What can we do for you? 1/14/2011. The Catalyst Center: Who are we?

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1 Medicaid Buy In Programs: Do They Make a Difference to Families of Children and Youth with Special Health Care Needs? Sara Bachman, PhD Boston University School of Social Work Meg Comeau, MHA Boston University School of Public Health The Catalyst Center: Who are we? Funded by the federal Maternal and Child Health Bureau A project of the Health and Disability Working Group at the Boston University School of Public Health The National Center dedicated to the MCHB outcome measure: all children and youth with special health care needs have access to adequate health insurance coverage and financing. What can we do for you? Create resources (publications, topical conference calls, webcasts) Answer TA questions about health care financing policy for CSHCN Guide stakeholders to data sources outside our own work Connect those interested in working together to address complex financing issues 1

2 What can t we do? No direct advocacy for individuals or groups No lobbying Currently, there are major gaps in the coverage and financing system that cause significant problems for CSHCN in accessing care and financial hardship for their families. Children with special health care needs aren t they taken care of? Common policy perception as long as you cover uninsured children (e.g. expand CHIP) CSHCN should be okay Especially given: Poverty Medicaid Disability IDEA State Title V Programs Medicaid TEFRA/HCBS waiver programs SSI = Disability = Medicaid 2

3 Type of insurance Not quite.. While most CSHCN do have health care coverage % of CSHCN by insurance category Private insurance only 60.3% Public insurance only 28.6% Both public and private 7.5% Uninsured 3.6% Unless otherwise noted, statistics in this presentation are from the Child and Adolescent Health Measurement Initiative. 2005/06 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved 03/22/10 from Simple coverage is not enough... Currently insured CSHCN whose insurance is inadequate (according to their families) National Average 33.1% 3

4 Underinsurance: typical gaps in coverage Habilitative therapies: physical, occupational, speech/language Prescription medications Durable medical equipment Eye glasses, hearing aids Consumable supplies: diapers, wipes, hearing aid batteries, disposable dressings, etc. Mental health services Dental care Pathways to hardship Uncovered medical expenses - 20% of families of CSHCN report they spend more than $1,000 per year on their child s medical expenses Pathways to hardship, continued Higher expenses for routine things every family spends money on 18.1% report their child s SHCN have caused financial problems for the family 4

5 Pathways to hardship, continued Loss of employment income % report at least one adult having to stop working or cut back on work hours Remember % of children with special health care needs HAVE HEALTH INSURANCE COVERAGE When families are the payer of last resort, continued. Family as a whole is affected fewer funds for food, clothing, housing, etc. Worst case scenario: Child may not receive needed services Material Hardship in US Families Raising Children with Disabilities. Parish, S., et al. Exceptional Children, Vol. 75, No. 1, pages Retrieved 9/27/09 from 5

6 So what can be done to: Cover more kids? Close gaps in coverage? Decrease family financial hardship? Medicaid as a framework for enhancing coverage and financing of care 6

7 Focus on Medicaid - why? Generally offers a more comprehensive benefit package with lower cost-sharing than CHIP or private insurance (EPSDT) Federal match stretches state dollars further Can serve as a wrap to fill in gaps in private coverage Serves as the children s insurance safety net Some ways to expand coverage and close gaps Medicaid buy-in program created through a waiver Medicaid buy-in program created through the Family Opportunity Act Katie Beckett/TEFRA waivers Increase HCBS waiver programs or slots within existing waivers Medicaid buy-in programs created through a waiver Example: The Massachusetts CommonHealth program Families can buy in to Medicaid coverage for a child: With a severe disability SSI criteria Full Medicaid coverage if uninsured Supplemental coverage if privately insured 7

8 The Massachusetts CommonHealth program No limit on family income Premium schedule based on a sliding scale The Family Opportunity Act s Medicaid Buy-in Option Part of the 2005 Deficit Reduction Act Not a waiver; state plan option Families can buy in to Medicaid coverage for a child: With a severe disability SSI criteria Full Medicaid coverage if uninsured Supplemental coverage if privately insured FOA provisions Limit on family income: must be below 300% of FPL (AGI) Premiums may be charged and there is a limit on how high they can be States may provide premium assistance to help families purchase private coverage 8

9 Current status of state legislation Programs implemented under FOA: North Dakota, Louisiana, Iowa Legislation passed but not yet implemented: Illinois, Texas Operational characteristics of current FOA buy-in programs North Dakota Open for enrollment 4/2008 Income Eligibility Up to 200% of FPL Premium Schedule by Income Five percent of family s adjusted gross income Amount of private insurance premium paid by family is deducted from their buy-in premium Operational characteristics of current FOA buy-in programs Louisiana Open for enrollment 10/2008 Income Eligibility Up to 300% of FPL Premium Schedule by Income Enrollees with income between 201% and 250% of the FPL with insurance pay $12 per month. For those with no private insurance, the premium is $30 per month. Enrollees with income between 251% and 300% FPL with health insurance pay $15 per month. Without insurance, the premium is $35 per month. If the premium is paid by a legal or natural parent not living with the child they pay $30 if income is between 201% and 250% and $35 if between 251% and 300%. 9

10 Operational characteristics of current FOA buy-in programs Iowa Income Eligibility Premium Schedule by Income Open for enrollment 1/2009 Up to 300% of FPL Zero Waiver-TEFRA-FOA comparison Waiver (KB, etc.) TEFRA FOA Level of care Institutional Institutional SSI disability Income level None None 300% FPL limit Benefits Medicaid + case mgmt, respite, etc. Medicaid Medicaid Authority Waiver State Plan State Plan Premiums Optional/none Optional/none Optional/none Entitlement No wait list? Yes Yes Some additional issues to consider.. 10

11 State health care reform Depth vs. breadth impact on underinsurance? Massachusetts experience CommonHealth as safety net History of children s issues, disability issues not being priorities (birth of Family Voices!) Federal health care reform: the ACA and CSHCN Essential benefits not EPSDT standard and still to be defined; only available in Exchange plans so not every CSHCN will be able to access Medicaid expansion up to 133% of FPL (only relevant in a handful of states) no TPL to reduce risk for full cost to Medicaid and state budget It s too much money; our state already has a budget deficit Costs for the SSI population not a good budget proxy Role of private insurance (TPL) Full Medicaid benefits for the whole family vs. full/supplemental coverage for a single CSHCN 11

12 It s too much money; our state already has a budget deficit continued. Disability and income criteria for FOA narrow eligibility limit $ exposure and concerns re: woodwork effect Estimates available for all states contact Catalyst Center for yours Catalyst Center Medicaid buy-in research project Participants: families of children enrolled in the Louisiana (FOA) and Massachusetts (waiver) buy-in programs Self-report by families through structured telephone interview OR online written survey Some limited qualitative interviews to follow How will we know if buy-in programs make a difference? Comparison of data from NS-CSHCN with survey findings in the areas of: Health insurance coverage source Adequacy of coverage Out-of-pocket spending Parental employment Family income Family stress/functioning 12

13 Catalyst Center resources State-specific eligibility and cost estimates Medicaid as a Second Language Frequently Asked Questions about the Family Opportunity Act s Medicaid Buy-in Option Online State-at-a-glance Chartbook on Coverage and Financing of Care for Children and Youth with Special Health Care Needs (the state pages ) Our shared goals in working to improve health coverage of CSHCN: Provide protections for families against financial hardship and medical debt Give kids access to coverage of quality health care so that they can LEARN, PLAY and GROW to their fullest potential! Discussion and Q & A Thank you for attending our session! 13

14 For more information, please contact: Meg Comeau, MHA Project Director The Catalyst Center Boston University School of Public Health OR