Best Practices in Medicaid - Idaho

The Center for Health Transformation is inviting leaders from all 50 states to share their transforming solutions for the Medicaid program. In order that key decision-makers and industry leaders from around the country may learn from others' successes, it is our intention to provide this interactive resource for showcasing the most innovative practices in the country. Please note that the following contributions have not been edited by CHT staff and will remain open indefinitely to future updates.

View Idaho's official Medicaid website >>

Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)

Idaho Medicaid is increasing consumer involvement in health care purchasing through two new initiatives:

1. Self-directed care for persons with disabilities.
   
2. Preventive health assistance benefits.
   

Both initiatives will provide support to eligible Medicaid participants for self-directed weight loss and tobacco cessation efforts.

Idaho Medicaid's consumer-directed service option allows participants to develop community supports and is modeled after the National Cash and Counseling Demonstration. This option enables participants in Idaho’s Medicaid Enhanced Plan to have greater freedom to manage their own care. The option was implemented in the fall of 2006 and is currently available to individuals who meet the eligibility requirements for Idaho Medicaid's 1915 (c) Home and Community-Based Waiver for adults with developmental disabilities. Approximately 15 participants in the start-up areas have selected this option. In the next few months, Idaho expects to begin marketing this option statewide and estimates that up to 200 participants will choose to direct their own care under this option. In addition, the Idaho Legislature has directed Idaho Medicaid to begin developing a similar consumer-directed option for families of children with developmental disabilities. Idaho Medicaid, in cooperation with the Idaho Council on Developmental Disabilities, has formed a Family-Directed Services Task Force to begin this work.

Preventive Health Assistance (PHA) benefits are available to Idaho Medicaid participants who indicate that they would like to improve their health behaviors. The health behaviors linked to PHA benefits are weight loss and tobacco cessation. Weight management participants complete activities to bring their body mass index (BMI) to a healthy level. Tobacco cessation participants complete activities to end their dependency on tobacco products. Participants earn PHA credits by enrolling in weight management/tobacco cessation programs and can spend these credits on pre-approved products and services that will support behavior change goals. Families paying premiums for their children's Medicaid coverage can also earn credits by keeping their children's immunizations and well-child checks current. These credits can be used to offset premium costs.

Delivering high quality, coordinated, long-term care for the disabled and/or the infirm

Idaho Medicaid has implemented a new Medicare-Medicaid Coordinated Plan for dual eligibles enrolled in two participating Medicare Advantage plans offered by Blue Cross of Idaho and United Healthcare Insurance Company. This new Coordinated Plan is designed to improve coordination between Medicaid and Medicare, including coordination of Medicaid-financed long-term care. Idaho Medicaid will also maintain its Home and Community-Based Waiver services to provide for non-institutional long-term care. In addition, Idaho is implementing a new grant-funded Aging Connections Program that will provide planning and education services to help Idahoans with long-term care financing needs.

Use of health information technology (electronic health records, e-prescribing, electronic billing, etc.)

House Bill 738a authorized the creation of a Health Quality Planning Commission, supported by Idaho Medicaid staff, to make recommendations to the Legislature and the Office of the Governor related to the development of a uniform, statewide, flexible, and interoperable health information exchange (HIE). Working with the Commission, Idaho Medicaid is collaborating with other Idaho payers, hospitals, and providers in a public-private partnership effort. The goal of health information exchange is to improve quality of care and health outcomes for Idahoans. The Commission has identified exchange of medication history, e-prescribing, and clinical messaging as likely components to be included in Idaho’s HIE. The Commission is in the process of establishing a 501(c) (6) entity to operate Idaho’s HIE and is in the process of hiring a project director to lead the effort.

Expanding coverage through private sector initiatives

Idaho has implemented two premium assistance programs through a Health Insurance Flexibility and Accountability (HIFA) Waiver (approved in November, 2004). The children’s premium assistance program is called the Idaho Health Insurance Access Card and is available as an alternative to Title XXI S-CHIP Programs (which cover non-Title XIX-eligible children to 185 percent FPG in Idaho). The adults’ program is called Access to Health Insurance and is available to adult employees of small businesses (2 - 50 employees), and their spouses, who have family incomes up to 185 percent FPG. The children’s program was implemented in July of 2004 and the adult program in July of 2005.

Both programs offer eligible individuals premium assistance in the amount of $100 per member, per month, maximum. Parents of eligible children may use the assistance to purchase any type of commercial major medical coverage (individual or group) for their children and eligible adults may use the program to assist them in purchasing employer-sponsored small-group insurance. Premium assistance for eligible children is limited to three children per family, so the maximum premium assistance amount per family is $500 (to cover both spouses and three children).

The State of Idaho has proposed three policy changes to its premium assistance programs since its inception:

1. Allowing mandatory eligibles to choose premium assistance over direct coverage.
   
2. Allowing premium assistance for currently insured persons.
   
3. Changing a State and Federal requirement (in Idaho’s HIFA Waiver) that employers participating in the adult program contribute 50 percent of dependent spouse premiums.
   

Idaho Medicaid made the third change through a HIFA Waiver amendment in December 2006; however, passage of the Deficit Reduction Act (DRA) has made the first two changes difficult for the state. Allowing mandatory eligibles to choose premium assistance is important because it is sometimes participant-preferred and is cost-effective. The DRA requires that early and periodic screening, testing, and diagnostic (EPSDT) coverage be provided to mandatory eligibles. This is not a workable requirement for commercial plans that mandatory eligibles might want to use premium assistance to enroll in.

With respect to using Medicaid premium assistance to maintain coverage for currently insured individuals, this would be allowable with the use of Title XIX funding rather than Title XXI funding. Since the time Idaho has implemented money-saving reforms through State Plan Amendments authorized by new DRA provisions, these savings do not accrue to Idaho’s HIFA Waiver. None of the proposed budget neutrality strategies for the waiver that have been put forth to CMS have been accepted and the State cannot demonstrate budget neutrality for this needed change within the HIFA Waiver. It will be very important in the coming months and years to allow better integration of states’ Medicaid budgets for with-waiver reforms and non-waiver reforms in the new policy environment created by the DRA.

Efforts to combat Fraud and abuse

Idaho Medicaid has enhanced restrictions on asset transfers used to make an individual eligible for Medicaid long-term care, expanding the look back period, and better defining annuities, consistent with the Deficit Reduction Act (DRA) provisions.

The Estate Recovery unit has implemented new Case Management software allowing for better asset and spousal tracking capabilities. TEFRA and Estate Liens are filed electronically with the Secretary of State’s office, and country records are researched to capture real property owned by, but not reported by, Medicaid participants. A small estate affidavit process has been implemented to collect from estates when probate is not opened.

Idaho Medicaid is also working to combat fraud and abuse by improving management of benefit utilization and by designing benefit packages appropriate to meet participants' needs. In particular, over-utilization and inappropriate utilization of mental health services in Idaho is being addressed in part by the creation of two new benchmark benefit plans, the Medicaid Basic Plan and the Medicaid Enhanced Plan. Each plan offers different levels of mental health benefits. In order to obtain enhanced mental health services under the Medicaid Enhanced Plan, participants must undergo a comprehensive assessment and must meet certain diagnostic criteria. This is a substantial and clear measure of medical necessity that ensures the service is driven by the participants' health needs. Medicaid is also operating a Mental Health Provider Credentialing Program that seeks to confirm providers are competent to provide the mental health services they are contracted to and that the providers are in substantial compliance to IDAPA and Provider Agreement requirements.

What changes would you make to the Federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state?

Title XIX has been partially modernized by the passage of the Deficit Reduction Act (DRA) of 2005 and Idaho has taken advantage of new flexibility in DRA Section 6044 in order to create new Secretary-approved targeted benchmark benefit plans. The ability to waive certain requirements such as State-wideness, benefit comparability, and freedom of choice within these benchmark benefit plans allows for improvements in Medicaid administration without requiring actual waivers. Certain other DRA provisions that affect Title XIX populations are extremely specific and will be more difficult to apply to Medicaid transformation efforts, such as provisions affecting co-pays. Even with the overall increase in flexibility in Medicaid administration (afforded) caused by the DRA, Title XIX is fundamentally too rigid to accommodate all of the reforms that are needed in Medicaid programs. The existence of mandatory and optional categories encourages states to continue to focus on regulation and compliance instead of on outcomes and beneficiary’s needs.

What are your future plans?

Idaho Medicaid has obtained the authority to modernize the Idaho Medicaid Program by creating three benchmark benefit packages: The Medicaid Basic Plan, the Medicaid Enhanced Plan, and the Medicare-Medicaid Coordinated Plan. The first two plans were launched in July 2006. The Coordinated Plan was implemented in the fall of 2006. During 2007 co-pays for non-emergent use of the emergency room/emergency transportation and a Medicaid buy-in program for workers with disabilities were also implemented. Additional Idaho Medicaid reform initiatives will be phased in over a three to five year period. Future reforms will include selective contracting for services such as medical transportation, and other reforms. An outsourced dental insurance benefit plan was implemented September 2007 for children and adults in the Medicaid Basic Plan. Idaho Medicaid recently renewed its two largest Home and Community-Based Services (HCBS) Waivers but continues to explore the possibilities for benefit design improvements through the new DRA authorities.