Two states present plans for reforming Medicaid
While health policy-makers look into ways to more cost-effectively meet the needs of high-risk, high-cost populations, officials from two states presented reports on their Medicaid structural reform efforts at the 2006 conference of the National Association of State Health Policy.
Idaho Medicaid director Patti Campbell said officials determined the current program was not sustainable and the current cost containment efforts were not working.
"There was a need to balance access, quality, and cost containment," she said, "and to recognize that one size doesn't fit all."
Ms. Campbell tells State Health Watch the program was operating with many rules, including some that were 30 to 40 years old, and it was time to update and modernize it. The approach to modernization, she said, included simplifying eligibility, establishing goals by target population, structuring benefits to meet health needs, balancing cost-effective purchasing with quality service, and phasing changes in over the next five to seven years.
The keystone of the effort is four benefit plans — a Basic Plan for low-income children and working-age adults; an Enhanced Plan for individuals with disabilities or special health needs; a Medicare/Medicaid Coordinated Plan for dually eligible individuals; and the state's Standard Plan.
Ms. Campbell says assignment to a plan is based on a beneficiary's health needs at the time of application or renewal. The state agency determines beneficiaries' health needs through a questionnaire completed at the time of application, as well as a number of questions on the application form itself, such as whether the person is an SSI recipient and whether the individual receives any other department services such as children's special health services or mental health services. Persons answering "yes" to any of these questions are automatically placed in the Enhanced Plan.
In addition, some beneficiaries may have mental health needs that don't show up in the application process, according to Ms. Campbell. The Basic Plan covers 26 mental health services a year and anyone who hits that limit is evaluated to determine if they should be moved into the Enhanced Plan.
Plan components
The Basic Plan covers major medical, preventive dental, basic mental health services, vision, and transportation services. Ms. Campbell said the Enhanced Plan covers Basic Plan benefits plus extensive mental health services, developmental disability services, long-term care, and targeted case management. Under the Medicare/Medicaid Coordinated Plan, dual eligible individuals can choose a Medicare Advantage Plan and the state's Medicaid program will pay for premiums and services not covered by the Medicare Advantage Plan.
Cost-sharing has been built into the reforms, with tiered Basic Plan premiums for individuals above 133% of the federal poverty level. The Enhanced Plan has tiered premiums for workers with disabilities who buy into the plan. And there are copays for selected services.
Prevention and wellness are an important part of the new structure, according to Ms. Campbell. Increased rates are paid to providers for well-child exams and adult routine annual wellness exams are covered. There is a new Healthy Schools initiative in which 10 schools were identified that have low nurse ratios and high low-income student populations. They received grants to provide nutritional and preventive services in the schools.
Under a Preventive Health Assistance program implemented Jan. 1, 2007, beneficiaries can earn up to 200 points per year for participating in weight loss and tobacco cessation programs and for well-child examinations and immunizations. The points can be used to obtain weight management program memberships, nicotine patches and gum, and bicycle helmets, or to pay coverage premiums.
State wants to reward participants
Ms. Campbell tells State Health Watch that unlike some states that are experimenting with contracts for behavior changes and punish beneficiaries who don't participate in the programs by cutting their benefits, Idaho wants people to participate and earn the rewards and is keeping the programs strictly voluntary. She said the Standard Plan covers only mandatory benefits and the state doesn't want to put people in that plan and doesn't want to use it as a penalty.
"We want people to get the extra benefits," she says.
While it is too early to definitively assess the success of the changes (the benefits program for dual-eligibles won't launch until April 2007), Ms. Campbell says savings are anticipated through better management of mental health services and through higher upfront payments for preventive services that should save money in the long run.
Asked about the hurdles that were encountered in implementing the changes, Ms. Campbell says the biggest issue was time.
"There was so much that had to be done to be able to start July 1, 2006," she says. "It took a lot to get all the communications out to everyone who needed to be involved. And we had to work to be sure we had a good process to move people into the new plans without a lot of administrative complexity."
Ms. Campbell says initial reactions have been positive or neutral, with only some concerns raised by some mental health providers who indicated services may need to be modified.
For states wanting to replicate what Idaho is doing, she says, key success factors from her experience include having broad involvement of stakeholders and legislators, realizing you can never do enough communicating, and being willing to draw a line at some point in the development process and start making decisions so you can move forward.
Kansas' WORK program
From Kansas, Mary Ellen Wright of the Kansas Department of Social and Rehabilitation Services told the NASHP conference about the state's Medicaid buy-in program, Work Opportunities Reward Kansans (WORK) program, and flexibility in benchmark benefits packages.
She noted the Ticket to Work and Work Incentives Improvement Act of 1999 allowed states to provide Medicaid coverage for individuals with disabilities who work and whose income is above 250% of the Federal Poverty Level. Such programs may have premium payments rather than spend-down provisions and states are given significant flexibility in program design. The act also provided grant funding for states to design and develop the infrastructure for a Medicaid buy-in program and Kansas received its first Medicaid Infrastructure Grant in January 2001.
The Kansas Medicaid Buy-in Program provides Medicaid healthcare coverage for those with income up to 300% of the Federal Poverty Level. Beneficiaries can have assets up to $15,000 and retirement accounts with no limit.
One of the requirements of the Ticket to Work law is that states receiving Medicaid Infrastructure Grants "offer personal assistance services statewide inside and outside the home to the extent necessary to enable an individual to be engaged in full-time employment." It provides a full 10 years of funding only to states achieving the personal assistance services requirement through either state plan service, 1915(b) or 1915(c) waivers, 1115 demonstration waivers, or some combination of those means.
Kansas has six 1915(c) Home- and Community-Based Services waivers, including adult waivers for developmental disability, physical disability, and traumatic brain injury that meet the Centers for Medicare & Medicaid Services requirements with one exception — Working Healthy enrollees can't be on Home- and Community-Based Services waivers.
The benchmark benefit package developed for WORK participants includes state Medicaid benefits; an assessment; personal assistance services, that are either self-directed or agency-directed, employs a "cash" model, and allows beneficiaries to purchase their personal assistance services in alternative ways; independent living counseling; and assistive services.
For more information on the Idaho changes, e-mail Ms. Campbell at [email protected] or telephone (208) 287-1158. For more information on the Kansas program, telephone Ms. Wright at (785) 296-5217.
While health policy-makers look into ways to more cost-effectively meet the needs of high-risk, high-cost populations, officials from two states presented reports on their Medicaid structural reform efforts at the 2006 conference of the National Association of State Health Policy.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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