| Catalyst Center Quarterly |
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Dear ,
Now that school is back in session, we thought you might like to borrow one of your child's newly sharpened pencils and try a worksheet of your own. We have created a TEFRA and FOA Medicaid Buy-in Educational Worksheet that you can use to learn about the similarities and differences between these two pathways to Medicaid for children with disabilities whose family income is higher than the state's eligibility limit. Step-by-step instructions will guide you through various data sources so you can retrieve the facts you will need about the insurance status of families in your state. We hope this tool will be a good introduction to using data to make the case for improving coverage for children and youth with disabilities.
Plus, as always, we bring you the latest news on financing of care for children and youth with special health care needs.
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The ACA addresses the need for affordable health insurance and improves consumer protections for children with special health care needs (CSHCN). Yet many families raising CSHCN who have health insurance report their insurance is inadequate.
States have options for providing alternate pathways to Medicaid for children with disabilities whose family income is higher than the state's eligibility limit. TEFRA and the Family Opportunity Act (FOA) Medicaid Buy-in Program are two specific programs that can help families whose private insurance doesn't pay for everything their child needs. These programs provide supplemental Medicaid coverage for co-pays, deductibles, and uncovered services for a child with a disability.
The Catalyst Center has created a TEFRA and FOA Medicaid Buy-in Educational Worksheet that you can use to learn about the similarities and differences between these two programs. Using step-by-step instructions, you can fill out the worksheet with data on the insurance status of families in your state.
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IN THIS ISSUE
So, what do you think?
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 Announcements & Events
Health Reform: Beyond the Basics - Upcoming Webinar Series
In preparation for the second Affordable Care Act (ACA) open enrollment period, which begins on November 15, 2014, Health Reform: Beyond the Basics is hosting a 4-part webinar series to review ACA coverage options, to determine household size, income, and premium tax credits, and to determine cost-sharing for marketplace plans, and eligibility for cost-sharing reductions. This series begins with:
Webinar: Eligibility for Coverage Programs
Date: October 9, 2014
Time: 2:00 to 3:30 pm ET
This is an opportunity to review ACA coverage options, how employer-sponsored insurance affects eligibility for marketplace coverage and premium tax credits, and how tax credits are calculated. Register for the Eligibility for Coverage Programs webinar.
Read more about this four-part webinar series.
Webinar Recording: Medicaid and CHIP Outreach and Enrollment Considerations in Immigrant Communities
Recorded: July 17, 2014
This webinar, presented by the Insure Kids Now: Connecting Kids to Coverage National Campaign, highlighted Medicaid and Children's Health Insurance Program (CHIP) outreach and enrollment strategies targeted to immigrant children and children in families with mixed immigration status. The webinar addressed eligibility rules, enrollment procedures, and engagement of immigrant families through effective communication. Download the slides, transcript and video.
Webinar Recording: Racial & Ethnic Enrollment Under the Affordable Care Act: Part I - What Does the Data Show?
Recorded: September 12, 2014
Hosted by the National Health Equity Coalition (NHEC), this webinar was the first in a two-part webinar series about how provisions of the Affordable Care Act (ACA) are working to reduce health inequities among communities of color. This webinar focused on the data that the U.S. Department of Health and Human Services is using to evaluate the impact of health care reform on health inequities. Enter your e-mail address to listen to the Racial & Ethnic Enrollment Under the Affordable Care Act: Part I - What Does the Data Show? archive.
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| Media Highlights
Texas and Florida Expand Medicaid - For Kids By Phil GalewitzKaiser Health News September 29, 2014The Affordable Care Act (ACA) includes two Medicaid expansion provisions. The adult Medicaid expansion is optional. It creates a pathway to Medicaid for all adults, ages 19 through 64, who are not disabled and not pregnant, and whose household income is less than 138% of the federal poverty level (FPL). The ACA also includes a Medicaid expansion that raises income eligibility from 100% FPL to 138% FPL for 6- to 19-year-old children. This provision of the ACA, which went into effect on January 1, 2014, is mandatory. As a result, 6- to 19-year-old children in 21 states moved from the Children's Health Insurance Program (CHIP) to Medicaid. The benefits to children and their families were numerous. Prior to January, in states that used the minimum Medicaid income eligibility limit for children's Medicaid, only 0- to 6-year-olds were eligible for Medicaid up to 138% FPL. The children's Medicaid expansion unified coverage for all children, birth to 19. Moving from CHIP to Medicaid provides comprehensive benefits, which includes the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit. And, families have fewer out-of-pocket expenses as they are no longer paying monthly CHIP premiums. Despite this good news, there are concerns that states have missed an opportunity by not expanding Medicaid eligibility for adults. In fact, 11 of the 21 states where children moved from CHIP to Medicaid are not going to implement the adult Medicaid expansion. See the Status of State Action on the Medicaid Expansion Decision.
Should You Be Able to See Any Doctor You Want? By Jason MillmanThe Washington PostSeptember 26, 2014Objective D of the Affordable Care Act (ACA) is to " reduce the growth of health care costs while promoting high-value, effective care." One of the ways insurers control the cost of health insurance premiums is to contract with small numbers of providers and hospitals. But at what cost? These narrow networks limit a consumer's choice of doctors, hospitals, and other health care providers. Insurers used narrow networks to control costs even before the ACA, although they have become increasingly common since the law went into effect. In reaction to narrow networks, an orthopedic surgeon in South Dakota is sponsoring a ballot initiative that would make it possible for any provider who meets a health insurer's standards to join that insurer's network. If passed, South Dakota would be the 28th state with an "any willing provider" law. Health insurers say these laws contribute to increased costs. While some people and hospitals have complained about narrow networks, this article reports that "generally" enrollees who purchased marketplace plans are satisfied with their coverage. This article reports that current network standards are not likely to change while states take more time to study the effects of narrow networks.
California to Broaden Autism Coverage for Kids through Medicaid By Daniela HernandezKaiser Health NewsSeptember 15, 2014To date, 37 states and the District of Columbia have enacted autism insurance reform laws that require some private health insurers to cover autism services, including applied behavioral analysis (ABA) for children diagnosed with autism spectrum disorders. But what about children with autism who are insured by Medicaid? Help is on the way, and California is leading the way. On September 15, 2014, California's Medicaid program began covering behavioral therapy, which can include ABA when medically necessary. This decision was in response to an informational bulletin issued by Centers for Medicare and Medicaid Services (CMS) in July. While the Clarification of Medicaid Coverage of Services to Children with Autism bulletin does not specifically state that Medicaid programs must cover ABA, it does specify that "the goal of EPSDT ( Early and Periodic Screening, Diagnostic and Treatment) is to assure that children get the health care they need, when they need it - the right care to the right child at the right time in the right setting." The bulletin also provides information about how states can cover autism services, including ABA, under section 1905 benefit categories. As illustrated by the Cruz family profiled in this article, this change will be particularly beneficial for parents do not speak English and who find it difficult to advocate for needed services for their children with autism. However barriers remain. There are limited numbers of providers who speak Spanish, often families cannot take time from work to attend therapy visits with their child, and many families remain unaware that behavioral therapies are covered as part of their child's Medicaid benefit.
HHS Awards $3.2 million to Help Support Minority Enrollment in Health Insurance Coverage Lydia SermonsHHS Office of Minority HealthSeptember 11, 2014The Affordable Care Act (ACA) has created new pathways to affordable health insurance for the uninsured. Yet, inequities in health insurance rates persist among racial and ethnic minorities. The goal of the Partnerships to Increase Coverage in Communities (PICC) initiative is to close the health insurance gap that exists between minority populations and the national average. The Office of Minority Health within the U.S. Department of Health and Human Services awarded PICC grants totaling $3.2 million to 13 organizations that will work to "identify, inform and enroll minority populations" and underserved communities in coverage through the health insurance marketplaces. Read the list of the PICC Initiative awardees.
HHS Awards More Than $295 Million in Affordable Care Act Funds to Increase Access to Primary Care at Health Centers HRSA Press OfficeSeptember 12, 2014In an effort to increase access to primary care, the Affordable Care Act (ACA) includes funds that will enable 1,195 health centers throughout the country, and in Puerto Rico, the Virgin Islands, and the Pacific Basin to hire more staff and keep longer hours. These centers will also be able to provide additional services, such as vision, oral, pharmacy, and behavioral health services. Health centers not only improve access to care, they help connect people to coverage through a variety of outreach and enrollment activities. See the list of Health Center Expanded Services FY 2014 Awards recipients.
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Medicaid and CHIP FAQs: Services to Address Autism
Centers for Medicare and Medicaid Services
September 2014
This Frequently Asked Questions (FAQ) bulletin from the Centers from Medicare and Medicaid Services (CMS) addresses questions raised by the July 7, 2014 Clarification of Medicaid Coverage of Services to Children with Autism. These include: - If CMS now requires Medicaid programs to cover applied behavioral analysis (ABA). CMS recognizes that applied behavioral analysis (ABA) is just one "treatment modality" for autism spectrum disorders (ASD). States are not mandated to provide ABA. But, under the federally mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit, states are required to provide medically necessary services to children birth to 21, which include "providing medically necessary services available for the treatment of ASD."
- What happens to 1915(c) waivers that provided autism services to children in a specified age range (ages 3 to 9) or to a 1915 (c) waiver that included individuals younger than and older than 21. All children with ASDs younger than 21 who need autism-related services will receive those services as part of the state plan rather than through a waiver. Individuals 21 and older can continue to receive autism services through 1915(c) waivers.
Designing Care Management Entities for Youth with Complex Behavioral Health Needs: Implementation Guide No. 2
By Grace Anglin, Adam Swinburn, Leslie Foster, Cindy Brach, and Linda Bergofsky
Agency for Healthcare Research and Quality
September 2014
Maryland, Georgia, and Wyoming are using Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration grant funds to implement or expand Care Management Entities (CMEs) for youth with complex behavioral health needs. This guide, from the Agency for Healthcare Research and Quality (AHRQ) provides an overview of how CMEs can provide a holistic approach to meeting the needs of youth with complex behavioral health needs and help coordinate services across multiple agencies. There are strategies for designing, funding, and managing CMEs, establishing eligibility criteria, and monitoring and evaluating the work. |
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The Catalyst Center is a national center dedicated to working with states and stakeholder groups on improving health care insurance and financing for Children and Youth with Special Health Care Needs (CYSHCN). For more information, please visit us at www.catalystctr.org or contact Meg Comeau, Co-Principal Investigator, at mcomeau@bu.edu.
The Catalyst Center is funded under grant #U41MC13618 from the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.
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