Alabama Medicaid Update Tina G Pippin Dental Program Director Alabama Dental Association Annual Session June 16, 2006
Medicaid was established in 1965 by federal law to provide medical assistance to low income and resource individuals.
States may choose to have a Medicaid program, but must comply with all federal Medicaid requirements once a program has been implemented.
Funded through a federal and state partnership (generally 70/30 in Alabama)
“ Rules” continued
Federal law sets minimum eligibility and benefit levels.
With few exceptions, Alabama’s program is at the federal minimum level for eligibility.
Alabama has one of the most conservative benefit packages in the country.
Medicaid cannot make any more program cuts and still be in compliance with federal regulations.
Don’t be confused…
Medicaid is a federal and state program and provides medical assistance to low income and resource individuals.
Medicare is a federal program to provide medical insurance generally to individuals aged 65 and older.
Who Determines Eligibility
Three Alabama agencies certify individuals for Medicaid.
Agencies certify certain groups of individuals for Medicaid based on their circumstances.
These agencies are:
The Social Security Administration
The Department of Human Resources
The Alabama Medicaid Agency
The Face of Medicaid
Demographics FY 2005
20.7% of Alabama’s total population (includes all eligibility categories)
46% of all deliveries in Alabama
37.9% of Alabama’s children (under 19)
19.7% of Alabama’s elderly (65 and above)
74% of nursing home days in Alabama
Total Medicaid Eligibles As a Percentage of Alabama’s Population Note: Includes individuals eligible for Plan First FY
Medicaid Children Under age 19 as a Percent of Alabama’s Child Population FY
Children in Working Families As of September 2005 Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.
What are the sources of health insurance coverage in Alabama? 3.7% 31.4% 53.7% 11.2% AL Rate UNK Individual Coverage 25.3% Public Program 62.6% Employer Sponsored Coverage 14.6% Uninsured US Rate (CPS 2001) Coverage
AL Uninsurance Rates by Age All rates reflect point in time data.
Eligible and Payment Distribution By Age FY 2005
Medicaid Eligibles by Aid Category FY 2005
Eligibles Percent Distribution by Race FY 2005
Cost Per Eligible FY 2005 By Category By Gender By Age
Economic Impact Hospital Care Primary Care Maternity Care Pharmacy MEDICAID
High Medicaid Counties FY 2005 These 12 counties have the highest concentration of Medicaid eligibles across the general population (30% or greater). Bullock 35% Lowndes 33% Butler 33% Macon 31% Conecuh 31% Marengo 30% Dallas 41% Perry 43% Greene 40% Sumter 39% Hale 32% Wilcox 46%
These 11 counties have the highest concentration of Medicaid eligibles across the children’s population (50% or greater). Bullock 66% Lowndes 55% Butler 56% Macon 50% Conecuh 56% Perry 63 % Dallas 65% Sumter 65% Greene 66% Wilcox 71% Hale 50% High Medicaid Counties FY 2005
In FY 2004, Medicaid paid approximately $3.7 billion to providers for various health care services rendered; $2.7 billion represents federal funds brought into the State.
In FY 2005, Medicaid paid approximately $3.9 billion to providers for various health care services rendered; $2.8 billion represents federal funds brought into the State.
Medicaid expenditures supported more than 84,323 jobs in various industries within the state. 1 1 Economic Impact of the Alabama Medicaid Agency on the Economy of the State of Alabama and its Counties, Amy K. Yarbrough, MSHA, MBA, Administrative Fellow, University of Alabama at Birmingham Economic Impact (continued)
5 counties receive in excess of $100 million
Jefferson $520 million
Mobile $252 million
Tuscaloosa $144 million
Madison $127 million
Montgomery $315 million
8 counties receive payments in excess of $60 million.
16 counties receive payments in excess of $40 million.
31 counties receive payments in excess of $20 million.
Financial Impact by County FY 2005
Without Medicaid revenue, critical components of Alabama’s healthcare infrastructure could not continue to exist.
52% of the patient days at The Children’s Hospital of Alabama are paid for by Medicaid.
77% of the patient days at USA Children’s and Women’s Hospital are paid for by Medicaid.
Source: Information obtained from Medicare Cost Reports as filed.
Financial Impact by Hospital
Federal Funds 70.83% Benefit Payments 98.0% Administrative Costs 2.0% State Funds 29.17 % Where It Comes From, Where It Goes FY 2005
Distribution of Payments Excluding Hospital Disproportionate Share Payments FY 2005
Dental Care Expenditures FY 1998-2005 Millions FY
Medical Care Expenditures FY 1994-2005 Billions Excludes DSH payments, enhancements, and pharmacy rebates FY
Medicare Modernization Act, 2003
Health Insurance Portability and Accountability Act
(Currently implementing NPI)
Pryor Amendment, 1990 (Mandated open drug formulary)
OBRA 1989 (Mandated the EPSDT program)
CCA 1988 (Mandated coverage of QMB)
History of Unfunded Mandates
General Fund Contributions Medicaid as a Percent of the GF FY
Medical Services Update
Town Hall Presentation to Provider Support Personnel
Improve health care outcomes for Medicaid recipients through creation of a medical home while containing the escalating cost of quality health care.
Basic Program Concepts
Providers enroll as a Primary Medical Provider (PMP)
Patients are assigned to a PMP
Services must be provided directly or through referral ( NO REFERRAL needed for Dental Services)
PMPs are paid a monthly case management fee based on signed contract
Who Can Be A PMP?
Specialists (ex: special needs child)
Who Is IN Patient 1st?
Infants Of SSI Mothers
Who is NOT In?
Institutionalized (nursing homes, group homes, MR facilities, DYS) Lock-Ins
Enrollees of Private HMO
Real World Numbers
1,018 PMPs Enrolled
74 Clinic Based
448,708 Total Enrollees
84,247 Over 21
364,461 Under 21
* As of 4/20/06
Program Redesign . . .
This time around …
A cost effective model
More program accountability
Have ability to demonstrate success
More focus on affecting behavior
Effective patient management tools through program enhancements
Moving Into the 21st Century Tools to Help the PMP Manage the Patient In-Home Monitoring InfoSolutions ePrescribing
In-Home Monitoring aka Disease Management
Partnership with USA Hospital and the Alabama Department of Public Health (ADPH)
Targets chronic diseases through claims utilization
Diabetics initial phase
Can monitor blood sugars, weight and blood pressure
Coordination with Primary Physician
Supported with case management
Web based with real-time reporting available
Purpose is to inform providers of prescription activity based on Medicaid paid claims data.
Desktop or PDA tool for physicians
Download patient prescription information
e-Prescribing Component of InfoSolutions
Download prescription history
Automatically alerted to potential drug-to-drug interactions
Prescribe/refill multiple medications
Print prescriptions up to 30 feet away using Bluetooth technology
Establish “favorites” list of frequently prescribed medications
View both Blue Cross/Medicaid formulary
Plan f i rst
Different from “regular” family planning
Have to use enrolled providers
Providers dispense birth control pills and the “patch”
Nuva Ring is not covered
Women will have to recertify each year
Successful … very
95,448 women enrolled (3/06)
Teen enrollment grew by 21% during 1st five years
9,014 births averted in DY 4 (10/03-9/04)
Approximately 25% of women utilize private providers (in addition or instead of public)
Enrollees were 42% more likely to use contraceptives and 33% more likely to use effectively
Prescription Utilization FY 2005
Pharmacy Expenditures Percent Change from Previous Year Net of Rebates
The Preferred Drug List (PDL), monthly brand limit, and system edits continue to be important management tools.
These programs are estimated to save 20% of the pharmacy program expenditures in FY 2007.
Program Update Projected FY 2007 expenditures with program initiatives - $443.6; without initiatives - $554.5; before rebates. Medicaid Fiscal Division
Monthly Brand Limit
July 1, 2004 a monthly brand limit was implemented, allowing 4 brand prescriptions per month with unlimited generic and OTC prescriptions.
Children and nursing home patients are excluded.
Anti-psychotic and anti-retroviral drugs are allowed up to total of 10 brand prescriptions.
Allowances are made for additional brands per month for certain classes if a physician needs to “switch” a patient from one brand to another in the event of adverse or allergic reactions.
November 1, 2003 a Preferred Drug List (PDL) was implemented, requiring that drug classes be reviewed by our Pharmacy and Therapeutics (P&T) Committee for clinical recommendations for inclusion into the PDL.
Medicaid is currently re-reviewing implemented classes into our PDL to ensure up-to-date clinical information is taken into consideration for PDL clinical decisions.
Medicare Part D Update
Medicare Prescription Drug Coverage What Do You Need To Know?
Medical Insurance (doctor visits)
NEW Medicare Prescription Drug Benefit
Eligibility and Enrollment
Entitled to Part A and/or enrolled in Part B
Must reside in the plan’s service area
Program voluntary (for most)
Must enroll with the drug plan
Monthly fees apply (for most)
Prescription Drug Benefit
Available to everyone with Medicare
Provides coverage for brand-name and generic drugs
Medicare contracts with private companies
Benefit started January 1, 2006
Extra help with drug cost available for many people with limited income and resources
Initial Enrollment Period
November 15, 2005 through May 15, 2006
Penalty of 1% per month added to monthly fee if
Enrollment is delayed and
Beneficiary is without “creditable coverage”
Coverage Varies by Plan
Select the Plan that meets your needs
Plans may not cover all drugs
Plans must give a 60-day notice if they decide not to cover a drug
Plans must have Appeals process
What to do if your Prescription Plan will not pay for your medicine?
Check with your doctor to see if he/she can switch you to a medicine that the plan will cover
If your medicine can not be changed ask your doctor to request an appeal on your behalf
Requesting a Coverage Determination or Appeal
Beneficiary can request
Prescribing physician can request
Others can assist with form completion, letter writing, etc.
Enrollment and Appeals Guidance http://www.cms.hhs.gov.gov/PrescriptionDrugCovContra/06_RxContracting_EnrollmentAppeals.asp
“ How to File a Complaint, Coverage Determination, or Appeal” http://www.medicare.gov/Publications/Pubs/pdf/1112.pdf
Premise Good oral health prevents pain, suffering, missed days of school or work and unnecessary costs due to dental treatment.
Why Is Good Oral Health Important?
Dental related illness causes poor children to “miss” 12 times more school days than children from higher income families
Poor oral health has been associated with other medical problems including heart disease and premature births
Is There An Oral Health Problem In Alabama?
Two out of five Alabama schoolchildren are estimated to have untreated tooth decay
Almost 70% of low-income children in Alabama did not visit a dentist last year
Is There An Oral Health Problem In Alabama?
Alabama has 30% fewer dentists per capita than the nation and our dentists are not distributed evenly (38 dentists in Alabama versus 54 per 100,000 population nationally)
One-third of all Alabamians over age 65 have no teeth, the 9th highest percentage in the country
Dental Program Vision Statement
To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child.
Alabama Medicaid Dental Program
Approximately 450,000 Medicaid eligible children with limited access to dental services
8 counties with no Medicaid dentists or one Medicaid dentist
Limited participation in other counties with most not accepting new Medicaid patients
Increased dental rates to 100% of BCBS 2001 rates
More procedure codes covered
Increased provider assistance
Made case management services available
Increased enrolled dentists to over 700
Where to begin?
Where do I find ______?
Alabama Medicaid Provider Manual
Provides All Information on Policy and Billing
Now Available on CD Rom
You are responsible for policies listed in the manual.
Appendix B Electronic Media Claims (EMC) Guidelines
Appendix E Medicaid Forms
Appendix G Non-Emergency Transportation (NET)
Appendix I Outpatient Hospital and ASC Procedures
Appendix J Explanation of Benefit Codes
Appendix K Third Party Carrier Codes
Appendix L AVRS Quick Reference Guide
Appendix N Medicaid Contact Information
Come On Board!!!
How do I become a provider?
For an enrollment application Contact
EDS provider enrollment unit 1-888-223-3630
Medicaid’s dental program 1-334-242-5997
EDS issues a 9 digit provider number (effective the first day of the month the application is received)
You must receive a provider number for each physical location where you perform services
Keep records for 3 years plus current
Provide same services to Medicaid patients as all other patients
Can bill recipients when services are non-covered or patient exceeded limits
Can limit number of patients seen, days seen or ages
Chapter Three--Eligibility Who is eligible?
Three important questions to ask…
Are they eligible?
Are they under the age of 21?
Do they have full Medicaid benefits?
Three Primary Ways 1. Provider Electronic Solutions Free Software provided by EDS. Quick response time – one at time or in batches 2. Automated Voice Response Toll free Number 1-800-727-7848 Available 23 hrs/day, 7 days per week 3. Secure Website: