Medicaid Reimbursement for Medicaid Reimbursement for TB ServicesTB Services

Carol J. Pozsik, RN MPHCarol J. Pozsik, RN MPH

Executive DirectorExecutive Director

National TB Controllers Assn.National TB Controllers Assn.

History of TB FundingHistory of TB Funding

Prior to 1982 states were dependent on State or Prior to 1982 states were dependent on State or local funds for program operationlocal funds for program operation

1982 Federal Cooperative Agreements for TB 1982 Federal Cooperative Agreements for TB began providing staff and travelbegan providing staff and travel

Today, State and local funds still provide some Today, State and local funds still provide some financial support for patient diagnosis, treatment, financial support for patient diagnosis, treatment, prevention and surveillance. prevention and surveillance.

In general, funding for TB from both state and In general, funding for TB from both state and federal sources has been on the decline for federal sources has been on the decline for several years.several years.

BackgroundBackground

Many TB programs still provide free Many TB programs still provide free outpatient services to clients using state outpatient services to clients using state and local funds.and local funds.

Because TB is a communicable disease, if Because TB is a communicable disease, if patient doesn’t have to pay for clinic visits patient doesn’t have to pay for clinic visits and medications they will be more likely and medications they will be more likely seek and complete treatment. seek and complete treatment.

BackgroundBackground

Majority of TB clients are low incomeMajority of TB clients are low income Majority of TB clients are male and do not Majority of TB clients are male and do not

qualify for traditional Medicaid servicesqualify for traditional Medicaid services Females are more likely to be Medicaid Females are more likely to be Medicaid

eligible because they can be enrolled in eligible because they can be enrolled in Maternity, Family Planning and the WIC Maternity, Family Planning and the WIC Program Program

BackgroundBackground

Some Medicaid programs cover limited TB Some Medicaid programs cover limited TB services services if the client is already eligibleif the client is already eligible and and if there is an existing billing system in if there is an existing billing system in place.place.

Most TB programs do not collect income Most TB programs do not collect income information unless they are trying to bill information unless they are trying to bill traditional Medicaid.traditional Medicaid.

BackgroundBackground

Some TB programs provide funding for Some TB programs provide funding for inpatient hospitalization for complicated inpatient hospitalization for complicated diagnosis and treatment that is beyond the diagnosis and treatment that is beyond the scope of regular outpatient servicesscope of regular outpatient services

CDC Cooperative Agreement funds do not CDC Cooperative Agreement funds do not pay for drugs, x-rays and other direct pay for drugs, x-rays and other direct treatment servicestreatment services

What is Medicaid?What is Medicaid?

Federal-State matching entitlement programFederal-State matching entitlement program Title XIX of the Social Security ActTitle XIX of the Social Security Act Provides medical assistance for certain Provides medical assistance for certain

individuals and families who have low incomes individuals and families who have low incomes and resourcesand resources

Largest program providing medical and health Largest program providing medical and health related services to America’s poorest peoplerelated services to America’s poorest people

ImplementationImplementation

Federal govt. sets broad guidelinesFederal govt. sets broad guidelines States:States:

Establish their own eligibility standardsEstablish their own eligibility standards Determine type, amount, duration and scope Determine type, amount, duration and scope

of servicesof services Set rates of payment for servicesSet rates of payment for services Administer their own programsAdminister their own programs Programs vary from state to statePrograms vary from state to state

Basis of EligibilityBasis of Eligibility

Medicaid does not provide medical assistance Medicaid does not provide medical assistance for for allall poor persons even under the broadest poor persons even under the broadest provision of Federal statuteprovision of Federal statute

To qualify must be in Mandatory Eligibility groupTo qualify must be in Mandatory Eligibility group Low income is only one test of established Low income is only one test of established

thresholds for eligibility (determined by each thresholds for eligibility (determined by each state within the Federal guidelines)state within the Federal guidelines)

States generally have broad discretion in States generally have broad discretion in determining which groups Medicaid will coverdetermining which groups Medicaid will cover

Examples of Mandatory Eligible Examples of Mandatory Eligible GroupsGroups

Recipients of AFDC (Aid to Families with Recipients of AFDC (Aid to Families with Dependent Children)Dependent Children)

SSI Recipients (Supplemental Security SSI Recipients (Supplemental Security Income (aged, blind, disabled) who qualify Income (aged, blind, disabled) who qualify in states with more restrictive eligibility in states with more restrictive eligibility requirementsrequirements

Pregnant women whose family income is Pregnant women whose family income is below 133% of poverty levelbelow 133% of poverty level

Examples of State OptionsExamples of State Options

Infants up to age one and pregnant Infants up to age one and pregnant women not covered under the mandatory women not covered under the mandatory rules rules

Persons receiving care under home or Persons receiving care under home or community based waivers are eligible.community based waivers are eligible.

TB-infected persons who would be TB-infected persons who would be financially eligible for Medicaid at the SSI financially eligible for Medicaid at the SSI income level (only for TB-related income level (only for TB-related ambulatory services and for TB drugs)ambulatory services and for TB drugs)

The TB Medicaid OptionThe TB Medicaid Option

1993 Medicaid Act was amended to allow 1993 Medicaid Act was amended to allow states to extend eligibility for Medicaid to states to extend eligibility for Medicaid to TB infected personsTB infected persons

Must meet State income eligibility criteriaMust meet State income eligibility criteria Covers both TB infection and disease, Covers both TB infection and disease,

including suspected casesincluding suspected cases Coverage limited to treatment periodCoverage limited to treatment period Does not qualify client for other Medicaid Does not qualify client for other Medicaid

servicesservices

Federal – State MatchFederal – State Match

Match is determined at Federal level by a Match is determined at Federal level by a CommitteeCommittee

Federal “matches” State cost of servicesFederal “matches” State cost of services Example: May be 50% State and 50% Example: May be 50% State and 50%

FederalFederal Match differs from state to state.Match differs from state to state.

EligibilityEligibility Medicaid policies for eligibility and Medicaid policies for eligibility and

services are complex, and vary services are complex, and vary considerably among similar sized and/or considerably among similar sized and/or adjacent statesadjacent states

A person eligible for Medicaid in one State A person eligible for Medicaid in one State might not be eligible in another state.might not be eligible in another state.

Services within a State may change from Services within a State may change from year to yearyear to year

Medicaid TB Option CoverageMedicaid TB Option Coverage(State dependent)(State dependent)

Outpatient Clinic visitsOutpatient Clinic visits MedicationsMedications DOT (Directly Observed Therapy) visitsDOT (Directly Observed Therapy) visits X-rays (Diagnostic and Follow-up)X-rays (Diagnostic and Follow-up) Laboratory testsLaboratory tests

Major Limitations of Medicaid Major Limitations of Medicaid TB OptionTB Option

Does not pay for: Does not pay for:

Contact Investigation (rules vary)Contact Investigation (rules vary)

Hospitalization Hospitalization

Payment for ServicesPayment for Services

Operates as a Vendor SystemOperates as a Vendor System State pays providers directly (includes health State pays providers directly (includes health

departments)departments) Providers must accept reimbursement as Providers must accept reimbursement as

payment in fullpayment in full State generally has broad discretion to State generally has broad discretion to

implement reimbursement methodology and rate implement reimbursement methodology and rate for services (There is a Federally imposed upper for services (There is a Federally imposed upper limit and specific restrictions.)limit and specific restrictions.)

Payment for ServicesPayment for Services

Some states impose nominal deductibles Some states impose nominal deductibles or co-payments from clientsor co-payments from clients

Medicaid Option Sounded Good Medicaid Option Sounded Good 1993 - 2007 1993 - 2007

NTCA survey about the Medicaid Option NTCA survey about the Medicaid Option done in 2006 – 2007done in 2006 – 2007

All fifty states surveyedAll fifty states surveyed

Who has the TB Medicaid Option?Who has the TB Medicaid Option?

Only five states:Only five states:

ArkansasArkansas

CaliforniaCalifornia

MaineMaine

South DakotaSouth Dakota

WisconsinWisconsin

Why Other Programs Don’t Have Why Other Programs Don’t Have The Medicaid Option?The Medicaid Option?

State covers the costs of treatment: drugs, clinic State covers the costs of treatment: drugs, clinic operations (Some pay for hospitalization)operations (Some pay for hospitalization)

Medicaid agency does not have funds for the TB OptionMedicaid agency does not have funds for the TB Option Public health administration will not support applying for Public health administration will not support applying for

the Optionthe Option Administrative set-up too difficult for TB program – few Administrative set-up too difficult for TB program – few

clerical staff to do the workclerical staff to do the work Bill Medicaid, then must bill all clients – not enough staffBill Medicaid, then must bill all clients – not enough staff Match is too large up front – funds taken from TB Match is too large up front – funds taken from TB

Program’s State monies causing deficits in funding Program’s State monies causing deficits in funding required servicesrequired services

Two states did not know about Medicaid OptionTwo states did not know about Medicaid Option

Why Don’t Other Programs Have Why Don’t Other Programs Have The Medicaid Option?The Medicaid Option?

Too time consuming to apply (2 years)Too time consuming to apply (2 years) Sufficient funding from Medicaid eligible pts.Sufficient funding from Medicaid eligible pts. State has the Option – not all counties use itState has the Option – not all counties use it Indian Health Service covers most clientsIndian Health Service covers most clients Gaps in coverage – drugs, hospitalization, no Gaps in coverage – drugs, hospitalization, no

field DOTfield DOT Has expanded coverage for Medicaid eligiblesHas expanded coverage for Medicaid eligibles Medicaid reimburses for lab, diagnostic tests, Medicaid reimburses for lab, diagnostic tests,

xrays and private M.D. visits xrays and private M.D. visits

Problems for States with Problems for States with ImmigrantsImmigrants

Undocumented cannot qualify for Medicaid Undocumented cannot qualify for Medicaid programsprograms

Path to Citizenship and Guest Relations Path to Citizenship and Guest Relations programs require 5 years in US even after programs require 5 years in US even after becoming citizens to become eligible for becoming citizens to become eligible for MedicaidMedicaid

Refugees are only eligible for 6 – 9 monthsRefugees are only eligible for 6 – 9 months Financial burden is great upon TB programs who Financial burden is great upon TB programs who

have large population of foreign born clientshave large population of foreign born clients

Information About Medicaid OptionInformation About Medicaid Option

Institute of Medicine Report, “Ending Institute of Medicine Report, “Ending Neglect”, 2000, pages 68 – 70, California Neglect”, 2000, pages 68 – 70, California Case Study pages 72-73.Case Study pages 72-73.

Wisconsin TB Program Website:Wisconsin TB Program Website:

http://dhfs.wisconsin.gov/tb/resourceshttp://dhfs.wisconsin.gov/tb/resources

““All That Glitters Is Not Gold”All That Glitters Is Not Gold”

Some things will have to changeSome things will have to change