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Medicaid Title XIX of the Social Security Act

Overview

Medicaid is the jointly funded federal/state program that pays for medical assistance for individuals and families who meet certain eligibility criteria. It is the largest source of public funding for medical, health-related and long-term care services for individuals with disabilities. Individuals with traumatic brain injury often rely on Medicaid for rehabilitation, therapies and home and community-based services (i.e. personal care, in-home supports).

(a) Further Medicaid Reductions, Caps or Block Grants

The Deficit Reduction Act (DRA) of 2005 imposed policies to reduce Medicaid spending and the President has proposed further reductions for FY 2008. These policies and proposals affect eligibility and benefits (i.e. rehabilitation services) that adversely impact individuals with traumatic brain injury.

NASHIA opposes:

• Any proposal to further reduce or cap federal match funds provided to states for Medicaid services, for provider reimbursement or program administration.
• Block granting the Medicaid program.
• Any efforts that would result in eliminating populations or services that are presently covered by the Medicaid program.

(b) Cost sharing-provisions

The DRA contains new cost-sharing provisions which give states wide latitude in determining co-payments. However, the DRA is silent with respect to the co-payments that can be imposed on non-exempt individuals with incomes below the federal poverty level, including people with disabilities. Congressional leaders have notified the Centers for Medicare and Medicaid (CMS) that Congress did not intend to have made so fundamental a change to the Medicaid program as allowing the imposition of unlimited cost sharing on the lowest income Medicaid beneficiaries while imposing clear limits on higher income beneficiaries, without expressly providing states with that authority in the legislative language.

NASHIA supports any congressional and Administration efforts to clarify to the states the intent of these provisions so as not to deter individuals with disabilities who are low income from receiving Medicaid services due to co-payments.

Emergency Room Co-payments

The DRA permits states to submit a state plan amendment allowing hospitals to impose cost sharing for non-emergency services provided in hospital emergency rooms, if they follow strict notice requirements. This provision requires that the beneficiary receive a medical screening (as defined in Medicare law) and a determination by the emergency room that the beneficiary does not have an emergency medical condition. This provision conflicts with the Emergency Medical Treatment and Active Labor Act (EMTALA), which prohibits hospitals from delaying the screening to inquire about the individual’s method of payment or insurance status. Congress should not deter individuals from seeking treatment due to co-pay requirements. NASHIA supports clarification of the conflicting DRA and EMTALA provisions.

(c) Case Management

The DRA allows federal financial participation for case management services only if there are no other third parties liable for the care, such as another medical, social or educational program. A state is required to allocate the cost of case management services between Medicaid and any other relevant federal program and only bill Medicaid for its portion. This places hardships on other social or educational programs that are already stretched to cover the array of needs. In addition, the Administration’s FY 2008 budget recommendations propose to reduce the federal financial participation for targeted case management services.

NASHIA supports efforts to clarify federal financial participation for case management and to ensure that individuals with traumatic brain injury who are currently being covered by targeted case management services retain that service. NASHIA opposes lowering the federal share for targeted case management services.

(d) Children’s Health and Related Services

Early and Periodic Screening, Diagnosis and Treatment Program

The Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) offers an array of preventive, primary and remedial health care services to children under the age of 21. The program is a mandatory service required to be provided under a State’s Medicaid program. The DRA permits states to provide scaled-back health benefit packages to children, as long as those eligible for EPSDT receive those services as wrap-around coverage to the scaled back benefits package. The DRA also contains a provision that gives States the option to provide “benchmark” or “benchmark-equivalent” health care benefits to certain beneficiary groups which may be more limited. Under this option, children must continue to receive EPSDT benefits, either directly or through a benchmark or bench-mark equivalent plan. Children with disabilities who are eligible for Medicaid on the basis of disability are exempt from this provision. However, children with disabilities who qualify for Medicaid on the basis of income, not disability, are included in this provision.

While Congress did not intend to make changes to the EPSDT Program in the DRA, there are conflicting sections with regard to EPSDT and wrap around benefits. Youth aged 19-21 can be enrolled in the benchmark coverage and, for them, the wrap-around benefit appears to be optional.

NASHIA supports retaining comprehensive benefits under the EPSDT program for children as a mandatory. In addition, NASHIA supports the coordination of EPSDT services and wrap around services.

Medicaid Coverage for School-Based Health Care Services

The Medicare Catastrophic Coverage Act (1988) stipulated that Medicaid -- not the Department of Education -- pays for medical services provided to Medicaid-eligible children with special health care needs. Each child must have an Individualized Education Plan, in accordance with IDEA in order for Medicaid to pay for their school-based care. The Administration proposed for

FY 2008 to cut the HHS’ budget for Medicaid school reimbursement for related services and transportation. NASHIA supports the Medicaid school-based health program to cover necessary services that might not otherwise be covered under IDEA funding.

State Children’s Health Injury Program (SCHIP) Reauthorization

The State Children's Health Insurance Program (SCHIP) is jointly financed by the Federal and State governments and is administered by the States to offer health insurance for children, up to age 19, who are not already insured. SCHIP is a block grant program with a fixed annual funding level. Federal funding has not kept pace with State needs, and consequently, States are experiencing short falls. The SCHIP legislation is up for reauthorization in 2007. NASHIA supports reauthorization of SCHIP and increased funding to cover uninsured low-income children.

On May 25, 2007, President Bush signed a $120 billion emergency supplemental appropriations bill for FY 2007, the ‘‘U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007” (H.R. 2206), which includes approximately $393 million for State shortfalls in SCHIP.

Family Opportunity Act

The DRA authorized the Family Opportunity Act (FOA) which allows families who have a child with disabilities to buy into Medicaid if their income do not exceed 250 percent of poverty (about $47,000 for a family of four). This would prevent families from having to place children out of the home for services, and would also give children a full range of services that are often not covered by private insurance. NASHIA supports funding for states to implement this program.

(f) Community Support and Long Term Care Options

Historically, funding for long-term services under the Medicaid program has had an institutional or nursing home bias. NASHIA supports efforts to rebalance Medicaid service delivery to offer an array of community services of supports. These efforts include:

Direct Support Professionals Fairness and Security Act

For individuals with traumatic brain injury direct support professionals are often the key to living successfully in their home communities. Direct support professionals refer to personal care assistants, home care aides or staff in community support programs who assist people with disabilities with medications, mobility and activities of daily living. While direct support staff are crucial to community living, they are generally paid minimum wages. As a result, people with disabilities often experience continuous turnover of direct support workers or they find themselves unable to get workers at all. NASHIA supports legislation which would provide funds to States to enable them to increase the wages paid to targeted direct support professionals in providing Medicaid services to individuals with disabilities.

Home and Community-Based Services Options

Section 6086 of the DRA, known as the Expanded Access to Home and Community-Based Services (HCBS) for the Elderly and Disabled, became effective on January 1, 2007. This is a new option for states to provide HCBS without states needing to use a waiver process. The provision allows states to provide any of the services now covered under HCBS waivers; and requires states to establish stricter eligibility (level of care) criteria for institutional services than for community-based services. In addition, states may continue to provide services through their existing waiver programs.

NASHIA supports:

• Amending Section 6086 to ensure that the state flexibility provisions do not undermine progress at the state level to provide services to more people in the community.
• Provisions to ensure that eligibility criteria that are developed at the state level are broad enough to include individuals with cognitive, neurological and mental health disorders and that services are available statewide.

NASHIA opposes any incentives to states to offer such optional services as rehabilitative services only to persons qualifying under the HCBS option -- where the number of individuals receiving the service can be capped.

Personal Services and Supports

In keeping with the many efforts to encourage Medicaid to pay for services in one's own home, in lieu of a nursing home, legislation has been introduced for a number of years to allow Medicaid funding to be used for personal assistance services and supports for people of all ages in their homes and communities. The Medicaid Community-Based Attendant Services and Supports Act, known as MiCASSA, enables people to make choices as to where they wish to live. NASHIA supports mandated state Medicaid plan coverage of community-based attendant services and supports for certain Medicaid-eligible individuals.

Self-Directed Personal Assistance Services (Cash and Counseling)

As of January 2007, states may offer the option of self-directed personal care services as a regular state plan or HCBS waiver service as provided by the DRA. The DRA prohibits use of self-directed personal services for beneficiaries who live in homes or property owned, operated or controlled by a service provider. Individuals using this new option are allowed to hire, fire, supervise and manage the people providing the services and, if the state allows, may use family members. NASHIA supports this provision and any incentives to states to use this option.

 

Legislation/Regulations

Budget Deficit Reduction Act (DRA) of 2005 (P.L. 109-171) [PDF 616 KB]

President George W. Bush signed the Budget Deficit Reduction Act (DRA) of 2005, into law on February 8, 2006. The new law, P.L. 109-171, contains several provisions relating to long-term services and supports, including Money Follows the Person; a new option for States to provide home- and community-based services (HCBS) without using a waiver process; allow States to provide any of the services now covered under HCBS waivers; and requires States to establish stricter eligibility (level of care) criteria for institutional services than for community-based services. In addition, States may continue to provide services through their existing waiver programs.

The bill also reauthorizes TANF (Temporary Assistance for Needy Families), makes changes in the SSI Program, as well as includes provisions of the Family Opportunity Act, which had been introduced as a separate bill.

Fact Sheets

Kaiser Commission on Medicaid and the Uninsured’s Massachusetts Health Care Reform Plan: An Update [PDF 133 KB]

Kaiser Commission on Medicaid and the Uninsured’s SCHIP Turns 10: An Update on Enrollment and the Outlook on Reauthorization from the Program’s Directors [PDF 1 MB]

CMS’ The Deficit Reduction Act: Important Facts for State & Local Government Officials [PDF 122 KB]

CMS’ Medicaid and Citizenship Letter to State Medicaid Directors (June 2006) [PDF 849 KB]

CMS’ Medicaid and Citizenship Eligibility Fact Sheet [PDF 100]

DCP’s DRA Timeline [PDF 131 KB]

HHS’ Welfare Reform: Deficit Reduction Act of 2005 Fact Sheet [PDF 69 KB]

NASHIA’s Deficit Reduction Act (DRA) Policy Update [PDF 292 KB]

NASHIA’s Summary of the Major Provisions of the Family Opportunity Act of 2005 [PDF 124 KB]

FY 2006 Budget Reconciliation Bill Highlights, Conference Committee Recommendations (1/06/06) [Word 70KB]

Medicaid, Title XIX of the Social Security Act

Sign-on Letters

Letter to the Centers for Medicare and Medicaid Services [PDF 154 KB] sent November 6, 2007 from NASHIA expressing grave concerns about CMS' proposed rulemaking (NPRM) pertaining to potential elimination of
reimbursement under Medicaid for school-based administration expenditures and certain transportation costs for students with disabilities that was published in the Federal Register on September 7, 2007.

Letter to the Centers for Medicare and Medicaid Services [PDF 169 KB] sent October 10, 2007 from NASHIA expressing grave concerns about CMS' proposed rulemaking (NPRM) pertaining to Medicaid coverage of rehabilitative services that was published in the Federal Register on August 13, 2007.

Sign-on Letter to the Senate Finance Committee [PDF 72 KB] sent May 4, 2007 from the Disability Policy Collaboration (including NASHIA and
other organizations) expressing strong support for recommendations by
the Medicare Payment Advisory Commission (MedPAC) related to the
Medicare Advantage Program.

Medicaid Coalition letter sent to President Bush on Thursday, Jan. 13, 2005 [Word 84KB]