Health Care Reform: What’s in it for Homeless Families and Youth?


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Health Care Reform: What’s in it for Homeless Families and Youth?

  1. 1. Health Care Reform: What’s in it for Homeless Families and Youth? Presented by: Martha Knisley Technical Assistance Collaborative, Inc. National Conference on Ending Family and Youth Homelessness February 18, 2014
  2. 2. Overview  Health Care Reform: What’s In it For Homeless Families and Youth?  Core Medicaid Concepts with HCF Updates  Medicaid Managed Care  Introduction: Louisiana’s PSH Program 2
  3. 3. What’s in Healthcare Reform for Families and Youth  An opportunity to extend Medicaid coverage for youth;  For families, it reduces potential burden of crippling healthcare costs;  If a parent gets sick, they can go to a doctor, miss fewer days of work and address potential complications from chronic disease; and  Eliminates denial for pre-existing conditions. 3
  4. 4. What’s in Healthcare Reform for Families and Youth Coverage Details: • ACA increases mandatory eligibility for youth ages 6 to 19 to 133% from 100% of FPL; children 0-5 already at 133% although some states are up to 185% for this age group (state option); • The ACA imposed MOE: states cannot reduce child eligibility for Medicaid or CHIP until after September 30, 2019; • Potential eligibility issues for some parents in states not expanding; 4
  5. 5. What’s in Healthcare Reform for Families and Youth • States must provide Medicaid for youth through their 19th birthday and some states are taking option to provide coverage up through age 21; • Under ACA states may not enroll parents and caretaker relatives in Medicaid unless the child(ren) that live with them are enrolled in Medicaid, CHIP, or other minimum essential coverage; • If child was enrolled in Title IV-E foster care at age 18, then they can stay on Medicaid until age 26; • Thirty-three states have continuous eligibility option (“churn”) that allows youth to stay on Medicaid/CHIP for a full year before renewal. 5
  6. 6. What’s in Healthcare Reform for Families and Youth • Providers can assist families and youth by providing enrollment information and assistance, helping gather documentation and providing assistance to make choices and better understanding options and categorical programs; • For providers serving youth this includes understanding EPSDT benefits, optional benefits and the CHIP (Children’s Health Insurance Program) in their state. 6
  7. 7. Core Concepts of Medicaid Coverage • Medicaid is first and foremost an Insurance Plan • Established through a Medicaid State Plan Key issues: • Contrast between Medicaid and Medicare • Eligibility and coverage groups • Means for covering services 7
  8. 8. Medicaid: Insurance Plan and More • Medicaid is a major payor of health care services in this country—over $500 billion annually with 55 million people enrolled; • Regardless of your state’s position on expansion, states cover a portion of Medicaid costs and the federal government pays a portion (FMAP); • The Medicaid “insurance plan” includes both mandatory and optional services; CMS and state Medicaid agencies also shape health policy; 8
  9. 9. Medicaid State Plan • The Medicaid State Plan is a written plan between a State and the Federal Government that outlines Medicaid: – eligibility standards; – provider requirements; – payment methods; and – health benefit packages; • A Medicaid State Plan is submitted by each State (continuously) and approved by the Centers for Medicare and Medicaid Services (CMS). 9
  10. 10. Medicaid State Plan States must, among other requirements: • ensure that services are provided in all parts of the state (the “statewideness” requirement); • establish or designate a single State agency to administer the plan; • require the State health agency to establish health standards for medical providers; • provide coverage to certain categorically eligible individuals; • provide services for all recipients in the same amount, duration and scope (the “comparability” requirement); • provide individualized plans of care for recipients. 10
  11. 11. Contrasting Medicaid and Medicare • The Medicaid program is a medical welfare program based on financial and functional need; • Applicants must meet income and asset eligibility requirements, or must demonstrate a qualifying disability or functional need for services; • Eligibility for Medicare is not based on financial need; • Medicare provides a standard benefit that provides partial coverage 11
  12. 12. Eligibility and Coverage Groups • Federal law and the state Plan establish: – eligibility rules, which include income, asset, citizenship, and residency requirements; – Mandatory and optional groups; – There are many requirements—and new options with ACA; • There are many “means” for covering services; • Regardless of target population, category of service or means, providers must meet state specific requirements and enroll in the state Medicaid program. 12
  13. 13. Eligibility and Coverage Groups • Optional coverage varies by type service and is influenced by categorical and mandatory requirements; • States analyze their costs • The ACA presents many new options and expanded FMAP for newly eligible beneficiaries, for Health Homes, other increases in expansion states. 13
  14. 14. 14 Mandatory Benefits Optional Benefits Essential Benefits • 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 (when licensed or otherwise recognized by the state) • Transportation to medical care • Tobacco cessation counseling for pregnant women • 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 • Dental Service; Dentures • Prosthetics; eyeglasses • Other practitioner services • Private duty nursing services; personal care • Hospice • Case management • Inpatient psychiatric services for individuals under age 21 Market Place (10 essential services): 1. ambulatory patient services 2. emergency services 3. Hospitalization 4. maternity and newborn care 5. mental health and substance use disorder services, including behavioral health treatment; 6. prescription drugs 7. rehabilitative and habilitative services and devices 8. laboratory services 9. preventive and wellness services and chronic disease management 10. pediatric services, including oral and vision care Coverages
  15. 15. Means for Covering Services • Medicaid is an individual benefit—thus costs for care vary by individual based on their use and need; • CMS and State Medicaid programs are continuously analyzing and creating options and costs: costs incurred and costs avoided; • CMS offers different “means” to states for flexibility--- including managing care through waivers and options; • State plan options 15
  16. 16. Health Care Reform: Medicaid Costs 16 Basic and preventive services —for all Extensive Use/ Chronic care Deep End
  17. 17. Coverages • The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid; • Under EPSDT, states are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. 17
  18. 18. Coverages EPSDT is made up of the following screening, diagnostic, and treatment services: – Screening Services – Vision Services – Dental Services – Hearing Services – Other Necessary Health Care Services – Diagnostic Services – Treatment 18
  19. 19. Coverages • Another means of covering services is through “waivers”; • Waivers permit states to be excused from one or more of the Medicaid State Plan requirements – an example of this is the “statewideness” requirement; • The Affordable Care Act also provides some new options for coverage through State Plan Amendments; • One word on HCBS. 19
  20. 20. Homeless Service Provider Options • Many organizations serving homeless families and youth are also Medicaid providers; • And/ or organizations can assist with enrollment and helping families and youth gain access to needed services; • How do you decide what works for your organization? – There is a role for every organization, healthcare matters 20
  21. 21. Three Steps for Providers to Examine Options • Crosswalk your services, provider qualifications, mgmt. capacity with requirements for specific Medicaid programs/ services; • “Map” the Medicaid system for persons who you serve from: enrollment referral assessment individualized plan service delivery (may need to authorized or approved at several points) and then repeated with re-evaluations and redeterminations. • Establish an agency business plan with multiple options. 21
  22. 22. Basics: Medicaid Managed Care • States “manage” care by enrolling people into managed care plans; either on a voluntary or mandatory basis; • States can implement a managed care delivery system using three basic types of federal authorities: • State plan authority [Section 1932(a)] • Waiver authority [Section 1915 (a) and (b)] • Waiver authority [Section 1115] • Regardless of the authority, states must comply with the federal regulations that govern managed care delivery systems. 22
  23. 23. Basics: Medicaid Managed Care • All three types of authorities give states the flexibility to not comply with statewideness, comparability and freedom of choice requirements; • States also have options types of approaches and for paying managed care organizations: – MCOs through a fully capitated model or – Primary Care Case Management arrangements. • There are literally dozens of models and hundreds of organizations managing Medicaid benefits across the country. 23
  24. 24. What’s In It: Medicaid Managed Care • Components (established with a mix of federal and state requirements) : – Establish networks; – Qualify providers; – Establish medical or clinical homes; – Pay providers negotiated or fixed fees for services, per diems or per episode; – Authorize and/or approve services; – Assure access---to programs and services; – Manage utilization and care; manage formulary; – Meet quality standards. 24
  25. 25. Louisiana PSH • A strong coalition of advocates, state leaders, providers and political leaders created the Louisiana PSH program as part of the state’s recovery hurricane effort in 2006; • This effort grew to include 3000 subsidies including 2000 PBV and 1000 S+C subsidies and $69 million for “start up” services; and • a significant change in Louisiana’s Medicaid program five years later; 25 Single family units in Jefferson Parish
  26. 26. Louisiana PSH 26 • PSH model is permanent, cross disability largely scattered site with families and single adults holding their own leases and getting assistance from local service providers; • Early efforts created nearly 1,000 units as set asides in LIHTC programs—today tenants in those units get Section 8 PBVThe Preserve in New Orleans • Over 60% of participants were homeless at time they entered the program
  27. 27. 27 Good Luck!! Resources: TAC Website: Contact Info: