Transcript Texas Medicaid Curriculum

Texas Medicaid
Medical and Dental
Information Series
Module 7
Version 1.2 (6/22/2010)
2/22/2013
1
Module 7
Medicaid Curriculum Overview
Module 1: General Structure of the Texas Medicaid System
Module 2: Understanding Medicaid Clients and Health Literacy
Module 3: Texas Health Steps
Module 4: Navigating Insurance and Managed Care
Module 5: Interfacing with Medicaid as a Provider
Module 6: Special Medicaid Programs
Module 7: Special Medical Issues
Module 8: Special Dental Issues
2
Module 7
Special Medical Issues
3
Module 7
Module 7: Objectives
After completing this module, you should be able to:
Discuss additional Texas Medicaid programs that
provide health services to children and adults including:
Behavioral health services
Prescription drug benefits
Benefits for “Dual Eligibles” (those eligible for both
Medicare and Medicaid)
Long-term care programs
Review briefly the health topics discussed in previous
modules
4
Module 7
True or False?
1.
Medicaid covers only behavioral health services
provided by a psychiatrist.
2.
Only medications listed on the Preferred Drug List
(PDL) are reimbursable through Texas Medicaid.
3.
Texas Medicaid must cover all medications for which a
manufacturer offers a rebate.
4.
PACE programs coordinate and provide preventive,
primary, acute and long term care services for elderly
individuals who live in the community.
5.
Hospice is for all age groups, including children,
during their final stages of life.
5
Module 7
Behavioral Health
Services
Texas Medicaid defines
Behavioral Health Services
as: Services used to treat a
mental, emotional, or
substance use disorder.
Medicaid makes behavioral
health services available to
Medicaid-eligible children
and adults.
6
Module 7
Behavioral Health Services:
Basic Services
Screening, diagnosis, and referral to
needed services
Freestanding psychiatric hospital services
(for patients younger than 21 and older
than 64 years of age)
Psychiatric hospitalization services in
psychiatric unit within a general acute
care hospital
Counseling and psychotherapy services
Medication services
Substance use disorder treatment
services
Rehabilitation and case management
services for people with severe and
persistent mental illness and children with
severe emotional disturbance
7
Module 7
Behavioral Health Expenditures
Mental and
behavioral health
constitutes about 3%
of all Texas health
care expenditures
DSHS expenditures
for mental health
care in 2009 totaled
$1.8 billion-- 26.3%
more than in 2005.
Texas Health Care Expenditures by
Service Category (2009)
Medicaid and CHIP
Prisoner Health Care
3.1%
21.2%
State Employee and
Retiree Medical Benefits
6.2%
1.8%
67.7%
Mental Health
Services
Other Agencies and
Higher Education
Institutions
8
Module 7
Behavioral Health: Eligible
Providers and Care Settings
Providers
Psychiatrists
Primary Care Physicians
Psychologists
Licensed Clinical Social Workers
Licensed Professional Counselors
Licensed Marriage and Family Therapists
Advanced Practice Nurses and Physician Assistants
Settings
Private practices
Private and public psychiatric
and general hospitals
Community mental health centers (e.g. MHMR facilities)
Licensed substance use disorder treatment programs
Federally Qualified Health Centers (FQHCs)
9
Module 4
Behavioral Health &
Managed Care
Medicaid managed care, including STAR and STAR+PLUS, cover
standard behavioral health services such as help for drug or alcohol
problems and mental health services
Medicaid managed care plans can offer additional value-added
services, such as:
Health psychology interventions to help manage chronic medical
conditions
Intensive outpatient treatment/ day treatment
Inpatient substance abuse detoxification treatment
10
Module 7
The NorthSTAR Program
NorthSTAR is a behavioral health program that
serves the seven counties within the Dallas
service area.
NorthSTAR provides integrated behavioral
health services (mental health, chemical
dependency, and substance abuse treatment)
through a behavioral health organization
(BHO), currently ValueOptions®
NorthSTAR is known as a behavioral health
carve-out of the STAR and STAR+PLUS
Medicaid Managed Care Programs in the
Dallas service area.
NorthSTAR program's goal is to provide
clinically necessary behavioral health services
to enrollees, through a network of qualified and
credentialed providers.
11
Module 7
Prescription
Drug Coverage
In 1971, Texas Medicaid began
providing optional coverage of
outpatient medications.
• Patients enrolled in fee-forservice Medicaid receive
services through the Vendor
Drug Program (VDP).
• Patients enrolled in Medicaid
managed care organizations
receive services through their
MCOs.
12
Module 7
Medicaid Prescription Drug
Coverage
Texas Medicaid covers prescription
drugs that are dispensed through over
4,500 Texas pharmacies.
Medicaid reimburses pharmacy
providers only for outpatient
prescription drugs.
Over-the-counter drugs are covered
for patients enrolled in Medicaid,
Children with Special Health Care
Needs and Kidney Health Care
Programs, but not for patients in
nursing facilities.
13
Module 7
Limitations on Prescription
Drugs, by Patient Group
Unlimited Prescriptions
Children under 21 years of
age
Aged, blind, or disabled
(ABD) nursing home clients
ABD adults in the
community with waiver
eligibility
Limited to Three
Prescriptions/Month
TANF fee-for-service adults
ABD fee-for-service adults
without waiver eligibility
Managed care clients
(STAR, STAR Health,
STAR+Plus)
14
Module 7
Preferred Drug List (PDL)
Program
The Medicaid PDL is a method to control
growing medication costs, while also
insuring that program recipients have
access to medically necessary medications.
Medications on the PDL can be
prescribed without prior authorization.
All “non-preferred” drugs require prior
authorization.
Medications receive their “preferred” or
“non-preferred” designations based on their
safety, efficacy, and cost effectiveness.
HHSC saved approximately $245.8 million
in general revenue during the 2008-2009
biennium as a result of the PDL, due to
supplemental rebates and prescribing shifts.
The PDL
can be obtained from:
www.txvendordrug.com/pdl
15
Module 7
Prescription Drug Coverage:
Federal Drug Rebate Program
The Omnibus Budget Reconciliation Act of 1990 requires that drug
manufacturers pay medication rebates for drugs dispensed under
state Medicaid programs. Additionally, this law mandates that:
States must cover all drugs for which the manufacturer provides a
rebate.
States must maintain an open formulary for all drugs of
manufacturers that have signed a federal rebate agreement.
States may require prior authorization
to limit the use of drugs.
Approximately 36% of the Vendor
Drug Program’s budget is funded by
rebates paid by pharmaceutical
manufacturers
16
Module 7
Texas Drug Code Formulary
The Texas Drug Code Formulary covers more than 32,000 drugs
including single source and multi source (generic) products.
The Texas Medicaid formulary can be found at:
www.txvendordrug.com/formulary/formulary-search.asp
The Texas Medicaid formulary and PDL are also
available on the Epocrates drug information system.
17
Module 7
Texas Drug Code Formulary
Search Results
PDL Prior Authorization = Yes…
The drug is “non-preferred” and
requires prior authorization before
Medicaid will cover it
Clinical PA Auth. Required = Yes…
The drug is subject to clinical edits,
requiring the pharmacy to first check
a client’s Medicaid medical and drug
claims histories for consistency with
the edit criteria for that drug.
18
Module 7
Non-PDL Prior Authorization
Drug Search
Providers may also search specifically for drugs that do not require
prior authorization.
www.txvendordrug.com/formulary/PDLSearch.asp
19
Module 7
Prescription Drug Prior
Authorization
Prior authorization is
necessary for any drug
not on the PDL and can
be obtained via two
methods:
Telephone: 1-877-PA-TEXAS
(1-877-728-3927)
Online:
https://paxpress.txpa.hidinc.com
20
Module 7
72-Hour Emergency Prescriptions
Both federal and Texas laws
require that a 72-hour
emergency supply of
prescribed medications be
provided when:
A medication is needed
without delay
Prior authorization is not
available (e.g. prescriber
can not be contacted or is
unable to request it)
Emergency prescriptions do
not count towards the threeprescription limit for those
subject to this limit.
21
Module 7
The Vendor Drug Program (VDP)
The VDP provides prescription drug services to eligible Texas
Medicaid recipients in these programs:
Texas Medicaid fee-for-service
Children with Special Health Care Needs
Kidney Health Care Programs
The VDP processes prescription drug claims from contracted
pharmacies and reimburses pharmacies for the cost of the drugs
22
Module 7
VDP ePrescribing
Medicaid prescriptions are now accepted via eprescription (e-Rx), and all managed care plans
are required to provide e-Rx services.
In order to submit an e-Rx that meets CMS
requirements for “brand medically necessary”
dispensing, the prescribing physician should do
the following on the electronic prescription
transaction that is sent to the pharmacy:
Select the option for “Dispense as Written”
(DAW) on the electronic prescription pad.
Type “Brand Medically Necessary” in the
“Notes to Pharmacy” free-text field.
23
Module 7
Prescription Drugs for Medicaid
Managed Care Clients
As of March 1, 2012 clients enrolled in Medicaid managed care
(STAR, STAR+PLUS) obtain prescription drug benefits through their
managed care organizations (MCOs).
Each MCO will contract with a pharmacy benefits manager (PBM)
that will process prescription claims and work with pharmacies that
serve Medicaid managed care clients.
MCOs will use the state-approved formulary for pharmacy benefits.
24
Module 7
Medicaid Managed Care
Service Areas
Service Areas
Effective March 1, 2012
25
Module 7
What are the most prescribed drugs?
Texas Medicaid Top 10 Drugs
By Usage (Claims in 2010)
Ibuprofen
Amoxicillin
Hydrocod…
Azithromycin
1,482,930
1,241,673
By Expenditure (Paid in 2010)
Abilify
Singulair
$90,402,420
$84,636,490
868,965
Nexium
$69,095,046
847,432
Seroquel
$67,759,635
Singulair
635,844
Synagis
$46,187,032
Albuterol…
595,775
Zyprexa
$43,039,565
C-Phen DM
567,929
Cefdinir
$38,744,539
Oralyte
478,288
Concerta
$34,822,941
Cefdinir
469,244
Vyvanse
$29,646,374
Loratadine
402,028
Suprax
$28,365,603
26
Module 7
Dual Eligibility
Dual Eligibles are individuals who
qualify for Medicare and Medicaid
benefits.
Medicare is a federally administered
health insurance for:
• People 65 years or older
• People under age 65 with certain
disabilities
• People of any age with End-Stage
Renal Disease
27
Module 7
Review: Medicaid vs. Medicare
What is the difference?
Texas Medicaid
Medicare
Authorized by Social Security Act of 1965
Established in Texas – 1967
Jointly Funded by State and Federal
Government, administered by State &
regulated by CMS
Funded by Federal Government &
administered by CMS
Entitlement program
based on income
Entitlement program
based on age or disability
Low income families, children,
pregnant women, disabled, elderly
People 65 years or older, or people
with disabilities
Eligibility and enrollment in both programs concurrently is possible
CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare,
Medicaid, and the Children's Health Insurance Program.
28
Module 7
Common Medicaid Myths
Myth
Medicaid pays the nursing home
bill for all seniors.
Fact
Medicaid eligibility for seniors is
limited to the very poor or those
with large health expenses who
have depleted their savings.
Medicaid prohibits individuals from
transferring savings to others in an
attempt to qualify for nursing home
care without exhausting their
assets. Sixty percent of nursing
home residents are not on
Medicaid at the time of their
admittance into a facility.
Even after individuals deplete their
assets, they are still required to
apply their income, including Social
Security and pension checks,
towards their care costs, except for
an average monthly $30 personal
needs allowance.
29
Module 7
How Medicaid and Medicare
Work Together
By federal law, Medicare coverage is primary to Medicaid
When a patient receives a service covered under both programs,
Medicare pays first, and the remainder (if any) is payable by
Medicaid.
Medicaid also serves dual eligibles by providing services not
covered by Medicare, including:
Nursing home care beyond Medicare’s
100-day limit
Some prescription drugs
Eye glasses
Hearing aids
For those who qualify, Medicaid may also cover
some out-of-pocket Medicare expenses
such as co-insurance, premiums, and
deductibles
30
Module 7
How Medicaid and Medicare
Work Together to cover Nursing Home Care
First 20 days:
Medicare pays
Next 80 days:
Medicare pays + Medicaid
covers co-insurance
After 100 days:
Medicaid pays
31
Module 7
Full vs. Partial Eligibility for
Medicaid
Full Eligibility
Partial Eligibility
Medicaid pays deductibles
and co-insurance for
Medicare-covered services
Medicaid pays for Part D
(prescription drug coverage)
premiums or deductibles
Recipients may receive
Medicaid services not
covered by Medicare (e.g.
long-term services and
supports)
Depending on income,
Medicaid pays for Part A
(hospital insurance) and/or
Part B (medical insurance)
Medicare provides the
majority of prescription
coverage, while Medicaid
covers those drugs not
covered under Medicare
Full vs. Partial
Eligibility is based on
income and eligibility
for Supplemental
Security Income
(SSI)
32
Module 7
Dual Eligibility: Special
Considerations for Providers
Enrollment
All physicians must
be enrolled in
Medicare before
they can enroll in
Medicaid.
Exceptions are
gynecologists,
pediatricians,
pediatric
psychiatrists, and
providers
performing only
Texas Health Steps
medical or dental
checkups
Prior Authorization
If a patient’s
primary coverage is
Medicare, providers
must always
confirm with
Medicare whether a
service is a
Medicare benefit
for the patient.
If Medicare denies
this service, then
Medicaid prior
authorization is
required.
Billing
For those services
covered by both
Medicare and
Medicaid, Medicare
is the primary
coverage and the
claim must be filed
with Medicare first.
33
Module 7
Long-Term Services
and Supports
Nursing Facility Care Services
Mental Retardation Services
Primary Home Care Services
(PHCS)
Home and Community-based
Waivers
Day Activity and Health Services
(DAHS)
Hospice Care Services
Program for All-inclusive Care for
the Elderly (PACE)
Consumer-Directed Services
(CDS)
34
Module 7
Nursing Facility Care Services
Nursing Facility Care provides 24-7 nursing care for people whose
medical condition requires the skills of a licensed nurse on a regular
basis.
The nursing facility must provide for the medical, nursing, and
psychosocial needs of each recipient, including:
Room and board
Social services
Over-the-counter drugs (prescription drugs are
covered through the Medicaid Vendor Drug
program or Medicare Part D)
Medical supplies and equipment
Personal needs items
Rehabilitative therapies
Augmented Communication Device Systems
Power Wheelchairs
Emergency Dental Services
35
Module 7
Services for Persons with
Intellectual Disabilities
The Texas Department of Aging and Disability Services (DADS)
administers several long-term services and support programs for
individuals with intellectual disabilities.
Each of the DADS support programs for individuals with intellectual
disabilities has different eligibility criteria; however, most criteria are
based on:
Cognitive functioning levels
Adaptive behavior skills, which indicate the ability to care for oneself
Physical disability levels
36
Module 7
DADS Programs & Services for
Persons with Intellectual Disabilities
Home and Community Based Services (HCS)
HCS provides individualized services and supports to persons with intellectual and
developmental disabilities who are living with their family, in their own home or in other
community settings, such as small group homes.
Intermediate Care Facilities for Persons with Intellectual Disabilities
This program provides residential and habilitation services to people with intellectual and
developmental disabilities and/or a related condition.
In-Home and Family Support Program
This program provides direct grant benefits to people who have physical disabilities and or
their families to help them purchase services that enable them to live in the community or in
their own homes.
Texas Home Living Program
This program provides selected essential services and supports to people with intellectual
and developmental disabilities who live in their family homes or their own homes.
37
Module 7
DADS Programs & Services for Persons
with Intellectual Disabilities Continued
State-Supported Living Centers
The state has 13 State-Supported
Living Centers that provide 24-hour
residential, treatment and training
services for people with intellectual and
developmental disabilities.
38
Module 7
Primary Home Care
Primary Home Care (PHC) provides attendant services to people
with an approved medical need for assistance with personal care
tasks.
PHC is available to eligible adults whose health problems cause
them to be functionally limited in performing activities of daily living
according to a practitioner’s statement of medical need.
Services can include having in-home attendants who help recipients
with activities of daily living including:
Bathing
Grooming
Meal preparation
Housekeeping
39
Module 7
Home and Community-based
Waivers
DADS waiver programs provide communitybased services and supports for people who
qualify for admission to institutional settings
but have made the choice to receive receive
services in the home or in a community
setting as a cost effective alternative.
DADS administers seven waiver programs
and maintains interest lists for most
programs.
A person can be enrolled in only one waiver
program at a time.
Community-based
Alternatives
Community Living
Assistance and Support
Services
Consolidated Waiver
Program
Deaf Blind Multiple
Disabilities
Medically Dependent
Children Program
Home and Communitybased Services
Texas Home Living Waiver
40
Module 7
Day Activity and Health
Services (DAHS)
DAHS licensed facilities provide daytime services Monday through
Friday to clients residing in the community in order to provide an
alternative to placement in nursing facilities or other institutions.
Eligibility Requirements:
Full Medicaid recipient
Medical diagnosis and physician’s orders requiring a licensed
vocational nurse’s or a registered nurse’s care or have a functional
disability related to the medical diagnosis
One or more personal care or restorative
needs that can be stabilized, maintained
or improved by participation in DAHS
Services can include nursing and
personal care, noontime meal, snacks,
transportation, social, educational,
and recreational activities.
41
Module 7
Hospice Care Services
Medicaid recipients who no longer choose
curative treatment and who have a physician’s
prognosis of six months or less to live are
eligible for Medicaid Hospice services.
Service can be delivered in the following
settings:
Home-based care
Community-based care
Long-term care facilities (e.g. nursing homes)
Eligibility Requirements: Hospice is for all age groups, including
children, during their final stages of life.
Hospice services can include: physician and nursing care, medical
social services, counseling, home health aide, personal care,
homemaker and household services, physical, occupational, or
speech language pathology services
42
Module 7
Program for All-inclusive Care
for the Elderly (PACE)
Program for All-inclusive Care for the Elderly (PACE) programs
coordinate and provide all needed preventive, primary, acute and
long term care services so older individuals can continue living in
the community.
PACE utilizes interdisciplinary teams, including physicians, nurses,
social workers, therapists, van drivers and aides, to exchange
information and solve problems as the conditions and needs of
PACE participants change.
PACE Eligible Populations:
Age 55 or older
Meet the medical necessity for nursing
facility admission
Live in a PACE service area (Amarillo,
El Paso, or Lubbock)
Have limited income and countable
resources
43
Module 7
PACE Services
PACE uses a comprehensive care approach, providing an array of
services for a capitated monthly fee.
PACE provides all health-related services, including inpatient and
outpatient medical care, and specialty services including:
Dentistry
Podiatry
Social services
In-home care
Meals
Transportation
Day activities
Housing assistance
Nationally, the average age of
PACE participants is 80 years old,
and 93% live alone in the
community.
Seventy-five percent of participants
are female.
The average PACE participant has
7.9 medical conditions, many of
which are chronic conditions
including diabetes, dementia,
coronary artery disease, and
cerebrovascular disease
44
Module 7
Consumer Directed Services
(CDS)
The CDS option allows Medicaid clients or their legally authorized
representatives to serve as an employer and assume responsibility
for screening, hiring, training and dismissing providers.
Those who elect to use the CDS option must select a Consumer
Directed Services Agency (CDSA) to conduct financial management
services such as payroll and employer taxes.
Benefits of Choosing CDS
Control over who provides services and
who comes into the home.
Consumers train their own service
providers and set their work schedule.
Consumers set the pay and benefits within
the funds allotted for their program.
Most people who choose the CDS option
do so because they want the
independence that comes with employing
the people who provide their services.
45
Module 7
Texas Medicaid
Series Summary
Module 7 concludes the Texas Medicaid Medical and
Dental Series for medical residents and students. The
following slides provide a summary of the series.
46
Module 7
REVIEW: What is Medicaid?
Medicaid is a federal health care program that is jointly funded by federal
and state money. Medicaid is jointly funded by the state and federal
governments:
About one-third funded by the State of Texas
About two-thirds funded by the Federal Government
In December 2011, about 1 in 7 Texans relied on Medicaid for health
insurance or long-term services (3.7 million of the 25.9 million).
Medicaid was created through Title XIX of the 1965 Social Security Act, and
established in Texas in 1967.
In Texas, Medicaid is administered by the Texas Health and Human
Services Commission (HHSC).
Medicaid is an entitlement program, which means:
The number of eligible people who can enroll cannot be limited.
Any services covered under the program must be paid.
47
Module 7
REVIEW: The Medicaid Team
Providers: Medical, Dental and Other Services
HHSC: Single State Agency
MCOs: Managed Care Organizations
TMHP: Claims Administrator
DSHS
DARS
DADS
MAXIMUS: Medicaid and
CHIP Enrollment Broker
ICHP: Quality Monitor
48
Module 7
REVIEW: What Does Medicaid
Cover?
Acute and preventive health care
for all ages
Physician visits
Inpatient and outpatient services
Pharmacy, lab, and radiology
costs
Long-term services for
elderly and individuals with
disabilities
Mental health and
substance abuse treatment
Dental Services (for patients
under the age of 21)
Preventive
Therapeutic
49
Module 7
REVIEW: Who is Eligible to
Deliver Medicaid Funded Services?
Individual Health Care Providers
Doctors, dentists, advanced practice registered
nurses, physician assistants, physical
therapists, optometrists, and psychologists
Outpatient Facilities
Rural health clinics, federally qualified
health centers, school clinics, family
planning agencies, and mental health
centers
Inpatient Facilities
Hospitals and skilled nursing
facilities
Providers of Goods & Services
Durable medical equipment, ambulance,
pharmacies, radiology, and labs
50
Module 7
REVIEW: How Many People
Does Texas Medicaid Serve?
How many individual Texans received Medicaid-funded services at some
point in the year? About 4.57 million
Texas Annual Unduplicated Medicaid Enrollment
SFYs 2001-2011
4.5
4.0
3.36
3.5
Millions
3.0
3.63
3.73
3.81
2004
2005
2006
3.83
3.85
2007
2008
4.02
2.96
2.61
2.5
2.0
1.5
1.0
0.5
0.0
2001
2002
2003
2009
51
Module 7
Texas Medicaid Spending
The Major Categories
By Services Type, State Fiscal Year 2011
Clinic &
Hospital
Outpatient
$2.9 billion Hospital Inpatient
$3.5 billion
10%
13%
Physician &
Professional $5.1
billion
18%
Supplemental
Payments
22%
Medicare Parts A, B
& D $1.5B
Disproportionate
Share Hospital
Program $1.6B
Upper Payment Limit
$2.8B
Dental $1.8
billion
5%
Long Term Services
& Supports $6.3
billion
23%
Prescription Drugs
$2.6 billion
9%
52
Module 7
REVIEW: What Does Medicaid
Cost?
In 1967, Texas Medicaid served fewer than 1 million people at a cost
of less than $200 million
In 2011, Texas Medicaid served more than 3 million people at a cost
of $29.4 billion, representing about 26% of the total state budget
Federal funds are based on
the Federal Medicaid
Assistance Percentage
(FMAP) the matching rate
that changes annually.
For federal fiscal year (FFY)
2011, the Texas FMAP was
66.46%.
53
Module 7
REVIEW: What are Examples
of Texas Medicaid Programs?
Texas Health Steps
Provides medical prevention and dental
preventive/treatment services to eligible children
Programs for Women and Children
Programs for family planning and pregnant women,
Medicaid Buy-In for Children, and women’s cancers
Prescription Drugs
Prescription medications through local pharmacies
Behavioral Health Services
Long-Term Services and Supports
Mental, emotional, and chemical dependency
treatment for eligible patients
Programs for those with physical, intellectual and
developmental disabilities
54
Module 7
REVIEW: What is Texas
Health Steps?
Perhaps the best known of Texas
Medicaid programs is THSteps,
which provides medial and dental
preventive care and screening to
eligible children.
THSteps is the name for the
federally-required Early and
Periodic Screening, Diagnosis and
Treatment (EPSDT) services in
Texas.
Module 3 will focus
specifically on
Texas Health
Steps.
55
Module 7
10 Myths About Medicaid
Myths 1, 2 & 3
MYTH 1: Medicaid is an
antiquated program and
needs to be modernized.
MYTH 2: Medicaid is a
rigid, one size fits all
program.
FACT: Medicaid has
demonstrated throughout
its history that it is an
innovative program and
evolves with the changing
American health care
system.
FACT: States have taken
advantage of Medicaid’s
flexibility to customize
their program-about twothirds of Medicaid
spending is for “optional”
services or populations.
MYTH 3: Medicaid
spending is out of control.
FACT: The per enrollee
cost growth in Medicaid
(6.1 percent) is lower than
the per enrollee cost
growth in comparable
coverage under Medicare
(6.9), private health
insurance (10.6), and
monthly premiums for
employer-sponsored
insurance (12.6).
Medicaid is a program
that is most in demand
when the country is
experiencing economic
difficulties.
56
Module 7
10 Myths About Medicaid
Myths 4, 5, 6 & 7
MYTH 4: Medicaid
provides “Cadillac”
insurance coverage that is
more than a person needs.
MYTH 5: Medicaid covers
too many people and
crowds out private health
insurance.
FACT: The Medicaid
program serves several
populations that require
services not readily
available in standard
health insurance plans.
FACT: Most of the people
covered by Medicaid do
not have access to other
insurance, because they
can’t afford, their
employers don’t offer
coverage, or they are
priced out of the private
market due to illness or
disability.
MYTH 6: Medicaid is a
welfare system for people
who don’t work.
FACT: Sixty-five percent
of people who receive
Medicaid are from
working families.
MYTH 7: Medicaid pays
the nursing home bill for
wealthy seniors.
FACT: Medicaid eligibility
is limited to the very poor
or those with large health
expenses who have
depleted their savings.
57
Module 7
10 Myths About Medicaid
Myths 8, 9 & 10
MYTH 8: Medicaid’s openended federal financing
encourages overspending.
FACT: During the most
recent economic
downturn, states worked
hard to contain costs in
their programs even as
they served more people.
MYTH 9: The Medicaid
program is inefficient.
FACT: Medicaid
compares favorably to
other parts of the
American health system
when measuring
administrative efficiency
and per enrollee costs.
MYTH 10: Medicaid is a
poor-quality program that
has little impact on access
to care or health and people
on Medicaid dislike the
program.
FACT: FACT: Medicaid
has secured access to
primary and preventive
health care for its
beneficiaries that is
comparable to that of the
privately insured and
greatly exceeds that of
the uninsured
58
Why Take Medicaid
Patients?
Module 8
We treat patients based on need, not on
their ability to pay cash. We take all
comers. I love delivering babies and
taking care of kids, and in Texas if you
want to do OB and kids, its hard to do
enough volume if you don't take
Medicaid. The Texas Health Steps
program through Texas Medicaid is such
a good evidenced-based model for all
well child checks, that we use the same
guidelines and forms for all of our well
child checks, Medicaid or not.
Dr. K, Family Physician
59
Module 7
Test Your Knowledge about
Insurance: True or False?
1.
Medicaid covers only behavioral health services provided by a
psychiatrist.
FALSE: Medicaid covers mental health services provided by
Psychiatrists, Primary Care Physicians, Psychologists, Licensed
Clinical Social Workers, Licensed Professional Counselors,
Licensed Marriage and Family Therapists
2.
Only medications listed on the Preferred Drug List (PDL) are
reimbursable through Texas Medicaid.
FALSE: Medications not on the PDL can be prescribed but
require prior authorization. Medications on the PDL do not
require prior authorization.
3.
Texas Medicaid must cover all medications for which a
manufacturer offers a rebate.
TRUE: The Omnibus Budget Reconciliation Act of 1990 requires
that drug manufacturers pay medication rebates for drugs
dispensed under state Medicaid programs.
60
Module 7
Test Your Knowledge about
Insurance: True or False?
4. PACE programs coordinate and provide preventive, primary,
acute and long term care services for elderly individuals who
live in the community.
TRUE: Program for All-inclusive Care for the Elderly
(PACE)utilizes interdisciplinary teams, including physicians,
nurses, social workers, therapists, van drivers and aides, to
exchange information and solve problems as the conditions and
needs of PACE participants change.
5. Hospice is for all age groups, including children, during their
final stages of life.
TRUE: All Medicaid recipients who no longer want curative
treatment and who have a physician’s prognosis of six months
or less to live are eligible for Medicaid Hospice services.
61
Module 7
Medicaid Resources
Texas Health & Human Services Commission
www.hhsc.state.tx.us/medicaid
Texas Medicaid & Health Care Partnership
www.tmhp.com
Texas Medicaid Provider Procedures Manual
www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx
Texas Health Steps
www.dshs.state.tx.us/thsteps/providers.shtm
www.dshs.state.tx.us/dental/thsteps_dental.shtm
www.dshs.state.tx.us/thsteps/default.shtm
CHIP/ Children’s Medicaid
www.chipmedicaid.org
DADS Long-term Services and Supports:
cfoweb.dads.state.tx.us/referenceguide/guides/FY11ReferenceGuide.pdf
Medicare Information
www.medicare.gov
62
This Texas Medicaid curriculum
was prepared by
Betsy Goebel Jones, EdD
Project Director
Tim Hayes, MAM
Project Designer
Authors: Module 7
Betsy Goebel Jones, EdD
David RM Trotter, MA
Module 7
63