MedicaidMedicaid 101 101

Stacey ShumanNative American Contact

Region VI, DallasCenters for Medicare & Medicaid Services

• CMS/IHS partnership for Indian health care

– Working together to meet the challenge

• CMS revenue and Indian health programs

• Importance of enrolling AI/AN in Medicare, Medicaid

and CHIP

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CMS Programs and AI/AN health

• States Determine:– Who is covered– How providers are paid– What services are covered

• CMS Provides:– Oversight of Program– Technical Assistance– Federal Matching Funds

Medicaid Administration

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• Mandatory Categorically Needy Groups - Required by Statute– Children and Families– Pregnant Women– Disabled and Aged Individuals

• Optional Categorically Needy Groups – States Select

• Medically Needy – States Select• Tribal Documents must now be accepted as

proof of citizenship and identity for Medicaid and CHIP

Medicaid - Who is Covered?

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• Exemptions from Resource tests include:– Property held in trust or under the

supervision of the Secretary of Interior (BIA)• IIM Accounts - Restricted or unrestricted• Monies paid out from exempt resources are

treated as exempt asset conversions,• NOT INCOME in the month of receipt

Resource Exemptions for AI/AN

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• Exemptions from Resource tests include:– Property located on a reservation or

within the most recent boundaries of a reservation• Real property and improvements• Ownership interest in: Rents, Leases,

Royalties, Usage rights• For use of: Natural resources,

Fish/shellfish, Harvesting animals, Harvesting plants or timber

Resource Exemptions for AI/AN

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• Also excluded are items with religious, spiritual, traditional or cultural significance or used to support subsistence or a traditional lifestyle according to tribal law or custom.

• Monies received for usage or ownership rights for excluded resources are – NOT income in the month of receipt– May be countable as a resource the first of the

following month

Resource Exemptions for AI/AN

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• State Medicaid Agency Staff• TANF Agencies (State Agencies or

County Agencies)• Tribes Who Administer TANF

– The State must enter into interagency agreements with other State Agencies, County Agencies or TANF Tribes, if they are going to do eligibility determinations.

Medicaid - Who Can Determine Eligibility?

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States must provide outstationing opportunities to

apply for family and children’s Medicaid at all

Tribal 638 programs (FQHC authority) and Urban Indian Health programs or have an alternate plan approved by

CMS.

Special Provisions in Medicaid

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• CMS Support for Health Fairs, Local Outreach Events

• Outreach Grants– General CHIP Outreach Grants– Outreach Grants for Indian

Children– Future Outreach Opportunities

Enrollment Opportunities

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• Outstationing• Tribal Eligibility Offices• CHIPRA Grantees• Online Applications• Develop Partnership with

States and Local Offices

Enrollment Opportunities

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• State Program Web Sites• State Eligibility Manuals• Attend State Training Sessions if

Possible• Enroll and Attend Training to be

SHIPs (State Health Insurance Program)

• Attend Area Training Sessions

Eligibility Requirements

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• Mandatory Services• Optional Services • All Medically Necessary Services

for Children under 21, whether or not the State has elected the service

• States also must assure Transportation to Medicaid covered appointments

What Does Medicaid Cover?

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• Review Provider Manuals• Review State Plans for

Coverage Groups and Covered Services

• Become familiar with Covered Services

• Review Eligibility Manuals

Maximize Utilization

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• States design payment methodology, within Federal upper limit and other regulatory requirements.

• Medicaid is the payer of last resort, except– Indian Health Service is the payer

of last resort after all CMS programs.

Payment for Medicaid Services

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• Obtain NPI• Enroll as a provider

• States where program operates

• Enroll as Primary Care Provider for programs operated in Managed Care environment

• Make Sure ALL Tribal Programs are Enrolled

I/T/U Enrollment as Providers

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• Work with State Contacts, Managed Care Plans to determine trends, billing errors

• Work with Coders– Provide training– Support Coders– Provide resources needed– Work with Medical professionals on

charting, etc., to make sure everything is captured

Billing for Services Provided

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• Nominal cost sharing for Medicaid services can be charged.– Children under 18 cannot be

charged cost sharing– AI/AN who use I/T/Us and

Contract Health Service (CHS) are exempt from cost sharing in certain circumstances.

Cost Sharing in Medicaid

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• AI/AN who utilize or are eligible to utilize I/T/Us are exempt from Premiums and Enrollment fees.– I/T/U should provide a letter or

document for the individual to take to the State.

– IHS provided a letter that can be used by I/T/Us to verify this exemption.

Cost Sharing Exemptions for AI/AN

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• AI/AN who have ever received an I/T/U service are exempt from coinsurance, deductibles or copayments.

• I/T/U can provide a letter or document for the individual to take to the State.

• IHS provided a letter that can be used by I/T/Us to verify this exemption.

Cost Sharing Exemptions for AI/AN

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• Properties exempt from Medicaid estate recovery action:– Property located on a reservation or within

the most recent boundaries of a reservation• Real property and improvements• Ownership interest in: Rents, Leases,

Royalties, Usage rights• For use of: Natural resources,

Fish/shellfish, Harvesting animals, Harvesting plants or timber

Estate Recovery Protections for AI/AN

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• Items with religious, spiritual, traditional or cultural significance or used to support subsistence or a traditional lifestyle according to tribal law or custom.

• Ownership interests left as a remainder in an estate in rents, leases, royalties or usage rights in listed properties, as long as they can be clearly identified as such.

Estate Recovery Protections for AI/AN

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• An AI/AN enrolled in managed care can choose to utilize an I/T/U– Managed Care plan must pay the

I/T/U a negotiated rate or not less than their normal payment for the service to a participating provider

– State must assure the I/T/U receives payment up to the normal State Plan rate for that facility

Managed Care Protections for AI/AN and I/T/Us

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• Prior to submitting a proposed change to CMS, States must seek advice from I/T/Us for any Medicaid change likely to have a direct impact on an AI/AN person or an I/T/U– State Plan Changes– Demonstration Proposals– Waiver proposals, amendments,

extensions, renewals

Consultation Requirements

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100% Federal Financial Participation for services provided through IHS or Tribal 638 Clinics.

Special Medicaid Provisions

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• Urban & Tribal Indian Health Clinics can bill as FQHCs—(defined as FQHCs in the law) cost based reimbursement.

• Tribes and Tribal Organizations can enter agreements with States to provide Medicaid Administrative Match to draw federal funds.– Any federal funds drawn by states based

upon Tribal matching costs must be given to the Tribe or Tribal Organization.

Other Special Provisions in Medicaid

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CHIP 101CHIP 101The Children’s Health Insurance The Children’s Health Insurance

ProgramProgramThe Children’s Health Insurance

Program Crystal FrancisNative American Contact

Region IV, AtlantaCenters for Medicare & Medicaid Services

• State – Federal Partnership– Broader State Flexibility than Medicaid

• Can be Medicaid Expansion• Can be Separate Insurance Program• Can be Combination Medicaid and

Separate Insurance• Can be 1115 Waiver

– States receive higher (enhanced) Federal Matching Rate (FMAP)

CHIP Administration

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• Basic Medical Services– Inpatient/Outpatient– Preventive Services– Physician/Clinic– Immunizations

• Can be modeled after private sector insurance plans—more options for coverage than Medicaid

What Does CHIP Cover

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• Managed care protections in Medicaid also apply to CHIP

• Resource exclusions for Medicaid also apply to CHIP

• Tribal Documents must now be accepted as proof of citizenship and identity for Medicaid and CHIP

Special Provisions in CHIP

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– American Indian/Alaska Native Children are exempt from the cost sharing provisions of CHIP

– States must seek advice from I/T/Us prior to submitting to CMS for State Plan Amendments, Demonstration proposals, Waiver proposals, waiver amendments, waiver extensions and waiver renewals if they are likely to have a direct impact on Indians or Indian health providers.

Special Provisions in CHIP

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• Medicaid – Eligibility Decision in 45 days– Fair Hearing Process if Negative Decision– Appeal if payment or service is denied

• CHIP– Eligibility Decision in 30-45 days – Fair Hearing Process if Negative Decision– Appeal if payment or service is denied

Applicant Rights

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Medicaid and Indian Health:Simplifying and Strengthening Eligibility

under Health Care Reform

Pamela Carson and Crystal Francis

Centers for Medicare & Medicaid Services

Key Components of Medicaid Eligibility

Under Health Care Reform

• Medicaid coverage for everyone with household income under 133 percent FPL• Eligibility based on “household income” and “modified adjusted gross income” - No asset tests - Disregards no longer apply• Alignment with Exchange and CHIP

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Guidance Available

Patient Protection and Affordable Care Act (ACA) Notice of Proposed Rule Making (NPRM) Other Guidance on ACA has been issued:

- State Health Official (SHO) Letters- State Medicaid Director (SMD) Letters- Final Rules- Informational Bulletins

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SMD 11-001:Tobacco Cessation Services

http://www.cms.gov/smdl/downloads/SMD11-007.pdf

Guidance on Medicaid coverage of tobacco cessation services

Encourages States to provide tobacco cessation services for all Medicaid beneficiaries- Mandatory for Pregnant Females- Optional Service for all other Medicaid Beneficiaries

Clarifies that telephone “quit lines” will be coverable for the first time, as an option

Effective June 24, 2011

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SMD 11-004:Electronic Health Record (EHR)

Incentive Programshttp://www.cms.gov/smdl/downloads/SMD11004.pdf

ARRA established the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

Expands on SMD Issued August 17, 2010 Criteria for Health Information Exchange Promotion

-Costs based on the fair share principle and appropriately allocated- Must leverage efficiencies with other Health Information Exchange funding- Activities must be developmental and time-limited.

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FQHCs for the Medicaid Electronic Health Record (EHR) Incentive

Program http://questions.cms.hhs.gov/app/answers/detail/a_id/10417/kw/tribal/session/L3NpZC8xbVN1S0F3aw%3D%3D

Tribal Clinics were required to be paid as Federally Qualified Health Centers (FQHCs) for the Medicaid EHR Incentive Program

Guidance was corrected after stakeholder feedback.Tribal clinics are eligible for Medicaid EHR Incentive

ProgramEligible professionals in Tribal Clinics may be

subject to the “needy individual patient volume threshold, rather than the “Medicaid patient volume threshold.”

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Guidance for Exchange and Medicaid Information

Technology (IT) Systemshttp://www.cms.gov/Medicaid-Information-Technology-MIT/Downloads/exchangemedicaiditguidance.pdf

CMS released “Exchange/Medicaid IT Guidance

2.0” on May 31, 2011. Support of Exchanges, Medicaid and Children's Health Insurance Programs for coverage under the Affordable Care Act. Describes the data services hub supporting State systems.

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NPRM:Helping People with Disabilities

Live in Their Communitieshttp://edocket.access.gpo.gov/2011/pdf/2011-9116.pdf

Published in Federal Register February 25, 2011– 1915(k) provides States the opportunity to cover

HCBS attendant services and supports for Medicaid eligible individuals with incomes not exceeding 150% of the federal poverty level

Published in Federal Register April 15, 2011– States would no longer need separate waivers to

provide HCBS to the elderly, people with physical and intellectual disabilities, and those with mental illness (1915c waiver).

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Concurrent Hospice Care for Children

in Medicaid and CHIPhttps://www.cms.gov/smdl/downloads/SMD10018.pdf

SMD Letter 10-018 released September 2010 Guidance on implementation of Section 2301 of the

Affordable Care Act- Hospice services are an optional benefit under Medicaid and CHIP- Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provision requires Medicaid and CHIP programs operating as Medicaid expansions to provide all medically necessary services, including hospice services, to individuals under age 21.

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Dental Services in FQHCs

CHIPRA section 501(d) States may not prevent a Federally-Qualified

Health Center (FQHC) from entering into contractual relationships with private practice dental providers in the provision of FQHC services.

Dental services furnished off-site by private dental providers who contract with FQHCs will be covered by Medicaid and CHIP as FQHC services

Oral Health Strategy is available on the CMS website.

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NPRM:Access to Covered Medicaid

Serviceshttp://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/2011-10681.pdf

Published in Federal Register May 6, 2011Create a standardized, transparent process to

assure that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers

Affects only Medicaid Fee-for-Service PaymentsPublic notice to providers is required when

changing Medicaid payment methods and standards.

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Model Interstate Coordination Process

http://www.cms.gov/CHIPRA/Downloads/InterstateCoordination.pdf

CMS required to develop a model process to coordinate Medicaid and CHIP enrollment, retention and access to care for children who frequently change their address.

Secretary must submit a Report to CongressCMS released a model process for interstate

coordination in July 2010

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SMD 11-008:Financial Models Supporting

Integrated Carehttp://www.cms.gov/smdl/downloads/Financial_Models_Supporting_Integrated_Care_SMD.pdf

CMS is outlining two models for States pursuing integration of primary, acute, behavioral health and long term services and supports for their full benefit Medicare-Medicaid enrollees.

- Capitated approach to integration for Medicare-Medicaid enrollees

- Managed fee-for-service (FFS) approach to integration. States need to submit a letter of intent by October 1, 2011 to initiate the process.Target implementation December 31, 2012

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SMD 10-07 & SMD 11-003 :National Correct Coding Initiative

(NCCI) Methodologies

http://www.cms.gov/smdl/downloads/SMD11003.pdf

Clarifies the non-applicability of the appeals component of the five National Correct Coding Initiative (NCCI) methodologies

CMS Must Notify States:(1) Medicare NCCI methodologies “compatible” with claims filed with Medicaid(2) NCCI methodologies for claims filed with Medicaid for which no national correct coding methodology has been established for Medicare; and (3) How they must incorporate these methodologies for claims filed under Medicaid.

States are Not Obligated to Implement the Appeals Component

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SHO 11-001:CHIPRA Quality Measures

http://www.cms.gov/smdl/downloads/SHO11001.pdf

Launched the “CHIPRA Technical Assistance and Analytic Support Program” to support child health care quality measurement, reporting, and improvement efforts.

- Provide information and support to uniformly collect, calculate, and report the core measures;

- Ensure that the data collected is used to inform decisions about policies, programs, and practices to improve quality of care; and

- Share emerging best practices and lessons learned.

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Proposed Rule:Affordable Insurance

Exchangeshttp://www.ofr.gov/OFRUpload/OFRData/2011-17610_PI.pdf

Framework to assist States in building Affordable Insurance Exchanges

Provides Guidance and Options on How to Structure Exchange:- Setting standards for establishing Exchanges, setting up a Small Business Health Options Program (SHOP), performing the basic functions of an Exchange, and certifying health plans for participation in the Exchange, and;

- Ensuring premium stability for plans and enrollees in the Exchange

Comment period ends September 28, 2011 Regional listening sessions and meetings will be established

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NPRM:Home Health Services

http://www.gpo.gov/fdsys/pkg/FR-2011-07-12/pdf/2011-16937.pdf

Issued July 5, 2011Provides Guidance on Home Health Services

- Physicians must document the face-to-face encounter with Medicaid Individual- Home health services cannot be restricted to the home- Includes a definition of medical supplies, equipment and appliances

Effective January 1, 2010

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Recent NPRMS

Issued August 12, 2011The Medicaid Program; Eligibility Changes

under the Affordable Care Act of 2010, CMS-2349-P;

Patient Protection and Affordable Care Act:  Establishment of Exchanges and Qualified Health Plans; proposed rule; CMS-9989-P; and

The IRS Health Insurance Premium Tax Credit, REG-131491-10

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Pamela Carson Native American ContactRegion V Chicago Centers for Medicare & Medicaid Services

Centers for Medicare & Medicaid Services

CMS Resources

CMS Resources to Assist Tribes

• At each CMS Regional office, there is a Native American Contact (NAC) who is available to provide technical assistance to Tribal programs

• Contact your NAC if your tribal program has questions about eligibility, enrollment, coverage or reimbursements in Medicare, Medicaid and CHIP.

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CMS Resources to Assist Tribes

• NACs work with the Tribal Affairs Group (TAG) , Office of External Affairs, CMS, located in Baltimore

• NACs also work with key CMS components in Medicare, Medicaid and CHIP

• The Tribal Affairs Group and NACs serve as a liaison between the Agency and Tribal communities and other Federal Agencies in regards to AI/AN health and CMS programs.

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Role of the NAC

• Point of contact for Tribes and States in each regional office for AI/AN Issues– Coordinate with other RO Staff– Technical assistance on AI/AN State Plan

Amendments– Review State Plan Amendments, State Programs

for AI/AN Impact– Assist IHS/Tribes with eligibility, coverage and

reimbursement issues– Assist IHS/Tribes with Medicare Like Rates

questions and enforcement

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Role of the NAC

• Provide training and information to States and Tribes on AI/AN Issues

• Work on policy groups for AI/AN issues• Encourage and facilitate consultation and

relationship between States and Tribes• Distribute program information Materials

designed for AI/AN population to Tribes and IHS

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Role of the NAC

• Contribute to planning and resource sessions for annual HHS Tribal Consultation

• Work with CMS campaigns and focus to adapt to the AI/AN population

• Help assure access for AI/AN to CMS programs

• Assist IHS/Tribal facilities with Certification issues

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CMS/IHS Activities

• TTAG Meetings• All Tribes Calls• Medicine Dish Broadcasts• Training and Information at IHS National Meetings• Regional Conference Calls or Meetings• Organizations

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CMS Resources to Assist Tribes

www.cms.hhs.gov American Indian/Alaska Native Information

Special flyers/materialsMedicare Learning NetworkProvider Enrollment Forms

www.medicare.govMedicare Part D Enrollment

Preventive ServicesSearch Tools

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CMS Resources to Assist Tribes

http://www.cms.gov/center/ir.aspa Spotlight

Important Links Special Topics for Tribal Health

Providers Helpful External Resources

CMS Tribal Contacts

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CMS Resources to Assist Tribes

• www.videocast.nih.gov. Previous “Medicine Dish” programs

can be seen on the National Institute of health website

►Go to – http://videocast.nih.gov

►Click on Past Events

► Select Centers for Medicare & Medicaid Services

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