Group: Health & Human Services - Department of Health

Agency: Health

Line Item: Medicaid Mandatory Services

Function

Medicaid is a joint federal/state entitlement service that provides health care to selected low-income populations. Overall, Medicaid is an "optional" program, one that a state can elect to offer. However, if a state offers the program, it must abide by strict federal regulations. It also becomes an entitlement program for qualified individuals; that is, anyone who meets specific eligibility criteria is "entitled" to Medicaid services. The federal government establishes and monitors certain requirements concerning funding, and establishes standards for quality and scope of medical services. Requirements include services that must be provided and specific populations that must be served. States may expand their program to cover additional 'optional' services and/or 'optional' populations. In addition, states have some flexibility in determining certain aspects of their own programs in the areas of eligibility, reimbursement rates, benefits, and service delivery.

There are currently 53 services included in the entire Medicaid Program. Of these, inpatient hospital, outpatient hospital, intermediate care facilities for the mentally retarded, long-term care, physician, dental, pharmacy, and health maintenance organizations make up approximately 60 percent of all Medicaid expenditures. Medicaid services in Utah is accounted for in two budgetary line items: Medicaid Mandatory Services and Medicaid Optional Services. The line dividing mandatory and optional services is occasionally blurred by the fact that some optional services are mandatory for specific populations or in specific settings. For example, the federal government requires more services be provided to children and pregnant women. Additionally, clients in institutionalized settings must be provided a wider range of services. A brief description of each service is found in a list of defined terms.

Mandatory services in the Medicaid Program are those that the federal government requires to be offered if a state has a Medicaid program. These include: inpatient and outpatient hospital, physician, skilled and intermediate care nursing facilities, medical transportation, home health, nurse midwife, pregnancy-related services, lab and radiology, kidney dialysis, Early Periodic Screening Diagnosis and Treatment, and community and rural health centers. The State is also required to pay Medicare premiums and co-insurance deductibles for aged, blind, and disabled persons with incomes up to 100 percent of the Federal Poverty Level.

There are six programs within the Medicaid Mandatory Services line item, which include Inpatient Hospital, Nursing Home, Contracted Health Plans, Physician Services, Outpatient Hospital, and Other Mandatory Services.

While Federal law and regulations currently mandate some specific services within the program, the State has some flexibility and has been granted waivers that allow some latitude in program implementation, as well as to offer some optional services.

Medicaid is a joint federal/state entitlement service consisting of three programs that provide health care to selected low-income populations: (1) a health insurance program for low-income parents (mostly mothers) and children; (2) a long-term care program for the elderly; and (3) a funding source for services to people with disabilities.

The Early Periodic Screening Diagnosis and Treatment Program, called Child Health Evaluation and Care (CHEC) in Utah, is a mandatory program which requires the State to screen all Medicaid children at scheduled intervals. The mandate includes providing all medically necessary services that can be covered under the program, such as organ transplants or any other service needed, regardless of cost. Utah's 12 local health departments participate in administering the services for this program. Eligibility for many of the new Medicaid Programs, which Congress has added in recent years, is based on a person's income relative to the Federal Poverty Level (FPL).

The State has designated five major population groupings that may receive health care from the Medicaid Program. These include: (1) the elderly who receive federal SSI and persons in nursing facilities (grouped together as aged); (2) blind and/or disabled individuals; (3) children who receive Temporary Assistance for Needy Families (TANF) benefits, or are in the Foster Care program; (4) TANF adults, with dependent children; and (5) pregnant women. Each of these groups is discussed in more detail later in this section.

Aged

Individuals aged 65 and over qualify for Medicaid if they qualify for the Federal Supplemental Security Income Program, which provides an income of approximately 77.6 percent of the Federal Poverty Level (FPL). They also qualify for food stamps. Many of the elderly also qualify for Medicare coverage. The Medicaid Program pays for the premiums and deductibles for those eligible under both programs. Medicare pays the actual medical cost for most of these people. Medicaid is also required to pay Medicare premiums, co-insurance, and deductibles for anyone qualifying for Medicare who has income up to 100 percent of FPL, but only has to pay Medicare premiums for those between 100 and 135 percent of FPL.

Medicaid also covers non-SSI aged people whose income does not exceed 100 percent of FPL. Aged people with income over 100 percent of FPL can spend down to the Medically Needy Income Limit (45% of FPL) to receive Medicaid.

A Medicaid waiver has been approved for the Division of Aging and Adult Services which allows Medicaid to pay for some services in home and community-based settings. The waiver diverts some elderly people from nursing facility care.

Blind and Disabled

Persons receiving assistance due to blindness have always been part of the Medicaid Program.

Persons with disabilities are also eligible for services under the Medicaid Program. The criteria for disability require that a person be unable to participate in gainful activity for at least a year, or have a medical condition that will result in death. Among the disabilities covered are mental retardation, mental health, spinal injury, and AIDS. Income is limited to 100 percent of the Federal Poverty Level for blind and disabled individuals. An asset test similar to that for TANF is required. Eligible individuals also qualify for food stamps.

Temporary Assistance to Needy Families (TANF) and Foster Care

Aid to Families with Dependent Children (AFDC) was a joint federal-state program which provided financial assistance to families with children deprived of the support of at least one parent. On August 22, 1996, President Clinton signed the welfare reform bill, which ended the Aid to Families with Dependent Children (AFDC) entitlement program and replaced it with block grants to the states and the Temporary Assistance to Needy Families (TANF). In general, however, people who meet AFDC eligibility criteria that were in effect on July 16, 1996 are eligible for Medicaid. Also, those people who qualify for a TANF grant are eligible for Medicaid.

Family Employment Program (FEP)

There are two groups of people who qualify for Medicaid under the TANF Program. These include: (1) those in the basic program where a child is deprived of the support of one parent, and (2) those in two-parent families that qualify under the unemployed parent program. Over 90 percent of eligible families are deprived because of divorce, desertion, or unwed mothers. TANF families may also qualify for food stamps. Depending on family size, the TANF grant and food stamps provide between 62 and 74 percent of the Federal Poverty Level. There is an asset limit of $2,000 for families in the TANF Program. The asset limit does not include a residence or a car with an equity value of less than $8,000. In addition to the basic Family Employment Program (FEP), there is also a program for unemployed two-parent families. This program provides cash assistance for seven months in any 13-month period. One parent in families in this program is required to work 32 hours a week (in an emergency work program) and spend at least 8 hours a week seeking regular employment. With the exception of the time limitation and work requirement, the criteria and benefits for the Family Employment Program - Two Parent (FEP-TP) are the same as those for the regular FEP. Federal law requires that the family be eligible for Medicaid for the full 12 months of the year. Besides those eligible through FEP cash assistance, there are several programs which provide transitional Medicaid coverage for periods of 4 months (for child support-related eligibles) or 24 months (for people who no longer receive cash assistance due to child support payments or earnings). Children in Foster Care are eligible for Medicaid coverage if they meet Medicaid Program requirements. The State is responsible for their medical care. Most children placed in foster care have histories of abuse or neglect. This often means there are unresolved medical and mental health problems that must be dealt with.

In addition to the previously mentioned TANF children, there are four groups of children covered under the Medicaid Program. These are (1) medically needy children, (2) children under age 6 with family income up to 133 percent of the Federal Poverty Level (FPL), (3) children and youth between age 6 and 18 with income up to 100 percent of FPL, (4) children in subsidized adoptions.

The Medically Needy Children program is for children who do not qualify for assistance under normal Family Medicaid because they are not deprived of the support of a parent. The asset test is the same as for TANF; the family is allowed to spend down to become eligible. This is an optional group, meaning it is not required by the federal government, and so coverage could be terminated. Many children who have been eligible for this group in the past have become eligible in the mandatory programs for children.

The program for children under age six with family income up to 133 percent of FPL is a mandatory program. The program for children born after September 30, 1983 with family income up to 100 percent of the FPL is designed to provide coverage for children in poverty. There is an asset test required for children in this category of $3,000 for a family of two; one home is exempted, and a car with an equity value of $1,500 is allowed.

Each year, a number of children come into the custody of the State and are placed for adoption. Some of these children have serious medical problems which makes them hard to place. In some of these cases, the State subsidizes the adoption. Some families receive a small stipend to assist in the cost of care for these children, and the State covers the child's medical care under Medicaid until the child is 18 years old.

TANF Adults

The group referred to as TANF Adults includes those adults with dependent children who are either categorically or medically needy and meet the basic program requirements. Some of the individuals may be required to "spend down" to obtain Medicaid services, which means that they must reduce their disposable income with payments to Medicaid or with medical bills which they have incurred. Some of the waivers expired at the end of 2000, others have continued.

Pregnancy

The prenatal/pregnancy program helps pregnant women receive prenatal care. The program covers the mother from the time of application to 60 days after the birth. A woman only needs to meet the eligibility requirements in any one month to be eligible for the balance of the pregnancy. Children born to women on this program can be covered on Medicaid (after the first 60 days) for the rest of the first year under the postnatal program.

Statutory Authority

Medicaid Mandatory Services is governed by several chapters of the Utah Health Code in Title 26 of the Utah Code.

• UCA 26-18 establishes the Medical Assistance Program, commonly referred to as Medicaid and its administrative arm, the Division of Health Care Financing.
• UCA 26-19 authorizes the Department to recover Medicaid benefits paid by the Division from third parties, including estates and trusts.
• UCA 26-35a creates the Nursing Care Facilities Account and levies an assessment on the owners of nursing care facilities to generate seed money which draws down additional federal funds for the operation of those facilities.

Intent Language

The Legislature intends that the Department of Health pay for case management services for individuals affected by Prader-Willi Syndrome out of the existing Medicaid Mandatory Services budget.

Funding Detail

Program: Inpatient Hospital

Function

Medicaid covers inpatient visits at a hospital for most services without a prior authorization. Some services may require a prior authorization. Some imaging services require manual review for medical necessity after the service.

Funding Detail

Program: Nursing Home

Function

Medicaid clients must meet nursing facility level of care as described in Administrative Rule R414.502 to receive this service.

Additionally, clients must pass a low asset test to qualify for this service. The asset test includes a 'look back period' of 5 years where asset transfers are examined to determine if an inappropriate transfer of assets took place. Any findings of improper transfers delay Medicaid qualification. Once a client qualifies for nursing home care, there is no limit on the time they receive that care for as long as they continue to qualify.

The restrictions on building new nursing facilities is described in UCA 26-18-502 and UCA 26-18-503.

Funding Detail

Program: Contracted Health Plans

Function

The majority of Utah Medicaid clients are enrolled with one of 3 contracted physical health plans: Molina, Select Access (Intermountain Healthcare), and Healthy U (University of Utah Hospitals and Clinics). Molina and Healthy U process and pay claims for their providers. Medicaid pays these health plans the amount they pay their providers. Medicaid's aggregate payments to Healthy U and Molina may not exceed what Medicaid would have paid, in aggregate, for the same services had they been paid as fee-for-service Medicaid claims. In addition, Medicaid pays Healthy U and Molina an administrative fee for each service provider. The administrative fee covers the following: case management, disease management, HEDIS reporting, quality improvement programs, performance improvement projects, quality committees, health needs assessments, utilization management, prior authorization, provider credentialing and re-credentialing, newsletters, and outreach. In the case of Select Access, Medicaid processes claims for Select Access members and pays Select Access' providers based on Medicaid's fee schedule. Medicaid also pays Select Access a service network fee per member per month.

Funding Detail

Program: Physician Services

Function

Medicaid clients may visit any willing physician provider to receive services. This includes any specialist physician. Medicaid clients must have a medical need for seeking physician services as Medicaid does not pay for annual wellness or preventive health visits.

Funding Detail

Program: Outpatient Hospital

Function

Medicaid covers outpatient visits at a hospital for most services without a prior authorization. Some surgeries may require a prior authorization.

Funding Detail

Program: Other Mandatory Services

Function

Other mandatory services include Home Health Services, Rural Health Clinic, Federally Qualified Health Centers, Indian Health, Radiology, Laboratory, and Well Child Care. Detailed coverage information is contained in the Medicaid provider manuals.

Funding Detail