Learn 90% of What You Need to Know to Succeed in the Medicaid Industry in Under 90 Minutes

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MEDICAID CRASH COURSE

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NOTE: The info below gives you an idea of the basic content and features of the Medicaid Crash Course. See the sneak peek for the actual table of contents and excerpts from different parts of the book.

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What is the Medicaid Crash Course ©?

The Medicaid Crash Course © is an in-depth whitepaper that covers all major topics in the Medicaid industry in a way that allows the reader to get up to speed quickly.

Who is the Medicaid Crash Course © designed for?

People working in the Medicaid industry for less than 3 years. The main audience includes consultants, doctors, analysts, government officials, business owners, IT professionals and others.

How is this different from information I can get from other sources like the Kaiser Family Foundation, Urban Institute, and other sources?

There are many, many great sources of information about Medicaid out there. The main value of the crash course is:

1. It covers a broad array of topics, in depth IN ONE PLACE, saving you a lot of time searching and piecing together different concepts

2. It is FACT-BASED, NOT ADVOCACY FOCUSED. The vast majority of information about Medicaid is driven by particular agendas (whether to increase or decrease spending, coverage, etc). Very little information is focused on what you need to know from a basic information stand-point. The Crash Course acknowledges that the Medicaid profession really is an industry, with people and groups that benefit politically and financially.

3. It GETS RIGHT TO THE POINT, with the RIGHT BALANCE of DETAIL and BIG PICTURE.

How does it cover so much ground, and still communicate information effectively? Do you think the claim “Learn 90% of what you need to know to succeed in the Medicaid Industry in Under 90 minutes” is true?

The Crash Course is designed using several important features to engage the reader and make conceptual understanding easier. And yes, we do think the claim is true.

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KEY FEATURES of the MEDICAID CRASH COURSE

Features of the Crash Course

?

Question-based format

Focus on Main Concepts

Visual presentation of

information

Links to Further Reading

Fly-outs and

Sidebars Discussion of Key

Players Section

Summaries Topical Index

Question format for easy, but in-depth understanding of a broad range on industry topics

All of the information is presented in an easy to understand question format. The 6 major questions covered are:

1. What is Medicaid?

2. Who can get Medicaid?

3. What is the difference between Medicaid and Medicare?

4. What is the State Children’s Health Insurance Program?

5. What is the history of Medicaid?

6. What are the big issues in Medicaid today?

Main concepts

The main concepts needed to understand the topics are introduced early in each question. The discussion builds off of these concepts to help the reader quickly engage with the material, to retain more of the information and to be able to think for themselves about the issues.

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Visual presentation of information and concepts

A picture is worth more than a 1,000 words – and the Crash Course uses pictures throughout to help communicate more information clearly.

Fly-outs and sidebars

Sometimes you may want to finish off the main topic being discussed –

and sometimes you may want to wander off into related info. The fly-outs and sidebars bring in related information in a way that allows you to choose how to deep to go.

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Key players

Where appropriate, the key players involved in any one topic are identified. It is helpful to know who gains or loses in any issue to fully understand the issue.

Further reading

No one can write a document that tells you everything about any subject. After each major section, we provide you a list of links that allow you to easily explore more about the topics that are interesting to you. With the foundational concepts and understanding you get from the Medicaid Crash Course©, you will be equipped to build upon your new-found Medicaid expertise.

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Summaries

Instead of just diving into any major topic, there are insightful summaries at the beginning of each section to help prepare you to learn.

Index

Maybe you don’t want to read it all in one sitting – the topic index at the back allows you to read at your pace and serves as a reference tool even after you are done.

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Disagreements in the industry

Ever wonder how things could be as cut and dry in the Medicaid industry as some folks would have you think? That’s because they’re not. Medicaid is complex. It helps to hear both sides of a story, and that’s what the “Disagreements in the Industry” sections help you do.

Table of Contents Q1: What is Medicaid? ………………………………………………………………….3

Main Concepts …………………………………………………………………….4

How Medicaid Works in 2 Easy Steps …………………………………………..5

Types of services covered by Medicaid …………………………………………..6

Key Players …………………………………………………………………………..…9

Disagreements in the Medicaid Industry ………………….………………………10

Further Reading for “What is Medicaid?” ……………………….…………………11

Q2: What is the difference between MediCAID and MediCARE? …………..…….12

MediCARE vs. MediCAID: Differences in Who and What is Covered ………..13

One program vs. 50+ programs ……………………………………………………14

Medicare “Part D” Program …………………………………………………………….14

Dual eligibles ……………………………………………………………………………...15

Key Players ………………………………………………………………………...…....16

Disagreements in the Industry …………………………………………………....18

Further Reading for “What is the Difference Between Medicaid and Medicare?” ..19

Q3: Who can get Medicaid? …………………………………………………………20

Aid categories / Eligibility groups ……………………………………………………...21

Retro-active eligibility ……………………………………………………………………….21

Federal Poverty Level (FPL) ………………………………………………………………22

Key Players ………………………………………………………………………………..23

Disagreements in the Industry ……………………………………………………...23

Further Reading for “Who Can Get Medicaid?” 24

Q4: What is the State Children’s Health Insurance Program

(S-CHIP / SCHIP)? ………………………………………………………………….25

Balanced Budget Act of 1997 (BBA) ………………………………………………………25

FPL flexibility ……………………………………………………………………………….26

Branding ……………………………………………………………………………….26

Expansion of Medicaid vs. separate program ……………………………………26

S-CHIP Reauthorization Act of 2009 (CHIP-RA) ……………………………………27

Key Players ………………………………………………………………………………..27

Use of tobacco to funds ………………………………………………………………27

Enrollment freezes ……………………………………………………………………….28

Expansion Attempts in 2007 ………………………………………………………………28

“Crowding out” ……………………………………………………………………….29

Further Reading for “What is S-CHIP?” ……………………………………………..29

Q5: What is the history of Medicaid? ………………………………………………….30

Timeline of Major Events in History of Medicaid: 1965 - 2008 ……………………31

Initiatives to expand to pregnant women and children …………………………….32

Initiatives to increase services paid for by Medicaid ……………………………………..33

Initiatives to replace institutional services with community-based services …………...34

Initiatives to Expand Medicaid Under Health Reform ……………………………..35

Further Reading for “What is the History of Medicaid?” ……………………………..36

Q6: What are the big issues in Medicaid today? …………………………………...37

Value (Quality –Cost) …………………………………………………………………………38

Issue #1 - Making Managed Care Work for the Medicaid Population …………….39

Issue # 2 – Rewarding performing providers and punishing non-performing providers (Pay for Performance (PFP) in Medicaid) ……………………………………………….41

Issue #3 – Managing Chronic Conditions in the Medicaid Population …………….44

Issue #4- Getting the Most Bang for the Medicaid Buck (ROI) ……………………..49

Issue # 5 – Stopping the Fraud and Waste in Medicaid ……………………………...52

Issue #6 – Understanding and Managing the Impact of Health Reform on

Medicaid/CHIP ………………………………………………………..63

Further Reading for the “What are the Big Issues in Medicaid Today?” ……………68

EXCERPTED FROM – Question 1: What is Medicaid? Main Concepts While there is a lot to know about Medicaid, if you keep in mind these 3

concepts, you will be able to grasp most of the issues you may encounter in the Medicaid

industry:

the People who are covered by

Medicaid

Eligibility is the reason a person

receives insurance from Medicaid.

Eligible people get coverage either

due to their poverty or disability

status.

the Providers who render services

to Medicaid members

Physicians, nurses, hospitals, local

community mental health agencies, foster homes, home health and durable medical equipment

companies – these are all providers of Medicaid services (just to name a few). Medical

professionals and companies have an option of whether they will participate in the Medicaid

insurance program, and many select not to because of lower reimbursement rates and higher

regulatory and administrative burdens.

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Types of services covered by Medicaid

Medicaid covers most of the same types of services that private health insurance covers It often

covers more things than private health insurance, depending on

the state. The big buckets usually used to classify Medicaid

spending are Long Term Care, Acute Care and Administrative Services.

Medicaid consumed an average of 21% of state budgets in 2010.

Long term care relates to nursing homes as well as services for members who may live in an

institutional facility (such as for mental health/developmentally disabled members). Long term

care can also be used to describe services such as home health and rehab. It is critical to note

that Medicaid pays for nursing homes and Medicare does not. As such, long term care has

become a huge portion of national Medicaid spending.

Types of Services Covered by Medicaid

Disagreements in the Medicaid Industry In general, the major

disagreements in the Medicaid industry can be bucketed into two categories – reimbursement and coverage:

Reimbursement

Providers of all types claim that Medicaid reimbursement for their services is too low to cover

their costs. The subsequent point in this argument is that unless Medicaid payment rates are

increased, access to care and quality of care will have to go down. As data on what private

insurers pay for services is generally unavailable, assessing the legitimacy of these claims

remains difficult. As a result, most Medicaid payments for physicians and hospitals (the two

largest provider groups in terms of dollars) are tied to some percentage of the Medicare fee

schedule. Each state has discretion in how payment rates are set.

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Further Reading for “What is Medicaid?”

http://www.cms.hhs.gov/Medicaidgeninfo/

http://www.health.state.ny.us/health_care/medicaid/

http://www.socialsecurity.gov/disabilityresearch/wi/medicaid.htm

http://www.wisegeek.com/what-is-medicaid.htm

http://money.cnn.com/retirement/guide/retirementliving_healthcare.moneymag/index11.htm

http://whatismedicaid.com/

http://www.fdhc.state.fl.us/medicaid/

https://www.galongtermcare.org/(S(dmm0goqxc5khym55p2mmp145))/Content/InfoMedicaidCover.aspx

http://findarticles.com/p/articles/mi_m0795/is_nSUPP_v14/ai_14804360/

http://www.cms.hhs.gov/Medicaidgeninfo/

http://medicaidbenefits.kff.org/

http://www.dhhs.state.nh.us/DHHS/MEDICAIDPROGRAM/default.htm

http://www.cms.hhs.gov/MedicaidDentalCoverage/

http://en.wikipedia.org/wiki/Disproportionate_share_hospital

https://www.cms.gov/ActuarialStudies/downloads/MedicaidReport2008.pdf

EXCERPTED FROM – Question 2: Who can get Medicaid? Federal Poverty Level (FPL) This is a number used by Medicaid agencies to determine if a person (and their family) is poor

enough to be eligible for Medicaid. It starts out with numbers put out by the US Census Bureau, called the federal poverty threshold. The Department of Health and Human Services (DHHS) then issues guidance on how to use the numbers in eligibility processes.

State Medicaid programs have to cover people below a certain percentage of the FPL (children

under six in families below 133% of FPL, for example), but have discretion in being more

generous with coverage. Some states cover children and their families with up to 300% of the

FPL in annual income. Using the chart above, that would mean their household income could be

as high as $111,000 (if they had 8 members in their family).

EXCERPTED FROM – Question 4: What is CHIP?

Use of tobacco to funds Much of CHIP funding comes from tobacco taxes (the reauthorization bill in 2009 relied heavily

on an increase of 62 cents on the cigarette tax). Many advocates of the program point out that

tobacco consumption will likely continue to decrease as public health campaigns continue to

discourage smoking. As cigarette sales decrease, so does funding for CHIP.

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EXCERPTED FROM – Question 5: What is the history of Medicaid?

Initiatives to increase services paid for by Medicaid (throughout history of program)

While there are little restrictions on what Medicaid will pay for (states generally pay for more

services than Medicare does), there have been major efforts to expand particular services since

the program began. One of the earlier vehicles for service expansion was the Early and

Periodic Screening, Diagnosis, and Treatment program (EPSDT). The EPSDT program began

in 1967 to provide a battery of tests and services to children under 21. EPSDT was expanded

again in 1989 to cover more services for children.

EXCERPTED FROM – Question 6: What are the big issues in Medicaid today?

Issue # 2 – Rewarding performing providers and punishing non-performing providers (Pay for Performance (PFP) in Medicaid)

Pay for performance (PFP or P4P) is a

concept used to align the desired clinical

behavior of providers with Medicaid agency

objectives using incentives (usually direct or

indirect financial incentives). The Medicaid

agency sets the performance standard

using quality or utilization metrics, and will

reimburse providers based on performance

against those standards. Standards may be

based on evidence-based guidelines (such

as prescribing beta blockers after a heart

attack), but many are not (such as paying

providers to use new Health Information

Technology (HIT) systems to encourage

adoption). The earliest examples of P4P in Medicaid date back to the early 1990s.

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Pay for Performance Value Concepts

Cost Reduces cost by decreasing payments

to underperforming providers which

also pushes out underperforming

providers. Less underperforming

providers means less medical errors

which are costly. Quality Improves quality by encouraging

providers to follow clinical guidelines

and improve outcomes. Ultimately,

helps to retain higher-quality providers,

increasing overall quality of care

delivered.

A

acute care, 6-7

administrative services, 6

aged, blind and disabled (ABD), 20-21

aid categories, 20-21

American Reinvestment and Recovery Act (ARRA),35

B

Balanced Budget Act of 1997 (BBA), 25, 33

Breast and Cervical Cancer Treatment and Prevention Act (BCCTPA), 34

C Center for Medicaid and State Operations (CMSO), 9, 16

Centers for Medicare and Medicaid Services (CMS), 9

children,10, 20, 22, 25, 27, 29, 32, 34, 65

CHIP See State Children's Health Insurance Program (SCHIP)

CHIP Reauthorization Act of 2009 (CHIPRA), 26-27, 33, 35, 64-65

chronic conditions, 20, 37, 42, 44, 45, 47

community-based services, 34

coverage, 9, 10, 14-16, 18, 20-23, 25-29, 37, 39-40, 59, 65, 67

crowding out, 29

D Department of Health and Human Services (US DHHS), 14, 23

disabled, 7, 12, 20, 35

disease management, 39, 44, 45, 46, 47, 48

Disproportionate Hospital Share program (DSH), 7

dual eligibles (“duallies”, “duals”),15

durable medical equipment, 4, 62

E Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT), 33

eligibility,3-4, 9, 10, 14, 16, 20-23, 26-27, 32, 55-56, 65, 67-68

enrollment freezes,28

evidence-based medicine (EBM), 47

F

Federal Matching Percentage (FMAP), 6

Federal Poverty Level (FPL),10, 22, 26, 32

fraud /waste,52, 53, 54

H health reform, 35-37, 59, 63-67

home and community-based waivers, 35

I

income / citizenship verification, 23

income levels, 10

L lock-in programs, 54, 58

long term care, 6-7

low income Medicaid (LIM), 20-21

M managed care, 7,16, 21, 37, 39-40

Medicaid integrity contractors (MICs), 57

Medicare, 7, 9, 10, 12, 14-16, 18-19, 21, 25, 30, 33, 52, 56, 59, 61, 65

Medicare Payment Advisory Committee (MEDPAC), 16

N National Correct Coding Initiative (NCCI), 54, 58

nursing homes, 7

O OIG exclusion list, 60, 61

P

Part D,14, 15

Patient Protection and Affordable Care Act (PPACA), 35, 64, 65

pay and chase, 53, 54

pay for performance, 41, 42

Payment Error Rate Measurement (PERM), 55

poverty levels, 10

preferred drug lists, 51

pregnant women, 32

pre-pay, 53, 58, 59

Prescription Drug, Improvement and Modernization Act of 2003, 14

providers, 4, 6, 10, 35, 37, 41, 43, 47, 52, 53, 56, 57, 59, 61, 65, 66

R recovery audit contractors (RACs), 56

reimbursement, 4, 10, 15, 16, 18

retro-active (eligibility), 21

return on investment (ROI), 49

S State Children's Health Insurance Program (S-CHIP or SCHIP), 10, 25-29, 33, 35, 55- 56, 63-65

services, 4, 6, 7, 10, 12, 15, 16, 18, 21, 25, 28, 30, 33, 34, 35, 40, 45, 49, 50, 57, 65

T tobacco taxes, 27

treatment compliance, 47

U

US Census Bureau, 22, 23

V value (Quality -Cost), 38

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