Medicaid 101- Services for Adults

NDRN Webcast

Medicaid 101 ? Part II

 

Elizabeth Priaulx:  I am with the National Disability Rights Network and I would like to welcome you to the second part of a five part webcast series entitled Medicaid 101.  Today we will be covering Medicaid services for adults.  I would like to introduce our speakers.  Sarah Somers, an attorney with the National Health Law Program and Jane Perkins, the legal director at the National Health Law Program. NHeLP, as it is called, is a wonderful backup center to the protection and advocacy programs and hopefully many of you are familiar with Sarah and Jane who work out of the NHeLP North Carolina office.  For those Olmstead coordinators, thank you for joining us as well.  I just want to say that the Power Points on actual services were prepared entirely by NHELP despite the fact that it has a TASC logo in the corner. 

 

As an overview of the training, we will be discussing general service requirements, mandatory and optional services as well as due process.  If you have questions as they come up, feel free to E-mail me at [email protected] and I will contact you with the answer, so please do not hold back e-mailing your questions.  Thank you. 

 

Sarah Somers:  I want to start by giving you a little information related to the Deficit Reduction Act (DRA).  Following this, I will talk about the general service requirements, and the specific service requirements in the Medicaid Act.  Both Jane and I will discuss the DRA?s relevance to these service requirements as we cover each. Basically, pointing out some of the changes that were made by the deficit reduction act of 2005.  Some of them were helpful changes and some of them we would consider negative changes.  

 

 

I. General Global Requirements for Medicaid Services.  

 

A. Reasonable Promptness

 

First of all medical assistance, the way the statute is worded, is to be provided with reasonable promptness to all recipients.  

 

Reasonable promptness is a requirement that medical assistance be provided in a reasonably prompt manner.  The statute uses the phrase medical assistance and we had always operated under the assumption that this meant that Medicaid services are to be provided with reasonable promptness.  Recently if you have been following developments related to Medicaid enforcement by individual beneficiaries – courts have interpreted ?reasonable promptness? to mean only that payment for the service needs to be provided with reasonable promptness.  This can be a problem because if you are litigating and arguing that the services are not provided with ?reasonable promptness? the state may answer that they need only pay for the services with reasonable promptness Not ensure services are delivered with reasonable promptness.  It is our (NHeLP?s) position, and we had a briefing on this issue, that the proper interpretation is that the services are to be provided with reasonable promptness.  

 

B. Services Should be Provided with Reasonable Standards 

 

The second global requirement about Medicaid is that the extent of medical assistance should be determined in a manner consistent with reasonable standards.  The state is allowed to define reasonable standards and comply with the federal regulations specifying what reasonable standards might be.  

 

1. The regulations specify that the amount, duration and scope of service must be sufficient to achieve its purpose.

 

This is a relatively opaque concept, but it has been the subject of a fair amount of litigation.  Essentially the meaning of it is that they provide services in a form that makes it meaningful as a service. For example, your state agrees to cover inpatient hospital services and they say ?we will pay for one hospital visit a year no matter who you are or what your needs are.?  That is an extremely narrow scope of hospital services that may violate the amount, duration and scope requirement.  You can?t say you are covering hospital services if you cover it so skimpily and so narrowly.  

 

2. A regulatory requirement that services can?t be provided in a discriminatory manner based on condition.  

 

This applies to mandatory Medicaid services and as we go on you will see what I mean by mandatory versus optional.  One of the purposes behind the enactment of the Medicaid program was to address the fact that before 1965 medical services that were publicly covered were a patchwork.  Depending  on your state, your county and your town, the degree of public funded medical coverage available to you could vary widely, and the passage of the Medicaid Act was intended to impose a bit of uniformity on federally publicly funded insurance.  

 

C. Medicaid Services In The State Plan Must Be Available State-wide

 

Medicaid services listed in the state plan have to be in effect statewide.  No matter where you are in the state you should have access to the same type of coverage as other Medicaid beneficiaries around the state.  The one exception to this is home and community based waivers, but we will talk about in part IV of this 5 part Medicaid 101 training.  For other than Medicaid waivers ? services in the plan must be in effect statewide.  

 

D. Services Must Be Comparable Across Groups of Beneficiaries?  

 

The ?comparability? requirement has two dimensions.  First, please recall, there are individuals who are categorically needy and there are individuals who are medically needy who look sort of like the categorically needy people, but they have more money and they are entitled to Medicaid because they spend down based on medical bills to the Medicaid eligibility level.  The first comparability requirement is that there must be comparability between the medically needy population and categorically needy population.  The categorically needy have to have at least as broad of coverage as the medically needy do.  The medically needy can?t have more coverage.  The second ?comparability? requirement is comparability among similar types of groups of Medicaid beneficiaries, ie one categorically needy individual cannot have access to a fuller range of services than another categorically needy individual.  

 

The concept of comparability is particularly interesting of late because one of the changes enacted by the Deficit Reduction Act.  The DRA allows what are known colloquially as ?benchmark benefit plans?.  States can offer use of commercial benefit packages to Medicaid beneficiaries that are much less service rich than the normal Medicaid state plan. Right now people with disabilities on Medicaid who also receive SSI and people with disabilities on Medicaid who also receive Medicare cannot be forced into Medicaid ?benchmark plans?.  At least that is the way it is right now.  But forcing people on SSI and Medicare eligible people into a Medicaid ?benchmark plan? is something for you to watch out for.  Some states are requiring Medicaid beneficiaries to use a benchmark package that strongly limits coverage.  Right now this can?t include people on SSI or people in Medicare.