Medicaid & SCHIP 101 August 29-30, 2007

1. Medicaid & SCHIP 101August 29-30, 2007 Cynthia Gillaspie, Native American Contact Centers for Medicare & Medicaid Services Region VIII

2. Medicaid Medical Assistance Title XIX of the SSA Program began in 1965

3. Medicaid • Initially for AFDC recipients • Additions: • Disabled individuals • Pregnant women and children • Medicare cost sharing programs • Special payments to hospitals and community health centers

4. Medicaid Covers • 39% of all births • 50% of all nursing home care • 50% of care for HIV/AIDS recipients • 12% of the population • 13% of Medicare population • Medicaid reimbursement makes up 20% of the Indian Health Service Budget

5. What is Medicaid? • Jointly administered - federal/state program • Federal match varies from state to state (50-83%) based on per capita income

6. Medicaid Administration • Laws, regulations and policy - federal • Social security act • Code of federal regulations • State Medicaid manual, letters • State plan - states • Original • Amendments

7. Medicaid Administration cont. • State plan approval process • Plans vary state by state • Coverage • Eligibility • Payment policies

8. Medicaid Program Information • States determine: • Who is covered • How providers are paid • What services are covered IHS/Tribal Programs can be paid the AIR or Medicaid Rates—State’s choice

9. Who is covered? • Mandatory categorically needy: • Families with children who meet the AFDC requirements in place on July 16, 1996 (former AFDC program) • Poverty level pregnant women and infants at a minimum of 133% of FPL

10. Who is Covered? • Mandatory categorically needy: • Children under age 6 at a minimum of 133% of federal poverty level • Children 6 through 18 at a minimum of 100% FPL • SSI recipients (aged, blind & disabled individuals)

11. Who is Covered? • Qualified Medicare beneficiaries (QMB) • Through 100% of the poverty level • Specified low income Medicare beneficiaries (SLMB) • 101% - 120% of poverty level • Medicare qualified individuals (QI-1) • 121% - 135% of poverty level

12. Who is Covered? • Optional Categorically Needy • Infants or pregnant women through 185% FPL • Aged, blind disabled individuals through 100% FPL • Institutionalized individuals under a certain income level that does not exceed 300% of the SSI payment rate • Special Groups… • Foster care independence, Breast and Cervical Cancer, BBA or Ticket to Work Working Disabled

13. Who is Covered? • Optional Medically Needy • Families and children • Aged, blind & disabled Individuals who have too much income to qualify under a categorically needy group but not enough to meet their medical needs. The income limits for the medically needy programs may not exceed 133% FPL • Must pay a spenddown (patient liability) each month

14. Medicaid Eligibility • Eligibility rules follow cash program most closely related to the group SSI or old AFDC rules • States have flexibility to set income levels (for some groups) • States can elect less restrictive treatment of income and resources for some groups

15. Provider Payment • States have flexibility in developing payment systems for: • Providers, such as hospitals, nursing facilities, physicians, and laboratories, must accept Medicaid payments as payment in full. • Mechanisms for making payments must ensure that payments will be efficient and economical. • In addition, states’ payment rates must be sufficient to attract enough providers so that services will be as available to Medicaid beneficiaries as they are to the general population. • IHS and Tribal Facilities can be paid the AIR, a negotiated contract rate or the established provider rates for Medicaid in that State.

16. Provider Payment • Medicaid is the payer of last resort, except IHS • IHS is the exception to this payment rule • Services through IHS are 100% federally reimbursed to the state • Payment method must be in accordance with federal register each year, a negotiated rate or the State’s Medicaid fee for service rate.

17. Provider Enrollment • Enroll program, individual provider in Medicaid. • State MUST enroll all IHS facilities in Medicaid. • IHS providers can be licensed in ANY state—do not have to be locally licensed.

18. Medicaid Mandatory Services • Inpatient hospital services • Outpatient hospital services • Physicians’ services • Nursing facility services for individuals 21 or older • Home health services for anyone entitled to NF care • Rural health clinic services • Early and periodic screening, diagnosis and treatment for persons under age 21—States must provide any service through EPSDT even if it is not covered in their Medicaid program. • Nurse-midwife services • Family planning services

19. Medicaid Mandatory Services cont. • Pediatric or Family Nurse Practitioner Services • Federally-qualified Health Center Services • Other Laboratory and X-ray Services • Dental Services that would be covered if performed by a physician • Intermediate Care Facilities for the Mentally Retarded. • Doctor of Osteopath services provided to a child under 21 or a pregnant woman.

20. Medicaid Optional Services • Nursing facility services for persons under age 21 • Home and community based services • Hospice • Chiropractic • Private duty nursing services • Dental • Physical therapy • Occupational therapy • Services for individuals with speech, hearing and languagedisorders

21. Medicaid Optional Services • Prescription Drugs • Prosthetic Devices • Eyeglasses • Diagnostic, Screening, Preventive and Rehabilitative Services • Personal Care Services • Tuberculosis-related services for TB infected individuals who meet the States’ income and resource test for categorically needy disabled individuals

22. Medicaid Optional Services • Targeted case management services • Institutions for mental disease - age 65 and over • Inpatient psychiatric services for individuals under 21 years of age • NOTE: limits may apply to the services listed. The states have the authority to set limits within federal guidelines.

23. Cost Sharing in Medicaid • Adults may be charged cost sharing that does not exceed federal regulations • CHILDREN MAY NOT BE CHARGED COST SHARING (exception: long term care) • Long term care recipients pay a portion of individual income

24. Applying for Medicaid • Applicant completes an application. • Many states use a combined application form for Medicaid and other programs. • Interview and verification requirements vary from state to state TANF Tribes can determine eligibility for Medicaid if if the State contracts with them.

25. Eligibility Process • Final determination made within 45 days for families and children and the aged population. • 90 days for the disabled population (social security disability decision is binding) • The agency sends an approval or denial notice on each application

26. Beneficiary Rights • Receive assistance in completing the application. • Be accompanied or represented by anyone of choice. • Request a fair hearing. • Not provide information the State can obtain through other sources.

27. Other AI/AN Medicaid Provisions • Encouraged to consult with Tribes on Medicaid changes. • Required to consult with Tribes for Medicaid waivers.

28. State Children’s Health Insurance Program (SCHIP)

29. SCHIP • Created by the balanced budget act of 1997 (BBA) • Federal/state administration • Federal matching rate is higher

30. SCHIP • States have a great deal of flexibility • Program design • Medicaid expansion • Stand alone program • Combination • Income and resource limits • Application process • 1115 demonstrations

31. Who is Covered? • Eligible children • Uninsured • Not Medicaid eligible • Not residing in a public institution • Applicant not in institution for mental disease • Parent not a public employee with access to dependent health coverage

32. What SCHIP Covers. • Benefit package • Benchmark coverage • Benchmark equivalent • Secretary approved coverage (If Medicaid expansion, must be same benefit package as the Medicaid program)

33. SCHIP Administration • State plan process • States were to involve tribes in plan design • Enrollment goals • Health quality measurements • Maintenance of Effort Medicaid eligibility guidelines cannot be made more restrictive than 1997 guidelines

34. CMS’ Role • Policy decisions • State plan approvals • 1115 demonstration approvals • Guidance to states • Implementation/monitoring • Evaluation • When reviewing, CMS contacts Tribes for input.

35. SCHIP Cost Sharing • States can apply minimal cost sharing to children who are covered by stand-alone plans • States CANNOT apply cost-sharing in Medicaid expansions SCHIP plans • States CANNOT apply cost sharing to Native American children.

36. Provider Payment • Providers must enroll with State program. • IHS and Tribal providers receive same payments as other providers, or rate negotiated with the State. • Federal government pays SCHIP federal share, not 100% pass through like Medicaid. • States must enroll IHS and Tribal providers.

37. Resources • www.cms.hhs.gov • Native American pages • Medicaid and SCHIP Pages • CMS Native American Coordinators

38. CMS Regional NACs Region I – Boston (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) John F. Kennedy Federal Bldg., Rm 2275 Boston, Massachusetts 02203-0003 Irv Rich (617) 565-1247 / (617) 565-1083 fax / irvin.rich@cms.hhs.gov Region II - New York (New Jersey, New York, Puerto Rico, Virgin Islands) 26 Federal Plaza / Room 3800 New York, New York 10278-0063 Julie Rand (212) 616 - 2433 / julie.rand@cms.hhs.gov Region III – Philadelphia (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia) The Public Ledger Building 150 South Independence Mall West, Suite 216 Philadelphia, PA 19106 Tamara McCloy (215) 861-4220 / (215) 861-4240 fax / tamara.mccloy@cms.hhs.gov Region IV – Atlanta (Alabama, North Carolina, South Carolina, Florida, Georgia, Kentucky, Mississippi, Tennessee) The Atlanta Federal Center, Suite 4T20 61 Forsyth Street Atlanta, Georgia 30303-8909 Dianne P. Thornton (404) 562-7464 / (404)562-7481 fax / dianne.thornton@cms.hhs.gov Region V - Chicago (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin) 233 N. Michigan Ave., Suite 600 Chicago, Illinois 60601 Pam Carson (312) 353-0108 / (312) 353-3866 fax pamela.carson@cms.hhs.gov

39. CMS Regional NACs Region VI – Dallas (Arkansas, Louisiana, New Mexico, Oklahoma, Texas) 1301 Young Street, Room 833 Dallas, Texas 75202 Dorsey Sadongei (214) 767-3570 / (214) 767-0270 fax / eudora.sadongei@cms.hhs.gov Region VII - Kansas City (Iowa, Kansas, Missouri, Nebraska) Richard Bolling Federal Building 601 East 12th Street, Room # 235 Kansas City MO 64106 Nancy Rios (816) 426-6460 / 816-235-7394 fax Nancy.Rios@cms.hhs.gov Region VIII – Denver (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) 1600 Broadway, Suite 700 Denver, Colorado 80202 Cynthia Gillaspie (303) 844 – 4725 / (303) 844 – 7054 / cynthia.gillaspie@cms.hhs.gov Region IX - San Francisco (American Samoa, Arizona, California, Guam, Hawaii, Nevada, Northern Mariana Islands) 75 Hawthorne Street, Suite 408 San Francisco, CA 94105-3903 Rosella Norris (415)-744-3611 / Fax: 415-744-3771 rosella.norris@cms.hhs.gov Region X -Seattle (Alaska, Idaho, Oregon, Washington) 2201 Sixth Ave., Room 911 Seattle, WA 98121-2500 Terry Cumpton, Acting, (206) 615-2391 / teresa.cumpton@cms.hhs.gov