Transcript Texas Medicaid Medical and Dental Information Series Module 3 Version 1.2 (6/22/2010) 2/22/2013 Module 3 Medicaid Curriculum Overview Module 1: General Structure of the Texas Medicaid System Module.

Texas Medicaid
Medical and Dental
Information Series
Module 3
Version 1.2 (6/22/2010)
2/22/2013
1
Module 3
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
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Module 3
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Module 3: Objectives
After completing this module, you should be able to:
Review the purpose and structure of Texas Medicaid
Explain the purpose and goals of Texas Health Steps
(THSteps)
Identify the population eligible for THSteps services
Identify who may apply to be a THSteps provider
Describe the role of THSteps in promoting preventive
health care for Texas children and families
Explain the benefits to Public Health, Individual
Patients, and Health Care Providers that result from
THSteps and its emphasis on preventive care
Find Medicaid and THSteps resources
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THSteps: All About Prevention
The over-arching goal of THSteps is to encourage,
support and guide preventive health care for Texas
children and families, by:
Promoting good health habits
Periodic screening to prevent, detect or provide early
intervention for health problems
Immunizations to protect public and individual from
infectious disease
Why the focus on Preventive Health through THSteps?
To benefit public health, in terms of better health
outcomes, elimination of disease and health disparities,
and reduced costs
To benefit the individual patient, by providing a strong
foundation for improved wellbeing and quality of life
To benefit the provider, by offering initiatives and
resources that support practice and provision of care
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True or False?
Test Your Knowledge about Texas Health Steps
Texas Health Steps is the name for Texas’ program for
Early and Periodic Screening, Diagnosis and
Treatment (EPSDT).
THSteps covers children and adolescents through
age 23, or until graduation from college.
Case Management assists families with resources
such as educational, financial, or housing needs.
THSteps will reimburse physicians for applying
fluoride varnish to patients’ teeth.
Braces for cosmetic reasons only are a benefit
covered under Texas Health Steps.
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Module 3
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.
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REVIEW: Medicaid Functions
Department of State
Health Services (DSHS)
Governor
of Texas
Health &
Human
Services
(HHSC)
Executive
Commissioner
Single State
Agency
(HHSC)
Department of Assistive
& Rehabilitative
Services (DARS)
Department of Aging &
Disability Services
(DADS)
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Module 3
REVIEW:
Responsibilities
Medicaid fee-for-service claims administrator
Manages policy development
Collects HMO encounter data
Enrolls providers
Supplies provider relations representatives to enrolled providers
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Module 3
Benefits for Public Health
Texas Health Steps
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Health Care Coverage for Kids:
Implications for Public Health
Compared with children who have health insurance, children who
lack or have only intermittent health care coverage are at greater
risk for:
Delayed care and unmet health care needs
Lack of a usual source of care
Less access to preventive, specialist, or long-term care
Lower utilization rates
Care that imposes a high financial burden on their families
Poor health outcomes
This section provides an overview of Texas
programs that provide health care coverage for kids
as part of the State’s responsibility to improve
overall public health and wellness.
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What is Texas Health Steps?
Texas Health Steps is the Texas
Program for Early and Periodic
Screening, Diagnosis and Treatment
(EPSDT)
THSteps provides medical and dental
prevention and treatment services for
children of low-income families from
birth through age 20
Medicaid provides expanded services
through the Comprehensive Care
Program (CCP)
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Coloring the Full Picture of
THSteps
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Who Are the THSteps Patients?
Children from low income working
families
Many families are singleparent, working low-paying jobs
Children in foster care
Social Security Income (SSI)
recipients
Children of parents receiving
SSI benefits
Blind and/or disabled children
Infants of women covered by
Medicaid during their pregnancy
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Module 3
REVIEW:
Texas Medicaid
Texas Medicaid Recipients by Age
2011
Age 21-64
17%
Age 65+
6%
Age 0-5
36%
Age 15-20
11%
Age 6-14
30%
Unduplicated Clients
SFY 2011 = 4,567,077
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Module 3
Common Medicaid Myths
Myth
Medicaid is a welfare system for
people who don’t work.
Fact
65% of people who receive
Medicaid are from working
families.
Medicaid was originally
designed to provide coverage
to welfare recipients; however,
it was separated from the
welfare system in 1996.
Among Medicaid beneficiaries
who are out of the workforce
(or whose parents are not
working), Medicaid coverage
serves as a supplement to their
cash assistance and provides
needed health coverage.
Parents of children with
Medicaid often work in low
income jobs that do not offer
health insurance, or they
cannot afford health insurance
due to their low incomes.
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Module 3
Who can apply to be a THSteps
Provider?
Physicians (MD, DO)
Dentists
Physician Assistants (PA)
Advanced Practice Registered
Nurses (APRN)
Rural Health Clinics (RHC)
Federally Qualified Health Centers (FQHC)
Health care providers or facilities capable of performing checkups
under a physician’s direction, such as health departments, migrant
clinics, family planning clinics and school districts
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Medical & Dental Home
The foundation of THSteps is the health checkup, which prevents
disease, detects medical and dental problems early, and initiates
timely treatment.
THSteps encourages patients to establish medical and dental
homes, which function as a usual source of care
Medical and Dental Homes provide care that is
Accessible
Continuous
Comprehensive
Coordinated
Patient-centered
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Usual Source of Care (USC) for children:
Usual source of care by health care setting and insurance status
100
Percentage of Children
90
80
70
60
50
40
30
20
10
0
No USC
Private Office
Private
Medicaid
SCHIP
Clinic/Health Center
Uninsured
*Note: Few respondents identified the Emergency Department (ED) as their child’s USC. However, the uninsured were
more likely to identify the ED as their child's USC (1.6%) compared to privately and publically insured children.
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Comprehensive Care Program
(CCP)
The Children’s CCP is the expanded portion of Texas Health Steps
that took effect in 1990
CCP covers services for children birth through 20 years old that are
not usually allowed or are more limited under Medicaid for the adult
population, such as:
Treatment in freestanding psychiatric hospitals
Oral health care
Developmental speech therapy
Developmental occupational therapy
Augmentative communication devices/systems
Private duty nursing
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Module 3
Common Medicaid Myths
Myth
Medicaid coverage leads to poor
quality health care.
Fact
Medicaid provides access to
primary and preventive care that
is comparable to care available
for the privately insured,
especially where children’s health
is concerned.
THSteps coordinates services
to expand family awareness
and availability of health
services, increase preventive
services, and help families
obtain comprehensive services
through a network of private
and public providers.
THSteps contacts parents and
informs them of the benefits
under the program.
Please help us to insure that this myth never becomes a reality. Take good care of children with
Medicaid in your own practice, just as you do for your other patients.
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THSteps Costs to the State of Texas
Average monthly enrollment of THSteps eligible children at a given point in time
1,594,466
1,810,364
1,815,065
$92.01
Total Average Monthly
Cost per Recipient
Average Monthly Comprehensive Care Program
(CCP) Cost per Recipient
$53.55
$68.11
$45.23
$31.36
Average Monthly
Dental Cost per
Recipient
$23.96
Average Monthly Medical Cost per Recipient
$12.95
$8.32
$14.57
$7.62
$8.27
2005
2003
Medical
Dental
$15.63
2007
CCP
Total
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Module 3
REVIEW:
Medicaid vs. CHIP
(Children’s Health Insurance Program)
Texas Medicaid
CHIP
Authorized by Social Security Act
of 1965
Authorized by Balance Budget Act
of 1997
Jointly Funded by State and Federal Government
Entitlement program based on income,
assets and/or disability
Enrollment based on income
(not an entitlement program)
Low income families, children,
pregnant women, disabled, elderly
Children in families with too much
income or too many assets to qualify
for Medicaid and who meet the CHIP
income requirements
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Benefits for Individual
Patients
Texas Health Steps
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Health care Visits for Kids:
Implications for Patient Health
Parents want to do everything they can to keep their children
healthy. Preventive care benefits provided through THSteps make it
easier for parents to ensure their kids’ health.
Appropriate checkups and immunizations can prevent many health
problems.
Preventive care can catch problems before they start to get worse
and thereby help decrease the severity of illness and disease.
This section outlines the specific elements of the
THSteps medical and dental checkups and additional
health benefits to children and families. You’ll see how
THSteps’ emphasis on preventive health improved the
lives of two families.
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The Face of Medicaid:
Sylvia, Gracie & Josiah
Sylvia is Gracie and Josiah’s grandmother, and now their primary
caregiver
Sylvia’s income of $2300 per month puts her just over 150% of the
federal poverty guideline for a family of 3
Sylvia called 2-1-1, the Texas Information line, which referred Sylvia
to Medicaid so that she could get Gracie and Josiah enrolled for
services, and scheduled
to see a THSteps physician
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Module 3
The Face of THSteps:
Meet Gracie
Gracie is 4 years old
Sylvia describes her
granddaughter as shy and
reserved, preferring to engage in
solitary activities
Gracie recently started pre-school
Gracie’s teacher’s concerns: Inattention, temper
tantrums, few friends, poor school performance
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Module 3
The Face of THSteps
Meet Josiah
Josiah just turned 1
Sylvia describes her grandson
as a “little charmer” who is
playful and affectionate
Sylvia’s Concerns: Josiah
seems a little small to Sylvia,
although he appears to be in
overall good health
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THSteps Medical Checkup
Schedule
Babies & Toddlers
3-5 days old
2 weeks
2, 4, 6, 9, 12, 15 & 18 months
2, 2½, 3, 4 & 5 years
Older Children
Annually at ages
6-10 years
Preteens, Teens & Young Adults
Annually at ages 11-20 years
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Module 3
THSteps Medical Checkups
Periodicity Schedule, Birth-10 Years
The latest periodicity schedule can be downloaded from www.tmhp.com/Pages/Medicaid/medicaid_forms.aspx (located under the “Miscellaneous” section).
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THSteps Medical Checkups
Periodicity Schedule, 11-20 Years
The latest periodicity schedule can be downloaded from www.tmhp.com/Pages/Medicaid/medicaid_forms.aspx (located under the “Miscellaneous” section).
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THSteps Medical Checkups
Medical Checkup Components
Comprehensive Health &
Developmental History
Family and personal history
Nutritional screening
Developmental screening
Behavioral, social and
emotional screening
TB screening
Comprehensive Unclothed
Physical Exam
Measurements and
percentiles
Oral health screening
Hearing screening
Vision screening
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Module 3
Developmental Screening Example
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THSteps Medical Checkups
Medical Checkup Components (continued)
Module 3
Immunizations
Immunization
status must be
assessed at every
checkup, and
those indicated are
administered
according to the
Advisory
Committee on
Immunization
Practice (ACIP)
Recommendations
Age-Appropriate
Laboratory Tests
Including newborn,
anemia and lead
screens and
testing for
hyperlipidemia,
diabetes, and
sexually
transmitted
diseases
Health Education
Including
anticipatory
guidance, to help
parents know what
to expect
Dental referral
beginning at 6 months
As an additional
requirement in
Texas
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Module 3
Dental Care in the Health Home
According to the United States Surgeon General
and the Pew Charitable Trust, dental care is the
single greatest unmet need among children,
especially children from low-income families.
Medical professionals can help prevent
dental decay by:
Making dental referrals starting at 6 months of age.
Applying fluoride varnish, a protective gel that is painted on teeth
to help prevent early childhood cavities and reduce the
progression of cavities that have already started. Texas Medicaid
reimburses DSHS certified medical providers for limited
preventive dental care on children from 6 to 35 months of age
who have not established a dental home
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Referrals for
Medicaid-Covered Services
Primary care providers may
determine that a referral for
diagnosis or treatment is
necessary
Efforts should be made to
preserve continuity of care
Referrals may include:
Subspecialty care
Case Management for Children &
Pregnant Women
Hearing Services
Routine Dental care
Dental treatment and emergencies
Family planning and genetic
services
Early Childhood Intervention (ECI)
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Why is Preventive Care Important?
Gracie’s Story
Gracie’s 4-Year-Old Appointment:
Comprehensive health & developmental history and use of the
Ages & Stages Questionnaire
Comprehensive physical exam, including vision & hearing
TB screening and blood test for anemia and lead poisoning
Immunizations to prepare her for pre-school
Face-to-face health education & counseling for Sylvia
Dental referral
Gracie’s THSteps Exam Findings:
Moderate hearing loss
All other aspects of the exam were within
normal limits
Treatment: Gracie’s doctor referred her to an
audiologist, who fit her with hearing aids.
Outcome: Improvement at school and fewer
outbursts
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Module 3
Why is Preventive Care Important?
Josiah’s Story
Josiah’s 12-Month Appointment:
Comprehensive health & developmental history, including the
Ages & Stages Questionnaire
Comprehensive physical exam, including vision & hearing
TB screening and blood test for anemia and lead poisoning
Immunizations needed for daycare
Face-to-face health education & counseling for Sylvia
Dental referral
Josiah’s THSteps Exam Findings:
Weight below the 5th percentile for age
Mild developmental delay
Inadequate nutrition prior to moving in with Sylvia
Treatment: Josiah’s physician developed a nutrition
plan with Sylvia and scheduled follow-up visit to
monitor his growth at subsequent checkups
Outcome: Josiah gradually gained weight, and he is
now meeting his developmental milestones!
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Module 3
The Face of Medicaid
Jonathan, Trisha & TJ
TJ, the youngest of Jonathan and Trisha’s 3 children, is 11 years old
Jonathan’s father and Trisha’s mother have both been diagnosed
with Type 2 Diabetes
TJ prefers to play videogames and surf internet, and he rarely
participates in exercise or sports
TJ’s favorite foods are chicken fingers, soda, chips and vanilla icecream
Trisha’s Concerns: Weight gain & school problems
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Module 3
The Face of THSteps
TJ’s Annual Exam
TJ’s 11-Year Old Appointment:
Comprehensive health & developmental history, including nutrition
history
Comprehensive physical exam, including vision & hearing and BMI
TB screening
Face-to-face health education & counseling for Trisha
Dental referral
TJ’s THSteps Exam Findings:
Family history for diabetes and sedentary lifestyle
Weight 140 lbs, Height 4’ 9”, BMI 30.3
Non-fasting blood glucose of 220
Acanthosis nigricans on TJ’s neck and underarm
areas
Brown spots on TJ’s teeth
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Module 3
Why is Preventive Care Important?
Dr. Molina’s Plan for TJ
1.
Inform Jonathan, Trisha, and TJ that TJ has Type 2 diabetes
2.
Order labs: Hemoglobin A1c, lipid panel, TSH, CBC, CMP
3.
Counsel Jonathan, Trisha, and TJ on how to lose weight and
devise an exercise plan to fit TJ’s health status
4.
Refer TJ to a registered dietitian to formulate a dietary plan
5.
Refer TJ to diabetic counseling
6.
Schedule follow-up in 1 week to re-check blood glucose level,
review lab results, determine which medications are appropriate,
and reinforce dietary plan.
7.
Refer TJ to a dental home for a
comprehensive dental exam and treatment
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THSteps Dental Checkup
Schedule
Module 3
Birth to 6 months
Emergency dental services
Diagnosis and treatment of
Early Childhood Caries
6 months to 21 years
First dental visit at 6 months of age
Periodic dental checkups every 6 months
thereafter
Children younger than 36 months may be seen
every 3 months due to risk of developing
early childhood caries
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Module 3
THSteps Dental Checkups
Dental Checkup Components
Prevention &
Maintenance
Treatment for Teeth and
Gums
Emergency Dental
Services
Health-Related
Orthodontic Services
Including examinations, preventive
care and oral education
Such as fillings, extractions and root
canals
Including treatment of injuries and to prevent
loss of teeth
With prior authorization, such as to correct a cleft
palate or treat facial injuries
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Module 3
REVIEW:
Case Management (CM)
Services that assist Medicaid patients in gaining
access to needed medical, dental, mental
health, social, educational and other services
Case Managers (such as a nurse, social worker,
or mental health professional) assess a patient’s
needs and strengths, then develop and monitor
an individualized care plan
Case Management is available through such
programs as Case Management for Children &
Pregnant Women, Early Childhood Intervention
(ECI), and local mental health/mental retardation
services
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Case Management for Children
and Pregnant Women
Case managers assist children,
women who are pregnant, and their
families in getting help with:
Access to needed medical,
dental, and mental health
services, including transportation
Educational or school issues
Financial or housing problems
Medical supplies or equipment
What do case managers do?
Find out what families need
Make plans to meet those
needs
Refer and teach families how to
access community resources
and services near where they
live
Follow up regularly with families
to make sure their needs have
been met
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Module 3
Eligibility for Case Management
TJ was referred to case management to:
Help advocate for school services, including
testing for a possible learning disability,
special educational services, or tutoring
Help TJ’s parents obtain diabetic testing
supplies
TJ was eligible for case management services because his
family meets the following criteria:
Birth through age 20 with a health condition/ health risk
(a high-risk pregnant woman could also be eligible)
Texas Medicaid-eligible
In need of services to prevent illnesses or medical
conditions, to maintain function or slow further deterioration
Desire case management
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Why is Preventive Care Important?
Module 3
TJ’s Story
Dr. Molina is helping TJ’s family manage his Type 2 Diabetes,
through patient and parent education, implementation of a diet
and exercise plan, making appropriate referrals, and
managing medications.
Dr. Molina referred TJ to a dental home for an examination
and treatment of oral disease
TJ was referred for Case Management to help
his parents get the educational services TJ
needs. Their case manager will also help
TJ’s parents obtain diabetic testing supplies.
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Benefits for Health Care
Providers
Texas Health Steps
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Health Care for Kids:
Implications for Provider Support
Texas Medicaid recognizes that providing preventive care for
children requires provider and staff support, such as:
Connections to parents to help with appointments
Online resources for provider information and training
Emerging initiatives for continuous improvement of services and
support
This section describes new and ongoing programs
developed by Texas Medicaid that offer assistance and
resources to the providers who are essential to caring
for Texas children.
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Outreach and Informing Program
The Outreach and Informing Program provides
outreach, informing, and support services to
THSteps recipients. Outreach and informing staff:
Contact newly enrolled THSteps families to
inform them of the services to which they are
entitled
Encourage families to use the THSteps
preventive medical and dental checkup services
Provide families with a list of all THSteps
providers in their area
Assist families in setting an appointment for a
medical and/or dental checkup
Schedule transportation to a Medicaid-covered
service
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Module 3
Outreach and Informing Program
Provided Services
Marketing material distribution
Community presentations
Conducting home visits for THSteps
recipients and their parents/caretakers.
Maintaining a toll-free helpline that assists
THSteps recipients to:
Find a THSteps provider
Schedule an appointment with a THSteps
provider
Schedule transportation to a Medicaidcovered service
Request outreach assistance or home
visits
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Module 3
Managed Care Organizations
Outreach and Informing
Managed Care Organizations (MCO)
engage in enhanced outreach activities to
increase patient participation.
Call families with children new to the
HMO, and those due for a checkup
Provide assistance with appointment
scheduling
Help with scheduling transportation to
the appointment
Educate families about THSteps through
written materials such as member
handbooks, letters, brochures, fliers, and
posters
Call THSteps providers for available
checkup slots
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Managed Care Organizations:
Reminders to Reduce No-Shows
Module 3
Mail checkup and appointment reminder postcards or letters
Follow-up by phone
Identify and educate of migrant families about the availability of
accelerated Texas Health Steps services prior to leaving their homes
to travel to work
May offer incentives to members and/or to their providers for the
completion of timely checkups
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Module 3
THSteps Reminder Letters
In English
In Spanish
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Provider Outreach Referral Form
Contact patients who miss
appointments and assist them with
rescheduling
Locate patients for follow-up
Assist scheduling follow-up visits
Educate patients regarding the
importance of keeping
appointments
Provide feedback to provider
Assist patients by removing
barriers to keeping appointments
(i.e. transportation)
Access form at:
www.dshs.state.tx.us/thsteps/Missed appointment form 0209_secure.doc
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Module 3
Medicaid Transportation Program
Provides free rides for Texas Health
Steps and other Medicaid eligible
patients
Helps patients miss fewer appointments
Allows scheduling of multiple
appointments at one time
Results in fewer no-shows
THREE WAYS TO GET
TO THE DOCTOR
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Module 3
Online Provider Resources
www.TxHealthSteps.com
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THSteps Provider
Information
www.dshs.state.tx.us/thsteps/providers.shtm
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TMHP Provider Manual
www.tmhp.com
Providers > Reference Manual
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Online Provider Education
Computer-based online training at:
www.TxHealthSteps.com
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Medicaid Initiatives
Promotores Pilot Program: Community health workers dedicated to
outreach and education
Health Home Pilot Program: Development of the most efficient
models for the medical and dental home
Consultation and Referral Network: 24/7 Access to subspecialists
DSHS Laboratory Courier Service: To reduce specimen transit time
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Module 3
Test Your Knowledge about Texas
Health Steps: True or False?
1. Texas Health Steps is the name for Texas’ program for Early &
Periodic Screening, Diagnosis & Treatment (EPSDT).
TRUE: EPSDT is a mandated Medicaid program, which
Texas has chosen to name “Texas Health Steps.”
2. THSteps covers children and adolescents through age 23, or until
graduation from college.
FALSE: Eligible children are covered until their 21st birthday
regardless of educational status.
3. Case Management assists families with resources such as
educational, financial, or housing needs.
TRUE: Case Management assists Medicaid families in gaining
access to needed medical, social, educational, and other services.
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Test Your Knowledge about Texas
Health Steps: True or False?
4. THSteps will reimburse DSHS-certified physicians for applying
fluoride varnish to patients’ teeth.
TRUE: In part to increase access to early preventive dental
services, THSteps will reimburse physician providers who
perform a intermediate oral examination and apply fluoride
varnish on patients from 6 months up to 35 months of age who
have not established a dental home.
5. Braces for cosmetic reasons only are a benefit covered under
Texas Health Steps.
FALSE: Cosmetic dental procedures are not a THSteps benefit.
Orthodontic care must be medically necessary for coverage.
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Medicaid Resources
Texas Health & Human Services Commission
www.hhsc.state.tx.us/medicaid
Texas Medicaid & Healthcare Partnership
www.tmhp.com
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
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This Texas Medicaid curriculum
was prepared by
Betsy Goebel Jones, EdD
Project Director
Tim Hayes, MAM
Project Designer
Author: Module 3
Betsy Goebel Jones, EdD
Module 3
65