Enacted in 1965, Title XIX (19) of the Social Security Act established regulations for the Medicaid program, which provides funding for medical and health-related services for persons with limited income. Title XIX contains a number of provisions governing the acquisition, use and disclosure of Medicaid enrollees’ health information.
1.) State Plans for Medical Assistance and Payment to States
State participation in Medicaid is voluntary; each state designs and administers its own Medicaid program, funded jointly by the state and the federal government. Despite a state’s relative autonomy to develop its own Medicaid program plan, Title XIX predicates federal approval of state plans on the inclusion of certain provisions, and conditions federal financing of the program on the satisfaction of certain requirements. The following is a summary of all the health information provisions that must be included in each plan to earn federal approval and enable the state and providers to receive federal funds and reimbursement for services provided to enrollees.
b.) Requirements for Mental Hospitals, Institutions for Mental Diseases and Intermediate Care Facilities for the Mentally Retarded (ICF-MRs)
2.) Nursing Facilities
Every state plan for medical assistance is required to provide coverage for nursing home care for categorically eligible participants age 21 and older. States may, at their option, design their plan for the provision of nursing home care to include other Medicaid beneficiaries, including individuals under age 21 or the medically needy. In any case, any individual receiving nursing care must satisfy nursing home eligibility criteria, commonly known as level-of-care criteria. There are a number of nursing facility requirements with respect to the collection, use, and disclosure of health information.
3.) Home and Community-Based Care
In an effort to provide alternatives to nursing home care, states have a variety of options available in the form of home and community-based services. These alternatives to institutionalized care include home and community-based care for functionally disabled elderly individuals, the Program of All-Inclusive Care for the Elderly (PACE), consumer-directed services and home and community-based services provided via waiver and via plan amendment.
Prior to the passage of the Affordable Care Act, the threshold requirement to receive home and community-based services in any form was a need for institutionalized care. The ACA expanded states’ ability to provide services to entitled persons by permitting states to amend their plans and establish needs-based criteria for the receipt of home and community-based services. Such need-based criteria can be broad enough to include individuals whose needs do not meet the level of institutionalized care, but who would still benefit from receiving home and community-based services.
Whether via a waiver, an established program or a plan amendment, the plan for and provision of home and community-based services will necessarily rely on the collection and disclosure of enrollee participants’ health information. The following sections discuss all the health information-related provisions in the statute governing home and community-based care