Download Tuberculosis (TB) Related Medicaid Option

Medicaid Reimbursement for
TB Services
Carol J. Pozsik, RN MPH
Executive Director
National TB Controllers Assn.
History of TB Funding
 Prior to 1982 states were dependent on State or
local funds for program operation
 1982 Federal Cooperative Agreements for TB
began providing staff and travel
 Today, State and local funds still provide some
financial support for patient diagnosis, treatment,
prevention and surveillance.
 In general, funding for TB from both state and
federal sources has been on the decline for
several years.
Background
Many TB programs still provide free
outpatient services to clients using state
and local funds.
 Because TB is a communicable disease, if
patient doesn’t have to pay for clinic visits
and medications they will be more likely
seek and complete treatment.
Background
 Majority of TB clients are low income
 Majority of TB clients are male and do not
qualify for traditional Medicaid services
 Females are more likely to be Medicaid
eligible because they can be enrolled in
Maternity, Family Planning and the WIC
Program
Background
 Some Medicaid programs cover limited TB
services if the client is already eligible and
if there is an existing billing system in
place.
 Most TB programs do not collect income
information unless they are trying to bill
traditional Medicaid.
Background
 Some TB programs provide funding for
inpatient hospitalization for complicated
diagnosis and treatment that is beyond the
scope of regular outpatient services
 CDC Cooperative Agreement funds do not
pay for drugs, x-rays and other direct
treatment services
What is Medicaid?
 Federal-State matching entitlement program
 Title XIX of the Social Security Act
 Provides medical assistance for certain
individuals and families who have low incomes
and resources
 Largest program providing medical and health
related services to America’s poorest people
Implementation
 Federal govt. sets broad guidelines
 States:
 Establish their own eligibility standards
 Determine type, amount, duration and scope
of services
 Set rates of payment for services
 Administer their own programs
 Programs vary from state to state
Basis of Eligibility
 Medicaid does not provide medical assistance
for all poor persons even under the broadest
provision of Federal statute
 To qualify must be in Mandatory Eligibility group
 Low income is only one test of established
thresholds for eligibility (determined by each
state within the Federal guidelines)
 States generally have broad discretion in
determining which groups Medicaid will cover
Examples of Mandatory Eligible
Groups
 Recipients of AFDC (Aid to Families with
Dependent Children)
 SSI Recipients (Supplemental Security
Income (aged, blind, disabled) who qualify
in states with more restrictive eligibility
requirements
 Pregnant women whose family income is
below 133% of poverty level
Examples of State Options
 Infants up to age one and pregnant
women not covered under the mandatory
rules
 Persons receiving care under home or
community based waivers are eligible.
 TB-infected persons who would be
financially eligible for Medicaid at the SSI
income level (only for TB-related
ambulatory services and for TB drugs)
The TB Medicaid Option
 1993 Medicaid Act was amended to allow
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states to extend eligibility for Medicaid to
TB infected persons
Must meet State income eligibility criteria
Covers both TB infection and disease,
including suspected cases
Coverage limited to treatment period
Does not qualify client for other Medicaid
services
Federal – State Match
 Match is determined at Federal level by a
Committee
 Federal “matches” State cost of services
 Example: May be 50% State and 50%
Federal
 Match differs from state to state.
Eligibility
 Medicaid policies for eligibility and
services are complex, and vary
considerably among similar sized and/or
adjacent states
 A person eligible for Medicaid in one State
might not be eligible in another state.
 Services within a State may change from
year to year
Medicaid TB Option Coverage
(State dependent)
 Outpatient Clinic visits
 Medications
 DOT (Directly Observed Therapy) visits
 X-rays (Diagnostic and Follow-up)
 Laboratory tests
Major Limitations of Medicaid
TB Option
 Does not pay for:
Contact Investigation (rules vary)
Hospitalization
Payment for Services
 Operates as a Vendor System
 State pays providers directly (includes health
departments)
 Providers must accept reimbursement as
payment in full
 State generally has broad discretion to
implement reimbursement methodology and rate
for services (There is a Federally imposed upper
limit and specific restrictions.)
Payment for Services
 Some states impose nominal deductibles
or co-payments from clients
Medicaid Option Sounded Good
1993 - 2007
 NTCA survey about the Medicaid Option
done in 2006 – 2007
 All fifty states surveyed
Who has the TB Medicaid Option?
Only five states:
Arkansas
California
Maine
South Dakota
Wisconsin
Why Other Programs Don’t Have
The Medicaid Option?
 State covers the costs of treatment: drugs, clinic
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operations (Some pay for hospitalization)
Medicaid agency does not have funds for the TB Option
Public health administration will not support applying for
the Option
Administrative set-up too difficult for TB program – few
clerical staff to do the work
Bill Medicaid, then must bill all clients – not enough staff
Match is too large up front – funds taken from TB
Program’s State monies causing deficits in funding
required services
Two states did not know about Medicaid Option
Why Don’t Other Programs Have
The Medicaid Option?
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Too time consuming to apply (2 years)
Sufficient funding from Medicaid eligible pts.
State has the Option – not all counties use it
Indian Health Service covers most clients
Gaps in coverage – drugs, hospitalization, no
field DOT
 Has expanded coverage for Medicaid eligibles
 Medicaid reimburses for lab, diagnostic tests,
xrays and private M.D. visits
Problems for States with
Immigrants
 Undocumented cannot qualify for Medicaid
programs
 Path to Citizenship and Guest Relations
programs require 5 years in US even after
becoming citizens to become eligible for
Medicaid
 Refugees are only eligible for 6 – 9 months
 Financial burden is great upon TB programs who
have large population of foreign born clients
Information About Medicaid Option
 Institute of Medicine Report, “Ending
Neglect”, 2000, pages 68 – 70, California
Case Study pages 72-73.
 Wisconsin TB Program Website:
http://dhfs.wisconsin.gov/tb/resources
“All That Glitters Is Not Gold”
Some things will have to change