Texas Medicaid
Medical and Dental
Information Series
Module 1
Version 1.2 (6/22/2010)
2/22/2013
1
Module 1
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
2
Module 1
General Structure of the Texas
Medicaid Program
3
Module 1: Objectives
Module 1
After completing this module, you should be able to:
Describe the purpose and background of Medicaid
Identify who benefits from services supported by Texas
Medicaid
Contrast Medicaid with other major health programs
Describe the organization of Medicaid in Texas
List features of Medicaid Managed Care
Identify examples of Texas Medicaid programs
Outline advantages to serving as a Medicaid provider
Find Medicaid resources
4
Module 1
True or False?
Test Your Knowledge about Texas Medicaid:
Medicaid is funded solely by the federal
government.
Medicaid is an entitlement program based solely
on age.
Medicaid benefits include many optional services
that a state can choose to provide.
Non-disabled children account for more than half of
Texas Medicaid spending.
Physician visits, inpatient services, and pharmacy
costs are all examples of acute health care costs
that Medicaid covers.
5
Module 1
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.
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Module 1
What Does Medicaid Cover?
Acute and preventive health care
for all ages
Physician visits
Inpatient and outpatient services
Pharmacy, lab, and radiology
costs
Long-term services for
elderly and disabled clients
Mental health and
substance abuse treatment
Dental Services (for patients
under the age of 21)
Preventive
Therapeutic
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Module 1
Basic Principles of Medicaid
Social Security Act
Amount, Duration
and Scope
Freedom of
Choice
Comparability
Statewideness
All services must be
available statewide.
The same level of
services must be
available to all
clients or patients
(e.g., those with
similar disabilities).
With certain
exceptions,
including for
managed care, the
States must allow
Medicaid recipients
freedom of choice
among participating
providers of health
care services.
States must cover
each service in an
amount, duration,
and scope that is
“reasonably
sufficient” and may
impose limits on
services for adult
clients. A state may
not arbitrarily limit
services for any
specific illness or
condition.
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Module 1
Medicaid Benefits
The Social Security Act specifies…
Required Benefits
Optional Benefits
States may define their own amount, duration, and scope
of (or limitations on) Medicaid benefits
Example: Limitations on prescription drugs
Limits on coverage, for both required and optional
services, may not be imposed for children under 21 if there
is a medical necessity.
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Module 1
Mandated Services
Covered by Texas Medicaid, 2013
EPSDT (Texas Health Steps) medical and dental check-ups and
treatments for persons under 21
Physician services
Dental services
Family planning services
Inpatient & outpatient hospital
Lab and radiology
Nursing facility care
Home health care
Services by:
Federally Qualified Health Centers
Rural Health Clinics
Certified Nurse Midwives
Clinical nurse specialists and nurse practitioners
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Module 1
Examples of Optional Services
Covered by Texas Medicaid, 2013
Hospice services
Maternity service clinics
Prescription drugs
Podiatry
Optometry, including glasses
Hearing instruments
Renal dialysis
Rehabilitation services
All services are required for children under 21 years of age if medically
necessary; restrictions apply for many services to adults.
Medical or remedial care
provided by:
Physician extenders
Mental health providers
Chiropractors
Physical therapists
Occupational therapists
Speech therapists
Rehabilitative services for mental illness
In-home respiratory care
Attendant services
Program for All-Inclusive Care for the Elderly (PACE)
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Module 1
Who is Eligible for Medicaid
Benefits?
Medicaid primarily serves:
Low-income families
People with disabilities
Foster children
Babies born to mothers receiving
benefits at time of delivery
Pregnant women
(Services available for one year)
The elderly
Texas Medicaid 2011
100%
Non-Disabled
Children
90%
80%
32%
70%
Non-Disabled
Children
60%
61%
Non-Disabled Adults
10%
30%
Non-Disabled Adults 9%
Aged & Disability
Related
20%
Aged & Disability
Related
50%
40%
10%
58%
30%
0%
Caseload
Costs
12
Module 1
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
13
Module 1
Choosing a Provider:
Patient Options
Although the Social Security Act requires freedom of choice in
selecting Medicaid providers, it also allows states to set specific
guidelines, especially for managed care organizations
Medicaid fee-for-service patients may choose any Medicaid provider
Patients enrolled in Health Maintenance Organizations (HMOs)
have a primary care provider (or PCP) in a medical home
Patients in an HMO may choose any Medicaid primary care
provider or specialist within the HMO network
In most cases, a referral for specialty care from
the PCP is required for HMO patients
14
Module 1
Medicaid vs. Medicare
What is the difference?
Texas Medicaid
Medicare
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
Eligibility and enrollment in both programs concurrently is possible
CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare,
Medicaid, and the Children's Health Insurance Program.
15
Module 1
Medicaid vs. CHIP
What is the difference?
Texas Medicaid
Children’s Health
Insurance Program
(CHIP)
Authorized by Social Security Act
of 1965
Authorized by Balance Budget Act
of 1997
Jointly Funded by State and Federal Government
Entitlement program based on income,
assets and/or disability
Enrollment based on income
(not an entitlement program)
Low income families, children,
pregnant women, disabled, elderly
Children in families with too much
income or too many assets to qualify
for Medicaid and who meet the CHIP
income requirements
16
Module 1
Who can receive Full
Medicaid Benefits?
Categories of Eligibility
Low income families, pregnant
women, and children
Based on income level, age,
caring for a related Medicaid
eligible dependent child or
pregnancy
Cash assistance recipients
Based on receipt of Supplemental
Security Income (SSI)
People age 65 and older and those
with disabilities
Based on income level, age, and
physical or mental disability
17
Module 1
Who can receive Limited
Medicaid Benefits?
Categories of Eligibility
Medicare Beneficiaries
Based on income level and age
Non-Citizens
Legal permanent residents and
undocumented persons who are
not eligible for Medicaid based on
citizenship status may receive
emergency services.
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Module 1
How Many People Does
Texas Medicaid Serve?
At any one time, how many individuals are enrolled in
Medicaid? About 3.54 million
Texas Average Monthly
Medicaid Enrollment
SFYs 2001-2011
Millions
2.49
1.87
2001
2.68
2.88
2005
3.30
2.79
2.83
2.88
2006
2007
2008
3.54
3.00
2.10
2002
2003
2004
2009
2010
2011
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Module 1
How Many People Does
Texas Medicaid Serve?
How many individual Texans received Medicaid-funded services at some
point in the year? About 4.57 million
Texas Annual Unduplicated Medicaid Enrollment
SFYs 2001-2011
4.5
4.0
3.36
3.5
Millions
3.0
3.63
3.73
3.81
2004
2005
2006
3.83
3.85
2007
2008
4.02
2.96
2.61
2.5
2.0
1.5
1.0
0.5
0.0
2001
2002
2003
2009
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Module 1
Distribution of Medicaid Enrollees
State Total = 3,098,169
As of: August 2010
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Module 1
Texas Medicaid Recipients
State Fiscal Year 2011
Unduplicated Clients
SFY 2011 = 4,567,077
Ethnicity
54%
22%
Hispanic
Age
Caucasian
36%
30%
0-5
6-14
Gender
17%
20%
30%
Other
6%
65+
45%
Female
10%
17%
21-64
55%
0%
AfricanAmerican
11%
15-20
8%
Male
40%
50%
60%
70%
80%
90%
100%
22
Module 1
How does Texas enroll Medicaid
participants?
Fee for Service
Managed Care
Traditional arrangement in
which a provider is paid for
each individual service that
a patient receives
Structured clinical,
financial, and
organizational activities
designed to improve
continuity and access to
health care services,
promote appropriate use of
services, and contain
costs.
MCO: Managed Care Organization, a health organization that finances
and delivers health care through a specific provider network and
defined services and products
23
The Medical Home
Module 1
Key Feature of Medicaid Managed Care
Serves as a source for continuity of care from a primary care
provider (PCPs)
Provides comprehensive preventive and primary acute care
Provides specialty referrals and other services offered by a
managed care organization and coordinates all levels of patient care
Texas Medicaid PCPs:
Family physicians
Pediatricians
General internists
Obstetricians/gynecologists
Physicians’ assistants
Advanced practice registered nurses
Community clinics including
federally qualified health centers
(FQHCs) and rural health centers
24
Module 1
Medicaid Managed Care in Texas
Overview of Plans
STAR (Originally an acronym for State of Texas Access Reform)
A statewide managed care program in which HHSC contracts with MCOs to provide,
arrange for, and coordinate preventative, primary, and acute care covered services
STAR+PLUS
Provides integrated acute and long-term services and supports to people with
disabilities and the elderly
NorthSTAR
A capitated program in Dallas and surrounding counties that provides behavioral
health (mental health and substance abuse) services to Medicaid and medically
indigent patients
STAR Health
A statewide program to provide coordinated care to children and youth in foster and
kinship care
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Module 1
Percentage of Medicaid Clients
by Delivery Type, State Fiscal Year 2011
Service Delivery Types
STAR+PLUS
6%
Star Health
1%
Fee-forservice
25%
STAR MCO
43%
Star PCCM
25%
26
Module 1
What are Examples of Texas
Medicaid Programs?
Texas Health Steps
Provides medical prevention and dental
preventive/treatment services to eligible children
Programs for Women and Children
Programs for family planning and pregnant women,
Medicaid Buy-In for Children, and women’s cancers
Prescription Drugs
Prescription medications through local pharmacies
Behavioral Health Services
Long-Term Services and Supports
Mental, emotional, and chemical dependency
treatment for eligible patients
Programs for those with physical, intellectual and
developmental disabilities
27
Module 1
Texas Health Steps
Perhaps the best known of Texas
Medicaid programs is THSteps,
which provides medial and dental
preventive care and screening to
eligible children.
THSteps is the name for the
federally-required Early and
Periodic Screening, Diagnosis and
Treatment (EPSDT) services in
Texas.
Module 3 will focus
specifically on
Texas Health
Steps.
28
Module 1
Components of THSteps
Medical Checkups
Medical history
A complete physical examination
Screening of nutritional,
developmental, and mental-health
needs
Age appropriate laboratory tests
(including lead screening)
Routine immunizations
Health education
Vision and hearing screening
Oral health screening and referral
to a dental home
Referrals to other health care
providers as needed
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Module 1
Components of THSteps
Dental Checkups and Services
Preventive services
Dental examinations, cleanings, oral health education, topical
fluoride applications, application of sealants, maintenance of space
Treatment services
Restorations (fillings and crowns), endodontic treatment, periodontic
treatment, prosthodontics, oral surgery, implant services and
maxillofacial prosthetics
Emergency treatment
Procedures to control and treat bleeding, pain, acute infection,
immediate tooth loss, and injury to teeth or supporting structures
Health Related Orthodontic Services (prior authorization needed)
Correction of cleft palate, crossbite therapy, treatment of severe
malocclusion, and treatment of facial accidents involving severe
traumatic deviation
30
Module 1
The Medicaid Team
Providers: Medical, Dental and Other Services
HHSC: Single State Agency
charged with the administration
& supervision of the Medicaid
plan
MCOs: Managed Care Organizations
TMHP: Claims Administrator
DSHS
MAXIMUS: Medicaid and
CHIP Enrollment Broker
DARS
DADS
ICHP: Quality Monitor
31
Module 1
Texas Medicaid
Operating Departments
Department of State
Health Services (DSHS)
Governor
of Texas
Health &
Human
Services
(HHSC)
Executive
Commissioner
Single State
Agency
(HHSC)
Department of Assistive
& Rehabilitative
Services (DARS)
Department of Aging &
Disability Services
(DADS)
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Module 1
Medicaid Functions
Operates as the single state agency responsible for Medicaid
Serves as primary contact point for the federal government
Administers the state Medicaid plan
Contracts with other state agencies to carryout certain Medicaid functions
Determines Medicaid eligibility
Operates the state’s acute care, prescription drug, and most managed care
programs
Develops Medicaid policies, rules, and reimbursement rates
Organizes and coordinates initiatives to maximize federal funding
Manages the Medical Care Advisory Committee (MCAC)
33
Module 1
Medicaid Functions
Texas Health Steps
Case Management for pregnant women and children
Newborn metabolic screening, newborn hearing screening
Family planning
Targeted case management and rehabilitation
Services for people diagnosed with a mental health condition
NorthSTAR Administrator
YES Waiver program for children with severe emotional disturbance
34
Module 1
Medicaid Functions
Early childhood intervention
Targeted case management for Blind Children’s Vocational Discover
and Developmental Program (BCVDDP)
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Module 1
Medicaid Functions
Nursing facility programs and services
Long-term care licensing and certification
Program of All-Inclusive Care for the Elderly (PACE)
Hospice
Nursing home Preadmission Screening and Resident Review (PASRR)
Intermediate Care Facilities and Mental Retardation Facilities, including
State Supported Living Centers.
Targeted case management for people with intellectual disabilities
Home and community-based services for people with developmental
disabilities and those who would otherwise require nursing facility level
of care
36
Module 1
TMHP acts as the state's Medicaid fiscal agent and is responsible for paying
acute care claims, while the state of Texas is responsible for covering the
cost of claims.
Affiliated Computer Services, Inc. (ACS) meets consolidated contractual
Medicaid responsibilities with a team of subcontractors under the name of
TMHP (Texas Medicaid & Healthcare Partnership).
Responsibilities
Administers fee-for-service Medicaid claims
Manages policy development
Collects HMO encounter data
Enrolls providers
Supplies provider relations representatives to enrolled providers
37
Module 1
What Does Medicaid Cost?
In 1967, Texas Medicaid served fewer than 1 million people at a cost
of less than $200 million
In 2011, Texas Medicaid served more than 3 million people at a cost
of $29.4 billion, representing about 26% of the total state budget
Federal funds are based on
the Federal Medicaid
Assistance Percentage
(FMAP) the matching rate
that changes annually.
For federal fiscal year
(FFY) 2011, the Texas
FMAP was 66.46%.
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Module 1
Federal Medical Assistance Percentages
(FMAP), Fiscal Year 2011
Texas
66.46%
*Note: Percentages do not reflect temporary increases in FMAP provided by the American Recovery and Reinvestment Act of 2009.
39
Module 1
Texas Medicaid Spending
The Big Picture
By Services Type, State Fiscal Year 2010
PCCM Services
0.2%
Inpatient Hospital
11%
Capitated Care
21.8%
Mental Health Facility
0.3%
Nursing Facility
11.3%
ICF-IID
Other Care
14.4%
4.8%
Physician & Practitioner
5.1%
Personal Support
Services
4.2%
Prescribed Drugs
10.9%
Outpa ent Hospital
1.8%
Lab & X-Ray
3.8%
Home Health Clinic
3.5%
0.7%
Dental
6.2%
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Module 1
Texas Medicaid Spending
The Major Categories
By Services Type, State Fiscal Year 2011
Clinic &
Hospital
Outpatient
$2.9 billion Hospital Inpatient
$3.5 billion
10%
13%
Physician &
Professional $5.1
billion
18%
Supplemental
Payments
22%
Medicare Parts A, B
& D $1.5B
Disproportionate
Share Hospital
Program $1.6B
Upper Payment Limit
$2.8B
Dental $1.8
billion
5%
Long Term Services
& Supports $6.3
billion
23%
Prescription Drugs
$2.6 billion
9%
41
Module 1
Average Monthly Medicaid Spending
by Type of Eligibility, State Fiscal Year 2011
$1,600
$1,350
$1,400
$1,200
$1,000
$800
$640
$600
$400
$259
$200
$0
Non-disabled children
Aged, blind & disabled
Non-disabled adults, including
pregnant women
42
Module 1
Federal Health Care Reform
and Texas Medicaid
The federal health care reform Affordable Care Act
(ACA) will impact Texas Medicaid, the Texas
HHSC and other agencies. Examples of ACA changes include:
Benefit changes:
Concurrent hospice care and treatment services for children
enrolled in Medicaid and CHIP
Birthing centers as a Medicaid provider
Expanded Medicaid formulary
New provisions to address fraud and abuse
Increased use of the National Provider Identifier (NPI) on claims and
applications
Requiring face-to-face encounters with patients for the certification
of home health services and durable medical equipment
43
Module 1
ACA Medicaid Eligibility
Expansion
Effective January 1, 2014, ACA expands Medicaid to the following
groups:
Former foster care youth through age 25
Children ages 6-18 whose families have an income 100%-133% of
the FPL; this is the population of children currently eligible for CHIP
The “individual mandate” for health insurance could lead to the
enrollment of about 130,000 people who are currently eligible for
Medicaid or CHIP, but are not currently enrolled
If a Medicaid expansion is pursued by the state, income eligibility
could be expanded to adults ages 19 to 64 who are not currently
eligible for Medicaid, and have incomes ≤133% of the FPL.
With this option Texas could expect to experience a caseload
growth in 2014 of approximately 340,976.
44
Module 1
Texas Healthcare Transformation
and Quality Improvement Program 1115 Waiver
In December 2011, Texas was granted a waiver of certain federal
Medicaid requirements under Section 1115 of the Social Security
Act; the waiver:
Expands Medicaid managed care to the entire state, including managed
care for dental and prescription drug services
Creates 2 new funding pools, one to reimburse
hospitals for Uncompensated Care (UC) for
Medicaid and uninsured patients and one for
Delivery System Reform Incentive Payment
(DSRIP) to provide financial incentives to
encourage hospitals and other providers to
achieve quality health outcomes
Regional Healthcare
Partnership Regions
What is being “waived”?
Certain aspects of the Statewideness,
Comparability of Services and Freedom of
Choice requirements of the Social Security Act
45
Module 1
The Face of Medicaid:
The Patient’s Perspective
Amy and her husband Josh have
a 4-year old son, Ian, and another
child due in 6 months.
Josh’s work hours at a local
lumberyard have recently been
reduced. Amy is a full-time
cosmetology student and
does not currently work.
The family income is currently about $1,900 per month, which is less
than 120% of the current federal poverty level for a family of 3.
What services and support can Amy’s family expect from Texas
Medicaid this year?
46
Module 1
How Can Texas Medicaid Help
Amy’s Family?
Medicaid for Ian and the new baby (when it is born)
Medicaid: Treatment and prescriptions for any of the
children's acute illnesses or chronic conditions that
are medically necessary
THSteps
Medical check-ups, including routine
immunizations, physical examinations, and
anticipatory guidance/health education
Dental check-ups, including preventive services
and treatment
Amy
Medicaid: Pre-natal and pregnancy services for
Amy, including the delivery of her baby, and postpartum care
Women’s Health Program: Family planning after the
baby is born
47
Module 1
The Face of Medicaid:
The Provider’s Perspective
Lauren will graduate from dental school in
Texas this year, and she plans to establish
a general practice in her hometown in the
Texas Panhandle, in a county considered
to be “dental lagging.”
She’s looking forward to building
a practice and taking care of a wide range
of patients, including those with Medicaid.
What services and support can Lauren
expect from Texas Medicaid when she
enrolls as a Texas Health Steps Provider?
48
Module 1
How Can Texas Medicaid Help
Lauren Build Her Practice?
Payment to establish a dental home for her
patients as young as 6 months of age. The
first dental home visit can include (but is not
limited to) an oral exam, oral hygiene
instruction, dental prophylaxis, topical fluoride
application, and caries risk assessment.
Payment for dental services for her child
patients, 6 months to 21 years, to cover
dental visits every 6 months for diagnostic,
preventive, and routine therapeutic care.
49
How Does Texas Medicaid
Remain Dynamic & Progressive?
Module 1
Medicaid adjusts and grows to meet Texas’ changing health care
needs of its recipients and providers:
Legislation has led to expanded services and populations covered
Professional organizations provide feedback, medical
recommendations, and suggestions about practice guidelines
Provider feedback is actively sought
www.improvetxmedicaid.com
The Interactive Medicaid
Provider Voice System allows
providers to submit concerns &
suggestions to share with the
HHSC Medicaid Staff
50
Module 1
Common Medicaid Myths
Myth
Medicaid is a rigid, one-size-fitsall program.
Fact
States have taken advantage of
Medicaid’s flexibility to customize
their programs—about 2/3 of
Medicaid spending is for
“optional” services or populations.
Medicaid is designed with
minimum federal standards,
which require states to cover
certain populations and provide
certain benefits to key
populations.
In many ways it is a system
that operates as 50 separate
state coverage programs, with
states having the choice to
cover populations and services
beyond minimum standards.
51
Module 1
Common Medicaid Myths
Myth
Medicaid is a poor-quality
program that has little impact on
access to care or health and
Medicaid patients dislike the
program.
Fact
Medicaid offers access to primary
and preventive health care for its
patients that is comparable to that
of commercial coverage and
greatly exceeds that of the
uninsured.
Research supports Medicaid’s
role in improving access to
care for the people it serves.
Medicaid beneficiaries value
their coverage, are grateful for
the assistance it provides, and
often report satisfaction with
their coverage at the same
levels as those with
commercial insurance
coverage.
52
Module 1
Test Your Knowledge about
Texas Medicaid: True or False?
Medicaid is funded by the federal government.
FALSE: Medicaid is jointly funded by the federal and state
governments. In 2011, the state funded more than 33% of
Medicaid costs.
Medicaid is an entitlement program based on age.
FALSE: Medicaid is an entitlement program, but one based
on income, assets, and disability/age.
Medicaid benefits include many optional services that a state
can choose to provide.
TRUE: About 2/3 of the services provided under Texas
Medicaid are considered optional for adults, rather than
mandatory. Optional benefits in Texas include durable
medical equipment, optometry, and prescription drugs. All
federally allowable and medically necessary services are
provided to children under 21 years of age.
53
Module 1
Test Your Knowledge about
Texas Medicaid: True or False?
Non-disabled children account for more than half of Texas
Medicaid spending.
FALSE: Although non-disabled children account for about 66%
of the Medicaid caseload, they account for only about 33% of
the costs
Physician visits, inpatient services, and pharmacy costs are all
examples of acute health care costs that Medicaid covers.
TRUE: Medicaid covers all such acute care costs.
54
Module 1
TMHP Provider Manual
www.tmhp.com
Providers > Reference Manual
55
Module 1
Medicaid Resources
Texas Health & Human Services Commission
www.hhsc.state.tx.us/medicaid
Texas Medicaid & Healthcare Partnership
www.tmhp.com
Texas Health Steps
www.dshs.state.tx.us/thsteps/providers.shtm
www.dshs.state.tx.us/dental/thsteps_dental.shtm
www.dshs.state.tx.us/thsteps/default.shtm
CHIP/Children’s Medicaid
www.chipmedicaid.org
56
This Texas Medicaid curriculum
was prepared by
Betsy Goebel Jones, EdD
Project Director
Tim Hayes, MAM
Project Designer
Authors: Module 1
Betsy Goebel Jones, EdD
David Trotter, MA
Department of Family & Community Medicine
Module 1
57