Medicaid

1
Medicaid

• Title XIX of the Social Security Act of 1965
• Joint Federal and State program
• Hospital and medical expense coverage
• No Rx mandated, but states offer

2
Medicaid Funding

• Funded jointly by Fed / State
• Rates are based on the per-capita income in each
  state
• The Federal contribution ranges from 50 (the
  Federal minimum) to as high as 83 in poorest
  states
• States determine rates for MDs, health plans, etc

3
Eligibility

• Generally based on monthly income and financial
  resources
• Welfare status categorically needy
• Children and low-income adults who qualified for
  Aid to Families with Dependent Children (AFDC)
• Low-income, aged, blind, and/or disabled who
  qualify for Supplemental Security Income (SSI)
  benefits

4
Eligibility

• Medically needy
• Meet financial resource requirements of
  categorically needy
• Monthly income exceeds allowable maximum
• Spend-down
• Dual Eligible
• Medicare and Medicaid

5

• States have some discretion in determining which
  groups their Medicaid programs will cover
• and the financial criteria for Medicaid
  eligibility.
• Mandatory Medicaid eligibility groups are

6
Mandatory Medicaid Eligibility Groups

• Low income families with children
• Supplemental Security Income (SSI) recipients
• Infants born to Medicaid-eligible pregnant women
• Certain Medicare beneficiaries

• Children under age 6 and pregnant women whose
  family income is at or below 133 percent of the
  Federal poverty level.
• Recipients of adoption assistance and foster care

7
Optional Groups that States may Cover as
Categorically Needy

• infants up to age one and pregnant women not
  covered under the mandatory rules whose family
  income is below 185 percent of the Federal
  poverty level
• Optional targeted low income children
• Certain aged, blind, or disabled adults who have
  incomes above those requiring mandatory coverage,
  but below the Federal poverty level
• Children under age 21 who meet income and
  resources requirements for AFDC, but who
  otherwise are not eligible for AFDC

8
Optional Groups that States may Cover as
Categorically Needy

• Institutionalized individuals with income and
  resources below specified limits
• Persons who would be eligible if
  institutionalized but are receiving care under
  home and community-based services waivers
• TB-infected persons who would be financially
  eligible for Medicaid at the SSI level (only for
  TB-related ambulatory services and TB drugs)
• Low-income, uninsured women screened and
  diagnosed through a Center's for Disease Control
  and Prevention's Breast and Cervical Cancer Early
  Detection Program and determined to be in need of
  treatment for breast or cervical cancer.

9
Within Broad National Guidelines which the
Federal Government Provides, Each of the States

• establishes its own eligibility standards
• determines the type, amount, duration, and scope
  of services
• sets the rate of payment for services and
• administers its own program.

10
Benefits Provided

• Include most services
• Federal mandate Hospital, MD, lab, home health
  care
• Each state free to determine mix of other
  services
• e.g. Rx, vision, dental
• Long-term nursing care
• Unlike private insurance / Medicare

11
Federally Mandated Medicaid Benefits

• Prenatal Care
• Vaccines for kids
• Family planning services and supplies
• Nurse-midwife services
• Pediatric and family nurse practitioner services

• Rural health clinic services
• Federally qualified health center services
• Ambulatory services of an FQHC that would be
  available in other settings

12
Medicaid Rx Benefits

• Provided by all states
• High utilization population
• States are limited in their ability to manage Rx
  utilization
• Preferred drug lists and formularies cannot
  exclude MFG agreeing to contracted price
• May request nominal co-payment, but cannot deny Rx

13
Rising Rx costs

• Medicaid drug expenditures 10-20 increase / yr
• Cost Containment
• Drug rebate program
• Preferred drug lists / PA
• Formularies
• Supplemental rebates
• Cost-sharing
• Rx limits
• DUR Board

14
Extending Benefits

• States may provide Medicaid coverage to other
  groups
• As such, plans vary from state to state
• Medicaid is always second payer of benefits
• Waiver programs

15
Medicaid and Managed Care

• of Medicaid in Managed Care
• 1995 29 1997 48
• States can mandate managed care
• Must give patient choice of at least 2 options
• Plans must satisfy contractual and quality
  requirements (per BBA)

16
Eligibility

• Coverage mandated for
• Categorically needy
• Medically needy
• Dual eligible
• Expansion populations
• SCHIP
• PACE
• Those not meeting Federal income criteria
• Coverage from State funds

17
Access

• Adequate Capacity and Networks
• Reasonable hours of operation
• Geographic location
• Referral arrangements
• May not discriminate on basis of health status
• Outreach to prevent misuse/over-use of emergency
  services

18
Benefits

• Managed Care Plans
• Emphasis on health maintenance and preventive
  care
• Early and period screening, diagnostic, and
  treatment (EPSDT) services
• Screening
• Hearing
• Vision
• Dental

19
Reimbursement

• Providers must accept Medicaids payment as
  payment in full
• States may impose nominal deductibles,
  coinsurance, or co-payments
• Cannot require co-payments for emergency or
  family planning services
• or for pregnant women, children under 18 years
  old, nursing home residents, or categorically
  needy HMO enrollees

20
Marketing Practices

• Marketing material must be approved by State
• May not be false or misleading
• No other insurance products may be co-marketed
• Material must be disseminated throughout entire
  service area
• Standards of accuracy and understandably
  established by HHS
• Door-to-door and telephone solicitation prohibited

21
Quality Improvement

• Quality Improvement System for Managed Care
• Assessment and improvement standards
• Same standards as applied to Medicare
• Per discretion of State
• DUR Board

22
PACE

• Programs of All-inclusive Care for the Elderly
  (PACE)
• Comprehensive pre-paid healthcare services
• enhance quality of life
• enable frail elderly to live in the community
• Grants waivers of certain Medicare and Medicaid
  requirements to public and non-profit community
  based organizations that provide integrated care
  and long-term care to elderly persons who require
  a nursing facility level of care

23
State Childrens Health Insurance Program (SCHIP)

• Provides health assistance to uninsured
  low-income children
• Through separate programs, or
• Through expanded Medicaid programs

24
State SCHIP Programs Options

• Benchmark Coverage
• To the standard BC/BS provider option
• To the plan offered to state employees, or
• The HMO with the largest enrollment in the state
• Benchmark equivalent coverage
• Existing comprehensive state-based coverage
• Secretary of HHS approved coverage

25
SCHIP

• States file a State Child Health Plan with
  Secretary of HHS
• Includes info on current overages
• Enrollment and eligibility standards
• How to ID families
• Funding based upon total number of uninsured
  low-income children in the state
• And geographic cost factors

26
SCHIP Eligibility Requirements

• Under age 19
• Not currently eligible for Medicaid or having
  other health insurance
• Family income below the greater of 200 of
  federal poverty level or 50 percentage points
  above the states eligibility limits

27
Medicaid 1990s

• Costs rising 25/yr during early 1990s
• Eligibility expansion
• Increases in DHS spending
• General health care inflation
• High levels of health care needed
• managed care attractive solution
• Fixed rates / pmpm

28
Medicaid Managed Care

• Capitation creates incentives
• Less misuse of emergency services
• More preventive services offered

29
Medicaid Waivers

• Waive Federal requirements for eligibility or
  coverage/administrative regulations
• Section 1915(b) of Social Security Act
• Permits mandatory enrollment managed care plans
  or case managers
• Section 1115
• States can obtain matching Federal funds for
  additional expenditures
• Many states are taking advantage of the waiver
  opportunity

30
Challenges to Medicaid Reform

• Administrative Issues
• Plan Participation
• Traditional Providers

31
Future of Reform

• Extend benefits
• Elderly
• Disabled
• Mentally ill
• Rx coverage / benefit management
• Quality
• Assess consequences of Medicaid managed care
• Intended and unintended

32
Federal Employee Health Benefits Program (FEHBP)

• Largest employer-sponsored group healthcare
  program in the nation
• For Federal employees, retirees and their
  dependents and survivors
• Voluntary
• Over 10M enrolled
• Choice of FFS and MC plans

33
MCOs participating in FEHBP must

• Meet Federal State and licensing requirements
• Satisfy standards related to
• Access to care
• Benefit design
• Patient safety