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The Administration=s Proposals for the Medicaid Rehabilitation and Targeted
Case Management Options
Talking Points
- Mental
illnesses rank among the most disabling conditions, according
to the World Health Organization, the Surgeon General, President
Bush’s
New Freedom Commission and other sources.
- Adults
and children with serious mental disorders generally require a
range of intensive,
comprehensive community-based services in order to avoid institutionalization. Such
needed services include not only clinical care, but services to
overcome the cognitive, communication and social deficits often
associated with mental illness. Medicaid rehabilitation and targeted
case management services are the vehicles for providing Medicaid-eligible
persons with those comprehensive mental health services.
- Rehabilitation
services include intensive community services as crisis services,
medication
education and management, skills training and other remedial services
to enable an individual to live in the community. Targeted case
management (TCM) links beneficiaries not only to needed medical
services but also to educational, housing, social services and
other services they need, and case managers also coordinate and
monitor service provision.
- The
Department of Health and Human Services (HHS) recently urged Congress
to narrow
significantly the definitions of Rehabilitation and TCM services
under Medicaid. Adoption of the HHS proposals would have a devastating
impact on individuals with mental illness who depend on public
mental health services and reverse decades of progress in mental
health service delivery.
- While
federal oversight of these services may be appropriate,
as with any component of
the Medicaid program,
these oversight responsibilities do not in any way justify,
or bear any reasonable relationship to the set
of legislative changes now proposed. In short, adoption
of these proposals to limit Medicaid reimbursement of
rehabilitation and
TCM services would be like firemen destroying a home
in response to reports of the homeowner’s smoking in
bed.
Prohibiting Reimbursement
if Others Receive Services Through Other Funding Sources
- HHS
proposed language would prohibit Medicaid payment for these services
on the basis that
non-Medicaid covered individuals receive similar services free
of charge. This would severely limit Medicaid mental health coverage,
undermine the very purpose of the program and set a precedent for
shrinking other medical coverage. Medicaid-covered health services
are commonly available to other individuals through other funding
sources. Until now, that has never been considered a reason to
deny a Medicaid-covered person a Medicaid-covered service.
Changing the Definition
of Rehabilitation and TCM Services
- HHS’ proposed changes to the definition of rehabilitation
services would fundamentally alter and undermine the usefulness of
this service category which is the primary source of funding for
community-based mental health services. It enables states to offer
a wide range of services that foster an individual=s
recovery in the community far more effectively and efficiently than
in institutional settings. Specifically, HHS’ proposed changes would:
- Eliminate
the current law authority that rehabilitation services
can
be provided in any setting. Individuals
with serious mental illness have difficulty transferring skills
from one situation to another, some are homeless, many are unable
to leave their home or handle the transportation to a facility. While
some important rehabilitation
services are facility-based,
the flexibility to go
where
the client is when this
is
necessary is a critical
component
of psychiatric rehabilitation.
- Restrict
Medicaid reimbursement for only rehabilitation and TCM services
that are necessary to achieve specific, measurable outcomes.@ This
is
an
unreasonable,
often-unachievable,
standard. Moreover,
it
ignores
the
reality
that
these
services
are
also
needed
to
maintain
gains
made
or
to
prevent
deterioration
in
an
individual=s
condition and functioning.
- Require
that rehabilitation services be prescribed and provided
by, or under the direction of a
physician or licensed
practitioner. This
would create added administrative burdens and paperwork
but is unlikely to have any effect on
either quality or cost
of care.
Changes to Targeted
Case Management
- HHS proposes that Congress prohibit Medicaid funding for TCM where services
could be provided through any other programs or services.
- Ironically, while HHS calls
for virtually dismantling TCM in Medicaid, private insurers are
increasingly using similar techniques —under
the term Adisease management@ — in
recognition of the value of assigning a case manager to ensure
that the individual is following their treatment plan, has not
deteriorated, and can access additional services as needed.
- Targeted case management supports beneficiaries with severe and chronic
illness or disability, such as serious mental illnesses, HIV/AIDS
and developmental disabilities. These individuals need an array
of non-Medicaid supports for Medicaid services to be fully effective. Targeted
case management ensures that they get them.
- HHS
also proposes to cut the rate of reimbursement for TCM, based
on the notion that targeted
case management is an administrative task. But TCM is a service. Providers
are monitoring clinical status, making changes to a treatment
plan (under supervision) and advocating with other systems in
the client=s
interest. Targeted case management should be reimbursed at the
standard rate, not at a lower administrative rate.
See
the Administration's proposed legislative language
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