Emerging Opportunities in
Medicaid and Home Health
March 2015
VNAA Medicaid Work Plan
Educational Webinars
• Q1: Medicaid Basics for Home Health Providers
• Q2: Dipping Your Toe In: How to Engage in Medicaid
• Q3: Medicaid Managed Care Deep Dive
• Q4: Case Studies
Tools & Resources
• Q3: Medicaid Managed Care Toolkit
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What is Medicaid?
• A health insurance program that provides a comprehensive benefit
package for certain low-income individuals
• The largest source of health insurance in the country (and growing)
 ~68 million beneficiaries
• A federal-state partnership
 The federal government sets the basic parameters of the program
 States have significant flexibility to design their program within those
parameters
 States and the federal government share in the costs, which are never
less for the state than 50/50
Medicaid is shaped by each state’s unique insurance
environment, provider landscape, fiscal situation, and politics.
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What is Medicaid?
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Populations & Benefits
Mandatory Eligibility Groups
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Children under age 6 in families with income below 133% of the federal poverty line ($25,975 for a family of three
in 2013);
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Children aged 6-18 in families with income below the poverty line;
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Pregnant women with income below 133% of the poverty line;
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Parents whose income is within the state’s eligibility limit for cash assistance that was in place prior to welfare
reform; and
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Most seniors and persons with disabilities who receive cash assistance through the Supplemental Security Income
(SSI) program.
Optional Eligibility Groups
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Pregnant women, children, and parents with income above mandatory coverage income limits;
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Seniors and persons with disabilities with income below the poverty line;
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“Medically needy” people — those whose income exceeds the state’s regular Medicaid eligibility limit but who
have high medical expenses (such as for nursing home care);
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Certain groups of women who are in need of treatment for breast and cervical cancer;
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Certain low-income individuals with tuberculosis; and
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Childless adults below 133% FPL (138% due to standard 5% income disregard) **New ACA Population; Subject to
Higher FMAP**
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Medicaid Benefits
Mandatory Benefits
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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
Transportation to medical care
Tobacco cessation counseling for pregnant women
*Traditional VNAA member services in red.
Optional Benefits
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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
Optometry services
Dental Services
Dentures
Prosthetics
Eyeglasses
Chiropractic services
Other practitioner services
Private duty nursing services
Personal Care
Hospice
Case management
Services for Individuals 65+ in an Institution for Mental Disease
Services in an intermediate care facility for the mentally retarded
State Plan Home and Community Based Services- 1915(i)
Self-Directed Personal Assistance Services- 1915(j)
Community First Choice Option- 1915(k)
TB Related Services
Inpatient psychiatric services for individuals under age 21
Health Homes for Enrollees with Chronic Conditions – Section 1945
Other services approved by the Secretary
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Medicaid Spending Varies by State
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Aged & Disabled Are Priority Area of Focus
24%
63%
Medicaid’s Changing Environment &
Opportunities for Home Health
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Medicaid Context
• Unrelenting pressure on state budgets demand cost
containment
• Medicaid expansion brings significant growth of non-elderly
Medicaid population with different health needs in
expansion states
• Marketplaces and insurance reforms facilitate state efforts
to streamline coverage for residents
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Implications
 Emphasis on prevention & less costly care options (including HCBS)
 Focus on payment & delivery system reform
 Increased use of private managed care to create budget certainty and
shift insurance risk, including for high cost/high need populations
 Access pressures; increased need for coordination
 Increased need for behavioral health services
 Potential for alignment of Medicaid benefits and Marketplace plans
 Possible reduction in coverage of LTSS (not required for Marketplace)
Emerging Opportunities for
Home Health Providers
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New
Populations
Non-homebound
of all ages &
functional status
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Behavioral health
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Public health /
prevention
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Dev. disabled
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High risk
pregnant women
/ newborns
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Management of
HCBS networks
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PMPM for care
coordination;
management of
HCBS networks;
and services
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Assume
responsibility for
care coordination
across full
continuum of
care
New Payment
Arrangements
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VBP
New Services
Care
Coordination
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Why Home Health Providers
Medicaid programs – and their managed care contractors – seek high quality,
cost-effective solutions—and they incentivize (and reward) quality.
HHAs bring:
 Experience caring for vulnerable patients
 Experience coordinating medical care and social services with community
based organizations
 Ability to provide behavioral health and physical health services
 Proven history of being the least costly setting
 Ability for risk-based contracting
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Getting Involved
• Commit: to working with states and Medicaid plans
• Take initiative: plans and states will be interested in alternative
contracting proposals that help them achieve their goals
• Articulate your value: what you do, who you serve, and evidence that
shows how you can influence their value metrics
• Be open: to considering new benefits, new services, and new
contracting models
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Understand What You May Face
• All healthcare stakeholders are in some state of flux… it may be hard to get
states’ and plans’ attention at first
• MMC have limited experience with PAC and LTSS – you will need to clearly
define what services you offer and what populations you specialize in
• Unlike FFS, MMC are not necessarily required to use any willing provider
(varies by state) – you will need to be able to demonstrate that you bring
value
• Plans are used to handing over contracts for signature. You will need to
start the negotiation
Key Points about Reimbursement
• How reimbursement is set varies by state
• Rates are not determined at the federal level
• Reimbursement levels are set:
 In FFS Medicaid: by the state Medicaid Agency
 In managed Medicaid: by the managed care plan unless dictated by the
state (unusual)
• New delivery system models open the door to higher reimbursements,
shared savings
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Next Steps
VNAA Members:
• Share your experiences with Medicaid via VNAA focus groups and
interviews
• Participate in future webinars on Medicaid opportunities
• Attend Medicaid programming at the VNAA Annual Meeting
VNAA:
• Develop additional resources, including a Medicaid Managed Care Tool Kit
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Questions?
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Appendix
• Use of Managed Care
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Use of Managed Care