Transcript No Slide Title

Medicare & Medicaid
Recent Advances
Mary B. Tierney, MD
Keynote, International Society of
Psychiatric-Mental Health Nurses
April 2006
Denver, Colorado
Background and History
Social Security Act
 Title I — Old Age Assistance/Social Security
 Title IV —TANF and Foster Care
 Title V — Maternal and Child Health Block Grant
 Title XVI — SSI/Aged Blind and Disabled
 Title XVIII — Medicare
 Title XIX — Medicaid
 Title XXI — SCHIP
Medicare & Medicaid
Eligibility Requirements and
Options
Federally Funded Insurance and
Eligibility Requirements
 INSURANCE
 Medicare/Title
XVIII of the
Social Security
Act
 ELIGIBILITY
 Title I of the
Social Security
Act/Social
Security
 End Stage Renal
Disease
Federally Funded Insurance and
Eligibility Requirements - Medicaid


INSURANCE
Medicaid/TitleXIX of the Social Security Act




ELIGIBILITY
TANF
SSI
Multiple other categories that are de-linked
from “welfare” such as TANF

State Children’s Health Insurance
Program/Title XXI of the Social Security Act




Flexible eligibility
Medicaid expansion
Separate Program
Combination of the two
MANDATORY & OPTIONAL
COVERAGE - Medicaid
 MANDATORY
 TANF
 SSI
 Pregnant Women & Children
 Low Income Children under
19 years
 Foster Care and Adoption
Assistance
 OPTIONAL
 Infants to age 1 year
 Non-institutionalized
Disabled Children
 Home and Community
Based Services
 Children meeting income
requirements but not
TANF eligible
SUMMARY
 Medicare eligibility is relatively narrowly defined
 Medicaid is complex, broad, expansive and
variable
Medicare & Medicaid
Services & Benefits
MEDICARE BENEFITS
 Part A – Hospital & Skilled Nursing Facilities
 Part B – Supplementary Services includes
Physician Services, diagnostic services,
supplies, PT, psychologists, radiology and
therapeutic services
 Therapeutic rather than preventive
MMA Benefit
 One time initial wellness physical
examination within 6 months of
enrollment
 Screening for heart disease and diabetes
 Added to cancer screenings, bone mass
measurement and vaccinations
 Prescription drug benefit
Medicaid Services
 Inpatient hospital
 Nursing Facilities
services
other than IMD for
over age 21 years
 Outpatient hospital
services
 EPSDT under age
21 years
 Rural Health Clinic
Services
 Family Planning
 Federally Qualified  Physician services
Health Centers
Medicaid Services
 Medical and dental
 Health care by
surgical services
licensed practitioners
(e.g. Psychologists)
 Pediatric and Family
Practice Nurse
 Laboratory and X-Ray
Practitioners
 Home Health
 Nurse Midwives
Optional Services
 Physical and Occupational Therapy
 Prescription Drugs
 Rehabilitation Option
 Clinic Option
 Targeted Case Management
 Any other medical or remedial care
recognized under State law and specified
by the Secretary of HHS
EPSDT
 A Benefit Under Medicaid: birth -21 years
 Mandates a Set of Benefits Including
Preventive, Diagnostic, and Treatment
Services, Such as Health Histories;
Physical Examinations; Developmental
Assessments; Vision, Hearing and Dental
Services; Immunizations
 Mandates Screening for Both Physical
and Mental Health Issues
EPSDT
Diagnosis and Treatment
 When screening examinations so indicate.
 What services — all services covered under
the state plan and any additional services
(diagnostic or therapeutic) that are round
necessary to diagnose and treat conditions
found as a result of a screen regardless of
any limitations under the state plan
WAIVERS
 1915 [b] mental health carve out
 1915[c] home and community-based waivers
 1115 waivers
SUMMARY
 Medicaid services are much broader and deeper than
Medicare and private health insurance especially for
behavioral health services
 Medicaid services for children and adolescents are
much broader and deeper than those for adults over
21 years
 Much of the differential is due to EPSDT
Trends in Medicare
and Medicaid
Growth in Medicare Spending as a Share of GDP and
in Beneficiaries as a Share of Total Population
25.00%
Medicare as a Share of GDP
23.4%
22.1%
Prescription Drug Benefit as a share of
Medicare
20.00%
Medicare as share of the population
18.3%
15.00%
14.8%
13.2%
13.8%
12.1%
10.00%
9.5%
8.41%
6.95%
5.00%
5.08%
3.66%
0.00%
0.70%
1.32%
1.90%
2.29%
1970
1980
1990
2000
0.78%
1.31%
1.84%
2.14%
2010
2020
2030
2040
Largest Health Care and
Financing Program
 Medicaid Spending in FY 2004 ~ $300 billion
(compared to Medicare ~ $290 billion)
 Health coverage for over 59 million in U.S. at
some point during the year (Compared to
Medicare: 43 million)
 Medicaid covers more than 17% of the population
 Medicaid funds over half of publicly financed
mental health services in U.S.
Sources: CMS, CBO Medicaid Baseline March 2006
Medicaid Enrollees by Eligibility Group
Children historically represent the largest eligibility group of Medicaid enrollees.
Persons Served (in millions)
50
Age 65 & Older
Children Under 21
Other**
2004 Total :
52 million
Blind & Disabled
Adults
Adults:
13 million
40
30
Children Under Age
21:
25 million
20
10
Blind & Disabled:
9 million
0
1975
1980
1985
1990
1995
2000
2004
Age 65 & Older:
5 million
Fiscal Year
Note: “Adults” refers to non-elderly, non-disabled adults; disabled children are included in the blind & disabled category.
**The ”Other” category was dropped in 1999.
Source: CMS, CMSO, Medicaid Statistical Information System, CBO.
Medicaid Enrollment and
Eligibility Milestones, 1965-2006
60
59 Million
Beneficiaries
Millions of Medicaid Beneficiaries during year
Section 1115 Waivers Expand
Medicaid Eligibility (1991-1993)
50
40
Recession and
State Fiscal
Crisis
(2001-2004)
30
20
Medicaid Eligibility Expanded to
Women and Children (1984-1990)
10
AFDC
Repealed
(1996)
0
1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004
Medicaid
Enacted
(1965)
SSI
Enacted
(1972)
SCHIP
Enacted
(1997)
SOURCE: Kaiser Commission on Medicaid and the Uninsured analysis of data from the
Centers for Medicare and Medicaid Services, 2004. CBO March 2005 Medicaid Baseline.
New Trends in Medicare
Medicare Prescription Drug
Improvement and Modernization Act
of 2003
(MMA)
MMA Drug Benefit
 Full implementation of prescription drug
benefit in 2006
 Choose a prescription drug plan and pay
a premium of $35/month
 Cost sharing with Medicare depending
upon the amount spent
 Managed Care Option
Beneficiary and Government Share of Spending in
2006, at Individual Expenditure Levels, Under the
New Medicare Drug Benefit
Beneficiaries Share
Plan/Government Share
$15,530
$10,830
$6,155
$4,220
$1,500
$2,355
$1,500
$1,500
$562
$438
$1,000
$1,312
$688
$2,000
$1,500
$3,000
$2,500
$4,000
$3,500
$3,645
$3,780
$3,845
$4,170
$4,470
$5,000
$6,000
$8,000
$10,000
$15,000
$20,000
Individual's Total Annual Drug Expenditures
Source: Congressional Budget Office estimates
Beneficiary and Government Share of Spending in 2006,
at Individual Expenditure Levels, Under the New
Medicare Drug Benefit
100%
90%
80%
28%
34%
44%
22%
38%
47%
50%
70%
61%
63%
70%
60%
50%
40%
30%
72%
66%
56%
78%
62%
53%
50%
20%
39%
38%
30%
10%
0%
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$8,000
$10,000
$15,000
$20,000
Individual's Total Annual Drug Expenditures
Plan/Government Share
Beneficiaries Share
Source: Congressional Budget Office estimates
Medicare Population by Level of
Prescription Drug Spending
>$5,100
15%
<$250
25%
$2,251-$5,100
27%
$251-$2,250
33%
Source: Congressional Budget Office estimates
RECENT DEVELOPMENTS
 Major problems with implementation
 Multiple choices in drug coverage plans and variation
in what drugs are covered by plan
 Delay in ability to sign up for program due to
bureaucratic “glitches”
 Major problems in serving people eligible for both
Medicare and Medicaid [“Dual Eligibles”]
RECENT DEVELOPMENTS
 Major impact on the Medicaid budgets
 State Medicaid agencies are continuing to
cover the “dual eligibles”
 Recent Federal response to Medicaid agencies
continuation of coverage
RECENT CHANGES IN THE
MEDICAID PROGRAM
 Increased economic pressure on the States because of the:
 Problems with the Medicare prescription drug benefit for “dual
eligibles” and the “Claw Back” provision
 The effects of “Katrina” and people losing health insurance
through their jobs
 Reduction in the Federal Medicaid match of $10 billion
RECENT CHANGES IN THE
MEDICAID PROGRAM
 Katrina: individuals and families lost private health insurance
due to the devastation in the Gulf Coast
 Medicaid will cover those individuals through an waiver of
Federal Regulations
 Individuals will be covered in the States in which they and their
families will be living
 Pressure could be on Medicaid programs that are “optional”
including mental health services, especially those that are
community based
RECENT CHANGES IN THE
MEDICAID PROGRAM

$10 billion reduction in Medicaid: Federal legislative changes put financial pressure to cut
services including behavioral health

Changes in eligibility and services provided to different categories of people who are enrolled in
Medicaid

Also there are major changes in the Deficit Reduction Act that reducing the scope of important
programs that serve children and adults with behavioral health issues including:
- Targeted Case Management
- EPSDT
- Rehab option
Deficit Reduction Act:
Major Implications for Medicaid
 Requires proof of citizenship
 Limits Targeted Case Management
 Gives states authority (for some groups of
children and adults) to
 Offer alternative benefit packages
 Require premiums
 Require coinsurance
 Require copayments to be paid before a service
 Allows coverage of certain disabled children
 Born in 2001 or after
 Allows premiums up to 7.5% of income
TCM Changes
 No Medicaid $ for foster care services -whether paid thru Title IV-E or state (reinforces
current rules)
 Nor if any other third party liable to pay for
service, including:
as reimbursement under a medical, social,
educational or other program
S-CHP-Like Benchmark Plans
 States may move certain groups into plans
(requirements re plans same as under S-CHIP).
Private insurance model
 Exceptions: SSI, disabled, CW children, those with
any spend-down requirements, TEFRA children and
TANF-recipients
 State must provide wraparound EPSDT benefit to
children under 19 ; unclear for children 19+
Premiums & Copays
 New state options
 No cost sharing for those in poverty
 100-150% FPL no premium; 10% copays,
capped at 5% family income
 Over 150% FPL premiums, 20% copays; total
capped at 5% family income
 All indexed to medical inflation
Penalities for non payment
 State may terminate Medicaid if some or all
premium is unpaid
 State may permit providers to deny services if
copayments not met
Providers may waiver this requirement on a case by
case basis
Who Can/Cannot be Charged
 For children:
 No premiums or cost sharing for children under 18 in
mandatory eligibility groups (including IV-E & IV-B kids
regardless of age)
 No cost sharing for emergency services
 For drugs:
 Up to 20% of cost of drug for families 150% FPL or above,
nominal amounts for others
Budget Bill Plusses
 Family Opportunity Act phased in:
 Family income above Medicaid but under 300% FPL
($58,500) can buy into Medicaid at state option for disabled
child under age 19
 Phased in by age: those 6 or under in 2007; 13 or under in
2008, under 19 in 2009.
 State can charge sliding scale premiums – no more than 5%
income if under 200% FPL; 7.5% income if 200-300% FPL
Budget Bill Plusses
 Authorizes 10 state demonstrations of home &
community-based services waiver for children
in RTCs
Begins in 2007
For children in demo when it ends, state may
continue to provide H&CB services
Budget neutrality and other rules the same as
current H&CB waiver rules
Budget Bill Plusses
 Authorizes 10 state demonstrations of home &
community-based services waiver for children
in RTCs
Begins in 2007
For children in demo when it ends, state may
continue to provide H&CB services
Budget neutrality and other rules the same as
current H&CB waiver rules
YOUR THOUGHTS
Contact Information
Mary B. Tierney, MD
202-403-5620
[email protected]