full Medicaid benefits may be eligible for Healthy Steps. Medicaid looks at a family's total countable income and subtracts allowed expenses to establish net income. Some of the more common allowable expenses are: • Taxes and other work related expenses • Health insurance premiums • Dependent care expenses • Child support paid to a non household member • Other deductions may apply

41. Who Is Eligible for Medicaid? • For Medicaid the following asset limits apply: • Aged, Blind or Disabled: • $3,000 for a one person household, • $6,000 for two person household, plus • $25 for each additional person in the household • There is no asset test for children and families

42. Who Is Eligible for Medicaid? • Children who are in foster care, subsidized adoption under Title IV-E OR receive Supplemental Security Income (SSI).

43. Who Is Eligible for Medicaid? • Children who have developmental delays AND need special community supports to remain at home (HCBS Waiver)

44. Who Is Eligible for EPSDT? Any child who is Medicaid-enrolled is eligible for EPSDT benefits up until their 21st birthday or as long as they have Medicaid eligibility.

45. Note: Non-citizens with appropriate documentation under any of the above categories may be eligible for Medicaid, but only for a limited period of time. These children are entitled to EPSDT.

46. Note: Undocumented Non-citizens under any of the above categories can be eligible for Medicaid, but receive only emergency care, which includes labor and delivery for pregnant women.

47. Please Note: • ALWAYS refer people to submit • an application even if they appear to be above the financial limits. If not • eligible for Medicaid, the child may be eligible for Health Steps or the Caring Program

48. Each waiver is built for a specific population Waivers must be passed by legislation Allows children at risk of institutionalization to stay in the community Some waivers, waive income limits, otherwise not be eligible for Medicaid A waiver for Medically fragile children is being developed at the current time for ND Home and Community Based Service Waivers

49. Different waivers are administered by different agencies. Medicaid's benefits are more inclusive than some private insurances Provide case management, and other services (different waivers provide different services) Home and Community Based Service Waivers

50. Home and Community Based Service Waivers • Eligibility criteria for all Medicaid Waivers requires qualifying for Long Term Care . • The individual must have functional needs (ADL’s) • Provide case management, and other services