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Cost of Care

Medicaid in the House and Senate Budgets

This past weekend, the House of Representatives presented it’s biennial budget. NC Health News has put the House’s plans for Medicaid next to the Senate plans for convenient comparison.

By Rose Hoban

It can be a challenge to understand the differences between the budgets presented by the Senate (414 pages) and by the House of Representatives (305 pages). So we’ve done what we can to put the two Medicaid proposals side-by-side.

Requires DHHS to prepare detailed plan to reform Medicaid; establishes 22-member Medicaid reform advisory committee. Report due no later than the beginning of the 2014 short session. Requires DHHS to prepare detailed plan to reform Medicaid. Report due no later than March 17, 2014.
Sets tighter guidelines for amending the state’s Medicaid State Plan and applying for Medicaid waivers from the federal Centers for Medicare and Medicaid Services. The provision includes a requirement that members of the legislature get advanced notice of any amendments being proposed to CMS. Sets tighter guidelines for amending the state’s Medicaid State Plan and applying for Medicaid waivers from the federal Centers for Medicare and Medicaid Services.The provision includes a requirement that members of the legislature get advanced notice of any amendments being proposed to CMS.
A similar provision was in the original House proposal, but was amended out in committee. The argument is that these doctors don’t bill as much because they’re so busy supervising medical students/residents that they can’t generate as much income by seeing patients. Limits extra pay available to doctors at UNC and ECU who get supplemental pay for supervising medical residents.
Moves coverage for children currently in the State Children’s Health Insurance Plan who live in families with incomes under 133% of federal poverty level ($31,300 for family of four) as ordered by the Affordable Care Act. Allocates $30 million extra over two years to cover increased costs Moves coverage for children currently in the State Children’s Health Insurance Plan who live in families with incomes under 133% of federal poverty level ($31,300 for family of four) as ordered by the Affordable Care Act. Allocates $30 million extra over two years to cover increased costs
Provides incentives to counties to share in Medicaid/Medicare fraud-recovery activities Provides incentives to counties to share in Medicaid/Medicare fraud-recovery activities
Changes Medicaid to comply with implementation of the Affordable Care Act. Creates new procedures for changing medical policies in Medicaid or the SCHIP (NC Health Choice) and requires greater legislative oversight. Requires DHHS to create and present a detailed report on the five-year projected costs and submit for review any proposed changes. Changes Medicaid to comply with implementation of the Affordable Care Act. Creates new procedures for changing medical policies in Medicaid or the SCHIP (NC Health Choice) and requires greater legislative oversight. Requires DHHS to create and present a detailed report on the five-year projected costs and submit for review any proposed changes.
Gives DHHS authority to enact any amendments to the state’s Medicaid plan that have been approved by the federal Centers for Medicare and Medicaid services, but also allows the department to adopt temporary rules as necessary, but requires DHHS to consult with the state budget office about possible fiscal impacts of any temporary rules. Requires DHHS to get permission from the Rules Review Commission and the Office of State Management and Budget in order to enact any state plan amendments, but also allows the department to adopt temporary rules as necessary.
Sets eligibility for Medicaid:

  • Elderly, blind and disabled at or below 100% Federal Poverty Level ($11,490 for a single person)
  • Pregnant women up to 185% of the FPL ($21,256)
  • Infants and children up to five years of age with family income less than 200% of the FPL ($47,100 for a family of four)
  • Children aged 6-18 with family incomes up to 100% of FPL ($23,550 for a family of four) until Jan 1, 2014, when the Affordable Care Act goes into effect
  • Children aged 6-18 in families earning less than 133% FPL ($31,322 for a family of four) after Jan 1, 2014, when the Affordable Care Act goes into effect
  • Workers with disabilities earning less than 150% FPL ($17,235 for a single person)
Sets eligibility for Medicaid:

  • Elderly, blind and disabled at or below 100% Federal Poverty Level ($11,490 for a single person)
  • Pregnant women up to 185% of the FPL ($21,256)
  • Infants and children up to five years of age with family income less than 200% of the FPL ($47,100 for a family of four)
  • Children aged 6-18 with family incomes up to 100% of FPL ($23,550 for a family of four) until Jan 1, 2014, when the Affordable Care Act goes into effect
  • Children aged 6-18 in families earning less than 133% FPL ($31,322 for a family of four) after Jan 1, 2014, when the Affordable Care Act goes into effect
  • Workers with disabilities earning less than 150% FPL ($17,235 for a single person)
  • People who are eligible for Work First Family Assistance (welfare), Supplemental Social Security and State/County Special Assistance also become eligible for Medicaid

 

 

Others eligible for Medicaid include:

  • Adoptive children with special needs
  • Independent foster care adolescents
  • Low-income women who need treatment for breast of cervical cancer
Others eligible for Medicaid include:

  • Adoptive children with special needs
  • Independent foster care adolescents
  • Low-income women who need treatment for breast of cervical cancer
As funds allow, Medicaid may also enroll children who are in families with incomes between 133% FPL and 200% FPL (between $31,322 and $47,100 for a family of four) As funds allow, Medicaid may also enroll children who are in families with incomes between 133% FPL and 200% FPL (between $31,322 and $47,100 for a family of four)
Retains pregnant women up to 185% FPL on Medicaid. Establishes the “Insurance Premiums for Pregnant Woman” program: Moves pregnant women earning under 185% FPL, and not having access to other forms of insurance, onto health insurance plans offered on the federally run Health Benefits Exchange, with premium assistance paid by state funds after Jan 1, 2014, when the ACA goes into effect. However, this is not defined as an entitlement.
Provision allows young people who turn 19 after June 1, 2013 and who are due to lose Medicaid eligibility to retain coverage in the State Children’s Health Insurance Plan (NC Health Choice) until Jan 1, 2014, when the Affordable Care Act goes into effect and they can buy health insurance on the federally run Health Benefits Exchanges Provision allows young people who turn 19 after June 1, 2013 and who are due to lose Medicaid eligibility to retain coverage in the State Children’s Health Insurance Plan (NC Health Choice) until Jan 1, 2014, when the Affordable Care Act goes into effect and they can buy health insurance on the federally run Health Benefits Exchanges
No inflationary increases for Medicaid services; co-pays, reimbursement rates and fees remain the same unless specifically changed by the General Assembly. Exceptions:

  • hospital charges to account for inflation
  • Community Health Centers
  • Rural Health Centers
  • state-operated Services
  • hospice
  • Medicare Part B & D premiums
  • HMO premiums
  • drugs
  • MCO capitation payments
No inflationary increases for Medicaid services; co-pays, reimbursement rates and fees remain the same unless specifically changed by the General Assembly. Exceptions:

  • hospital charges to account for inflation
  • Community Health Centers
  • Rural Health Centers
  • state-operated Services
  • hospice
  • Medicare Part B & D premiums
  • HMO premiums
  • drugs
  • MCO capitation payments
Medicaid beneficiaries are

  • entitled to 22 health care visits, but beneficiaries must get prior authorization for anything beyond 10 visits
  • only entitled to three visits per year for adult rehabilitation set-up and evaluation
  • must receive prior authorization for more than four brand-name prescriptions
Medicaid beneficiaries are:

  • entitled to 22 health care visits, but beneficiaries must get prior authorization for anything beyond 10 visits
  • limited to adult private-duty nursing at the rate of $432/day
  • only entitled to three visits per year for adult rehabilitation set-up and evaluation
  • must receive prior authorization for all mental health drugs, with addition of provision for 72-hour emergency supply
Reduces state Medicaid reimbursement based on hospitals costs from 80% to 70%, saving the state $52.6 million over two years Reduces state Medicaid reimbursement based on hospitals costs from 80% to 70%; also changes the way hospitals get reimbursed for outpatient services, saving the state $62 million over two years
Sets a single, flat fee to reimburse for Medicaid-covered emergency department visits that cannot be cost-settled Sets a single, flat fee to reimburse for Medicaid-covered emergency department visits that cannot be cost-settled
Changes formula for dispensing pharmaceuticals for Medicaid patients; sets dispensing fee to pharmacists at $9.87 for all drugs Changes formula for dispensing pharmaceuticals for Medicaid patients; sets dispensing fee to pharmacists at $9.87 for all drugs
Orders DHHS to work with Community Care of North Carolina to improve pharmacy management and identify patients who use many drugs and work on reducing the cost of their use No mention of pharmacy management
Increases the amount the state holds back from Medicaid payments made to hospitals from $43 million to $95 million Increases the amount the state holds back from Medicaid payments made to hospitals from $43 million, instead ties assessment on hospitals to 15.6% of annual Medicaid payments made to hospitals. Estimated increase about $14 million over two years.
Sets an application fee of $100 to each provider enrolling in the Medicaid program for the first time. Fee also gets charged to all providers when they re-credential every three years. Requires Medicaid providers to bill and be paid electronically – no more checks. Sets an application fee of $100 to each provider enrolling in the Medicaid program for the first time. Fee also gets charged to all providers when they re-credential every three years. Requires Medicaid providers to bill and be paid electronically – no more checks.
Creates a shared savings program, wherein DHHS will withhold 2% of Medicaid payments to doctors, hospitals, dentists, drugs, personal care services, chiropractors, podiatrists, nursing homes, adult care homes, opticians and optical suppliers and hearing-aid providers, with payments being paid back to the providers starting June 2014 if those providers save Medicaid dollars. Creates a shared savings program, wherein DHHS will withhold 4% of Medicaid payments to doctors, hospitals, dentists, drugs, personal care services, chiropractors, podiatrists, nursing homes, adult care homes, opticians and optical suppliers and hearing-aid providers, with payments being paid back to the providers starting Jan, 2015 if those providers save Medicaid dollars.
Addresses cost containment by allowing for $5 million per year to support cost-containment activities. The money can be used to hire additional staff, fund pilot programs or provide grants to outside entities to implement cost-containment programs. Sets out requirements for a Medicaid cost-containment board that would include legislative appointees, gubernatorial appointees, an actuary, an expert in health informatics, two providers and a health insurance representative. Addresses cost containment by allowing for $5 million per year to support cost-containment activities. The money can be used to hire additional staff, fund pilot programs or provide grants to outside entities to implement cost-containment programs.
Transfers $43 million per year from the Medicaid Special Fund to DHHS. Helps to replace General Fund dollars used to cover the Medicaid shortfall.
Requires notice of changes to DHHS to be posted on the web Requires notice of changes to DHHS to be posted on the web
Requires Medicaid to monitor prescriptions for anti-psychotics given to children under 18 years of age and get prior authorization for off-label use No mention
No mention Allows Medicaid to contract for discounted volume purchases of services, medical equipment, supplies and appliances

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