Medicaid in Montana -2021

1 FOR MORE INFORMATION CONTACT DPHHS PIO JON EBELT AT OR CALL 406-444-0936. Medicaid in Montana 2021 Medicaid in Montana Report to the 2021 Montana State Legislature 2 Medicaid in Montana Table of Contents List of Figures .. 4 List of Tables .. 5 Medicaid - Authorities .. 6 State Plan .. 6 Medicaid - Eligibility .. 8 Medicaid Eligibility Infants and Children .. 9 Medicaid Eligibility Low Income Montanans .. 10 Medicaid Eligibility Special Populations .. 11 Medicaid Eligibility People with Disabilities .. 12 Medicaid Eligibility Categorically and Medically Needy .. 13 Medicaid Benefits .. 14 Population Specific Supports .. 15 Waivers The Basics .. 16 1915c Waiver HCBS for Individuals with Developmental Disabilities .. 17 1915c Waiver HCBS for Individuals for Aged and Physically Disabled.

2 18 1915c Waiver HCBS for Individuals with SDMI .. 19 1115 Waiver Waiver for Additional Services and Populations .. 20 1115 Waiver Plan First .. 20 1115 Waiver Health and Economic Livelihood 20 1915(b) Waiver Passport to Health .. 21 Indian Health Service (IHS) and Tribal Health Activities .. 23 Standard Medicaid Enrollment and Expenditures .. 27 Providers .. 43 Claims Processing .. 45 Payment Methodologies .. 46 Medicaid in Montana Report to the 2021 Montana State Legislature 3 Medicaid in Montana Medicaid Cost Containment 47 Health Outcome Initiatives .. 48 Program and Payment Integrity Activities .. 54 Montana Medicaid Benefit-related Expenditures .. 36 Glossary .. 57 Acronyms .. 59 Medicaid in Montana Report to the 2021 Montana State Legislature 4 Medicaid in Montana List of Figures Figure 1 2019 SSI Monthly Income Standards.

3 12 Figure 2 Indian Health Service/Tribal Reimbursement by State Fiscal Year .. 24 Figure 3 Medicaid 2019 Enrollment and Expenditures by Major Aid Categories .. 28 Figure 4 Medicaid Enrollment Adults and Children (Excludes Medicare Savings Plan Only) .. 29 Figure 5 Disabled Medicaid Enrollment Adults and Children (Excludes Medicare Savings Plan Only) . 29 Figure 6 Medicaid Enrollment Age 65 and Older (Excludes Medicare Savings Plan Only) .. 30 Figure 7 Family Medicaid Enrollment (Excludes Medicare Savings Plan Only) .. 30 Figure 8 Medicaid Poverty Child Enrollment (Excludes Medicare Savings Plan Only) .. 31 Figure 9 Medicaid Enrollment Pregnant Women and Infants .. 31 Figure 10 Total Medicaid Expenses SFY 2019 .. 34 Figure 11 Medicaid : Average Monthly Enrollment SFY 34 Figure 12 Medicaid : Average Expenditure per Enrollee SFY 2019.

4 35 Figure 13 - Medicaid Enrollment by Percent of Population .. 35 Figure 14 Standard Medicaid Benefit Expenditures by Category: FY 2016 to FY 2019 .. 37 Figure 15 Standard Medicaid Benefit Expenditures SFY 2019 .. 38 Figure 16 History of Expenditures and Enrollment .. 39 Figure 14 Medicaid Expansion Benefit Expenditures by Category: FY 2016 to FY 43 Figure 17 Traditional Medicaid Federal Dollar Matching Share SFY 2006-2023 .. 55 Medicaid in Montana Report to the 2021 Montana State Legislature 5 Medicaid in Montana List of Tables Table 1 - Services Funding Rates .. 7 Table 2 - Administration Funding Rates .. 7 Table 3 2019 Federal Poverty Levels and Gross Monthly Income .. 9 Table 4 American Indian Medicaid Payments .. 24 Table 5 Summary of Standard Medicaid Enrolled Persons for SFY 2019.

5 27 Table 6 Enrollment and Expenditures by Standard Medicaid Category SFY 2019 .. 28 Table 7 Enrollment and Expenditures by County SFY 2019 .. 32 Table 8 Enrollment and Expenditures by County SFY 2019 (continued) .. 33 Table 9 Standard Medicaid Benefit Expenditures by Category .. 36 Table 10 Standard Medicaid Average per Month Enrollment .. 40 Table 11 Standard Medicaid Monthly Reimbursement Per Member .. 41 Table 12 Standard Medicaid Reimbursement Totals All Demographic Groups .. 42 Table 13 Comparison of Paper and Electronic Claims Processed (2019) .. 45 Table 14 Montana Medicaid Benefits Federal/State Matching Rate .. 55 Table 15 Traditional Medicaid Comparison of Regular vs. Actual/Enhanced Dollar Match .. 56 Medicaid in Montana Report to the 2021 Montana State Legislature 6 Medicaid in Montana Medicaid - Authorities The Montana Medicaid Program is authorized under 53-6-101, Montana Code Annotated, and Article XII, Section XII of the Montana Constitution.

6 The Department of Public Health and Human Services administers the program. Each state Medicaid program is a combination of state plan and waiver authorities, allowing each state to meet the unique needs of their citizens. State Plan The state plan is a formal, written agreement between a state and the federal government, submitted by the single state agency (42 CFR ) and approved by CMS, describing how that state administers its Medicaid program. The state plan: provides assurances that a state will abide by federal rules in order to claim federal matching funds; indicates which optional groups, services, or programs the state has chosen to cover or implement; and describes the state-specific standards to determine eligibility, methodologies for providers to be reimbursed, and processes to administer the program.

7 Waivers States seeking additional flexibility can apply to the Secretary of HHS for formal waivers of certain statutory requirements. For example, states can request waivers of provisions requiring service comparability, statewideness, and freedom of choice in order to offer an alternative benefit plan to a subset of Medicaid beneficiaries, to restrict enrollees to a specific network of providers, or to extend coverage to groups beyond those defined in Medicaid law. In exchange for the flexibility offered by waivers, states must meet budgetary criteria and provide regular reports and evaluations to CMS to show that the requirements of the waiver are being met, which are not requirements placed on state plans.

8 Also unlike most SPAs, waivers require lengthy applications and must be renewed periodically. A state can operate significant portions of its program under waiver authority but must maintain a complete and up-to-date state plan in order to access federal funds. MACPAC Reference Guide to Federal Medicaid Statute and Regulations Medicaid in Montana Report to the 2021 Montana State Legislature 7 Medicaid in Montana Medicaid A State and Federal Partnership The Medicaid program is jointly funded by the federal government and states. The federal government reimburses states for a specified percentage of allowable program expenditures depending on the expenditure type. TABLE 1 - SERVICES FUNDING RATES Services Funding (SFY 2021) State Share Federal Share Indian & Tribal Health Services 100% Medicaid Expansion 10% 90% Family Planning Service 10% 90% Money Follows the Person 17% 83% Breast and Cervical Cancer Program 24% 76% Community First Choice (FMAP +6%) 29% 71% Standard FMAP 35% 65% State Funded 100% TABLE 2 - ADMINISTRATION FUNDING RATES Administration Funding (SFY 2021) State Share Federal Share Systems Development (if pre-approved)

9 10% 90% Systems Development 25% 75% Skilled Medical Personnel 25% 75% Claims Processing Systems and Operations 25% 75% Eligibility Determination Systems and Staffing 25% 75% All Other Administration 50% 50% FMAP Federal Medicaid funding to states, called the Federal Medical Assistance Percentage (FMAP), is calculated by comparing personal income in each state with the national average. Medicaid in Montana Report to the 2021 Montana State Legislature 8 Medicaid in Montana Medicaid - Eligibility Montana Medicaid provides coverage for the following groups/populations: Infants and Children Subsidized Adoptions, Subsidized guardianship , and Foster Care Pregnant Women Low Income Families with Dependent Children Low Income Adults Low Income Adults with an SDMI Aged, Blind/Disabled and/or receiving Supplemental Security Income Breast and Cervical Cancer Treatment Montana Medicaid for Workers with Disabilities (MWD) Medically Needy More information is available at.

10 Montana Healthcare Programs Member Services Offices of Public Assistance (OPA) Medicaid in Montana Report to the 2021 Montana State Legislature 9 Medicaid in Montana Medicaid Eligibility Infants and Children Newborn Coverage Children born to women receiving Medicaid (at the time of their child s birth) automatically qualify for Medicaid coverage through the month of their first birthday. Healthy Montana Kids Plus (HMK Plus) Provides medically necessary health care coverage for children through the month of their 19th birthday, in families with countable income up to 143% of the Federal Poverty Level (FPL). Montana Medicaid and HMK Plus pay for services that are: - Provided by a Montana Medicaid /HMK Plus enrolled provider - Within the scope of listed Medicaid /HMK Plus covered services Subsidized Adoption, Subsidized guardianship and Foster Care Children eligible for an adoption or guardianship subsidy through DPHHS automatically qualify for Medicaid coverage.