Health Reform and Children in Medicaid

Barbara Edwards

Director

Disabled and Elderly Health Programs Group

Center for Medicaid and CHIP Services

Centers for Medicare & Medicaid Services

November 13, 2013

1

Children Under ACA: Medicaid & CHIP

Medicaid/CHIP Children

0

133% FPL

241% FPL

400% FPL

Exchange Subsidies

Adults

Children

Medicaid Adults

Varies by State

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Early Periodic Screening Diagnosis and Treatment (EPSDT)

Mandates most Medicaid coverable services (1905(a) services), as needed to treat or ameliorate a child’s condition

Includes optional 1905(a) services (therapies, rehabilitation, including MH/SUD treatment, pharmacy, dental, vision, etc.) even if not otherwise covered by State Plan for adults

Medicaid Benefit – Ages 0-20

Medicaid benefit for children (0 through 20) is Early Periodic Screening Diagnosis and Treatment (EPSDT)

EPSDT is an option under CHIP

Doesn’t include as a mandate non-1905(a) services (HCBS waiver services, health home, etc.)

Can we get a list of 1905a services?

Coverage of MH, SUD?   

3

New Adult Group category up to 133% FPL (includes newly eligible and some existing categories) 

Medicaid benefit is Section 1937 Alternative Benefit Plan

Essential Health Benefits as a base for ABP

19 and 20 years olds: EPSDT must still be provided

ACA Benefit for Adults Ages 19 through 64

30 + million children covered by Medicaid and CHIP

Under ACA, coverage for children remains largely under traditional Medicaid and CHIP

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Ten Essential Health Benefits

Ambulatory Patient Services 

Emergency Services 

Hospitalization 

Maternity and Newborn Care 

Mental Health and Substance Use Disorder Services Including   

       Behavioral Health Treatment 

Prescription Drugs 

Rehabilitative and Habilitative Services and Devices 

Laboratory Services 

Preventive and Wellness Services and Chronic Disease Management 

Pediatric Services Including Oral and Vision Care 

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5

MHPAEA

The Mental Health Parity and Addictions Equity Act (MHPAEA) requires group insurers to ensure that the “financial requirements” and “treatment limitations” that are applicable to mental health and substance use benefits are no more restrictive than the predominant financial requirements and treatment limitations for medical and surgical benefits covered by the plan

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MHPAEA and Medicaid

MHPAEA Applies to:

CHIP Program

Medicaid MCOs

Section 1937 non-managed care Alternative Benefit Plans and benchmark equivalent plans

MHPAEA does not apply to regular state Plan Services 

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MHPAEA and Children’s Health Insurance Program 

For CHIP programs, MHPAEA applies to all delivery systems, including fee-for-service and managed care  

If State CHIP plan provides full coverage of the EPSDT benefit the MHPAEA requirements shall be deemed to be met

States not providing full EPSDT benefits under their CHIP State plan need to ensure these plans comply with MHPAEA 

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Improved, effective benefit design for MH/SUD for children and adults

Technical Assistance to states for ABP/EHB

Focus on parity and on evidence based practices

ACYF partnership for children in foster care who need trauma informed care

Informational Bulletins for improved screening & benefit design on Medicaid.gov

CMCS Goals

30 + million children covered by Medicaid and CHIP

Under ACA, coverage for children remains largely under traditional Medicaid and CHIP

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