1. Idaho Medicaid Overview Disability Rights Idaho

2. Idaho Medicaid Overview ▪Medicaid is a federal/state partnership program designed to provide the benefits of medical insurance to people in poverty. ▪Federal law controls over state law, but the federal law gives states many choices. ▪Federal funds pay for about 70% of the costs of Medicaid benefits in Idaho.

3. Idaho Medicaid Overview Eligibility (Generally) States are required to give Medicaid coverage to certain people if they want to receive federal funds, e.g. people who receive Temporary Assistance to Families in Idaho (TAFI), or Supplemental Security Income (SSI), certain children in families with very low income, and children in foster care.

4. Idaho Medicaid Overview Eligibility (Generally) ▪States are allowed to choose to cover other groups at the option of the state, e.g. ▪Children in higher income families such as those in the "Home Care for Certain Disabled Children " program (commonly called Katie Beckett), ▪people with higher incomes who live in nursing homes or other long term care facilities, people with higher incomes who participate in "Home and Community Based Services Waivers" (HCBS), and ▪the Medicaid for workers with Disabilities program..

5. Idaho Medicaid Overview Eligibility (Generally) ▪States choose the optional coverage in a document they file with the federal Center for Medicaid and Medicare Services (CMS) called the State Medicaid Plan.

6. Idaho Medicaid Overview Covered Services (Generally) ▪Some services are required to be covered by states such as Physicians services, hospitalization, and nursing homes. ▪Some are optional such as Prescription Drugs, Personal Assistance Services, Developmental Therapy, Mental Health Rehabilitation Services. ▪States can create their own Medicaid covered services and get them approved for HCBS Waivers, (Residential Habilitation, Attendant Care, Self -Directed Services)

7. Children’s Services (EPSDT) ▪States are required to offer all children who are covered by Medicaid all of the services on the required, and on the optional, list under a provision called "Early and Periodic Screening, Diagnosis and Treatment" (EPSDT).

8. Long Term Care Facilities ▪Medicaid covers the cost of care in "Long Term Care" facilities which includes Nursing Facilities (NF), such as Boise Samaritan and Capital Care. ▪ Intermediate Care Facilities for people with Intellectual Disabilities (ICF/ID) such as Southwest Idaho Treatment Center and Tomorrow's Hope.

9. Long Term Care Eligibility ▪In Idaho, coverage for LTC includes coverage for people with incomes up to the highest level paid by Social Security Disability Benefits, about $1200.00 per month although they are required to contribute a portion of their income to the cost of their care.

10. Medicaid Home and Community Based Services Waivers §1915 (c) Waivers ▪States are allowed to create their own set of services which they can offer to eligible people as an alternative to long term care. ▪Idaho Currently has 2 HCBS Waivers: ▸ Aged and Disabled (A&D) ▸ Developmental Disability (DD)

11. Home and Community Based Services Waivers ▪Children’s Redesign is adding 2 new waivers: ▪a children’s DD waiver for children who meet ICF/ID level of care, and ▪the “Act Early Waiver” for 3-6 year olds with autism or serious behavioral disorders

12. Medicaid Home and Community Based Services Waivers Eligibility for HCBS ▪To qualify a person must be able to prove that: ▸ They are eligible for care in a Medicaid long term care facility (NF, ICF/ID, Hospital) ▸ It costs less (either individually or overall) to give them Medicaid services in their own home, than to care for them in a LTC facility ▸ They can be safely and effectively cared for in their own home with the waiver services.

13. Medicaid Home and Community Based Services Waivers ▪Federal Medicaid laws do not allow states to cover free standing adult psychiatric hospitals. ▪Therefor adult psychiatric hospitalization does not count as “long term care” for HCBS purposes. ▪Psychiatric Hospitalization for CHILDREN is allowed under Medicaid. ▪Some states have children’s mental health HCBS waivers — NOT Idaho.

14. Home Care for Certain Disabled Children - "Katie Beckett" ▪Some children whose families are not in low income brackets can qualify for Medicaid if: ▸ The child is under the age of 18 years ▸ He/she would qualify for SSI if his/her parents' income were not counted. ▸ He/she would qualify for care in a long term care facility (NF, ICF/MR, or Hospital) ▸ It is safe and effective to care for the child in his/her home with Medicaid and other services ▸ The cost of caring for the child in his/her home is less than the cost of caring for them in a LTC facility.

15. Medicaid Rehabilitation Services ▪Federal Medicaid Rules allow states to include Rehabilitation Services in their state plans – States can define these services ▪Idaho uses this category to offer : ▸ Developmental Therapy (DDA Services, including Intensive Behavioral Intervention or IBI) ▸ Mental Health Services – e.g. Psycho-Social Rehabilitation, Partial Care.

16. Benchmark Plans Idaho Has three “benchmark plans” ▪Basic Plan- Generally healthy people with very low income ▪Enhanced Plan- People with disabilities, chronic conditions or other health needs ▪Medicare Coordinated Plan- People who also qualify for Medicare coverage “Dual Eligible”

17. Plan Coverage ▪Basic- required services, prescription drugs, common medical treatments ▪Enhanced- DD services, Mental Health services,Waiver services, Long term care ▪Medicare Coordinated- All of the enhanced plan services but with features to coordinate with Medicare coverage.

18. Qualifying for Enhanced Plan ▪Medicaid intended that anyone needing services in the enhanced plan would be immediately switched to the enhanced plan. ▪Everyone on SSI or other disability programs qualifies.

19. Idaho Medicaid Covered Services (some examples) Federally Required 1.Physician Services 2.Hospital Services 3.X-Rays, Laboratory 4.Outpatient Hospital 5.Nurse Practitioner 6.Nursing Homes 7.Home Health Services Federally Optional 1.Personal Care Services (up to 16hr/wk) 2.Prescription Drugs 3.Rehabilitation Services (DD therapy, PSR, Mental health clinics, PT, OT,) 4.Prosthetics 5.Child Psychiatric Hospitals Waivers (HCBS) 1.Certified Family Homes 2.Supported Living (Res Hab) 3.My Voice My Choice (Self Determination) 4.Personal Assistance Services 5.Assistive Technology

20. Who Gets What? Everyone on Medicaid Column A 1.Required Services if medically necessary 2.All Optional Services included in the State Plan (and the person’s Benchmark plan) Children under 21 years Column B 1.All of the services in Column “A” 2.All federally Optional Services not in the State plan if Medically Necessary. 3.Services beyond the limits placed on a service in the State plan If Medically necessary HCBS Waiver Participants Column “C” 1.All of the Services in Column “A” 2.All of the services in the waiver for which they are eligible.

21. Features of Medicaid Coverage ▪No Deductible - Medicaid recipients cannot be required to pay any initial fees for covered services from a provider who participates in Medicaid. ▪No Co-payment - Providers are required to provide the service at the rate set by Medicaid. They are not allowed to collect any amount from the patient / recipient. There are provisions for some Medicaid recipients to pay nominal co-payments, Idaho is considering new copayments.

22. Features of Medicaid Coverage ▪HCCDC (Katie Beckett) families are asked to pay a voluntary premium (not a co-pay) based on the family’s income. Failure to pay the premium does not result in loss of services.

23. Features of Medicaid Coverage ▪There are also Medicaid programs which require some Medicaid recipients to pay a portion of their cost of care (e.g. HCBS/A&D waiver, MWD). ▪Third party payers - Others who may be responsible for paying the cost of services such as private Insurance carriers, parents who owe child support, or tortfeasors can be billed or even sued by Health and Welfare for Medicaid costs.

24. Features of Medicaid Coverage ▪Providers are required to bill any insurance before collecting from Medicaid. ▪Other insurance premiums - If a Medicaid recipient is eligible for health insurance, Medicaid can pay the cost of the premiums to maintain the coverage.