MEDICAL ASSISTANCE
MEDICAL ASSISTANCE
(MEDICAID)
(MEDICAID)
in
in
in
in
MARYLAND
MARYLAND
Workshop for Parents and Providers
A Partnership between
The Parents’ Place of Maryland and
1 1
and
Georgetown University Center for Child and Human Development
About
About
Th M l d F il A I i i i
Th M l d F il A I i i i
The Maryland Family Access Initiative
The Maryland Family Access Initiative
A project funded by the federal Maternal A project funded by the federal Maternal and Child Health Bureau to:
and Child Health Bureau to:
assist families to access comprehensive services assist families to access comprehensive services from managed care organizations which meet all from managed care organizations which meet all needs of their children with SHCN and
needs of their children with SHCN and needs of their children with SHCN, and needs of their children with SHCN, and
to ensure their enrollment in the plan best suited to ensure their enrollment in the plan best suited to their individual needs.
to their individual needs.
About Parents’ Place of Maryland
About Parents’ Place of Maryland
About Parents Place of Maryland
About Parents Place of Maryland
How do we help? How do we help?
How do we help? How do we help?
Education Education
Information Information
Technical assistance Technical assistance
Supportive activitiesSupportive activities
3 3
About Georgetown University Center
About Georgetown University Center
for Child and Human Development
for Child and Human Development
for Child and Human Development
for Child and Human Development
The Center providesThe Center provides
research research
training training
policy analysis and development policy analysis and development pp yy yy pp
technical assistancetechnical assistance
Medicaid
Medicaid: The Puzzle The Puzzle
5 5
Medical
Medical
Assistance
Assistance
is very
is very
is very
is very
important for
important for
children with
children with
children with
children with
special health
special health
care needs
care needs
Why is Medicaid Important?
Why is Medicaid Important? y y p p
Able to meet all or most of the needs of Able to meet all or most of the needs of children who are enrolled
children who are enrolled
Free or very low outFree or very low out--ofof--pocket costspocket costs
Recognizes children with special needsRecognizes children with special needs
Recognizes children with special needsRecognizes children with special needs
Waivers for special populationsWaivers for special populations
Several options in MarylandSeveral options in Maryland
Several options in MarylandSeveral options in Maryland
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Medicaid in Maryland
Medicaid in Maryland
Medicaid in Maryland
Medicaid in Maryland
Complicated systemComplicated system
Complicated systemComplicated system
Administered through the Department of Administered through the Department of Health and Mental Hygiene
Health and Mental Hygiene Health and Mental Hygiene Health and Mental Hygiene
Provides services through Provides services through managed care managed care i ti
i ti ff ff ii tt
organizations
organizations, , feefee--forfor--serviceservice, , carvecarve--outsouts
Multiple ways to become eligibleMultiple ways to become eligible
Eligibility & Entry
Eligibility & Entry
Eligibility & Entry
Eligibility & Entry
MCHP MCHP
SSI
9 9
Income Based
Income Based
Income Based
Income Based
Low Income familiesLow Income families
Eligible for Temporary Cash Assistance Eligible for Temporary Cash Assistance gg pp yy (TCA)
(TCA)
Medically needy but greater than TCA Medically needy but greater than TCA standards
standards
EntryEntry: Local Department of Social Services : Local Department of Social Services (DSS)
(DSS)
Foster Care/Adoption
Foster Care/Adoption
Foster Care/Adoption
Foster Care/Adoption
Foster CareFoster Care
Foster CareFoster Care
Subsidized Adoption servicesSubsidized Adoption services
Entry:Entry: Local Department of Social ServicesLocal Department of Social Services
Entry:Entry: Local Department of Social Services Local Department of Social Services
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SSI
SSI
SSI
SSI
Children with DisabilityChildren with Disability
Disability Determination Disability Determination yy
Income and Resources EligibilityIncome and Resources Eligibility
Recipients of SSI Recipients of SSI pp
Age 18Age 18
Entry:Entry: Social Security AdministrationSocial Security Administration
Entry:Entry: Social Security AdministrationSocial Security Administration
MCHP
MCHP
MCHP
MCHP
Age: children up to 19 yearsAge: children up to 19 years
Pregnant women of any agePregnant women of any age
Based on income Based on income
Enroll in HealthChoice MCOEnroll in HealthChoice MCO
Entry:Entry: Local Health DepartmentLocal Health Department
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MCHP Premium
MCHP Premium
MCHP Premium
MCHP Premium
Age: children up to 19 yearsAge: children up to 19 yearsgg pp yy
Based on income Based on income
Pay monthly family contributionPay monthly family contributionyy yy yy
Enroll in HealthChoice MCOEnroll in HealthChoice MCO
Entry:Entry: Local Health DepartmentLocal Health Department
Entry:Entry: Local Health DepartmentLocal Health Department
Refugees
Refugees
Refugees
Refugees
Qualified immigrants or refugeesQualified immigrants or refugees
Qualified immigrants or refugeesQualified immigrants or refugees
Strict guidelines for qualifyingStrict guidelines for qualifying
Residency requirements for immigrantsResidency requirements for immigrants
Residency requirements for immigrantsResidency requirements for immigrants
Entry:Entry: Local Department of Social ServicesLocal Department of Social Services
15 15
Waivers
Waivers
Waivers
Waivers
Medically qualifiedMedically qualified
Need institutional level of careNeed institutional level of care
Rehabilitative hospital level of careRehabilitative hospital level of care
Alternative to InstitutionalizationAlternative to Institutionalization
Limited number of recipients Limited number of recipients
Entry:Entry: Different entry pointsDifferent entry points
How does my child get care
How does my child get care
from MA?
from MA?
Medicaid in
in
Maryland
HealthChoice Fee-for-service/carve-outs HealthChoice Fee for service/carve outs
7 MCOs Therapies Mental Health REM
17 17
HealthChoice
HealthChoice
HealthChoice
HealthChoice
7 M d C O i ti (MCO )
7 M d C O i ti (MCO )
7 Managed Care Organizations (MCOs)7 Managed Care Organizations (MCOs)
Family chooses MCOFamily chooses MCO
Covers most children on MedicaidCovers most children on Medicaid
Select a primary care providerSelect a primary care provider
Select a primary care providerSelect a primary care provider
Authorizations for referralsAuthorizations for referrals
Some Services Covered by
Some Services Covered by
H l hCh i
H l hCh i
HealthChoice
HealthChoice
Inpatient & Inpatient & outpatient
outpatient Clinic servicesClinic services
Prescription drugsPrescription drugs p
p
Physician carePhysician care
Lab & XLab & X--rayray
Prescription drugsPrescription drugs
Dental careDental care
M di l i t
M di l i t
y y
Nursing homeNursing home
Home healthHome health
Medical equipmentMedical equipment
Diapers (qualified)Diapers (qualified)
Home healthHome health
Medical suppliesMedical supplies Therapies Therapies
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Fee For Service/Carve
Fee For Service/Carve--outs outs
No Referrals NeededNo Referrals Needed
Mental health servicesMental health services
Therapies such as OT PT speechTherapies such as OT PT speech
Therapies such as OT, PT, speech, Therapies such as OT, PT, speech, audiology
audiology
Use Red and White CardUse Red and White Card
Use Red and White CardUse Red and White Card
Therapy Services
Therapy Services
PT, OT, Audiology, Speech & LanguagePT, OT, Audiology, Speech & Language
No referral required from PCP or MCONo referral required from PCP or MCO
May access services from any May access services from any yy yy participating provider
participating provider
Use Red and White CardUse Red and White Card
Use Red and White CardUse Red and White Card
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Mental Health Services
Mental Health Services
Mental Health Services
Mental Health Services
Administered through an organization Administered through an organization called MAPS
called MAPS called MAPS called MAPS
Case management for child & familyCase management for child & family
Core Service Agencies provide services atCore Service Agencies provide services at
Core Service Agencies provide services at Core Service Agencies provide services at the local level in some counties
the local level in some counties
May use Medicaid approved therapists in May use Medicaid approved therapists in
Mental Health Services
Mental Health Services
Mental Health Services
Mental Health Services
MAPS determines who will qualify for MAPS determines who will qualify for mental health services
mental health services
Refers child to mental health Refers child to mental health
providers/core service agencies providers/core service agencies
p g
p g
PrePre--authorizes nonauthorizes non--emergency careemergency care
Therapeutic Behavioral ServiceTherapeutic Behavioral Service
Therapeutic Behavioral Service Therapeutic Behavioral Service
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Rare & Expensive Case Management
Rare & Expensive Case Management
(REM)
(REM)
(REM)
(REM)
Qualifying diagnosesQualifying diagnoses
Children with Special Health NeedsChildren with Special Health Needs
Fee for serviceFee for service
Fee for serviceFee for service
Case managementCase management
N th i ti i d
N th i ti i d
No authorizations requiredNo authorizations required
REM Services
REM Services
REM Services
REM Services
All Medicaid services includedAll Medicaid services included
All Medicaid services includedAll Medicaid services included
Coordination of services/case Coordination of services/case management
management management management
Assisted LivingAssisted Living
Community SupportCommunity Support
Assistive equipmentAssistive equipmentq pq p
Environmental ModificationsEnvironmental Modifications
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What are
What are waivers waivers? ?
What are
What are waivers waivers? ?
waivers waivers
. . . and
. . . and
where do
where do
where do
where do
Waiver Programs
Waiver Programs are different are different
f M di id d MCHP
f M di id d MCHP
from Medicaid and MCHP:
from Medicaid and MCHP:
1
1 Waivers have different medical and financialWaivers have different medical and financial
1.
1. Waivers have different medical and financial Waivers have different medical and financial eligibility rules so more children can qualify eligibility rules so more children can qualify for the programs because the parents’
for the programs because the parents’ income and assets are not taken into income and assets are not taken into consideration
consideration
2.
2. Waivers have some additional servicesWaivers have some additional services
3.
3. A limited number of children can be in A limited number of children can be in
W i P
W i P
Waivers Programs Waivers Programs
27 27
Wai ers
Wai ers
Financial eligibility: Individual's income andFinancial eligibility: Individual's income and
Waivers
Waivers
Financial eligibility: Individual s income and Financial eligibility: Individual s income and assets not family’s income
assets not family’s income
Acts as “payer of last resort” to privateActs as “payer of last resort” to private
Acts as payer of last resort to private Acts as payer of last resort to private insurance
insurance
P h t t d b i t
P h t t d b i t
Pays whatever not covered by private Pays whatever not covered by private insurances
insurances
Autism waiver
Autism waiver
Autism waiver
Autism waiver
Diagnosis of AutismDiagnosis of Autism
Diagnosis of AutismDiagnosis of Autism
Have an IEP or IFSPHave an IEP or IFSP
A t 21
A t 21
Age: up to 21 yearsAge: up to 21 years
Entry: Local School System Entry: Local School System
Approved Plan of CareApproved Plan of Care
Enroll in Health Choice/MCOEnroll in Health Choice/MCO
Enroll in Health Choice/MCO Enroll in Health Choice/MCO
29 29
Autism Waiver Services
Autism Waiver Services
Autism Waiver Services
Autism Waiver Services
Intensive Individual Support ServicesIntensive Individual Support Services
Intensive Individual Support ServicesIntensive Individual Support Services
Therapeutic IntegrationTherapeutic Integration
Family trainingFamily training
Environmental accessibility adaptationsEnvironmental accessibility adaptationsyy pp
Service coordinationService coordination
Residential HabilitationResidential Habilitation
Residential HabilitationResidential Habilitation
DD Waiver
DD Waiver
DD Waiver
DD Waiver
Developmental Disability or MentalDevelopmental Disability or Mental
Developmental Disability or Mental Developmental Disability or Mental Retardation
Retardation
Entry: Regional DDA officeEntry: Regional DDA office
Entry: Regional DDA office Entry: Regional DDA office
Age: Children and AdultsAge: Children and Adults
Enroll in Health Choice/MCOEnroll in Health Choice/MCO
31 31
DD Waiver Services
DD Waiver Services
DD Waiver Services
DD Waiver Services
Approved Plan of Care Approved Plan of Care
Intensive Individual Support Services Intensive Individual Support Services
Therapeutic IntegrationTherapeutic Integration
RespiteRespite
RespiteRespite
Environmental Accessibility AdaptationEnvironmental Accessibility Adaptation
Intensive Behavior ManagementIntensive Behavior Management
Intensive Behavior Management Intensive Behavior Management Program
Program
Assistive technologyAssistive technology
Prevocational servicesPrevocational services
M d l W i
M d l W i
Model Waiver
Model Waiver
Must have complex medical needsMust have complex medical needs
Must have complex medical needsMust have complex medical needs
Technology dependantTechnology dependant
A l th 22 ld
A l th 22 ld
Age: less than 22 years oldAge: less than 22 years old
Would otherwise be hospitalizedWould otherwise be hospitalized
Entry: The Coordinating CenterEntry: The Coordinating Center
33 33
Model Waiver Services
Model Waiver Services
Model Waiver Services
Model Waiver Services
Case ManagementCase Management
Case ManagementCase Management
Home health aideHome health aide
S i l di l i t d li
S i l di l i t d li
Special medical equipment and suppliesSpecial medical equipment and supplies
Participation of MD in plan of care meetingParticipation of MD in plan of care meeting
Private duty nursingPrivate duty nursing
Use Red and White CardUse Red and White Card
Use Red and White CardUse Red and White Card
The Last Piece of the Puzzle . . .
The Last Piece of the Puzzle . . .
The Last Piece of the Puzzle . . .
The Last Piece of the Puzzle . . .
EPSDT
35 35
Maryland Healthy Kids/EPSDT
Maryland Healthy Kids/EPSDT
Maryland Healthy Kids/EPSDT
Maryland Healthy Kids/EPSDT
VeryVery important service for children important service for children
Available to all children up to 21 yrs.Available to all children up to 21 yrs.
Available to all children up to 21 yrs.Available to all children up to 21 yrs.
Comprehensive screeningComprehensive screening
DiDi i (Ei (E ll titi /A/A t)t)
Diagnosis (Evaluation/Assessment)Diagnosis (Evaluation/Assessment)
All medically necessary treatmentAll medically necessary treatment
Therapeutic behavioral service Therapeutic behavioral service
Medicaid: The
Medicaid: The Puzzle Puzzle
Eligibility Importance
Eligibility
S i Getting
Services Getting Care
37 37
For More Information
For More Information
For More Information
For More Information
The Parents’ Place of MarylandThe Parents’ Place of Maryland 1
1 800800 394394 56945694 1
1--800800--394394--56945694 www.ppmd.org
Department of Health and Mental HygieneDepartment of Health and Mental Hygiene
Department of Health and Mental Hygiene Department of Health and Mental Hygiene
(DHMH) (DHMH)
1
1--800800--284284--45104510
www.dhmh.state.md.us/mma/
Baltimore Health Care AccessBaltimore Health Care Access
410
410--649649--05210521
