Florida Medicaid and Implementation of SB 2654

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1 Florida Medicaid and Implementation of SB 2654 Shachi Mankodi Counsel to the Chief of Staff Florida Agency for Health Care Administration Autism Compact Presentation September 18, 2008

2 Overview What is Medicaid? What is the Medicaid state plan and what are waivers? What does Medicaid currently cover for people with developmental disabilities? 1

3 What is Medicaid? Medicaid is a health insurance program for certain groups of low income individuals. Medicaid is jointly financed by state and federal funds. Designated state Medicaid agency works within federal guidelines to: Establish eligibility standards. Determine benefits and services. Set payment rates. 2

4 Florida Medicaid A Snapshot Expenditures Eligibles $15.2 billion estimated spending in Fiscal Year Federal-state matching program 56.83% federal, 43.17% state. Florida will spend approximately $7,210 per eligible in Fiscal Year % of all Medicaid expenditures cover hospitals, nursing homes, Intermediate Care Facilities for the Developmentally Disabled (ICF/DD s); Low Income Pool and Disproportionate Share Payments. 10% of all Medicaid expenditures cover prescription drugs. Fifth largest nationwide in Medicaid expenditures. 2.1 million eligibles. Elders, disabled, families, pregnant women, children in families below poverty. Fourth largest Medicaid population in the nation. Providers/ Plans Approximately 80,000 Fee-For-Service providers 19 Medicaid Managed Care plans. 3

5 Medicaid Structure States must submit a Medicaid State Plan to the federal Centers for Medicare and Medicaid Services (CMS). Federal Medicaid laws mandate that certain benefits and certain populations be covered. Medicaid programs vary considerably from state to state, and within states over time because of differences in: optional service coverages. limits on mandatory and optional services. optional eligibility groups. income and asset limits on eligibility. provider reimbursement levels. 4

6 Florida Medicaid Mandatory Services Advanced Registered Nurse Practitioner Services Early & Periodic Screening, Diagnosis and Treatment of Children Family Planning Home Health Care Hospital (Inpatient & Outpatient) Independent Lab Nursing Facility Personal Care Services Physician Services Portable X-ray Services Private Duty Nursing Respiratory, Speech, Occupational Therapy Rural Health Therapeutic Services for Children Transportation Florida Medicaid Mandatory Services for All Eligibles FY Mandatory 40.13% of $14.9Billion 5

7 Adult Dental Services Adult Health Screening Ambulatory Surgical Centers Assistive Care Services Birth Center Services Children s Dental Services Hearing Services Vision Services Chiropractic Services Community Mental Health County Health Department Clinic Services Dialysis Facility Services Durable Medical Equipment Early Intervention Services Healthy Start Services Home and Community-Based Services Hospice Care *States are required to provide any medically necessary care required by child eligibles. Florida Medicaid Optional Services* Intermediate Care Facilities/ Developmentally Disabled Intermediate Nursing Home Care Optometric Services Orthodontic Services Physician Assistant Services Podiatry Services Florida Medicaid Optional Services for All Eligibles FY Optional 59.87% of $14.9 Billion Prescribed Drugs Primary Care Case Management (MediPass) Registered Nurse First Assistant Services School-Based Services State Mental Hospital Services Subacute Inpatient Psychiatric Program for Children Targeted Case Management) 6

8 Key Medicaid Rules Services must be available statewide in the same amount, duration and scope within each eligibility group. Recipient must be Medicaid-eligible on date of service. Service must be a covered service that is medically necessary. Medicaid is payer of last resort. Medicaid state plan benefits must be exhausted before a similar waiver benefit is used. 7

9 What Are Waivers? Allow states to implement services, programs or policies that are not otherwise allowed under federal law. Federal CMS must approve a waiver before a state can implement it. Waivers must be periodically renewed. 3 major kinds of waivers: Research and Demonstration 1915(b) Freedom of choice of providers, managed care 1915(c) Home and community based services 8

10 1915 (c) Home and Community Based Services Waivers Purpose: Allow state Medicaid programs to cover long-term care services in a home or community setting instead of in a nursing home or ICF/DD Provisions waived : Comparability: services may be limited to a targeted group of individuals (e.g., elderly or people with specific diagnosis) State-wideness: services may be limited to particular geographic areas (e.g., county, region) 9

11 1915(c) Home and Community-Based Services Waivers (con t.) State can also limit a 1915(c) waiver by: number of people served dollar amount per person diagnosis or condition age Individuals must meet: Financial eligibility standards Medical eligibility standards (e.g. diagnosis or level of care) 10

12 Florida s 15 HCBS Waivers Adult Cystic Fibrosis Adult Day Health Care Aged/Disabled Adult Alzheimer s Disease Assisted Living for the Elderly Channeling Familial Dysautonomia Model Nursing Home Diversion Project AIDS Care Traumatic Brain Injury/Spinal Cord Injury Waivers for People with Developmental Disabilities Developmental Disabilities (Tier 1) Tier 2 Tier 3 Family and Supported Living (Tier 4) 11

13 Developmental Disabilities Waivers Currently serve about 30,000 beneficiaries (over 8,500 children) Eligibility: Age 3 or older Meet the level of care to reside in an ICF/DD Diagnosis of: Autism, Cerebral Palsy, Spina Bifida, Prader Willi Syndrome, or mental retardation (with an I.Q. of 60-69) There is currently a waitlist of 17,000 for these waivers, making it difficult for a child under age 5 to obtain services unless they enroll under crisis criteria. 12

14 DD Waiver Service Categories Support Coordination Employment and Training Individual and Family Supports Residential Services Environmental and Adaptive Equipment Therapeutic Supports Includes Behavior Analysis and Behavior Assistant Transportation Wellness Management 13

15 Other Services Provided to Medicaid Eligibles with Developmental Disabilities All state plan services are available (e.g., hospital, doctor, prescription drugs, durable medical equipment, home health) Some services are provided only to children (e.g., personal care, private duty nursing, therapies) Medicaid spends $20 million each year on occupational, physical and speech therapy for children diagnosed with autism spectrum disorder or Down Syndrome. 14

16 Children on Medicaid with Diagnosis of Autism Spectrum or Down Syndrome Age Group Autism Spectrum Down Syndrome 0-5 1,438 1,527 2, ,757 1,569 5, ,023 3,050 8,073 Total with Autism Spectrum and/or Down Syndrome 15

17 Physical Therapy Services 16

18 Occupational Therapy Services 17

19 Speech Therapy Services 18

20 Medicaid Waiver Behavioral Services What is Behavioral Analysis A highly specialized treatment that uses data collection and prescriptive, scientific methods to bring about behavior change. An evidence-based practice proven effective in the treatment of autism. Behavior Analysts (BAs) work one-on-one with autistic children, training in functional language and the treatment of atypical behaviors. BAs work directly with caregivers of autistic children to train caregivers in implementing the child s behavior plan. 19

21 Medicaid Waiver Behavioral Services What Does FL Medicaid Pay for Behavior Analysis? Florida Medicaid reimburses Behavior Analysts for services on the three Developmental Disabilities Waiver tiers and the Family/Supported Living Waiver. Florida Medicaid recognizes three levels of Behavior Analysis professionals for reimbursement under those waivers, as well as a paraprofessional level called Behavior Analyst Assistant. On these waivers, the Behavior Analyst meets with the individual typically 2 hours per week, while the Behavior Analyst Assistant meets with the individual for 8-10 hours per week to implement treatment recommendations. 20

22 Medicaid Waiver Behavioral Services How Many Behavior Analysts Practice In Florida? Behavior Analysts are nationally certified through the Certification Board for Behavior Analysis as either a Board Certified Behavior Analyst (BCBA) or a Board Certified Associate Behavior Analyst (BCBA). Florida has 669 Board Certified Behavior Analysts and 752 Board Certified Associate Behavior Analysts. There are 288 providers of Behavior Analysis providers registered as Medicaid DD waiver providers and 121 providers of Behavior Analysis services registered under the Family and Supported Living Waiver. Florida has 10 university-based training programs to certify Behavior Analysts. Additional programs exist throughout the United States and internationally 21

23 Developmental Disabilities Waiver Behavioral Services Provider Rates Service Description Unit Rates Behavior Analyst 15 Minutes $8.27 to $23.58 Behavior Assistant 15 Minutes $3.75 to $5.15 Behavior Assessment One Assessment $ to $

24 For questions about Medicaid services related to developmental disabilities, please contact: Beth Kidder Bureau Chief for Medicaid Services or Leigh Meadows Program Administrator Developmental Disabilities and Special Programs

Maryland Medicaid Program: An Overview. Stacey Davis Planning Administration Department of Health and Mental Hygiene May 22, 2007

Maryland Medicaid Program: An Overview Stacey Davis Planning Administration Department of Health and Mental Hygiene May 22, 2007 1 Maryland Medicaid In Maryland, Medicaid is also called Medical Assistance