The current New Mexico Medicaid and the New Mexico Medicaid Modernization - Research Paper Example

?The current New Mexico Medicaid and the New Mexico Medicaid Modernization Welfare services in New Mexico has been one of the poorest in the United States, reflecting the overall dismal situation of the state, which has been plagued by high rates of poverty, unemployment and a number of social ills such as alcohol and drug use in addition to the high incidence of suicides. During the 1990s, about twenty percent of the 1.8 million residents received Medicaid (Castro and Singer 2004). This is significantly lower than the national coverage. The state policy network has attempted to reform the healthcare situation in New Mexico beginning in 1994. The ensuing development reflected a positive transformation that featured numerous strategies and programs that helped to effectively expand health coverage and the development of successful health initiatives. Medicaid Modernization Development There are three significant stages in the current Medicaid/health policy in New Mexico. Such stages collectively represent the roadmap by which Medicaid has operated in the state. Castro and Singer have explained this in detail. The first of these was during the time that Bruce King served as governor of the state. He pursued a “carve-out” strategy in managing care and dispensing healthcare services. In his approach, the mental health services were funded and administered separately from the physical health portion of a non-profit Medicaid program. The objective was for the state to save on costs and expenditures that supposedly taxed citizens too much. This direction was rejected by the Republican administration that succeeded King’s term. Governor Gary Johnson implemented a different tactic back in 1995, favoring the so-called integrated managed care program, wherein “three for-profit managed care organizations competed for contracts to provide physical and mental services to Medicaid recipients. (Castro and Singer, 2004). This policy was revised and led to the current program which was initiated in 1997. An important feature of the Medicaid reform is the inclusion of the chronically mentally ill at the inception of the program. New Mexico’s Medicaid program also automatically enrolled Native Americans into the program unless they chose to reject such enrollment. Today, as reported by a congressional report in 2005, Medicaid in New Mexico “is the single largest payor for health care. All told, Medicaid programs cover the health costs of more than 400,000 New Mexicans… Although the least expensive to cover, those who benefit most from Medicaid are nearly 300,000 of New Mexico’s children… It also serves low-income adults and pregnant women. It also serves senior citizens and people with disabilities who receive the bulk of their health care through Medicare (US Congress 2005)”. Reform Implementation The Human Services Department's Medical Assistance Division (MAD) is the direct administrator of the New Mexico Medicaid program and leads the ongoing modernization efforts. In a report to the US Senate in 2005, Pamela Hyde, past Secretary of New Mexico’s HSD, stated that the agency, in pursuit of its objectives, had designed an innovative approach to behavioral services financing and service delivery, featuring the establishment of the state’s Interagency Behavioral Health Purchasing Collaborative. This interagency effort brought together 15 state agencies that enabled New Mexico to support and help the health requirements of its residents using different sources, including federal block grants, state general funds, and other funding resources in addition to Medicaid (Hyde, 2005). In New Mexico’s Medicaid Modernization Plan, it was declared that the state needed to modernize the Medicaid program to protect and improve services for those who depend on it most. As a result, Medicaid spending would rise to 16% of New Mexico’s total State budget in fiscal year 2012. Also the Health Care Reform would add approximately 130,000 to 175,000 new recipients to the Medicaid system , which will require around 300 to 600 million dollars more from 2014 to 2019 (Squier/HSD, 2011). This figures, HSD stressed, are inevitable especially considering that even without Health Care Reform, State spending will need to increase by 20% by 2019 in order to cover New Mexico residents who need Medicaid services. The modernization plan outlines several ambitious goals and that to be able to realize them; each would ideally operate within four fundamental principles. These are: 1. The incorporation of all services into a “second generation” of care better tailored to meet the needs of New Mexico’s vulnerable population and offer a full spectrum of benefits from newborns to nursing care; 2. The increase in personal responsibility by implementing sliding scale co-pays for some high-cost services, and pursing financial incentives to reward healthy behavior, 3. Institutes pay for performance targets that move us toward paying for health care outcomes rather than quantity of services provided, and 4. Increased administrative efficiencies by combining all our waivers into a single waiver so we can manage the program rather than the waivers. (Squier/HSD, 2011) From the aforementioned objectives and principles, a solid and reliable framework emerged in which reforms and programs could be systematically designed, implemented and evaluated. One of the most important offshoots of the attempts at reform is the establishment of safety net institutions on the part of administrative departments. These institutions are able to sustain the cost in complying with “credentialing, paperwork, as well as the utilization review requirements, without which behavioral health organizations would delay or withhold service authorization payments (Castro and Singer, 2004). Authorities have also made sure that Medicaid programs are developed and implemented with the help and guidance of advisory boards. Indian advisory boards, for instance, were established to interact and consult with the Indian tribes (King, 2009). Since 1999, HSD has a liaison officer exclusively tasked to communicate and collaborate with Native American tribes in the state. There is also the introduction of New Mexico HIS/State Medicaid Case Management Project. Similar to the Interagency Behavioral Health Purchasing Collaborative, the Medicaid Case Management Project is an initiative involving interagency cooperation. It was established in the 1990s and took three years to setup. In this initiative, case managers are trained for residents with specific health requirements. For instance, there is the case of Indians with serious mental health problems. Sanchez and McGuirk (1996) noted that this case management approach is highly effective and acceptable to residents because case managers work effectively and productively with mental health technicians and meet on a regular basis to discuss cases, share experiences, and standardize record keeping. An important aspect in the modernization efforts by the HSD is the involvement of stakeholders and their engagement in participative and inclusive activities that lead to policymaking. This has been demonstrated earlier with the case of stakeholder consultations. As a result, some important mechanisms were established to help ensure the preservation and consistency of the Medicaid and medical programs that are currently in place. This was explained in the policy paper published by the HSD under the current Secretary Sidonie Squier, entitled MEDICAID: Preserving the Program Now and for the Future. The paper effectively summarized how the four principles that were previously mentioned, are being followed and could help to establish and maintain program efficacy and continuity. The HSD administration acknowledged that the political culture, the bureaucratic hurdles and oppositions from several interest groups can make it difficult to effectively enforce the New Mexico Medicaid Modernization Plan but she maintained that decisions and actions must be made in order to move forward in the outlined objectives, emphasizing that the Medicaid system is unsustainable. Current Initiatives Currently, the HSD is making headway in the modernization plan. There are now approximately 40 categories of eligibility within New Mexico Medicaid. Some of these include Salud!, New MexiKids & New MexiTeens, Family Planning and Pregnancy, the Coordination of Long-Term Services (CoLTS) program, The Breast and Cervical Cancer Program and the Working Disabled Individuals (WDI) program. MAD is responsible for all Fee for Service (FFS) provider payments as well. In addition to traditional Medicaid services, MAD also administers Insure New Mexico! Solutions. These are state and federally funded insurance programs for individuals, non-profit organizations and small businesses as well as expanded coverage options for children and pregnant women. These programs include State Coverage Insurance (SCI), Premium Assistance for Kids (PAK) and Premium Assistance for Maternity (PAM). Salud! Salud! is the umbrella name for New Mexico’s Medicaid managed care program. Services are provided through some contracted Managed Care Providers (MCOs). This initiative has been responsible for several changes in New Mexico. For example, community health centers became participants in designated managed care organizations tasked with managing Medicaid clients. Problems and policies were also effectively analyzed and were classified according to which will be prioritized. Recently, the consulting group Alicia Smith and Associates was contracted to implement the redesigned Medicaid program wherein the current Salud! managed physical care, the CoLTS (see program below) long terms service program, the home community-based waiver programs, and the behavioral health managed care will be combined into one big waiver program (DRNM 2011). Coordination of Long-Term Services (CoLTS) CoLTS is a flagship program implemented within the Medicaid reform framework that features a managed care program similar to the case management project cited previously. The specific mandate of this initiative is to provide and coordinate services to Medicaid beneficiaries, which include “doctor visits, hospital services, home & community-based services and long-term care services” such as “medical care, home health services, personal care & support, meal preparation and physical therapy.” (HSD) Insure New Mexico! This initiative aims to make adults with a family income at/or below 200 percent of the federal poverty level (FPL) eligible for health insurance. Offering a Medicaid waiver program that would effectively draw resource from federal and state funding in addition to the contributions made by employers and employees on a sliding scale/income basis achieve this. Insure New Mexico! Also attempts to create a more favorable insurance environment wherein residents have easier access to healthcare insurance. For instance, it developed the Small Employers Insurance program (SEIP) in 2006 in order to allow organizations with fewer than 50 employees to buy insurance through a state sponsored and administered program within Insure New Mexico framework. Several other measures were adopted such as in areas of outreach, policy-making and the expansion of existing HSD services. New MexiKids/New MexiTeens As previously mentioned, children are the largest beneficiaries of Medicaid, representing almost two-thirds of the entire population covered. It is not surprising, hence, that HSD focus on the services for this sector. An excellent example of this is the New MexiKids program. Under this policy children up to 12 years old are eligible for Medicaid’s no cost or low cost health coverage. What this means is that Medicaid helps pay for regular check-ups, doctor visits, dental visits, hospital care, prescriptions, glasses and hearing and vision exams, among other medical services. This is also true for young adults under 19 years of age, which is also covered in a program called New MexiTeens. Eligibility is determined by family income: If a family's household income is less than 185% of the FPL, health care services can be provided to a child through New MexiKids and New MexiTeens at no cost. If the household income is between 185% - 235% of the FPL, some of the health care services that a child receives may require a low co-payment at the time those services are provided (Insure New Mexico Solutions). Children's Health Insurance Program Children's Health Insurance Program (CHIP) is another program that cover children beneficiaries. It effectively expanded the previous State Children's Health Insurance Program by raising the age cap from twelve to nineteen. In this policy, children and teenagers that belong to families with income between 185%-235 of the Federal Poverty Guidelines are now eligible for healthcare coverage. The HSD, however, explained that CHIP “requires nominal copayments for some services received. The program was designed in order to: 1) prove how co-payment requirements do not hinder access to Medicaid services; and, 2) make sure that New Mexico’s six-month waiting period of uninsurance for applicants do not lead to crowding-out or other related problems (HSD). Premium Assistance for Kids Another flagship program implemented by the HSD for children is the Premium Assistance for Kids (PAK). It is fundamentally a health care assistance policy for those children who are not covered or insured. Children can benefit from this program once their families are eligible for Medicaid coverage. Under Insure New Mexico! solutions, children up to twelve years old and teenagers under the age of 19 can utilize commercial and comprehensive health insurance, which includes preventive, primary and specialty care, inpatient and outpatient hospitalization, pharmacy, lab, x-ray, physicals, occupational and speech therapy provided that the income of their families meet the Medicaid requirements. (Insure New Mexico Solutions) Premium Assistance for Maternity Premium Assistance for Maternity is a health coverage program available to pregnant women who are not covered by Medicaid because of income. The policy is also within Insure New Mexico Solutions and shoulders part of pregnancy-related insurance premium. Benefits in this program include pre- and post-natal care, delivery, and other pregnancy-related health services although it does not cover procedures, services, pharmaceuticals, or miscellaneous items that are not related to pregnancy (Insure New Mexico Solutions). State Coverage Insurance State Coverage Insurance or SCI is an example of a program that falls under HSD’s objective of expanding healthcare coverage by making them accessible to New Mexico residents. This program ensures that health insurance products are made affordable to low-income adults. It operates within an employer-based system and is offered to “uninsured, low-income adults, ages 19 through 64, with countable family incomes of up to 200% of federal poverty level and who are not eligible for certain government health insurance benefits” (HSD). Working Disabled Individuals Medicaid has several eligibility requirements. Unfortunately, many individuals do not meet them. Disabled working individuals are a case in point. They are unable to qualify because of their income. For this reason, New Mexico established the Working Disabled Individuals (WDI). It caters to individuals identified by the Social Security Administration as disabled without regard to “substantial gainful activity” as well as those individuals with a recent attachment to the work force – those with enough earnings in a quarter to meet the SSA’s definition of a qualifying quarter. WDI is also available to those individuals who have has Social Security Insurance and Medicaid due to the initial receipt of Social Security Disability Insurance (SSDI) benefits, until Medicare entitlement. Conclusion It is clear that Medicaid and medical programs in New Mexico change with the agenda of each state governor that comes into office every four years. But the four principles adopted by the current HSD administration seem to address this issue effectively. The overall efficacy can be, of course, determined only when actual performance is completed so they could be examined and evaluated. In addition, the policy trend in recent years reflects a consistent preference for reform and modernization. Crucial to this point is the attempt to reconcile the expansion of coverage and the need to lower cost and state expenditures. The current Medicaid coverage and medical programs in New Mexico as implemented by the HSD follow a strategy that takes these variables into consideration. Several studies have evaluated the system in place. For example, Castro and Singer found that safety net institutions created in the delivery of health services led to diminishing revenue and additional workload for health workers. The positive side is, however, clear as well. As demonstrated by the medical programs cited by this paper, there is an obvious effort to expand coverage and provide benefits for those who need health insurance most. Works Cited Castro, A. and Singer, M. (2004). Unhealthy Health Policy: A Critical Anthropological Examination. Walnut Creek, CA: Altamira Press. Disability Rights New Mexico. (2011). “MEDICAID Re-design (Modernization) Moving Forward.” DRNM. Retrieved from: http://www.drnm.org/ Hyde, P. (2005). "Testimony of Pamela S. Hyde, J.D.: Senate Special Committee on Aging." In United States Senate Mandatory or Optional? : The Truth About Medicaid: Hearing Before the Special Committee on Aging. Washington, D.C.: DIANE Publishing. Insure New Mexico! (2011). "New MexiKids and New MexiTeens" Insure New Mexico! Retrieved from: http://www.insurenewmexico.state.nm.us/NewMexiKidsandTeens.htm. King, K. (2009). Medicare and Medicaid: CMS and State Efforts to Interact with the Indian Health Service and Indian Tribes. Washington, D.C.: DIANE Publishing. New Mexico Human Services Department (HSD). (2011). “Medical Assistance Programs.” Retrieved from: http://www.hsd.state.nm.us/mad/CMedAssisPrograms.html. Nikolewski, R. (2011). "Making changes to New Mexico’s Medicaid system." Capitol Report New Mexico. Retrieved from: http://www.capitolreportnewmexico.com/?tag=medicaid-modernization-plan. Sanchez, M. and McGuirk, F. (1996). The Journey of Native American People with Serious Mental Illness: First National Conference. Washington D.C.: DIANE Publishing. Squier, S. (2011). “Medicaid Modernization Plan.” New Mexico Human Services Department. Retrieved from: http://www.hsd.state.nm.us/pdf/Medicaid%20Modernization/Medicaid%20Modernization%20Plan%20-%20Purpose%20and%20Contract%20Award%206-14-11%20-%20FINAL.pdf. United States Congress. (2005). Congressional Record: Proceedings and Debates of the 109th Congress, First Session. Washington, D.C.: Government Printing Office. Read More