Workshop for Parents and Providers

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Jean Nash
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1 MEDICAL ASSISTANCE (MEDICAID) in MARYLAND Workshop for Parents and Providers A Partnership between The Parents Place of Maryland and Georgetown University Center for Child and Human Development 1

2 About The Maryland Family Access Initiative i i A project funded by the federal Maternal and Child Health Bureau to: assist families to access comprehensive services from managed care organizations which meet all needs of their children with SHCN, and to ensure their enrollment in the plan best suited to their individual needs. 2

services from managed care organizations which meet all needs of their children

3 About Parents Place of Maryland How do we help? Education Information Technical assistance Supportive activities 3

4 About Georgetown University Center for Child and Human Development The Center provides research training policy analysis and development technical assistance 4

5 Medicaid: The Puzzle 5

6 Medical Assistance is very important for children with special health care needs and their families 6

7 Why is Medicaid Important? Able to meet all or most of the needs of children who are enrolled Free or very low out-of-pocket costs Recognizes children with special needs Waivers for special populations Several options in Maryland 7

8 Medicaid in Maryland Complicated system Administered through the Department of Health and Mental Hygiene Provides services through managed care organizations, fee-for for-service, carve-outs Multiple ways to become eligible HealthChoice is the managed care part of the system 8

managed care organizations, fee-for for-service, carve-outs Multiple

9 Eligibility & Entry MCHP SSI 9

10 Income Based Low Income families Eligible for Temporary Cash Assistance (TCA) Medically needy but greater than TCA standards Entry: Local Department of Social Services (DSS) 10

11 Foster Care/Adoption Foster Care Subsidized Adoption services Entry: Local Department of Social Services 11

12 SSI Children with Disability Disability Determination Income and Resources Eligibility Recipients of SSI Age 18 Entry: Social Security Administration 12

13 MCHP Age: children up to 19 years Pregnant women of any age Based on income Enroll in HealthChoice MCO Entry: Local Health Department 13

14 MCHP Premium Age: children up to 19 years Based on income Pay monthly family contribution Enroll in HealthChoice MCO Entry: Local Health Department 14

15 Refugees Qualified immigrants or refugees Strict guidelines for qualifying Residency requirements for immigrants Entry: Local Department of Social Services 15

16 Waivers Medically qualified Need institutional level of care Rehabilitative hospital level of care Alternative to Institutionalization Limited number of recipients Entry: Different entry points 16

care Alternative to Institutionalization Limited

17 How does my child get care from MA? Medicaid in Maryland HealthChoice Fee-for-service/carve-outs outs 7 MCOs Therapies Mental Health REM 17

18 HealthChoice 7M Managed dc Care Organizations (MCOs) Family chooses MCO Covers most children on Medicaid Select a primary care provider Authorizations for referrals 18

19 Some Services Covered by HealthChoice Inpatient & outpatient Physician care Lab & X-ray Nursing home Home health Medical supplies Clinic services Prescription drugs Dental care Medical equipment Diapers (qualified) Therapies 19

health Medical supplies Clinic services Prescription

20 Fee For Service/Carve-outs No Referrals Needed Mental health services Therapies such as OT, PT, speech, audiology Use Red and White Card 20

21 Therapy Services PT, OT, Audiology, Speech & Language No referral required from PCP or MCO May access services from any participating provider Use Red and White Card 21

22 Mental Health Services Administered through an organization called MAPS Case management for child & family Core Service Agencies provide services at the local level in some counties May use Medicaid approved therapists in community 22

23 Mental Health Services MAPS determines who will qualify for mental health services Refers child to mental health providers/core service agencies Pre-authorizes non-emergency care Therapeutic Behavioral Service 23

24 Rare & Expensive Case Management (REM) Qualifying diagnoses Children with Special Health Needs Fee for service Case management No authorizations ti required Use Red and White Card 24

25 REM Services All Medicaid services included Coordination of services/case management Assisted Living Community Support Assistive equipment Environmental Modifications 25

26 What are waivers? waivers... and where do they fit? 26

27 Waiver Programs are different from Medicaid id and MCHP: 1. Waivers have different medical and financial eligibility rules so more children can qualify for the programs because the parents income and assets are not taken into consideration 2. Waivers have some additional services 3. A limited number of children can be in Waivers Programs 27

28 Waivers Financial eligibility: Individual's income and assets not family s income Acts as payer of last resort to private insurance Pays whatever not covered by private insurances 28

29 Autism waiver Diagnosis of Autism Have an IEP or IFSP Age: up to 21 years Entry: Local School System Approved Plan of Care Enroll in Health Choice/MCO 29

30 Autism Waiver Services Intensive Individual Support Services Therapeutic Integration Family training Environmental accessibility adaptations Service coordination Residential Habilitation Supported employment 30

31 DD Waiver Developmental Disability or Mental Retardation Entry: Regional DDA office Age: Children and Adults Enroll in Health Choice/MCO 31

32 DD Waiver Services Approved Plan of Care Intensive Individual Support Services Therapeutic Integration Respite Environmental Accessibility Adaptation Intensive Behavior Management Program Assistive technology Prevocational services Residential habilitation 24-hour emergency assistance 32

33 Model Waiver Must have complex medical needs Technology dependant Age: less than 22 years old Would otherwise be hospitalized Entry: The Coordinating Center 33

34 Model Waiver Services Case Management Home health aide Special medical equipment and supplies Participation of MD in plan of care meeting Private duty nursing Use Red and White Card 34

35 The Last Piece of the Puzzle... EPSDT 35

36 Maryland Healthy Kids/EPSDT Very important service for children Available to all children up to 21 yrs. Comprehensive screening Diagnosis i (Evaluation/Assessment) t) All medically necessary treatment Therapeutic behavioral service Included in all Medicaid options 36

37 Medicaid: ThePuzzle Importance Eligibility Services Getting Care 37

38 For More Information The Parents Place of Maryland Department of Health and Mental Hygiene (DHMH) Baltimore Health Care Access

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