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IV. Scope of services provided for the eligible recipients of medical assistance in Rhode Island
A. More particularly, we are speaking about Old Age Assistance recipients and the Medically Needy Only recipients who are 65 years of age and over.
B. It should be noted that the scope of services available to both the recipients of Old Age Assistance and the Medically Needy Only who are 65 years of age and over are identical in quantity and type of service except for four types of services which are available to the Old Age Assistance Recipients but not available to those who are Medically Needy Only.
C. SERVICES NOT PROVIDED MEDICALLY NEEDY ONLY
1. Podiatry services
(a) With reference to podiatry services, it should be noted that Federal Medicare does have a program of benefits which is even more inclusive than those services which are available to the Money Payment Recipients. I refer now to the surgical services of a podiatrist which are not included within the scope of benefits.
2. Optometric services
3. Ambulance services
(a) However, we should note that ambulance services, for the greater part, are available to these persons through Title XVIII (B) of Federal Medicare.
TOTAL NUMBER OF PERSONS (65 YEARS OF AGE AND OVER) ENROLLED AS ELIGIBLE RECIPIENTS OF OAA OR WHO ARE MEDICALLY NEEDY ONLY UNDER THE PROVISIONS OF TITLE XIX
It would appear from these statistics that, at the present time, a total of 24,328 people or 23.4 percent of the total population of Rhode Island who are 65 years of age and over are eligible for benefits under the Medicaid Program in Rhode Island, whereas 84,624 persons or less than 10 percent of the total population are eligible for the Rhode Island Medical Assistance Program.
N.B.-Rhode Island implemented its program of Medical Assistance for the Aging (MAA) in 1964, and more recently, the Medicaid Program under the provisions of title XIX on the basis of Pre-Enrollment of Eligible Recipients who would be potential recipients of medical services and supplies.
CHART I-DISTRIBUTION OF MEDICAL ASSISTANCE RECIPIENTS BY CATEGORY OF ASSISTANCE FOR THE FISCAL YEARS 1969-70
Medically needy recipients only, recipients with characteristics related to the categories
CHART 11.-TOTAL NUMBER OF PERSONS (65 YEARS OF AGE AND OVER) COVERED BY FEDERAL MEDICARE (TITLE XVIII (A AND B)) BLUE CROSS 65 AND THE RHODE ISLAND MEDICAL ASSISTANCE PROGRAM TOGETHER WITH THE PERCENTAGE ENROLLED IN THESE PROGRAMS
Note: Total population 65 years of age and over in the State of Rhode Island in the year 1970, 103,932. I consider these statistics highly significant in terms of adequate coverage of our elderly citizens under the provision of title XVIII (A and B), Blue Cross 65 and the Rhode Island medical assistance program.
CHART III-PERCENTAGE OF THE AVERAGE MONTHLY CASELOAD THAT RECEIVED 1 OR MORE MEDICAL SERVICES BY CATEGORY OF ASSISTANCE (JULY 1, 1966, TO JUNE 30, 1971) (UTILIZATION RATE)
Note: This tabulation certainly would lend support to the fact that the Rhode Island medical assistance program is a live program which is certainly utilized by its eligible recipients.
CHART IV. SCOPE OF MEDICAL SERVICES WITHIN THE PROVISIONS OF THE RHODE ISLAND MEDICAL ASSISTANCE PROGRAM ACCORDING TO CLASSIFICATION OF ELIGIBILITY
1 Nursing home care for the medically needy only recipients is limited to a maximum of 90 days, subject to prior authorization by the Office of Medical Standards and Review.
4. Out-patient department services
(a) There are certain out-patient department services included within the scope of our program; namely:
(1) Diagnostic and Therapeutic X-Ray Services.
D. ELIGIBLE RECIPIENTS
OF THE RHODE ISLAND
MEDICAL ASSSISTANCE PROGRAM
OBTAIN NECESSARY MEDICAL SERVICES IN THE FOLLOWING MANNER
1. When the eligible recipients require the services of a physician, dentist, pharmacist, etc., they are encouraged to seek these necessary medical services from the practitioner of their own choice, preferably a physician, pharmacist, dentist, etc. who will continue to provide these services on a continuous basis. We feel that this element of continuity of service provided by the same practitioner represents an important factor as it pertains to the quality of medical services available to these recipients.
2. Eligible recipients of the Rhode Island Medical Assistance Program are able to obtain needed medical services in the same manner as those who are not dependent upon a State-supported Medical Care Program for their medical care. In administering the Program, we have tried to remove every barrier or element which would differentiate these recipients from the average person paying for these services without State support. This is another indication that we have indeed captured the spirit of the Kerr-Mills Program and, more recently, the title XIX Program.
We have vigorously opposed certain proposals made by certain critics of the State Medicaid Program.-Proposals which have originated from frustration as it relates to their inability to cope with the expanding financial burdens imposed by these programs. There have been suggestions that we should not be permitting these eligible recipients to reach out and obtain medical services and supplies from the practitioners of their own choice. There have been those who maintain that these should be cleared through State-organized and administered clinics.
We do not feel that this approach can be justified.—We feel that this approach would detract from the dignity of these recipients in need of necessary medical services and supplies. We are proud of the fact that in the Rhode Island Program, eligible recipients are entitled to obtain medical services and supplies from the private practitioners, Neighborhood Health Centers or hospital clinics of their own choice. In fact, we are presently in the process of negotiating with the Rhode Island Group Health Plan in making provision for those eligible recipients who would seek to obtain their comprehensive medical care through this privately-administered health maintenance organization.
V. Significant aspects of certain types of services included within the scope of medical services provided eligible recipients of the medical assistance program
A. HOSPITAL SERVICES
1. When an eligible recipient requires hospital service, the attending physician will request these services through a community hospital. This patient will receive hospital services in accordance with the needs of his case. These services range from the coronary care unit and intensive care services to placement on a so-called "self-help unit."
2. There is actually no limit on the length of hospitalization. This is dependent totally upon the needs of the patient as certified by the attending physician and hospital utilization committees which are now active in all the hospitals. This does not mean that a patient can demand and receive unnecessary hospital services, but rather that he is entitled to benefits through the State Medicaid Program to receive necessary hospitalization in accordance with the specific needs of his case.
3. We do not require prior authorization for hospitalization. However, we do require that a Request for Extension be submitted by the hospital when hospitalization in excess of 15 days is needed by the patient. It should be noted that, in Rhode Island, 75% of hospital stays for eligible recipents of Medical Assistance fall within the 15-day period. We, therefore, feel that this requirement is reasonable since the majority of eligible recipients do not require more than 15 days of hospitalization.
(a) For those who do require in excess of 15 days of hospitalization, we as a responsible State agency, are simply requiring the hospital physician and, in some cases, the hospital utilization committee to certify that this hospitalization is necessary on the basis of the medical needs of the patient. 4. Four persons 65 years of age and over, prior authorization for extension of hospitalization is not required until after 60 days.-Since the majority of persons 65 years of age and over are entitled to benefits under the provision of Title XVIII (A), this means that:
(a) The State Agency is responsible for meeting the deductible of $60 which is required before Part A of Federal Medicare assumes responsibility for payment of hospitalization.
(b) The State Agency is responsible for payment of the co-insurance factor of $15 per day after the period of 60 days has elapsed.
(c) The State Agency also assumes responsibility of payment for the first three pints of blood which are not paid for by Federal Medicare.
Therefore, in an effort to avoid unnecessary expenditure of time and energy, the State Agency does not require prior authorization for hospitalization involving less than 60 days. It is quite clear that the State Program has very effectively complemented the hospital benefits which are available through the Federal Medicare Program which are available through Part A.
A constant careful surveillance is maintained for all hospital stays. All requests for extension beyond 15 or 60 days must be reviewed by the Medical Care Program Director who makes a decision in each case on the basis of the medical justification provided by the attending physician, the hospital utilization committee and, in many cases, an actual review of the complete hospital record.
5. In those instances involving patients 65 years of age and over who, in the opinion of the attending physician, are best cared for in private psychiatric instituitions, we do make payment for up to 150 days of hospital care. This means that the State Agency would become involved in paying a co-insurance after the 60th day and up to the 150th day.
6. With reference to hospitalization, there is a third group who require hospitalization in a chronic disease facility. These are State-operated institutions. We feel that they are fulfilling a very real need for those elderly persons who require more than the type of service which could be obtained in an extended care facility, skilled nursing home or rest home, but less than an acute hospital service obtained in hospitals for acute medical and emergency care.
These State institutions are caring for a representative sample of our caseload* who should not be imposing an unnecessary burden on the average private community hospital but yet do require a constellation of medical services on a 24hour basis which cannot be provided with equal effectiveness in an Extended Care Facility or Skilled Nursing Home.
7. Care for the Aged Mentally Ill in State mental hospitals is another provision of the Rhode Island Medical Assistance Program. It was not until 1965 that the Federal Government assumed broad responsibility for helping States meet the cost of treating the mentally ill. Even so, coverage under the provisions of the Medicaid Program is limited to patients age 65 or older.
Coverage for these patients in State Institutions became effective in 1965 with the passage of the Long Amendments of title XIX in the Social Security Act. The Long Amendments stipulate requirements which are designed to encourage States to develop an organized, comprehensive mental health care system.
It should be noted that the coverage under the Long Amendments is a State option and is not mandatory. Rhode Island opted to provide this coverage to its aged mentally-ill population. We have done so because we believe that these aged mental patients should not be relegated to a back ward existence in a State mental hospital.
Through the provisions of the Long Amendments, we have developed resources and services to provide alternate methods of care for these patients outside chronic care in mental hospitals. In addition, the State has developed methods for insuring that those who cannot be moved into alternate care arrangements are being provided needed services while they are in-patients-with regularly
*At the present time there are 1,638 persons residing in State public hospitals that are covered by the Rhode Island Medical Assistance Program.
scheduled case conferences and evaluations that determine whether optimum inpatient care is being provided.
Furthermore, Rhode Island, under its Medical Assistance Program also makes available to the elderly, as well as all of the eligible recipients of Medical Assistance, provision of payment for treatment in a psychiatrist's private office.
1. An eligible recipient of Medical Assistance is entitled to the services of a physician of his own choice.
2. There is no prior authorization required for the initial visit to a physician's office or for a home visit.
3. We do provide for the visits by a physician for up to two visits per month for a chronic illness and up to eight visits per month for an acute illness. When visits in excess of these standards are requested, prior authorization is required to justify the need for these additional visits.
4. With reference to in-patient hospital visits for persons 65 years of age and over, the physician admits a patient requiring hospitalization to the hospital of the physician's choice. The physician provides the necessary care without any requirement for authorization except for cases representing long-term hospital stays. When visits in excess of 37 visits are required, then the physician is required to obtain prior authorization.
5. Services of Consultants. In addition to the services of the attending physician, we also have provision for the payment of services of medical, surgical and other specialty consultants. This provision contributes to a better quality of medical care.
6. Physicians are paid in accordance with an established fee schedule for medical services provided eligible recipients of the Medical Assistance Program. This fee schedule represents a negotiated fee schedule which is acceptable to the overwhelming majority of participating physicians.
For surgical services, physicians are paid in accordance with the Blue Shield Plan B of Rhode Island. Studies have indicated that, as of 1968, reimbursement on the basis of Blue Shield Plan B represented approximately 69 percent of the usual and customary charges of participating surgeons. This means that the physicians of Rhode Island continue to make a contribution to the needy of our State and the responsible State Agency. Contrary to public opinion, physicians and surgeons are not reimbursed in toto for services rendered.
7. There was a time when the physicians' fee schedule was not generally acceptable to the medical profession; there were some physicians who were billing patients in addition to the allowances made by the Federal Medicare and the State Medical Assistance Programs. The State Agency has made every effort to curtail this practice. As of this year (1971), we can state with confidence that Medical Assistance Recipients are not compelled to supplement payments made in their behalf by the State Agency in conjunction with the Federal Agency through Federal Medicare.
CHART V. PHYSICIANS' EXPENDITURES FOR OAA AND MA RECIPIENTS TOGETHER WITH THE TOTAL PHYSICIANS' EXPENDITURES FOR ALL CATEGORIES OF ASSISTANCE
1 It should be noted that physicians' expenditures for eligible recipients 65 years of age and over do not include any payments made by Federal medicare SMI benefits. The expenditure represents payments made toward the deductible and coinsurance amounts not covered by Federal medicare.