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MEDICAID, Louisiana and Substance Abuse (Addiction) 

Background
With Title XIX of the Social Security Act, Congress enacted the Medicaid Program in 1965. Medicaid is a jointly funded cooperative venture between the federal and state governments. Medicaid helps states provide adequate medical care to eligible needy persons who are uninsured or under-insured. The federal government sets national guidelines but each state determines the following: eligibility standards; type, amount, duration and scope of services; rate of payment for services; and administrative structure for their respective programs.

Nearly one out of every five Louisiana residents is enrolled and eligible to receive Medicaid services (18.5 percent). The uninsured rated is estimated to be 19.1 percent and those with either private or other insurance is estimated to 62.4 percent. The ratios are based on the U.S. Census Bureau 2001 reports.

Medicaid is funded by both state and federal funds. Each state has a pre-determined match rate based on relative per capita income in the state. The federal government stipulates the rate at which the states must match Federal Financial Participation (FFP).

The state match portion is typically a combination of state general funds, provider taxes, and local government contributions. Louisiana relies more than most states on state general funds and less on provider taxes and local government contributions. The following tables show Medicaid match rates for Louisiana.

Louisiana Children’s Health Insurance Program (LaCHIP)

 Title XXI of the Social Security Act (1997) created the State Children’s Health Insurance Program (SCHIP) which enabled states to receive federal funds to expand health care coverage for uninsured children (birth to age 19) in families not eligible for Medicaid. Louisiana’s SCHIP program is known locally as LaCHIP.

EPSDT

 The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at section 1905(a) of the Act be provided to an EPSDT recipient even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population.

The EPSDT program consists of two mutually supportive, operational components:

(1) assuring the availability and accessibility of required health care resources; and (2) helping Medicaid recipients and their parents or guardians effectively use these resources. These components enable Medicaid agencies to manage a comprehensive child health program of prevention and treatment, to seek out eligibles and inform them of the benefits of prevention and the health services and assistance available and to help them and their families use health resources, including their own talents and knowledge, effectively and efficiently. It also enables them to assess the child's health needs through initial and periodic examinations and evaluations, and also to assure that the health problems found are diagnosed and treated early, before they become more complex and their treatment more costly.

The EPSDT benefit, in accordance with section 1905(r) of the Act, must include the following services:

Screening Services -- Screening services must include all of the following services:

Comprehensive health and developmental history -- (including assessment of both physical and mental health development); Comprehensive unclothed physical exam;

Appropriate immunizations; Lead Toxicity Screening; Vision Services; Dental Services; Hearing Services;

Health Education -- Health education is a required component of screening services and includes anticipatory guidance. At the outset, the physical and/or dental screening provides the initial context for providing health education. Health education and counseling to both parents (or guardians) and children is required and is designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention;

Other Necessary Health Care -- Provide other necessary health care, diagnosis services, treatment, and other measure described in section 1905(a) of the Act to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services;

Diagnosis -- When a screening examination indicates the need for further evaluation of an individual's health, provide diagnostic services. The referral should be made without delay and follow-up to make sure that the recipient receives a complete diagnostic evaluation. If the recipient is receiving care from a continuing care provider, diagnosis may be part of the screening and examination process. States should develop quality assurance procedures to assure comprehensive care for the individual;

Treatment -- Health care must be made available for treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by the screening services.

The Problem

Table A.3 provides estimates of substance use, abuse and dependence in Louisiana Medicaid recipients during state fiscal year 2000/2001. The estimates are based on the  number of recipients reported by DHH in the 2000/2001 Medicaid Annual Report, Louisiana prevalence estimates from the National Household Survey on Drug Abuse, 2000 and 2001, and reports from the Office for Addictive Disorders (OAD) on the number of Medicaid recipients admitted to an OAD treatment program during state fiscal year 2000/2001. The assumption here is that the prevalence rate for substance use and substance use disorders in the Medicaid population is no greater than or any less than the rates for the Louisiana general population.

Medicaid recipients age 20 and Under

The Louisiana Department of Health and Hospitals, reports that in state fiscal year 2000/2001 there were 502,050 children (age 20 or under) who were Medicaid recipients. Of that number, approximately 15,677 had an alcohol abuse or dependence diagnosis. This estimate is based on the NHSDA rates of alcohol abuse and dependence for youth (5.4% for 12-17 year olds and 12.26% for those18-20 years old, Office of Applied Studies, 2002). An additional 7,377 children (age 20 or under) would have an abuse or dependence diagnosis for an illicit drug other than alcohol. Approximately 46,073 additional children (age 20 or under) were current users of alcohol (NHSDA current use rate: 19.44% for those12-17, and 57.94% for those 18-20 years old).

 The Department of Health and Hospitals conducted a LaCHIP/Medicaid Provider Survey in June 2001. A total of 395 surveys were mailed out to participating providers along with instructions for completion of the survey. A total of 48 surveys were returned, a 12.2% return rate. Of theses providers, only 39.6% reported that they conducted health education on alcohol use; 41.7% reported that they conducted health education on drug use; and 52.1% reported that they conducted health education on tobacco.

In 2000, Louisiana amended its Medicaid State Plan for EPSDT Services to the following: “Substance Abuse services shall be available to recipients up to age twenty one through the Office of Addictive Disorders (OAD). OAD will either provide or arrange for the delivery of services and treatment.” This was needed because the Medicaid substance abuse benefit was drastically reduced. EPSDT requires that appropriate treatment is available to all recipients under age 21. Without a Medicaid substance abuse benefit, OAD was to provide these services. However, as can be seen in Table A.3, OAD provide services to less than two percent of those with a medical diagnosis of abuse or dependence under the age of 21.

Recommendations

Meet EPSDT mandates by implementing the following:

1. Provide training for Medicaid Primary Care Providers on screening and early intervention of substance use and substance use disorders (primarily alcohol)
2. Provide training for Medicaid Primary Care Providers on brief interventions with 20 and under population, who are using alcohol or other drugs but don’t yet have an abuse or dependence diagnosis (anticipatory guidance and health education)
3. Utilize technology to implement effective health education/prevention to those 20 or under appropriate to circumstance
4. Provide training for Medicaid Primary Care Providers on effective referrals for those screened with a potential abuse or dependence diagnosis
5.  Amend the Medicaid State Plan utilizing appropriate waivers where necessary to cover assessment/ differential diagnosis for substance use disorders
6. Amend the Medicaid State Plan utilizing appropriate waivers where necessary to cover brief interventions for those 20 and under with a substance abuse diagnosis, and prevent advancement to substance dependence
7. Amend the Medicaid State Plan utilizing appropriate waivers where necessary to cover appropriate treatment for those 20 and under with a substance dependence diagnosis, and prevent advancement to serious consequences of substance dependence such as victimization, crime, HIV transmission etc.

Provide services for Pregnant and Post Partum women with substance use disorders (see example from the State of Kentucky)

1. Provide training for Medicaid Primary Care Providers on effective referrals for those screened with a potential abuse or dependence diagnosis
2. Amend the Medicaid State Plan utilizing appropriate waivers where necessary to cover assessment/ differential diagnosis for substance use disorders
3. Amend the Medicaid State Plan utilizing appropriate waivers where necessary to cover case management services for Pregnant and Post Partum women with substance use disorders
4. Amend the Medicaid State Plan utilizing appropriate waivers where necessary to cover appropriate treatment for Pregnant and Post Partum women with substance use disorders