Human Services & Medicaid Issues Staff Presentation to the House - - PowerPoint PPT Presentation

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Human Services & Medicaid Issues Staff Presentation to the House - - PowerPoint PPT Presentation

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Human Services & Medicaid Issues Staff Presentation to the House Finance Committee April 21, 2010 1 PDF created with pdfFactory trial version www.pdffactory.com Human Services l Programs and services for: u Children and parents u Adults

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Human Services & Medicaid Issues

Staff Presentation to the House Finance Committee April 21, 2010

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Human Services

l Programs and services for:

u Children and parents u Adults with disabilities u Elderly u Veterans

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Departments

l Office of Health and Human Services l Human Services l Mental Health, Retardation & Hospitals l Children, Youth and Families l Elderly Affairs l Health

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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Entitlements

l Entitlements: Qualify for the program

if eligibility criteria is met

u Medicaid u Rhode Island Works u Subsidized Child Care u Supplemental Security Income Program

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Entitlements – Medicaid

l Title XIX of Social Security Act l Citizen or 5 yrs of legal permanent

residency

l Federal/State Partnership

u Mandatory populations & services that

states must provide

u Optional populations & services that

states chose to provide

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Entitlements – Medicaid

l Federal government shares in cost

u Medicaid (FMAP) match rate u Based on 3-yr avg. of states’ per capita income

l ARRA – enhanced rate until 1/1/2011 l Still not extended l FY 2011 rate at 58.54% if not extended

u Governor’s budget includes 64.19% assuming

extension

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Entitlements – Medicaid

l Children’s Health Insurance Program

u States receive a higher Medicaid match to cover

additional populations

u RI – children above 133 % to 250% of poverty

level

u FY 2010 CHIP match rate – 66.83% u FY 2011 CHIP match rate – 67.02%

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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ARRA Enhanced Rate

l FY 2010 General Revenue Savings:

u $194.8 million

l FY 2011 General Revenue Savings:

u $196.7 million u Governor includes $95.3 million more from

the extension

l FY 2012: General Revenues

u Add $208.0 million to adjust for lower rate

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ARRA Requirements

Maintenance of Effort Requirement:

l States cannot adopt eligibility standards,

methodologies or procedures that are more restrictive than those in place July 1, 2008

u Example: Cannot reduce eligibility for RIte

Care to parents from the current rate of 175 % of the poverty level to 150 % of the poverty level

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ARRA Requirements

Maintenance of Effort Requirement

l Cannot institute or increase

premiums that restrict, limit or delay eligibility

u Example: Cannot increase the RIte

Care monthly cost sharing requirement

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ARRA Requirements

Maintenance of Effort Requirement

l Cannot change methods of eligibility

redetermination

u Example: RIte Care family eligibility

is evaluated annually. State cannot change that to every 6 months

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ARRA Requirements

Maintenance of Effort Requirement

l Can limit scope, duration and amount of

services available

u Decrease services, institute waiting lists,

decrease reimbursements

u Examples: Limit the # of days an elderly

person can attend an adult day facility or limit the number of residential placements

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Medicaid (FMAP) Rate

52.59 % 52.51% FY 2008 61.04% 63.89% 2009 Enhanced (1/1/09) 63.92% 63.93% 2010 Enhanced 64.19% 64.27% 2011 Enhanced 52.35% 52.14 % 2012 Projected SFY FFY

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Medicaid Global Waiver

l State flexibility to provide Medicaid funded services

u Restructure long term care services u Provide services in the least restrictive

settings

u Provide services in the most appropriate

setting

u Address high cost cases

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Medicaid Global Waiver

l Allows the state to make program changes to address costs

u Established levels of care u Mandatory enrollment in managed care

plans

u Allow selective contracting u Durable medical equipment u Transportation

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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Medicaid - Populations

l Mandatory:

u Low Income Medicare Beneficiaries u Individuals who would qualify under 1996

AFDC eligibility standards (50% of poverty)

u SSI or SSDI recipients u Children under 6 and pregnant women at

  • r below 133% of poverty

u Infants born to Medicaid enrolled pregnant

women

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Medicaid - Populations

l Mandatory:

u Children 6 to 19 at or below 100% of the

poverty level

u Children who receive adoption assistance

  • r who live in foster care under a federally

sponsored Title IV-E program

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Medicaid - Populations

l Optional:

u Low income elderly or adults with disabilities u Individuals eligible for home and community

based waiver services

u Children and Parents above federal limits

  • RI: Children to 250% and parents to 175%

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Medicaid - Populations

l Optional:

u Individuals who are medically needy

  • Not eligible for Medicaid except for large

medical bills

u Children under 18 who would otherwise need

institutional care (Katie Beckett)

u Women eligible for breast and cervical cancer

program

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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Medicaid – Mandatory Acute Care Benefits

l Physician Services l Lab & X-ray l In/Outpatient

Hospital

l EPSDT l Family Planning

Services & Supplies

l Federally Qualified

Health Centers

l Rural Health Clinic

Services

l Nurse Midwife

Services as state law permits

l Certified Pediatric &

family nurse practitioner services

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Medicaid – Optional Acute Care Benefits

l Prescription Drugs l Rehabilitation &

Other therapies

l Clinic Services l Dental, dentures l Prosthetic devices,

eyeglasses

l Case management l Durable medical

equipment

l TB – related services l

Medical/ remedial care provided by

  • ther licensed

professionals

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Medicaid - Long Term Care Benefits

§Home & comm based §Targeted case mgt §Hospice- personal care § PACE program § Home health care

services for those entitled to nursing home care Home and Community Services

§ Intermediate Care Facility § 65 + in an IMD §inpatient psych hospital

services for under 21

§ Nursing facility

services for those 21 or

  • lder needing that level
  • f care

Institutional

Optional Mandatory

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Medicaid - Long Term Care Benefits

l State must provide nursing home care

u Highest level of care

l State also provides residential services:

u Children in DCYF custody u Adults with developmental disabilities u Adults with behavioral health issues

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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State vs. US Medicaid Spending

l Four Categories

u Children: RIte Care u Adults: RIte Care u Blind/Disabled: Includes Children u Elderly

l RI: 76.4% of expenses for 32.3% of

population

u Elderly, blind and disabled categories

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US Medicaid Spending

*Based on 2007 data

$6,120 100.0% $294,400 100.0% Total $14,058 24.1% $70,900 10.4% Aged $14,858 43.0% $126,700 17.7% Disabled $3,586 13.5% $39,700 23.1% Adults $2,435 19.4% $57,110 48.9% Children Per Enrollee Percent Cost (millions) Share of Enrollment US*

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US Medicaid Spending by Population

Elderly 24.1% Children 19.4% Adults 13.5% Disabled 43.0%

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US Medicaid Enrollment by Population

Elderly 10.4% Children 48.9% Adults 23.1% Disabled 17.7%

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RI Medicaid Spending

*Based on 2007 data

$9,341 100.0% $1,684.3 100.0% Total $23,647 25.0% $420.8 9.9% Aged $21,433 51.4% $865.0 22.4% Disabled $4,048 10.1% $170.5 23.4% Adults $2,848 13.5% $228.0 44.4% Children Per Enrollee Percent Cost (millions) Share of Enrollment RI*

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RI Medicaid Spending by Population

Disabled 51.4% Elderly 25.0% Children 13.5% Adults 10.1%

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RI Medicaid Enrollment by Population

Adults 23.4% Children 44.4% Elderly 9.9% Disabled 22.4%

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How RI Compares

l As a percent of the total population

covered, Rhode Island’s enrollment includes more disabled

l Costs for each group exceeds the US

average

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How RI Compares to US

$3,469 Average $9,589 0.9% Elderly $6,575 8.4% Disabled $462 (3.4%) Adults $413 (5.9%) Children RI vs. US Cost Per Enrollee % of our expenses

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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Medicaid - % of State Budget – All Funds

Medicaid 26% All Other 74%

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Medicaid - % of State Budget- General Revenues

Medicaid 26% All Other 74%

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Medicaid - % of State Budget- General Revenues w/o Enhanced Rate

Medicaid 33% All Other 67%

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Medicaid – Spending by Department

OHHS 0% DHS 74% DCYF 5% DEA 1% MHRH 20%

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Adults & Children

l RIte Care Population

u Children to 250% of poverty level u Adults to 175% of poverty level u Department of Human Services’ budget u March 2010: 121,690 recipients

l RIte Share: 11,258 enrollees

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Elderly

l Long Term Care and Acute Care

Expenses

u Nursing Homes u Home and Community Based Care

l Dual Eligibles l Medicare Primary Payer of acute &

primary benefits

l DHS and Elderly Affairs

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Elderly

l Admittance into nursing facility: need

nursing home level of care

u Meet 3 deficiency in activities of daily living

  • Mobility, bathing, dressing, meal

preparation

u Meet income eligibility

l Home and Community Based Services

u Deficiency in activities of daily living

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Elderly – Services

Optional X X Home Care Optional X X Adult Day Optional X X Assisted Living Optional

  • X

Hospice Mandatory

  • X

Nursing Home Type DEA DHS

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Disabled Populations

l Individuals with a physical or mental

disability

u Adults: physical or mental disability

  • Include adults w/ a developmental disability

u Children

  • Children with Special Health Care Needs
  • Children in DCYF custody

u Programs administered by the DHS, MHRH &

DCYF

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Disabled Adults

X X Adults with Behavioral Health Issues X X Adults with Dev Disabilities X X SSI Only MHRH DHS

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Disabled Population – Adults

l Meet the federal Social Security

Administration’s definition of a disability:

u Inability to engage in any substantial gainful

activity because of a physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period-not less than 12 months

l Meet income guidelines

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Disabled Population – Adults

l Receive either SSDI and/or SSI benefits

u SSI cash assistance benefit u Estimated 32,600 for FY 2011

l Medical benefits l Other Services

u Residential and other community based

services

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Disabled Population – Adults

l Individuals with developmental disability

u State has option to use one or both federal

eligibility thresholds. RI statute references both:

u First if a person’s IQ is 70 or below, they

are eligible for services.

u RI does not use this definition u Eligibility standard for Massachusetts and

Connecticut

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Disabled Population – Adults

l Second: person w/ severe, chronic disability

that is:

u Attributable to a mental or physical impairment

  • r a combination of both;

u Manifested before the person turned 22 and is

likely to continue

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Disabled Population – Adults

l Second: person w/ severe, chronic disability

that is:

u Results in substantial functional limitation in 3

  • r more areas of a major life activity: self care,

receptive and expressive language, learning, mobility, self-direction capacity for independent living and economic self-sufficiency

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Adults with Developmental Disabilities

Optional X

  • Residential-

intermediate care facility Mandatory X

  • Residential-

nursing home level of care Mandatory

  • X

Medical Type MHRH DHS Benefit

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Adults with Developmental Disabilities

Optional X

  • Group Homes/Shared

Living Optional X

  • Family Supports

Optional X

  • Respite

Optional X

  • Day & Supported

Employment Type MHRH DHS Benefit

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Disabled Population – Adults with Behavioral Health Issues

l Eligible for mental health treatment

through community support program:

u Definition: A severely mentally disabled

adult is a person 18 years or over, with a severe and/or persistent mental or emotional disorder that seriously impairs his/her functioning relative to such primary aspects of daily living as personal relations, living arrangements,

  • r employment

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Disabled Population – Adults with Behavioral Health Issues

l General Outpatient/Non community

support:

u Definition: An individual is 18 years or older

with a diagnosis and statistical manual (DSM)

  • f mental disorders that does not meet the

community support criteria

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Disabled Population – Adults with Behavioral Health Issues

l Substance Abuse Treatment Services

u Definition: An individual who meets the

American Society of Addiction Medicine placement criteria

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Adults with Behavioral Health Issues

Optional X

  • Day Treatment

Optional X

  • Residential

Support Mandatory

  • X

Medical Type MHRH DHS Benefit

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Disabled Population – Children

l Children with Special Health Care Needs

u SSA level of disability u Children in DCYF custody

  • Automatically enrolled in this category

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Disabled Population – Children

l Children with Special Health Care Needs

u Eligible for Katie Beckett provision

  • Disability requires institutional level of

care

  • Receive home based services
  • Includes children with autism

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Children w/Special Health Care Needs

Optional

  • X

Early Intervention Optional X

  • Residential

Optional

  • X

Psychiatric Hospitalization Optional

  • X

Katie Beckett Services Mandatory

  • X

RIte Care Benefits Type DCYF DHS Benefit

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Medicaid Expenses*

$1,744.7 M $827.2 M Total Expenses *OHHS Annual Medicaid Report FY 2008 p. 26 $223.9 M $106.2 M Optional Services Optional Population Mandatory Population $297.0 M $140.8 M Mandatory Services $584.2 M $277.0 M Optional Services $639.6 M $303.2 M Mandatory Services All Funds Gen Rev

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Medicaid Expenses by Population*

$22,968 $634.0 27,580 Disabled – Adults $264.0 $431.0 $416.0 Costs (millions)

*OHHS Annual Medicaid Report FY 2008 p. 19

$20,628 12,800 Disabled – Children $24,672 17,478 Elderly $3,504 118,789 Children/Parents Per Person Persons

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State Only/CNOM programs

l Previously state only programs l

Not subject to the ARRA maintenance of effort requirements

l Can make changes to these programs

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CNOM Funded Programs

$6.0 M $3.0 M MHRH – MH Services $1.3 M $0.6 M MHRH - DD Day Programs $2.6 M $1.2 M MHRH - CMAP $1.0 M $1.2 M $2.4 M Gen Rev $2.0 M DEA - Adult Day $2.5 M DEA - Home Care $5.0 M MHRH - SA Treatments All Funds

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CNOM Funded Programs

$1.8 M $0.8 M DHS - GPA Medical $1.2 M $0.6 M DHS – Community Health Centers $1.7 M $3.6 M Gen Rev $3.7 M DHS - Early Intervention $7.8 M DCYF - Residential Diversion Programs All Funds

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State Only Programs

$18.1 M DCYF - Residential Care $15.3 M DCYF - Purchased Placements $11.0 M DCYF- Foster Care $6.2 M Gen Rev DCYF- 18 to 21 yr. olds

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State Only Programs

$2.5 M MHRH - DD Day Programming * A correction has been made to the show the appropriate

expenses by program

$5.9 M MHRH - Substance Abuse Treatment* $0.8 M MHRH - Mental Health Treatment* Gen Rev

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Program Options

l Eliminate Programs

u Services for adults with behavioral health

issues

u Programs funded through CNOM

  • Adult day and home care
  • Early Intervention services

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Program Options

l Reduce services

u For adults with developmental disabilities -

day program

u Reduce number of days an individual

attends an adult day program

l Institute waiting lists

u Home and community care programs u Admission into a nursing home

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Optional Programs

$71.0 M $25.0 M DHS - Home & Community Care $5.1 M $2.1 M MHRH - Substance Abuse $1.2 M $0.4 M MHRH - DD Rehab $55.0 M $19.8 M MHRH - Day Services (Adults with DD) $63.2 M $22.5 M MHRH - MH Treatment Services (Rehab) All Funds Gen Rev

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Optional Programs

$3.7 M $1.5 M DCYF - Therapeutic Foster Care $8.0 M $2.9 M DCYF - 18 to 21 year olds $29.6 M $10.7 M DCYF - Residential (Group Homes & Purchased Placements) All Funds Gen Rev

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Program Reduction

l Reducing Programs: Consequences l Seek treatment in an alternate setting

u Increase hospitalization u Decrease in adult day or nursing home

care may result in nursing home placement

u Reduce family supports through DD

program

  • Placement in a group home

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Medicaid Providers

l Hospitals

u Community Hospitals & Eleanor Slater

Hospital

l Physicians l Nursing Homes/Assisted Living

Facilities

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Medicaid Providers

l Community Providers

u Developmental Disability Providers u Mental Health Centers u Community Health Centers u Adult Day Facilities

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Recent Assembly Actions

l Provider Reductions

u 4.7 % rate reduction applied to DD

providers

u Reduction to NICU rates u Implementation of DRG and a reduction to

hospital rates

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Recent Assembly Actions

l 2008 Assembly reduced parents eligibility

for RIte Care from 185% to 175% of poverty

l 2008 Assembly eliminated state only RIte

Care benefits for child care providers

l 2008 Assembly eliminated state only RIte

Care benefits for children

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Governor’s FY 2011 Budget

l Governor’s FY 2011 budget

u Savings of $42.6 million from

reprocurement of managed care contracts

u reduced payments to hospitals u $12.0 million in long term care u $7.0 million from restructuring DD network u $4.0 million from savings to the community

mental health providers

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Governor’s FY 2011 Budget

l Governor’s FY 2011 budget

u $10.0 million reprocurement of DCYF

services to continue system of care transformation

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Medicaid - Out year projections

$72.9 M $1,114.3 M 2015 $71.8 M $1,041.4 M 2014 $70.8 M $969.7 M 2013 $267.9 M $898.9 M 2012 Change to Prior Year Gen Rev Fiscal Year

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State Comparison

Do not Limited to 133% to 300% MA Do not Broader federal def DD Adults Limited No enrollment limit Katie Beckett to 150% to 175 % Parents to 185% to 250% Children CT RI

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Other States – Proposed Medicaid Cost Reductions

Reducing mental health/DD services Missouri Eliminate optional benefits – dentures, eyeglasses, prosthetics Arizona Eliminated EI /restricted DD services to those in a residential setting South Carolina Reduce day services to adults with developmental disabilities Massachusetts Reduce adult day services California Proposal State

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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Other Entitlement Programs

$23.6 M

  • WIC

$22.6 M $22.6 M SSI $276.5 M

  • Food Stamps

$47.1 M $8.3 M Child Care $43.2 M $ - RI Works All Funds Gen Rev Program

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Recent Assembly Actions

l 2008 Assembly passed Rhode Island

Works legislation to replace FIP

u Limited time to collect to 48 months in a 5 year

period

u Unlimited 60 months u Eliminated child only cases (except for SSI-only

cases)

l 2007 Assembly reduced child care eligibility from

225% to 180%

l Eliminated child care for those over age of 13

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Human Service Programs

l Entitlements l ARRA Requirements l Mandatory/Optional Populations l Mandatory/Optional Services l RI vs. US Medicaid Spending l State’s Medicaid Program l Other Entitlements l Other Programs

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Other Programs

0.4 M $0.4 M Hardship Expenses $4.2 M $0.6 M Health- HIV services $2.0 M $0.7 M Health – Smoking Cessation Programs $0.8 M $0.8 M Head Start $27.6 M $19.5 M Veterans Home

All Funds Gen Rev Programs

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Federal Health Care Reform

l Patient Protection and Affordable Health

Care Act

u Extends benefits to childless adults u Extends medical benefits to former foster

care children who were in state custody at 18

u Maintenance of Effort requirement u Unless state can prove a deficit u State impact still under review

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FY 2011 Budget Hearings

l OHHS/DHS – April 27, 2010 at 1:00 l MHRH – April 28, 2010 at 2:00 l DEA/DCYF – May 4, 2010 at 1:00 l Health – May 4, 2010 at the Rise

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SLIDE 91

91

Human Services & Medicaid Issues

Staff Presentation to the House Finance Committee April 21, 2010

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