1. Local Strategies for Effective Use of Medicaid E-MCH Conference Call March 18, 2004 Kathy Carson, Administrator, Parent Child Health Public Health - Seattle & King County

2. Partnerships are key Involve state Medicaid staff in coalitions and workgroups Get involved in efforts and workgroups Medicaid is sponsoring Include groups that can advocate with Legislature and interested legislators or their staff

3. Working for Medicaid Difficult job Rising medical costs mean Medicaid is taking an increasing portion of state budget Political basis for not only decisions but goals and values of the agency (covering kids or bringing caseload down) Change in administration can undo years of work, such as reducing barriers to application Maintain relationships with staff even if agency seems to be working against you

4. State-federal partnership Overall program options determined by Congress Funding split between federal and state Proportion determined by formula based on poverty level of state - poorer states pay lower proportion of cost Congress recently gave money to the states to support Medicaid by temporarily increasing the federal share

5. Two aspects - service and administration Service side –some services and eligibility levels mandated by Congress –states select from optional allowed services and covered populations to develop the state Medicaid plan –plan has to be approved by state legislature and CMS –state legislature has to appropriate funds for the state share –substantial changes require legislative authorization and reappropriation of state funds –small revenue neutral changes can be made with CMS approval only (WA recently changed from MCM to ICM)

6. Examples of change in state plan Expansion of eligibility for children to 200% FPL Addition of maternity support services of nurses, nutritionists and social workers –both of these had broad coalitions working with Medicaid, Medicaid proposed to legislature Addition of family planning benefits for 1 year post- partum –Medicaid proposed as a cost-saving strategy, backed by coalition of family planning providers Coverage for cancer treatment for women diagnosed through Breast & Cervical Health Program –proposed by advocates, passed by legislature who directed MAA to implement

7. Federal waivers When state legislature wants to add a service or an eligibility group that is not part of federal program, or impose cost- sharing Waiver requested of CMS Timeliness of federal response unpredictable

8. Examples of waivers Take Charge covers family planning services for all women and men under 200% FPL Legislature passed premiums for all children in families over 100% FPL, instructed MAA to submit federal waiver –Delayed response meant could not be implemented on legislative timeline –Allowed arguments in legislative session that successfully modified premium plan to over 150% FPL

9. Administrative Side Supports the ‘efficient operation of the Medicaid program’ Administrative tasks can be delegated to another public agency If other public agency can put up local rather than state funding for match, services can be expanded without additional state dollars

10. Types of Admin Activities Primarily outreach and linkage Other specific tasks can be delegated - for instance vaccine distribution and the statewide immunization registry Matched at the proportion of the population served by the activity that is covered by Medicaid

11. Enhanced & Non-enhanced Linkage activities that require a skilled medical professional can be matched at an enhanced rate of 75% federal/25% local –anticipatory guidance regarding treatment needs –skilled care coordination to get appropriate services for Medicaid covered person –professional consultation with Medicaid provider about treatment options/recommendations

12. Non-enhanced Outreach and linkage activities not requiring a skilled medical professional, even when done by a professional, are matched at 50% federal/50% local –finding uninsured eligible families –assisting with application or reapplication process –providing interpretation for Medicaid-covered services –referring into medical or dental care or any other Medicaid-covered service

13. Documentation required! CMS audits are basis of what is allowable Rules are divined from written audit findings and occasionally letters from CMS Medicaid eligibility percentage –used to allow multiple strategies for determining percentage –moving toward documentation of individual served and their eligibility status

14. Time studies Percent of each individual’s time spent on matchable activities is required One week per quarter for a large agency had been allowed, now saying one month a quarter Staff must understand what is matchable and what is enhanced - very important not only for accuracy of claim but when audited

15. Calculation Cost of activity determined by applying time study percentages to total cost, including allowable indirect Allowable indirect recently changed to mean federally negotiated indirect rate Adjusted cost of activity then multiplied by percentage of population served who are Medicaid enrolled Claim of either 50% or 75% of this adjusted cost

16. Another change Match can be claimed for eligible but not enrolled people for outreach activities only This will require a more detailed accounting of who was served by which matchable service

17. Is it worth it? Especially in tight economic times, this funding can be vitally important Supports the public health role of assurance of access to health care Allows public health to reach people that Medicaid can’t by going into the community Supports efficient use of Medicaid resources by guiding clients into appropriate services and educating them about how to use their medical benefits for preventive care

18. Public health has to take long view Economics and politics change - be ready to move with Medicaid to expand access to preventive services when the time is right Communicate about the impacts policies are having in the community - sometimes small adminstrative changes can have a positive impact Look for win-win opportunities where money can be saved through preventive services (ie, Take Charge)