Medicaid: What You Need to Know (CSH and Foothold)

Medicaid:
What You Need to Know
1

About Foothold Technology
Continue the conversation #VoicesofSH
Founded in 2001, Foothold Technology offers a web-based software
for human service providers, AWARDS, with a goal of creating a
working environment in which our clients are liberated from the
constraints of information management and are free to focus on their
mission.
2

About CSH
CSH is the national leader in supportive housing, focusing it on
person-centered growth, recovery and success that contributes to the
health and wellbeing of the entire community.
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Today’s Presenters
Paul Rossi
Director of Client Services,
Foothold Technology
Sue Augustus
Senior Program Manager
CSH
David Bucciferro
Senior Advisor,
Foothold Technology
4

Today’s Presentation
• Medicaid History
• Glossary of Terms
• Medicaid - Purpose, Coverage
and Eligibility
• Difference Between Medicaid
and Medicare
• Managed Care
• Medicaid Housing Related Services
• Value Based Care
• Medicaid Waiver Spotlights
• Resources
5

Glossary of Terms
• Medicaid is a federally supervised and State administered partnership that
provides primary, acute and long term care services to individuals and families
who meet income, resource and other categorical requirements.
• Enacted in 1965 as companion legislation to Medicare
• Originally focused on the welfare population:
• Single parents with dependent children
• Aged, blind, disabled
• Guarantees entitlement to individuals and federal financing to states. Includes
mandatory services and gives states options for broader coverage
Medicaid
6

Medicaid in the US
Continue the conversation #VoicesofSH 7

Glossary of Terms
Medicare is a health insurance program operated by the federal government
through the Social Security Administration which handles the enrollment.
• It is generally available to people over age 65 who are receiving Social Security
or Railroad retirement benefits
• People under age 65 who receive Social Security Disability Insurance (SSDI)
• People who have end stage renal disease or ALS.
• There are no income limitations for Medicare participants. Medicare participants
must also pay premiums, deductibles and co-payments.
Medicare
8

Medicaid v Medicare
• It depends on what coverage you choose and may include:
• Care and services received as an inpatient in a hospital or skilled nursing
facility (Part A)
• Doctor visits, care and services received as an outpatient, and some
preventive care (Part B)
• Prescription drugs (Part D)
• Medicare Advantage Plans (Part C) combine Part A and Part B coverage and
often include drug coverage (Part D) as well – all in one plan.
Medicare Coverage
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Medicaid v Medicare
• Depends on the coverage you choose – may include premiums, deductibles,
copays and coinsurance
• Part B premiums are either paid on a monthly basis or are deducted from your
SSDI or RSDI (retirement) benefits
• Medicare generally pays 80% of the charges – many people buy supplemental
policies to cover the remaining 20%
• Most people are enrolled in Parts A and B automatically when they turn 65.
Medicare Costs and Enrollment
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Glossary of Terms
• The Affordable Care Act (ACA) allows states to expand Medicaid eligibility to
uninsured adults and children whose incomes are at or below 138% of the
federal poverty level.
• Not all states have expanded Medicaid Services
Medicaid Expansion
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Medicaid in the US
Continue the conversation #VoicesofSH 12

Glossary of Terms
• Social determinants of health are the economic and social conditions that
affect health outcomes and are the underlying, contributing factors of health
inequities. Examples include housing, educational attainment, employment and
the environment.
• Access to safe, quality, affordable housing – and the supports necessary to
maintain that housing – constitute one of the most basic and powerful social
determinants of health.
Social Determinants of Health
13

Glossary of Terms
• A Medicaid state plan is an agreement between a state and the Federal
government describing how that state administers its Medicaid and CHIP
programs.
• It gives an assurance that a state will abide by Federal rules and may claim
Federal matching funds for its program activities.
• The state plan sets out groups of individuals to be covered, services to be
provided, methodologies for providers to be reimbursed and the
administrative activities that are underway in the state.
State Plan / State Plan Amendments
14

Glossary of Terms
• A Medicaid waiver is a provision in Medicaid law which allows the federal
government to waive rules that usually apply to the Medicaid program. The
intention is to allow individual states to accomplish certain goals, such as
reducing costs, expanding coverage or improving care for certain target
groups.
• There are several types of Waivers but they all fall under the authority of
Sections 1115 and 1915 of the Social Security Act
Medicaid Waivers
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Glossary of Terms
Section 1915(b) - Managed Care Waiver
Section 1915(b) allow states to develop Medicaid managed care plans. State
Medicaid agencies can contract with managed care organizations (MCOs) to help
manage quality, utilization, and costs, while also working to improve plan
performance and patient outcomes. MCOs provide health care services to
Medicaid beneficiaries and receive payment for these services from the state
Medicaid fund.
Waivers under this option can restrict the types of providers from which
beneficiaries can receive services and use associated savings to provide other
services.
Medicaid Waivers – Types (cont’d)
16

Glossary of Terms
Section 1915(c) - Home and Community Based Waivers
Section 1915 (c) waivers are option through which states can cover home and
community-based long-term services and supports for target populations.
Services can include care management, homemaker, home health aide, personal
care, adult day health, habilitation, and respite care.
States can also propose 1915(i) and 1915(j) and 1915(k) state plan amendments, all
of which provide additional flexibility to provide community based services and
supports to eligible residents.
Medicaid Waivers - Types
17

Glossary of Terms
Section 1115 Waivers - Research and Demonstration
Section 1115 of the Social Security Act gives the Secretary of Health and Human
Services authority to approve experimental, pilot, or demonstration projects that
promote the objectives of the Medicaid and Children’s Health Insurance Program
(CHIP) programs. Under this authority, the Secretary may waive certain provisions
of the Medicaid law to give states additional flexibility to design and improve their
programs. Must demonstrate budget neutrality and accept a cap on total
expenditures over a five year period.
Medicaid Waivers – Types (cont’d)
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Glossary of Terms
• Under fee-for-service (FFS), qualified Medicaid providers are paid for each
covered service such as an office visit, test, or procedure according to rates set
by the state.
• States may develop their payment rates based on: (1) the costs of providing the
service; (2) a review of what commercial payers pay in the private market; or (3)
a percentage of what Medicare pays for equivalent services. The service
provided must correspond to the description of covered services under the
Medicaid state plan, and the service must be delivered by a qualified Medicaid
provider.
Fee-For-Service
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Glossary of Terms
• Managed Care is a health care delivery system organized to manage cost,
utilization, and quality. Medicaid managed care provides for the delivery of
Medicaid health benefits and additional services through contracted
arrangements between state Medicaid agencies and managed care
organizations (MCOs) that accept a set per member per month (capitation)
payment for these services
Managed Care
20

Glossary of Terms
• In 2013, 72 percent of all Medicaid beneficiaries were enrolled in some form of
managed care (CMS 2015). States have incorporated managed care into their
Medicaid programs for a number of reasons. Managed care provides states
with some control and predictability over future costs. Compared with FFS,
managed care can allow for greater accountability for outcomes and can better
support systematic efforts to measure, report, and monitor performance,
access, and quality. In addition managed care programs may provide an
opportunity for improved care management and care coordination.
Managed Care - continued
21

Glossary of Terms
• Comprehensive Risk-Based
• Primary care case management (PCCM) programs
• Limited benefit package Plans
Three Primary Types of Medicaid Managed Care
22

Glossary of Terms
• In such arrangements, states contract with managed care plans to cover all or
most Medicaid-covered services for their Medicaid enrollees.
• Plans are paid a capitation rate, a fixed dollar amount per member per month
(PMPM), to cover a defined set of services. The plans are at financial risk if
spending on benefits and administration exceed payments; conversely, they
are permitted to retain any portion of payments not expended for covered
services and other contractually required activities.
Comprehensive Risk Based Managed Care
23

Glossary of Terms
• In some arrangements the health plan passes on a portion of the financial risk
to participating providers. In addition, states sometimes agree to share financial
risk with the health plan by assuming losses in excess of a specified level (e.g.,
above 107% of aggregate PMPM payments). Such arrangements are often
referred to as “risk corridors.”
• Many state Medicaid managed care programs have one or more benefits—
such as behavioral health services, oral health services, nonemergency
transportation, or prescription drugs—that are carved out and provided
separately through FFS or by limited-benefit plans.
Comprehensive Risk Based Managed Care - continued
24

Glossary of Terms
• In a PCCM program, enrollees have a designated primary care provider who is
paid a monthly case management fee to assume responsibility for managing
and coordinating their basic medical care. Individual providers are not at
financial risk in these arrangements and continue to be paid on a FFS basis.
Several states have enhanced their PCCM programs with targeted care
monitoring and chronic illness management to specific enrollees with high
levels of need, and by incorporating performance and quality measures and
financial incentives for providers.
Primary Care Case Management (PCCM)
25

Glossary of Terms
• Most states contract with limited-benefit plans to manage specific benefits or to
provide services for a particular subpopulation such as inpatient mental health
or combined mental health and substance abuse inpatient benefits, non-
emergency medical transportation, oral health, or disease management.
• (macpac.gov)
Limited Benefit Plans
26

Glossary of Terms
• Value-based care is a form of reimbursement that ties payments called Value
Based Payments for care delivery to the quality of care provided and rewards
providers for both efficiency and effectiveness.
• This form of reimbursement has emerged as an alternative and potential
replacement for fee-for-service reimbursement which pays providers
retrospectively for services delivered based on bill charges or annual fee
schedules.
• Value-based programs reward health care providers with incentive payments
for the quality of care they give to people covered within their
program.
Value Based Care, Payments and Programs
27

Glossary of Terms
• The Golden Thread is the real connection between the assessed consumer
needs, strengths, preferences and personal goals and the individual service
plan and services provided and reimbursed.
• Eligibility
• Assessments
• Person Centered Service Plan
• Service Delivery Tracking
• Billing
• Quality and Utilization Management
Golden Thread
28

Medicaid
• In 2015, CMS released an information bulletin to clarify circumstances under
which Medicaid funds can be used to pay for certain housing-related activities.
• These fall into three categories:
• Individual housing transition services
• Individual housing and tenancy sustaining services
• State-level housing-related collaborative services
• States can use different waiver authorities to cover these services.
Housing-Related Activities and Services
29

Medicaid
• Direct support is provided to individuals with disabilities, older adults needing
LTSS, and those experiencing chronic homelessness.
• Examples
• Assisting with housing application process and housing search process
• Developing an individualized housing support plan
• Conducting tenant screening and housing assessment that identifies the beneficiary’s
preferences and barriers related to successful tenancy
Individual Housing Transition Services
30

Medicaid
• Services that support individuals to maintain tenancy once housing is secured.
These service can be ongoing.
• Examples
• Education and training on the role, rights and responsibilities of the tenant and landlord
• Assistance with the housing recertification process
• Advocacy and linkage with community resources to prevent eviction when housing is or
may potentially become jeopardized
Individual housing and tenancy sustaining services
31

Medicaid
• Strategic and collaborative activities to assist in identifying housing resources
• Examples
• Developing formal and informal agreements and relationships with state and local housing
agencies to facilitate access to housing resources
• Working with housing partners to create and identify opportunities for additional housing
options for people wishing to transition to community-based settings
• Participating and contributing to planning processes for state and local housing agencies
State-level housing-related collaborative activities
32

Medicaid Waiver Spotlight
• Hawaii participated in first cohort of CMS Innovation Accelerator Program
• As a result of work under that program Hawaii submitted an 1115 Waiver
amendment focused on tenancy support and tenancy sustaining services to
increase supportive housing capacity for the state.
• CMS approved on 10/31/18
Hawaii – 1115 Waiver Amendment
33

• Behavioral Health, physical illness or a substance use diagnosis and chronically
homeless.
• Persons living in institutions, who cannot be discharged due to a lack of
appropriate housing plan for discharge.
• Living in Public Housing and at Risk of eviction AND has a qualifying condition/
diagnosis.
Hawaii – Eligibility for tenancy support services
34

• Foundational Community Supports =tenancy support and sustaining services in
supportive housing.
• Approved and implementing as of 1/1/18
• Persons who are currently homeless are eligible as they are engaged for
supportive housing. Providers cannot use the benefit for current residents.
Washington State – 1115 Waiver Services
35

Resources
• CSH - Corporation for Supportive Housing (csh.org)
• Supportive Housing Resource Center (shrc.footholdtechnology.com)
• National Alliance to End Homelessness (endhomelessness.org)
• Centers for Medicare and Medicaid Services – (cms.gov)
• US Interagency Council on Homelessness (usich.gov)
• Medicaid and CHIP Payment and Access Commission (macpac.gov)
• Henry J Kaiser Family Foundation (kff.org)
36

Contact Information
Paul Rossi
Director of Client Services,
Foothold Technology
paul@footholdtechnology.com
212-780-1450, ext. 8004
Sue Augustus
Senior Program Manager
CSH
sue.augustus@csh.org
312-332-6690 ext 2810
David Bucciferro
Senior Advisor,
Foothold Technology
David@footholdtechnology.com
212-780-1450, ext. 8037
37

Medicaid: What You Need to Know (CSH and Foothold)

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