Medicaid 101

Learn More about Medicaid

Medicaid: A Primer – Key Information on the Nation’s Health Coverage Program for Low-Income People
The primer examines how the Medicaid program is structured, whom it covers, what services it provides, how it is financed, and how much it costs. It also provides an overview of how Medicaid will change under the health reform law. [pdf; Kaiser Family Foundation]

Medicaid 101: What You Need to Know
The Alliance for Health Reform and the Kaiser Family Foundation present a briefing to discuss the basics of Medicaid and its role in the health care system. Speakers address questions on how the program is administered, how much it costs, and how it is financed, as well as how the Affordable Care Act affects the program and what states are doing to transform Medicaid to meet current and future needs of its beneficiaries. [podcast; Kaiser Family Foundation]

Medicaid Delivery Systems
Learn more about fee-for-service, Medicaid managed care, integrated care models (including health homes), CHIP, and other ways that Medicaid services are delivered. [url; Centers for Medicare and Medicaid Services]

Medicaid Terminology
Glossary and list of commonly used acronyms for Medicaid programs. Search for a specific term or download an Excel file with all the terms. [url; Centers for Medicare and Medicaid Services]

Change in the Rule on Essential Health Benefits
Effective January 1, 2014, a change in the federal rule on Essential Health Benefits allows reimbursement for preventive services that are delivered by non-licensed providers as long as services have been recommended by a physician or another licensed provider.

Essential Health Benefits and Community Health Workers
This webpage contains resources related to the new Medicaid rule, including examples of successful strategies for preventive service delivery by non-licensed providers, such as Community Health Workers (CHWs), and other resources related to the adaptation, licensure, and support of CHWs. [url; Association of State and Territorial Health Officials]

Medicaid and Community-Based Asthma Interventions: Recent Changes and Future Steps
This Q&A explains how the change in the rule on Essential Health Benefits will impact coverage of community-based interventions for low-income children with asthma. [pdf; Childhood Asthma Leadership Coalition]

State Medicaid and CHIP Policies
Every state’s Medicaid and CHIP program is changing and improving – many are expanding coverage for low-income adults; all states are modernizing their Medicaid/CHIP enrollment and renewal processes and improving their applications. This page contains links to some key documents and information about the Affordable Care Act’s Medicaid/CHIP changes to states’ programs. [url; Centers for Medicare and Medicaid Services]

Learn More about Pathways to Reimbursement

Medicaid Pathways to Asthma Reimbursement
This chart describes various strategies that Medicaid offers for expanding effective community-based asthma programs for low-income and medically underserved populations available to states as they seek ways of supporting community asthma management. [pdf; Childhood Asthma Leadership Coalition]

Pathways to Reimbursement: Understanding and Expanding Medicaid Services in Your State
This technical brief provides and overview of options for financing healthy homes services through your state’s Medicaid program, including waivers, managed care contracts, state plan amendments, and more. [pdf; NCHH]

Reimbursement for Healthy Homes Services: A Case Study of Leveraging Existing Medicaid Authority in Texas
This brief outlines the steps that the Texas Childhood Lead Poisoning Prevention Program took to set up the system for reimbursement, describes how the claims are currently supporting program activities, and offers tips for exploring reimbursement opportunities in other states. [pdf; NCHH]

Using Medicaid to Advance Community‐Based Childhood Asthma Interventions: A Review of Innovative Medicaid Programs in Massachusetts and Opportunities for Expansion under Medicaid Nationwide
This report reviews community asthma interventions, describes new initiatives underway in Massachusetts to promote community‐based asthma prevention for children, and discusses opportunities for state Medicaid programs to incorporate these interventions into Medicaid and the Children’s Health Insurance Program (CHIP) programs nationwide. [pdf; Childhood Asthma Leadership Coalition]

Medicaid Funding of Community-Based Prevention: Myths, State Successes Overcoming Barriers and the Promise of Integrated Payment Models
Medicaid funding for community-based prevention services has an important role to play in achieving the transformation of our healthcare financing and delivery system necessary to achieve the Three Part Aim. The findings in this paper reveal that federal and state policy makers can benefit from dispelling long-held myths, learning how states have been successful in supporting community-based prevention through Medicaid, and recognizing their challenges. [pdf; Nemours]

Integrating Housing in State Medicaid Policy
As evidence continues to establish supportive housing as an intervention that stabilizes people with chronic illnesses and/or behavioral health conditions and reduces health system costs, states are exploring ways to better utilize healthcare financing for the services that supportive housing residents need. CSH is working with and tracking state efforts to pursue the changes needed to finance through Medicaid the services that supportive housing residents need to achieve both housing and health stability.This brief describes these mechanisms and provides examples of state and local jurisdictions taking advantage of these opportunities. [pdf; CSH]

Waivers are vehicles states can use to test new or existing ways to deliver and pay for healthcare services in Medicaid and the Children’s Health Insurance Program (CHIP). For instance, a state may submit a waiver under Section 1115, Research and Demonstration Projects, to expand eligibility criteria, propose new services not typically covered by Medicaid or test new or innovative delivery systems to improve care, increase efficiency, and reduce costs. In general, Section 1115 demonstrations are approved for a five-year period and can be renewed, typically for an additional three years. Demonstrations must be “budget neutral” to the Federal Government, which means that, during the course of the project, federal Medicaid expenditures will not be more than federal spending without the waiver. [url; Centers for Medicare and Medicaid Services]

Medicaid 1115 Waivers: How Are They Transforming the Health System?
This webinar provides an opportunity for public health lawyers, health practitioners, and other stakeholders to learn about Medicaid 1115 waivers and their role in health system transformation. Presenters provide an overview of Section 1115 Medicaid waivers, how states have used them, and how they are impacted by health reform. Representatives from Arkansas and Texas discuss their state’s approach of utilizing Medicaid 1115 waivers and highlight how they have chosen to address population health and Medicaid Expansion. [webinar; The Network for Public Health Law]

Medicaid Managed Care Contracts
States have traditionally provided people Medicaid benefits using a fee-for-service system. However, in the past 15 years, states have more frequently implemented a managed care delivery system for Medicaid benefits. In a managed care delivery system, people get most or all of their Medicaid services from an organization under contract with the state. [url; Centers for Medicare and Medicaid Services]

State Plan Amendments (SPA)
A state plan is a contract between a state and the Federal Government describing how that state administers its Medicaid program. It describes groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed, and the administrative requirements that states must meet to participate. Many of the financing mechanisms described on this page would require a state to submit a state plan amendment, otherwise referred to as a SPA, to the Centers for Medicare and Medicaid Services (CMS) for review and approval. [url; Centers for Medicare and Medicaid Services]

Health Homes
The Affordable Care Act created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions. Health Homes providers are expected to integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person. [url; Centers for Medicare and Medicaid Services]

Targeted Case Management (TCM)
Case management includes services that assist eligible individuals to gain access to needed medical, social, educational, and other services. Targeted case management are case management services provided only to specific classes of individuals, or to individuals who reside in specified areas of the state (or both). These definitions were refined in Section 6052 of the Deficit Reduction Act of 2005, and this FAQ provides additional guidance on eligible activities. [url; Centers for Medicare and Medicaid Services]

State-by-state information on Targeted Case Management
This portal provides data related to Medicaid benefits covered in each state (including Targeted Case Management), limitations applied to those benefits, cost-sharing charges, and the reimbursement methodologies used for those benefits in effect at six specific points in time, the most recent being October 1, 2012. In general, the data presented represents a state’s policies applicable to adult Medicaid beneficiaries receiving care on a fee-for-service basis. [url; Kaiser Family Foundation]

Medicaid Administrative Claiming
Medicaid program costs can be classified as service or administrative. Administrative costs cover activities like enrolling individuals and coordinating and monitoring services for Medicaid recipients. Some of these administrative costs for healthy homes services may be reimbursable. [url; Centers for Medicare and Medicaid Services]

State Plan Amendments and Waivers: How States Can Change Their Medicaid Programs
It is helpful to understand the basics of both state plan amendments and waivers, because the best plan of action will depend on which process their state is pursuing. This brief provides an overview of and comparison between state plan amendments and waivers. [pdf; Families USA]

Other Tools and Resources

Medicaid Provision of Preventive Services Regulation – Questionnaire to Prepare for a Dialogue with State Medicaid Officials
As states turn their focus to improving population health, and since community prevention programs provided by a broader array of health professionals generally have not previously been reimbursed by Medicaid, new tools and methods are needed to help in the implementation process. This questionnaire is designed to prepare advocates to engage in a dialogue with their state Medicaid officials about pursuing these new opportunities. [doc; Nemours]

Preparing for Reimbursement
Through the Affordable Care Act, the landscape for healthcare is changing quickly. Hear firsthand from Dr. Stephen Cha, Chief Medical Officer at the Center for Medicaid and CHIP Services, about the new Medicaid reimbursement provision for non-medical providers delivering preventive care services, and what asthma programs should consider when engaging their state Medicaid offices. [podcast; Asthma Community Network]

Working Towards Reimbursement: The Experience in Kansas City
Kevin Kennedy, Managing Director and Environmental Hygienist, Center for Environmental Health, Children’s Mercy Hospital and Clinics, describes the key steps his program is taking to prepare for reimbursement for home visitation and assessment services and how they are engaging with two state Medicaid offices. [podcast; Asthma Community Network]

EPA Value Proposition Toolkit
A value proposition is a tool to help you communicate the unique value and benefits of your program to funders. It demonstrates that the health outcomes a program creates and the economic savings a program generates outweigh the program operating costs. Whether you are starting a new pilot project or you are a part of a well-established program, value propositions are effective tools to prepare your program for reimbursement as well as new funding streams. [url; Asthma Community Network]

Effective Strategies for Obtaining Reimbursement
Hear ways that asthma programs may benefit from new opportunities in today’s changing healthcare landscape. Learn about the Medicaid reimbursement provision for non-medical providers delivering preventive care services and how to engage effectively your state Medicaid office and managed care plans on reimbursement for asthma care services. Hear recommendations and key steps taken by one program that advocated for and received approval from CMS for Medicaid reimbursement as a Targeted Case Management Program. [webinar; Asthma Community Network]

Medicaid Coverage of Guidelines-Based Asthma Care across 50 States, the District of Columbia, and Puerto Rico, 2016-2017
This American Lung Association article published in the U.S. Centers for Disease Control and Prevention journal Preventing Chronic Disease, “Medicaid Coverage of Guidelines-Based Asthma Care across 50 States, the District of Columbia, and Puerto Rico, 2016-2017,” contains an analysis of asthma care coverage in state Medicaid programs. Additionally, the American Lung Association continues to collect data on Medicaid coverage of guidelines-based asthma care annually; the most recent coverage data and other resources from the Asthma Guidelines-Based Care Coverage Project is available here. [url; ALA/CDC]

Affordable Housing’s Place in Health Care: Opportunities Created by the Affordable Care Act and Medicaid Reform
This report examines the ways healthcare changes created by the Affordable Care Act (ACA) and earlier Medicaid reforms have created the potential for affordable housing providers to collaborate with healthcare providers, insurers, and other institutions to support the well-being of low-income and vulnerable individuals and families. [pdf; National Housing Conference]

Asthma Billing Codes
Medical billing codes help to provide uniform reporting of procedures performed and devices, supplies, and equipment acquired for or provided to a patient. Medicaid billing codes for asthma care services can vary according to state and what services are covered by Medicaid in that particular state. This applies to both the type of provider delivering the service, the length of the service provided, and the service itself, such as home-based asthma education, home assessments, and products that support environmental management of asthma triggers.

See also: Case Studies and Resources