Healthcare Payment Systems & Policy:
Medicaid & CHIP
Kimberly Davis
Policy Advisor for Policy Development
Medicaid/CHIP Division
Overview
Medicaid & CHIP Background
• Benefits
• Eligibility & Enrollment
• Costs & Financing
• Delivery Models
Texas Specifics
Current HHSC Initiatives
2
Medicaid & CHIP: Overview
Medicaid: What is it?
Provides medical coverage to eligible
individuals primarily:
•
•
•
•
•
•
Low-income families
Non-disabled children
Related caretakers of dependent children
Pregnant women
People age 65 and older
People with disabilities
Entitlement program = no enrollment
limitation
4
Medicaid: What is it?
Federal / State Program
• Funded jointly by state and federal governments
• Administered by states
• Subject to federal law and regulation:
– Requires coverage of certain populations and
services
– Allows states to cover additional populations and
services
5
Medicaid: Who runs it?
Federal level
• Centers for Medicare & Medicaid Services (CMS)
• Within the U.S. Department of Health and Human Services:
 Kathleen Sebelius – Secretary of Health and Human Services
 Cindy Mann – Director, Center for Medicaid and State Operations
Texas level
• Administered by single state agency – HHSC
• Billy Millwee – Texas State Medicaid Director




Single point of contact with federal government
Establishes Medicaid Policy
Administers state plan or agreement with the federal government
Administers Medical Care Advisory Committee (MCAC) mandated by
federal Medicaid law
6
Medicaid in the Federal Budget,
Federal Fiscal Year 2009
7
Medicaid State Plans:
State & Federal Program
State Plans = agreements with federal government
on:
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•
•
•
•
Eligibility
Services
Program administration
Financial administration
Other program requirements
State Plan Amendments (SPA) = requests to CMS to
change:
• Optional services provided, or
• Manner benefits are offered.
8
Medicaid Waivers:
State & Federal Program
Waivers = state request to CMS for permission to deviate from certain
requirements, often to:
•
•
•
•
Provide services beyond those in state plan.
Limit geographical areas.
Limit free choice of providers.
Implement innovative new service delivery and management models.
Common Types of Medicaid Waivers
• 1115 Waiver – Research and Demonstration – Test policy innovations likely
to further Medicaid program objectives.
• 1915(b) Waiver – Freedom of Choice – Allow states to implement managed
care delivery systems or otherwise limit individuals' choice of provider under
Medicaid (i.e. STAR+PLUS).
• 1915(c) Waiver – Home and Community-Based Services – Waive Medicaid
provisions to deliver long-term care services and supports in community
settings as an alternative to institutional settings.
9
CHIP: What is It?
Children’s Health Insurance Program (CHIP)
• Medical coverage for uninsured children up to age 19.
• Joint state-federal program, either:
– Extension of state Medicaid program
– Separate program
• Federal funding
– Limited to block grant amounts allocated to each state.
• Not entitlement program, so states can:
– Determine age and income eligibility.
– Cap enrollment.
– Limit service benefits (as approved by HHS).
10
Medicaid Benefits:
Acute and Long-Term Care
Acute Care
• Physician, inpatient, outpatient, pharmacy, behavioral health, lab, X-ray
services
• Health care for children and pregnant women for episodic health care
needs.
Long-Term Services and Supports
• Chronic health conditions requiring ongoing medical care & often social
support.
• Includes care:
 In facilities, e.g. nursing homes
 For behavioral health conditions
Distinction based on:
• Cognitive and medical condition
• Need for assistance with activities of daily living
• Degree to which a disability is chronic
• Nature of services provided
• Setting in which services are provided
11
Medicaid Benefits:
Mandatory vs. Optional
Mandatory
• Inpatient hospital services
• Outpatient hospital services
• Early and Periodic Screening,
Diagnostic, and Treatment
(EPSDT) services
• 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
• Smoking cessation for
pregnant women
12
Medicaid Benefits:
Mandatory vs. Optional
Optional
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•
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•
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
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•
•
•
•
•
•
Optometry services
Dental services
Dentures
Prosthetics
Eyeglasses
Chiropractic services
Other practitioner
services
• Private duty nursing
services
• Other services approved
by HHS Secretary
13
CHIP: Benefits
• Inpatient hospital services
• Outpatient hospital &
ambulatory services
• Lab & X-ray
• Surgical & medical physician /
physician extender services
(including immunizations &
well-baby / well-child exams)
• Emergency services
• Prescription drugs
• Behavioral health & substance
abuse benefits
• Physical / speech / occupational
therapy
• Home health
• Transplants
• Durable medical equipment
• Dental services
• Hospice care services
• Skilled nursing facilities
• Vision (eye exams / eyeglasses)
• Chiropractic services
• Tobacco cessation
14
CHIP: Benefits
Perinatal benefits = limited, basic prenatal care including:
• Prenatal & postpartum visits



First 28 weeks of pregnancy: 1 visit every 4 weeks
28 to 36 weeks of pregnancy: 1 visit every 2-3 weeks
36 weeks to delivery: 1 visit per week
 2 postpartum visits
 Additional visits if medically
necessary
• Delivery


Hospital facility charges
Professional services charges
• Other



Pharmacy (based on CHIP formulary)
Prenatal vitamins
Limited laboratory testing
– Assessments
– Planning services
– Education and counseling
• No cost-sharing requirements
15
Income and Federal Poverty Levels
Federal Poverty Level (FPL)
• Compared to family’s income level.
• Basis for Medicaid financial eligibility.
• Intended to identify the minimum amount of
income a family would need to meet certain, very
basic, family needs.
• Indicate annual income levels by family size and
are updated each year by the U.S. Department of
Health and Human Services.
16
Federal Poverty Income Levels, 2011
U.S. Department of Health and Human Services poverty
guidelines based on annual income
Family Size
100% FPL
1
10,890
2
14,710
3
18,530
4
22,350
5
26,170
6
29,990
7
33,810
8
37,630
At 100% of poverty, for families larger than 8, add $3,820 for each additional
person.
SOURCE: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638
17
Medicare and Medicaid Eligibility
Medicare
Medicaid
• Federally funded
• Federally administered
• Eligibility
• Jointly funded by federal
and state government
• Administered by state
• People age 65+
• People with disabilities
• People with end stage renal
disease
• Eligibility
•
Low-income individuals
• Pays for most long-term
care services & supports
18
Medicaid & Medicare: Dual Eligibles
Dual eligibles
• Individuals who are aged or disabled (Medicare eligible) AND
• Limited income (eligible for some Medicaid coverage)
Full Dual Eligibles
• Entitled to Medicaid benefits that Medicare does not cover.
• Include low-income individuals who are aged or disabled in
community, waiver programs, nursing homes, and state schools.
Other Dual Eligibles
• Eligible only for Medicaid payments for Medicare premiums,
deductibles, and coinsurance for Medicare services.
• Not entitled to Medicaid services.
• Include several categories of eligibility; incomes generally up to
135% of FPL.
19
CHIP Eligibility
CHIP covers children in families who:
•
•
•
Have too much income or too many assets to qualify
for Medicaid.
Cannot afford to buy private insurance.
Generally are below 200% of the FPL.
States can design their CHIP program as:
•
•
•
Medicaid expansion (7 states, D.C. and 5 territories)
Separate from Medicaid (17 states)
Combination of the two approaches (26 states)
20
Medicaid & CHIP: Texas Specifics
Texas Medicaid: Organization
22
Texas Medicaid: Optional Benefits
The state may choose to provide some, all, or no optional
services specified under federal law.
Optional services provided in Texas include:
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Prescription drugs
Physical therapy
Occupational therapy
Targeted case management
Some rehabilitation services
Certified Registered Nurse Anesthesiologists
Eyeglasses/contact lenses
Hearing aids
Services provided by podiatrists
Certain mental health provider types
23
Texas Medicaid: Pharmacy Benefits
HHSC Vendor Drug Program performs most pharmacy services
functions, including policy and program oversight, formulary
management, and pharmacy customer services.
Texas contracts with private companies for:
• Pharmacy claims processing
• Prior authorization services
• Administration of drug rebate program
Texas contracts with pharmacies to provide Medicaid clients with
pharmacy benefits.
• Over 4,200 licensed Texas pharmacies are under contract.
• Beginning March 2012, managed care organizations (MCOs) will be
responsible for providing pharmacy benefits to their members
24
Texas Medicaid Women’s Health
Program (WHP): Benefits
• Certain screenings related to
• Annual family planning
family planning:
exam & Pap smear
– Pregnancy test
• Follow-up visit, if related
to contraceptive method
– Rubella antibody test
– Routine urinalysis
• Counseling on specific
methods & use of
– Urine culture
contraception
– Complete blood count (CBC)
• Female sterilization
– Hemoglobin and hematocrit tests
• Follow-up visits related to
sterilization
• Sexually Transmitted
Infection (STI) Screenings
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–
–
–
Blood typing
Blood glucose screening
Lipid panel
Thyroid stimulating hormone test
25
Texas Medicaid Women’s Health
Program (WHP): Benefits
Services not covered through WHP:
• Mammography - screens for breast cancer are limited to a
clinical breast exam.
• Treatment for any conditions diagnosed during a WHP
visit.
• Visit for pregnancy test only.
• Visit for STI test or treatment only.
• Follow-up after an abnormal Pap test.
• Counseling on and provision of emergency contraceptives.
• Referrals made for medical problems to providers that
perform elective abortions.
• Other visits that cannot be appropriately billed with one of
WHP- allowable diagnosis codes.
26
Texas CHIP: Benefits
• Inpatient general acute & rehabilitation
hospital services
• Surgical services
• Transplants
• Skilled nursing facilities
• Outpatient hospital, comprehensive
outpatient rehabilitation hospital, clinic
& ambulatory health care center services
• Physician/physician extender
professional services (including wellchild exams & preventive health
services)
• Laboratory & radiological services
• Durable medical equipment, prosthetic
devices, & disposable medical supplies
• Home & community-based health
services
• Nursing care services
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•
•
•
•
•
•
•
•
•
•
•
•
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Inpatient mental health services
Tobacco cessation
Outpatient mental health services
Inpatient & residential substance use
treatment
Outpatient substance use treatment
Rehabilitation and habilitation
services
Hospice care services
Emergency services
Emergency medical transportation
Care coordination
Case management
Prescription drugs
Dental services
Vision
Chiropractic services
27
Texas CHIP Perinatal Program
Provides prenatal & post-partum care to pregnant women
ineligible for Medicaid due to:
• income (whose income 186%-200% FPL), or
• immigration status (with income below 200% FPL).
Upon delivery, CHIP Perinatal newborns in families:
• With incomes at or below 185% FPL:
– are deemed to Medicaid
– receive 12 months of continuous Medicaid coverage
• With incomes above 185% FPL up to 200% FPL:
– remain in CHIP Perinatal Program
– receive CHIP benefits for the remainder of the 12-month coverage
period
Members receiving CHIP Perinatal benefits are exempt from:
• 90-day waiting period, asset test & all cost-sharing, including
enrollment fees & co-pays
28
Medicaid Benefits: Compared to
Private Employer-Sponsored Coverage
29
Texas Medicaid: Eligibility
Medicaid serves:
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•
•
•
•
•
Low-income families
Non-disabled children
Related caretakers of dependent children
Pregnant women
People age 65 and older
People with disabilities
Texas Medicaid does not currently serve:
• Non-disabled, childless adults
30
Texas Medicaid Eligibility:
Percent of FPL June 2010
31
Texas Medicaid Women’s Health
Program (WHP): Eligibility
WHP Eligibility Criteria:
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•
•
•
•
•
Ages 18 – 44.
U.S. citizens & qualified immigrants.
Reside in Texas.
Not eligible for full Medicaid benefits, CHIP, or Medicare.
Not pregnant.
Not sterilized, infertile, or unable to get pregnant due to
medical reasons.
• No private health insurance coverage covering family
planning services.
– Exception if filing a claim would cause physical, emotional, or
other harm from a spouse, parent, or other person.
• Countable household income at or below 185% FPL.
32
Texas CHIP: Eligibility
General eligibility
• Uninsured children under age 19.
– CHIP Perinatal serves unborn children meeting eligibility
requirements.
• Gross income up to 200% FPL.
• U.S. citizens or legal permanent residents.
• Not eligible for Medicaid.
Families with net incomes above 150% FPL must meet assets criteria:
• Assets below $10,000.
• One vehicle is exempt up to $18,000; additional vehicles are exempt
up to $7,500.
Eligibility is determined for a 12-month period; income verification at 6th
month for families at 185% FPL and above
• CHIP Perinatal eligibility is determined for a 12-month period
33
Texas Medicaid: Enrollment
The Texas Medicaid program has grown considerably in
recent years.
• Texas Medicaid now serves over 3.4 million people out of a
total population of about 25 million (as compared to 2.8 million
in 2006).
• Persons who are aged, blind or disabled represent:
– 25% of Texas Medicaid recipients.
– 58% of Texas Medicaid costs.
– They often have complex medical conditions, needing both
• Acute care (e.g. hospitalization, outpatient services, and
laboratory), and
• Long term services and supports (LTSS) provided in the home or
community (e.g. assistance with daily living, skilled nursing, and
therapy services).
34
Texas Medicaid:
Historical Enrollment
History of Medicaid Eligibility: Caseload
September 1977- August 2010
35
Texas Medicaid: Enrollment by Age,
State Fiscal Year 2009
36
Texas Medicaid:
Enrollment & Spending
June 2011, 3.3 million people received Medicaid.
 Over 2.3 million are children.
 Over 700,000 are individuals who are aged, blind, or disabled.
Texas Medicaid beneficiaries & expenditures, state fiscal year 2009
37
Texas Medicaid: State Budget
Medicaid spending
FY 2010-2011
• $44.9 billion from
all fund sources
• $18.8 billion from
General Revenue
(GR), GRDedicated, and
Tobacco Settlement
Receipts
• 75% of all
appropriations for
HHS
38
Texas Medicaid: Historical Spending
Total Federal and State Medicaid Client Services Spending (millions)
1981
1991
2001
2011
$20,000.0
$16,000.0
Federal Client Services
Payments ($Millions)
$688.6
$2,350.2
$6,234.1
$16,146.3
State Client Services
Payments ($Millions)
$493.5
$1,333.6
$4,024.4
$8,550.1
Total Spending ($Millions)
$1,182.0
$3,683.7
$10,258.5
$24,696.4
$16.1 B
(millions)
Federal
Spending
$12,000.0
$8.6B
$8,000.0
State
Spending
$4,000.0
$0.0
1981
1991
2001
2011
39
Texas CHIP:
Enrollment & Spending
How many children in Texas are enrolled CHIP?
• Caseload for June 2011: 539,137 children
How much is spent on CHIP?
• Total state fiscal year 2010 budgeted* for CHIP
– $815.6 million from all fund sources
– $270.2 million from GR
*Based on FY 2010 Operating Budget. Includes all traditional CHIP
costs: client service costs for federally funded children, legal
immigrants, school employee children, and vendor drugs;
administrative and operating expenses.
40
Texas CHIP: Average Monthly
Enrollment, State Fiscal Year 2000-2010
41
Texas CHIP: Enrollment by Age,
State Fiscal Year 2010
42
Texas CHIP Perinatal Program:
Enrollment, State Fiscal Year 2007-2010
43
Texas Medicaid: FMAP
Federal Medical Assistance Percentages (FMAP)
• Portion of total Medicaid costs paid by the
federal government.
• Texas FMAP for federal fiscal year 2012: 58.42
– Of each dollar spent on Medicaid services in Texas,
the federal government pays approximately 58 cents.
• Based on average state per capita income
compared to the U.S. average.
• Small changes in the FMAP could result in
significant loss or gain of federal funds.
44
Texas Medicaid: DSH Payment
Medicaid Disproportionate Share Hospital (DSH) Program
• Source of reimbursement to state-operated and non-state (local)
Texas hospitals that treat indigent patients.
• Federal law requires that state Medicaid programs make special
payments to hospitals that serve a disproportionately large number
of Medicaid and low-income patients.
• Not tied to specific services for Medicaid-eligible patients, unlike
other Medicaid payments.
Total funds to all DSH hospitals in state fiscal year 2009:
$1.615 billion
• State DSH Hospitals: $339 million
• Non-state DSH Hospitals: $1.276 billion
45
Texas Medicaid: UPL Payment
Upper Payment Limit (UPL)
• Financing mechanism used by states to provide supplemental payments to
hospitals or other providers.
• Federal regulations allow states to pay providers up to what Medicare
would have paid, or the amount the hospital charges for services.
• States may use local funds transferred to the state to fund the supplemental
payments.
HHSC currently makes UPL payments to:
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•
•
•
•
•
4 state-owned hospitals
11 non-state large urban public hospitals
100 non-state owned rural public hospitals
7 children’s hospitals
11 state university physician group practices
unknown number of privately-owned hospitals in Private Hospital UPL
program
46
Texas CHIP: EFMAP
Enhanced Federal Medical Assistance
Percentages (EFMAP)
• Portion of total CHIP costs paid by the federal
government.
• Generally higher than Medicaid
 In 2012, the federal government pays 70.89% of
CHIP medical care expenditures
 Compared to 58.42% of Medicaid medical care
expenditures.
47
Texas CHIP: Historical Spending,
State Fiscal Year 2000-2010
48
Texas CHIP: Cost Sharing
CHIP annual enrollment fee:
• $0 for families with net income less than 150% FPL
• $35 for families between 151-185% FPL
• $50 for families between 186-200% FPL
Families are required to pay the enrollment fee
upon enrollment or renewal of CHIP.
49
Texas CHIP: Cost Sharing
Families enrolled in CHIP are responsible for
co-payments for certain plan benefits.
At or below
100% FPL
Preventative Health Care and
Shots
Office Visit
Non-Emergency Room Use
Generic Prescription
Name-brand Prescription
Inpatient Hospital Care
Outpatient Hospital Care
$0
$3
$3
$0
$3
$10
$0
101% to
150% FPL
$0
$5
$5
$0
$5
$25
$0
151% to
185% FPL
$0
$7
$50
$5
$20
$50
$0
186% to
200% FPL
$0
$10
$50
$5
$20
$100
$0
50
Texas Medicaid Women’s Health
Program (WHP): Savings
In 2008, WHP saved:
• $63 million (all funds) due to reduction in
expected births.
• $42.4 million (all funds) after paying program
costs.
State share of reduced Medicaid costs totaled:
 approximately $23.5 million (GR)
 net state share of savings after paying WHP
expenditures totaled approximately $21.4 million
(GR)
51
Medicaid Delivery Models:
Managed Care vs. FFS
Managed Care Programs in Texas
• STAR – provides acute care services to children, pregnant
women, and families.
• STAR+PLUS – provides acute and long-term services and
supports to individuals with disabilities and elderly people.
• NorthSTAR – provides behavioral health services to individuals
in a multi-county area in and around Dallas.
• STAR Health – provides a comprehensive managed care program
for children in foster care.
Fee-for-Service (FFS)/Traditional Medicaid
• A few eligibility categories remain in FFS.
• Individuals in FFS can choose any provider.
• FFS does not offer the management or utilization controls that
managed care provides.
52
Provider Reimbursement:
Managed Care vs. FFS
Payment and processes vary by delivery model
• Managed Care:
– HHSC pays MCOs a capitated rate.
– MCOs pay providers reimbursement rates established by
contracts with the providers.
– Providers send claims (bills for services) to the MCO for
payment.
• FFS:
– HHSC establishes FFS methodologies to pay providers.
– Claims are sent to state for payment.
53
Texas CHIP: Delivery Systems
CHIP Service Delivery Models include:
• MCO: A type of health care plan that arranges for or
provides benefits to covered clients
– The state pays the CHIP MCOs on a capitation basis: a set
dollar amount PMPM to cover the health care costs of clients.
– Client selects an MCO and a Primary Care Provider (PCP)
– PCP authorizes services within the network
– Providers are paid reimbursement rates established by the MCO
• Exclusive Provider Organization: A health plan that
arranges for or provides benefits to covered persons
through a network of exclusive providers
– Limited to services provided to client in network, except for
emergencies.
• Dental Maintenance Organization for dental services
54
Medicaid & CHIP: New Initiatives
Budget-Related Outcomes
of the 82nd Texas Legislature
Summary of Medicaid Funding for FY 2012-13
• $40.6 billion in All Funds ($17.1 billion in GR).
• Assumes expansion of managed care, anticipated to result in
a net savings of $385.7 million GR and increases in
insurance premium tax revenue collections.
• Funding levels continue provider rate reductions
implemented during the 2010-2011 biennium, including an
8% hospital rate reduction.
• Cost containment initiatives totaling $1.8 billion in GR
funds, including $450 million assumed in Rider 61.
56
Budget-Related Outcomes
of the 82nd Texas Legislature
Statewide Standard Dollar Amount (SDA)
• Converted hospital reimbursement from a hospital-specific,
cost-based reimbursement to a statewide base SDA effective
September 1, 2011.
• HHSC worked closely with hospital industry to develop the
statewide SDA.
• Add-on adjustments for hospital wages, medication
education, and trauma centers to recognize high-cost services
and geographic variations.
Hold Harmless:
• HHSC authorized to use up to $20 million in GR
($48.1 million all funds) to mitigate losses to hospitals that
are disproportionately impacted.
• Funding available up to September 1, 2012.
57
Budget-Related Outcomes
of the 82nd Texas Legislature
Medicare Equalization
• Past Texas Medicare-Medicaid Policy
– Part A - State limits Medicare coinsurance and deductible
payments to no more than the Medicaid rate for the same
service.
– Part B - State makes Medicare coinsurance and deductible
payments. Total payment for service may exceed Medicaid
rate.
• As of January 2012
– The 2012-13 General Appropriations Act directs HHSC to
align payment policies for Medicare Part A and B cost
sharing.
58
Initiatives from the
82nd Texas Legislature
Managed Care Expansion
• September 1, 2011
– Expanded existing STAR and STAR+PLUS service areas to
contiguous counties.
• March 1, 2012
– Expand STAR to new service areas.
– Expand STAR+PLUS to new service areas.
– Replace TX Primary Care Case Management Program (PCCM)
with a capitated MCO program.
– Carve the pharmacy benefit into the services delivered by the
Medicaid and CHIP MCOs.
– Develop statewide Medicaid dental MCOs.
59
Initiatives from the
82nd Texas Legislature
Reduce inappropriate utilization of Emergency
Departments (ED) by Medicaid recipients
• ED hospital rates
– As of September 1, 2011, HHSC applied a 40% reduction to facility
charges for non-emergent services delivered in an ED setting to
recipients of Medicaid FFS
• Medicaid cost-sharing
– Encourage personal accountability and appropriate use of health care
services.
– Cost-sharing includes non-emergency services through a hospital ED.
– HHSC is researching options for implementation.
– Target implementation date is December 2012.
• Develop incentives though MCOs for providers to:
– Offer evening and weekend hours, and
– Educate recipients about appropriate Emergency Department
utilization.
60
Initiatives from the
82nd Texas Legislature
Quality Initiatives
• Shift to paying for outcomes and quality instead of
volume.
– Quality-based payments for hospitals and managed care.
– Policy changes
• Example: Ending Medicaid payments for elective deliveries prior
to 39 weeks.
• S.B. 7 established:
– Quality-Based Payment Advisory Committee
– Texas Institute of Health Care Quality and Efficiency
61
Healthcare Transformation
1115 Waiver
Texas Health Care Transformation and Quality
Improvement Program 1115 Waiver includes:
• Managed care expansion
– Expands Medicaid managed care services statewide.
– Includes legislatively mandated pharmacy carve-in and dental
managed care.
• Hospital financing component
– Preserves hospital funding under a new methodology.
– Creates Regional Healthcare Partnerships (RHPs).
62
Healthcare Transformation
1115 Waiver
Under the waiver, trended historic UPL funds
and additional new funds are distributed to
hospitals through two pools:
• Uncompensated Care Pool
– Costs of care provided to individuals who have no
third party coverage for the services provided by
hospitals or other providers (beginning in first year).
• Delivery System Reform Incentive Payments
– Support coordinated care and quality improvements
through RHPs to transform care delivery systems
(beginning in later waiver years).
63
Healthcare Transformation
1115 Waiver Pool
64
Healthcare Transformation
1115 Waiver
RHPs:
• Will form around hospitals currently receiving UPL
payments.
• Will develop plans to address local delivery system
concerns with a focus on improved access, quality,
cost-effectiveness, and coordination.
• Must provide opportunities for public input in plan
development and review.
• Should encourage broad engagement of local
stakeholders in RHPs.
65
Chronic Conditions Waiver
S.B. 1, 82nd Legislature, First Called Session,
2011
• If feasible and cost-effective, HHSC may apply for a
waiver to more efficiently leverage use of state and local
funds.
• Would provide benefits to individuals eligible to receive
services through the county for chronic health
conditions.
• Requires broad-based input from interested persons.
• Must use intergovernmental transfers to maximize
federal Medicaid matching funds.
66
Affordable Care Act:
Medicaid Expansion
Medicaid eligibility expands to include individuals under age
65 with incomes up to 133% FPL
• Includes income deduction of 5 percentage points, creating
effective eligibility level of 138% FPL.
In 2014, Texas will experience 1.8 million increase in
caseload.
New client populations in Texas include:
•
•
•
•
Parents and caretakers at 14 - 133% of FPL
Childless adults up to 133% FPL
Emergency Medicaid in expansion populations
Children in foster care through age 25
Federal government bears full cost of coverage for new
eligibles for first 3 years of mandatory expansion.
67
Current & Estimated Future
Medicaid/CHIP Eligibility Levels
225
200
175
CHIP
200% FPL
CHIP
200% FPL
CHIP
200% FPL
Current
Medicaid
225% FPL
CHIP
200% FPL
Current
Medicaid
185% FPL
Current
Medicaid
185% FPL
150
Current
125
Medicaid
185% FPL
Current
Medicaid
133% FPL
100
NEW
Medicaid
NEW
Medicaid
133% FPL
(Currently CHIP)
NEW
Medicaid
133% FPL
133%
133% FPL
Current
Medicaid
100% FPL
75
Current
Medicaid
74% FPL
50
25
14% FPL
0
Newborns (<1
yr)
Children (Age 1- Children (Age 65)
18)
Pregnant
Women
SSI, Aged,
Disabled
Parents
Childless Adults Long-Term Care
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Affordable Care Act:
Eligibility Changes
State Health Benefit Exchange (HBE)
• The law requires each state to have a HBE.
• If a state chooses not to operate a HBE, the federal
government will operate an HBE for the state.
• Texas has not yet decided whether or not it will operate
an HBE.
• Medicaid, CHIP, and the HBE must interface.
• Applications through the HBE must be “deemed” to
Medicaid and CHIP with no additional required action by
the applicant.
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Affordable Care Act:
Medicaid Benchmark Benefit
Federal law allows for a Medicaid benchmark benefit that:
• Will be provided to the new Medicaid adult expansion population in 2014,
• May be different from the regular Medicaid benefit package,
• Must include essential health benefits (EHB), as defined by federal
Department of Health and Human Services (HHS).
In December 2011, HHS released initial guidance on EHB.
• Additional guidance specific to Medicaid is forthcoming.
• HHSC is reviewing the guidance and researching options for Texas while
awaiting additional guidance.
Texas will seek stakeholder input while developing the benchmark
benefit.
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Texas Health Care Coverage:
Post ACA Implementation
450
400
% of Federal Poverty Level
350
300
Unsubsidized
–
In or Out of
Exchange
Sliding Scale
Health
Insurance
Subsidies,
through
Exchange
400% FPL
Unsubsidized
–
In or Out of
Exchange
Sliding Scale
Health
Insurance
Subsidies,
through
Exchange
400% FPL
Unsubsidized
–
In or Out of
Exchange
Sliding Scale
Health
Insurance
Subsidies,
through
Exchange
400% FPL
Unsubsidized
–
In or Out of
Exchange
Sliding Scale
Health
Insurance
Subsidies,
through
Exchange
400% FPL
CHIP
CHIP
200% FPL
CHIP
200% FPL
CHIP
Unsubsidized
–
In or Out of
Exchange
Sliding Scale
Health
Insurance
Subsidies,
through
Exchange
400% FPL
Unsubsidized
–
In or Out of
Exchange
Sliding Scale
Health
Insurance
Subsidies,
through
Exchange
400% FPL
Estimated Insured
but not Subsidized
(In or Out of
Exchange)
15.5 million
Estimated Insured &
Subsidized in
Exchange
250
1.9 million
200
150
133%
100
50
Current
Medicaid
185% FPL
Current
Medicaid
133% FPL
NEW
Medicaid
Current
Medicaid
100% FPL
Current
Medicaid
185% FPL
NEW
NEW
Medicaid
133% FPL
Medicaid
133% FPL
Current
Medicaid
74% FPL
Newborns (<1 yr) Children (Age 1-5) Children (Age 618)
Pregnant Women
SSI, Aged,
Disabled
5.6 million
Estimate of
Ongoing Uninsured
14% FPL
0
Estimated
Medicaid/CHIP
Parents
Childless Adults
2.3 million
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Current State Challenges
Redesign of existing programs
• Strengthening and transforming the health care infrastructure.
• Streamlining Medicaid and CHIP eligibility determinations and
coordinating with the HBE.
• Effectively redesigning existing state and local programs currently
serving the population.
• Building adequate workforce to serve newly insured populations.
Uncertainties
• Pending federal guidance for many provisions, which complicates
states ability to implement.
• Long term fiscal planning as federal participation levels decrease
over time.
• Estimating the ongoing needs of the undocumented and remaining
uninsured populations.
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Additional Resources
Medicaid Managed Care Initiatives
www.hhsc.state.tx.us/medicaid/MMC.shtml
Approved Healthcare Transformation 1115 waiver
www.hhsc.state.tx.us/1115-waiver.shtml
HHSC News Releases
www.hhs.state.tx.us/news/release.shtml
Texas Medicaid Pink Book
www.hhsc.state.tx.us/medicaid/reports/PB8/PinkBookTOC.html
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