National Medicaid Issue

We have a few updates on waivers and DRA state plan activity to report:

Rhode Island: At the end of March, the state submitted a far-reaching concept paper to CMS for "The Rhode Island Global Consumer Choice Compact" waiver. The waiver would put a global cap on both acute and long-term services, putting the state at risk for both unanticipated growth in health care costs and enrollment. There are limited changes in benefits and increased cost-sharing for children and families, but extensive changes in the way long-term services would be provided. While the goals of the waiver include expanding community-based services and limiting institutional care, the capped funding creates significant risks for all beneficiaries, providers as well as the state. As in Vermont, the state would establish 3 levels of need for long-term services: highest, high and preventive. Only those beneficiaries who meet the criteria highest level of need would have an entitlement to services; others would be subject to the availability of funding -- a risk compounded by the capped federal funds. The criteria are not described in the waiver. There is also no information regarding the details of the financing of the waiver such as trend rates the state is seeking. We have been in touch with advocates and providers in Rhode Island who will be working on this, so let me or Joan know if you want more information regarding efforts there. We will update you as we learn more about these plans as well as the progress of this waiver. The concept paper is at http://www.eohhs.ri.gov/reports/documents/RIGlobalConsumerChoiceCompactWaiverFinal3-26-08toCMSmodified.pdf

Florida: Plans to expand Florida's waiver to additional counties have been hotly debated in the state's legislature and the outcome is still up in the air. The House budget bill would expand the waiver to 9 additional counties, including Miami-Dade in September 2010. The Senate bill does not include any aurhority for further expansion of the waiver. So it does appear that expansion will not be happening in the near future. Unfortunately the legislature is also considering significant cuts to the state's Medicaid program. (The Center's paper on state budget cuts was updated today and includes detailed information on the cuts being considered in Florida as well as other states. http://www.cbpp.org/3-13-08sfp.htm )

West Virginia: Some light has finally been shed on the impact of the state's Medicaid Redesign on children and adults needing mental health services. See the article from the April 7 Charleston Gazette reprinted below. What is especially disturbing is that only 7 percent of beneficiaries affected by the program are enrolled in the enhanced plan leaving the vast majority of beneficiaries in the basic plan with limits on prescription drugs and mental health services. (In order to get into the enhanced plan, beneficiaries must see their primary care provider and enter into a member agreement for the year. If this is not done within 90 days of the approval of an application or renewal of coverage, the beneficiary stays in the basic plan with limits on benefits for the year.) According to mental health providers, many of their patients have had problems scheduling appointments and getting their paperwork done and having the state put them in the enhanced plan in a timely manner. Since the plan went statewide last November, the problems have grown as described below. The state's responses regarding EPSDT are particularly troublesome. What they have said is that a child in the basic plan could get necessary mental health care services if they are determined necessary during a well-child visit. Some of the children affected have been approved for intensive behavioral health services by the state's own utilization review contractor, but services are not being provided because the child is in the basic plan and the services were not prescribed by the child's pediatrician or other primary care provider.

Let us know if you have any questions or any thoughts on any of this.

Judy and Joan

April 7, 2008
Medicaid fails mentally ill, group says
Changes force more people into mental hospitals, jails
By Eric Eyre
Staff writer
West Virginia's revamped Medicaid health insurance program for the poor has failed people with mental illness, according to behavioral health center executives from across the state.
The administrators predict thousands of low-income West Virginians with severe mental problems will be without services, forcing them into state mental hospitals and jails, or out onto the street - unless the state Medicaid office overhauls the program.
"You're talking about the people who are the most quickly dangerous," said John Russell, director of the West Virginia Behavioral Health Association.
The state has stopped reimbursing behavioral health centers for crisis services provided to the bulk of their Medicaid clients.
"They're implementing a program that will eliminate payment for crucial services for thousands of West Virginians," Russell said. "As a result, the only choice the state will have is to lock these individuals up in jails or state facilities. The more likely outcome will be to leave them to suffer on the street."
Three other behavior health center chiefs also spoke to the Gazette, but requested anonymity because they feared retribution from state Medicaid officials.
Medicaid spokeswoman Shannon Riley Landrum said the health administrators have overstated the impact of the program changes.
"They're presenting a worst-case scenario," Landrum said. "Information presented to us simply doesn't indicate this is happening."
Landrum said behavioral health centers could tap a special "uncompensated care" fund through the state Bureau of Behavioral Health and Health Facilities to pay for mental health services not reimbursed by Medicaid.
Also, the Medicaid office tweaked the program Tuesday, allowing behavioral health facilities to be paid for less-intensive mental health services typically provided by psychologists and psychiatrists, Landrum said.
"During a crisis, no one should be turned away from services," she said. "We have not heard of that happening. We have a lot of people worrying that will happen."
Last year, Medicaid recipients started switching over to a redesigned program called Mountain Health Choices.
They're given the choice to sign up for a bare-bones "basic" plan or an "enhanced" plan, which comes with more benefits but also stipulations, such as keeping doctor's appointments and staying away from hospital emergency rooms for minor illnesses.
Until last week's change, the basic plan for adults included no mental health services provided by behavioral health centers. Children on the basic plan are limited to "26 units" of service - an allotment that could be used up in two or three days, mental health group administrators say.
Landrum said that cap would be lifted if a child's doctor determines mental health treatment is "medically necessary" during an annual screening. Medicaid's enhanced plan provides a full range of mental health services. But only 6 percent of Medicaid recipients who require mental health help have signed up for the basic plan, according to a recent survey of all behavioral health centers in West Virginia.
Some Medicaid mentally ill patients simply don't have the mental capacity to know they should enroll in the expanded plan, the executives said. Others were automatically transferred from the traditional Medicaid program, which provided mental health services, to the basic plan because they didn't fill out the required form.
The Medicaid program started in three counties - Lincoln, Clay and Upshur - last year. The program has expanded to 49 of West Virginia's 55 counties.
"The pilot was a failure," Russell said. "It's been an administrative nightmare. There's never been an independent review."
Landrum said it was too early to call the redesigned Medicaid program a failure. Less than half of Medicaid recipients have switched over to Mountain Health Choices.
Of those, about 7 percent - 5,288 out of 73,257 - signed up for the enhanced plan, according to Medicaid enrollment data.
The behavioral health centers continue to provide services to mentally ill patients, racking up hundreds of thousands of dollars in bills that the state has refused to pay - even though the state contracted with a claims management company that approved the services, the health center administrators say.
The executives said their nonprofit agencies are no longer willing to shoulder the cost of the program's failure and will have to refuse to treat Medicaid recipients. People with Medicaid insurance make up about 40 percent of behavioral heath center patients - those with mental health and substance abuse problems - across the state.
"We're moving from a community system to an institutional system," said Tom Susman, a consultant for the mental health centers. "We're moving back in the direction of warehousing. The centers can no longer afford to take care of these patients, and they'll end up in state hospitals."
West Virginia has two psychiatric hospitals: Mildred Mitchell-Bateman Hospital in Huntington and William R. Sharpe Jr. Hospital in Weston. Both facilities are at full capacity, forcing them to divert dozens of patients to private psychiatric hospitals.
Russell said it's much cheaper for the state to treat mental patients in residential programs than in mental hospitals and jails. The state receives 3-to-1 matching funds from the federal government for Medicaid recipients who use behavioral health centers. State taxpayers pick up the entire cost of a patient's medical care once they're committed to a state mental hospital, he said.
The health center administrators plan to talk to lawmakers and advocacy groups in the coming weeks.
Medicaid officials said they've been meeting with behavioral health leaders since the new program's inception and will continue to do so.
"There are some individuals impacted by the changes in the program, and we're continually monitoring the issue," Landrum said. This is about our members receiving the right care at the right place at the right time. No member should be going without medically necessary services."
To contact staff writer Eric Eyre, use e-mail or call 348-4869.