Presentation on theme: "Texas Medicaid Basics Barry S. Lachman, MD, MPH October, 2012."— Presentation transcript:
Texas Medicaid Basics Barry S. Lachman, MD, MPH October, 2012
What is Medicaid? Jointly funded state-federal program providing health coverage to low-income and disabled individuals. Federal agency: Centers for Medicare and Medicaid Services (CMS) State agency: Health and Human Services Commission (HHSC)
Medicaid is entitlement program Federal law requires coverage for certain populations and services. States are allowed to cover additional populations. Eligibility is based on income, age and certain eligibility categories Guaranteed coverage for eligible services to eligible individuals.
Medicaid Eligibility Medicaid serves: Low-income families Children Related caretakers of dependent children Pregnant women Elderly Individuals with disabilities Eligibility criteria: Residency in Texas U.S. citizen or qualified aliens legally admitted for permanent residency Income and resource limits Functional and medical criteria for long-term services and support Most child applicants must be under age of 19
Medicaid Caseload Services for the aged, blind, and disabled are the largest share of program costs 50% of all enrollees are in FFS & PCCM models that were not designed to manage costs. 66% are children currently serves about 3.3 million people
Federal Poverty Level FPL is the definition of poverty used by the federal government as the reference point to determine Medicaid eligibility is the income level below which a person is officially considered to lack adequate financial resources and to be living in poverty
U. S. Dept. Of HHS 2011 Poverty Guidelines Federal Poverty Level Based on Family Income (based on U.S. Dept. of HHS poverty guidelines for 2011) Family SizeIncome 1$10,890 2$14,710 3$18,530 4$22,350 5$26,170 6$29,990
FPL Income Examples Individual $10,890 $14,484 $20,147 Family of 3 $18,530 $24,645 $34,281 $37,060
Texas FPL Eligibility *Annual income based on a family of 3 except for SSI and nursing home clients which are based on individual income 200%
Medicaid Benefits Mandatory Benefits The services states are federally required to offer as part of state program Optional Benefits Federally approved additional services that states can offer under Medicaid program
Services Covered Covers basic health care services physician services inpatient, outpatient care pharmacy, lab and x-ray long term care services for the aged and disabled
How is Medicaid Funded? Medicaid is funded by both state and federal governments. Federal share is based on Federal Medical Assistance Percentage (FMAP) FMAP is based on state’s per capita personal income compared to the U. S. average. Texas receives FMAP of approximately 60% meaning 60/40 split for most client services.
Supplemental Federal Funding Upper Payment Limit (UPL) – payments made to hospitals and physicians to make up the difference between what Medicaid pays for services and what Medicare would have paid for the same care. Disproporionate Share Hospital Program (DSH) – special payments made to hospitals that serve a disproportionately large number of Medicaid and low- income patients.
Health Reform: Myth and Truth Barry S. Lachman, MD, MPH
Why is Medicaid Important Safety Net for the underserved and vulnerable Key cog in assuring universal coverage for those under 133% of poverty
Medicaid Myths and Reality Myth: Federal Program – actually much State control Benefits are very generous – true, more than any commercial insurance or Medicare. However, covers those with disabilities who are more expensive. Fiscally unsustainable – State budgets are challenged; however, we are already paying for these services. 40% of health expenditures are wasted (IOM, 2012) Medicaid is a failure – fales. It has narrowed gap on health disparities. Multiple good studies show improved health outcomes in those served Could just move them into commercial insurance – false. Has been tried. It does not work.
The State of the Healthcare System Costs out of control Over 40 million uninsured Poor quality – Overall Texas is at or near the bottom on almost all measures Ration based on income Employer based model in rapid decline Insurance unaffordable for many Very inefficient system Multiple problems not just access 21
The Uninsured Over 40 million uninsured (US Census Bureau, New York Times, Austin American Statesman, Lubbock Times Texas highest uninsured rate in US (same) Texas highest number of uninsured children (KFF, US Census Bureau) Over 1 million uninsured children in Texas (Kids Count Survey) Dallas has second most uninsured of any city – 1.4 million (TMA) Over 90% of uninsured in Dallas are US citizens (CPPP) 1 in 5 women in Dallas uninsured (Dallas Women’s Foundation) Most are low income (Census Bureau, CPPP, Dallas Women’s Foundation, KFF) 22
Texas Health Statistics 47 th in % of insured children (KFF) 47 th in % of insured adults (KFF) 2 nd in number of uninsured adults (KFF) 2nd in Total Uninsured (KFF) 1 st in number of uninsured children (KFF) Public Mental Health expenditures (48 th ) Infectious Disease – 46th Lack of Health Insurance – 50th Early Prenatal Care – 50 th
Affordable or Not Texas cost cover 80% of uninsured for 1% increase in State Health Care Spending CPPP CMS (DMN 6/14/2012) – cover 30 million (75%) for 0.1% increase per year in costs Does not include any savings from bill Does not look at NPV of investment – what is the cost of not doing it over time
Supreme Court Ruling Upholds all challenged parts of ACA except Medicaid Expansion to 133% of poverty level (it is optional)
ACA Highlights Near universal coverage through Medicaid, Exchanges, Medicare, private health insurance Eliminates preexisting condition for coverage and continuation Eliminates ending coverage for honest errors on application Extends dependent coverage to age 27 Clinical trials coverage Small employer tax credits
More ACA Highlights Grants available to states: (1) to set up an Office of Health Insurance Consumer Assistance (2) to establish health insurance exchanges. TX applied and will get both! Begins new $11 billion investment in Community Health Centers. New funding for training primary care docs, nurses, other professionals. No copays on preventive services Minimum and essential benefits Medicaid payments to doctors must be equal to Medicare Limits excessive profits by insurers
28 2010: Closing the Rx “Doughnut Hole”: Shrinks Doughnut Hole by $250 in 2010 (rebate), 50% discount on brand-name drugs in the remaining gap; closes doughnut hole entirely by 2020 Jan. 2011: New preventive benefits: adds comprehensive annual check-up plus other prevention benefits, with no out-of-pocket costs. Adds 12 more years to Medicare Trust Fund Solvency: Not by cutting current Medicare benefits or doctor fees, but slowing growth in Medicare spending from 2010 to 2019. New Access to Community-Based Services and Supports: Medicare today does not cover community-based services to help seniors remain in their homes. A new voluntary insurance program (CLASS) will provide community-based assistance services and support. Starts in 2012 or 2013; 5 years to qualify for benefits. The “cuts” are largely limits on insurer profits in ACA whereas cuts in the “Ryan Budget” are real cuts to benefits and payments. Making Medicare Stronger
29 >$88,400 for a family of four; >400% of FPL Job-based coverage, or Full-cost coverage in the exchange $66,200-$88,400; 300-400% of FPL Job-based coverage, or Subsidized exchange coverage: premiums capped at 9.5% of income $44,100-$66,200; 200-300% of FPL Job-based coverage, or Subsidized exchange coverage: premiums capped at 6.3 – 9.5% of income $29,300-$44,100; 133-200% of FPL CHIP Job-based coverage, or Subsidized exchange coverage: premiums capped at 3% - 6.3% of income <$29,300 for a family of four; < 133% FPL Medicaid Children Adults (non-disabled adults, not eligible for Medicare) Family Income Health Reform Coverage Options by Income Family income based on 2009 federal poverty income levels for a family of four
Tikkun Olam(Healing the World) Jewish theologic concept dating to early Rabbinic Period Maimonides expanded to society as a whole Luria expounded the concept most clearly as part of the mystic tradition (Kabbalah) Jewish tradition celebrates and honors our obligations to the community Maimonides – Hierarchy of charitable acts Seventh Noachite commandment links Jewish tradition to social justice
Christian and Moslem Jesus ministry to the poor Islam – Zakah – clearly linked to social justice