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Medicaid The Program’s Purpose, Patients, and Providers Nancy Cooper Coordinator, Health Policy Fellowship OU-HCOM February 5, 2013 1.

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Presentation on theme: "Medicaid The Program’s Purpose, Patients, and Providers Nancy Cooper Coordinator, Health Policy Fellowship OU-HCOM February 5, 2013 1."— Presentation transcript:

1 Medicaid The Program’s Purpose, Patients, and Providers Nancy Cooper Coordinator, Health Policy Fellowship OU-HCOM February 5,

2 50% Private Insurance Employer-based group insurance or Single policy or Out of Pocket 50% State/Federal Gov. Medicare Medicaid CHIP Veterans Affairs Indian Health Service Federal Employee Health Benefits Program 2

3  Health and Human Services Centers for Medicare and Medicaid Services Medicare (Entitlement >65) Medicaid (Eligibility - poor) CHIP (Eligibility – near poor kids) Indian Health Service  Veterans Affairs/TriCare  Federal Employee Health Benefits Program (FEHBP) 3

4 Albany VFW - May 2 “In March this year Randy was diagnosed with stage four prostate cancer, His family and friends are having a benefit for him to help him with medical expenses. There will be a Chinese Auction and All You Can Eat for $7 from 5:00 – 7:00. If you would like to donate but can’t make the benefit, you can donate money at the First National Bank of Athens under the Randy B Cancer Fund.” The Athens Messenger April 27,

5 <133% Federal Poverty Level (FPL) 5  Financial Eligibility

6  Pregnant women (6 mo. post partum) & children up to age 6 <133% FPL  Kids 6-18 < 100% FPL  Medically needy Aged poor (“dual eligibles”) Blind Disabled on SSI  Nursing home care  Certain groups of legal immigrants  Kids who age out of foster care 6

7  Kids: 35.5 million (19% of cost)  Parents: 17.8 million (15% of cost)  Disabled:10.7 million (41% of cost)  Elderly poor: 5.7 million (20% of cost) Congressional Research Service, Medicaid: A Primer July

8  Federal- state partnership – 2/3:1/3 split  Total $438 billion in 2011  Federal Medical Assistance Percentage (FMAP)  No cap: feds will provide FMAP for all eligible patients 72% federal 28% state Congressional Research Service, Medicaid: A Primer July

9  Early and Periodic Screening, Treatment and Diagnosis for kids (HEALTH-CHEK)  Inpatient Hospital  Physician  Lab and X Ray  Outpatient (rural clinics and FQHCs)  Medical and surgical vision  Medical and surgical dental  Transportation to services  Nurse midwife, family nurse practitioner, pediatric nurse practitioner  Family planning services and supplies  Home health  Nursing home care  Medicare premium assistance 9 Congressional Research Service, Medicaid: A Primer July 2012

10  States can add OPTIONAL benefits Prescription drugs Inpatient psychiatric care for kids Access to licensed practitioners: podiatry, optometrists Routine dental care  States can expand eligibility with a waiver Raise income eligibility Cover poor childless adults Increase eligibility to people > SSI 10 Congressional Research Service, Medicaid: A Primer July 2012

11 11 Medicaid’s Challenges Takes up >25% of state budgets in unemployment = in eligibility (but less state revenue) Fairly generous benefits (mental health, dental and vision) but access problems due to low reimbursement

12 12

13  Number of boomers will grow from 42 to 73 million  Number of elderly over age 80 will triple  Highest number of divorcees (live alone)  Half live at or < FPL  1/3 retirees have NO savings 13 Congressional Budget Office 2/1/12

14 14 Medicare 49 Million Medicaid 69 Million 9.2 M AARP, Integrating Care for Dual Eligibles, % are over 65 41% disabled Most are very poor Fills in gaps: long term care, glasses, dental, pays Medicare premiums and cost share Hospital coverage, physician visits, drugs, some post hospital care

15  17 million poor, childless men and women  Affordable Care Act expands Medicaid to this population 100% FMAP for newly eligible for 3 years and 90% FMAP after 2017  SCOTUS ruling will leave decision to expand up to the states Kaiser Health News July

16  “For those few that are slow to come in, they're going to have to answer to people why they're turning this down and why they're letting people go without coverage.” Jack Lew, Chief of Staff 6/30/12  “As it stands now, there’s no way we can afford to do it.” Tony Keck, South Carolina’s Medicaid director July

17 17 Washington Post, “Medicaid expansion scorecard: 17 states say yes, 9 say no,” by Sarah Cliff 12/7/12

18  Set by the state – NJ lowest, WA highest  Lower than Medicare  Low fees affect access to care 18

19 19 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011 Gov. John KasichODJFS Director Michael Colbert

20 20 DD: developmental disabilities MH: mental health ADAS: alcohol and drug addiction services Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

21  CFC mostly Managed Care: HMO gets capitated payment per person Financial burden is on the HMO Does not cover long term care  By law, ABD long term and home based care are Fee for Service ($$$$$). 21 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

22 22 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

23 Kids: 1,093,724 Parents: 435,742 Pregnant women: 26,195 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May

24 112,019 seniors 242,091 adults with disabilities 37,989 children with disabilities 392,099 patients 24 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

25 Mandatory Benefits  Early and Periodic Screening, Treatment and Diagnosis for kids (HEALTH-CHEK)  Inpatient Hospital  Physician  Lab and X Ray  Outpatient (rural clinics and FQHCs)  Medical and surgical vision  Medical and surgical dental  Transportation to services  Nurse midwife, family nurse practitioner, pediatric nurse practitioner  Family planning services and supplies  Home health  Nursing home care $$$$$  Medicare premium assistance 25 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

26  Facility –based long-term care Nursing facilities Intermediate care for mentally retarded (ICF-MR) State developmental centers for mentally retarded (MR-DD)  Home and Community Based Services (HCBS) Personal care, homemaking, and nursing Adult day care Delivered meals Transportation Respite care Hospice and Program for All Inclusive Care for the Elderly (PACE) Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May

27 27 Ohio Department Job and Family Services web site accessed 1/30/13

28 28 Ohio Department Job and Family Services web site accessed 1/30/13

29  Physicians bill “reasonable and customary” charge  Providers can’t charge the patient for the difference between their bill and the Medicaid payment  Ave. wait of 41 days for reimbursement  Fee schedule available on ODJFS website Health Affairs “Do Reimbursement Delays Discourage Medicaid Participation By Physicians?” by Cunningham and O’Malley Feb

30 30 % Increase in Medicaid fees OHUS All services15.9%15.1% Primary Care13.6%20% Obstetrics6.8%8.8% Other services28.4%8.7% Kaiser State Health Facts/Ohio accessed 1/30/13 The good news

31 Medicaid to Medicare Fee Index 2008 OHUS All services Primary care.66 Obstetrics Other services Kaiser State Health Facts/Ohio accessed 1/30/13 More good news ACA will pay Medicaid primary care providers 100% of the Medicare rate for “evaluation, management an immunizations” in 2013 and 2014 (after that reimbursement rate will be up to the state).

32  Enroll via ODJFS website: Medicaid Information Technology Provider link Ohio Department Job and Family Services web site 32

33  ACA Maintenance of Effort limits states’ ability to control costs by changing eligibility or benefits  Have to maintain eligibility till Or lose FMAP 33 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

34  Individual-Centered Integrated Care Delivery System (CDS) Coordinate care for dual eligibles  Promote the use of health homes  Promote use of home-based long term care instead of nursing home care  Change hospital payments  Adjust nursing home payment formula – link $ to outcomes 34 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

35 Medicaid is a vital source of health care for 69 million vulnerable Americans BUT... 35

36 ALBANY — Randy Dewaine B., 52, of Albany, passed away at his residence Thursday, Dec. 30, 2010, after a hard-fought battle with cancer. Born Aug. 8, 1958, in Athens, he was the son of Sharon Michael B. of Athens, and the late Robert B. Sr. He was retired from the Southeast Psychiatric Hospital and an avid sports fan, having played basketball and softball, and loved playing music with family. The Athens Messenger, December,

37 37

38 38

39 1. Covering all people below the poverty line 2. Covering just low income children 3. Covering certain groups of low income people 39

40 1. Less than 10% 2. About 20% 3. More than 30% 40

41 1. True 2. False 3. Don’t know 41

42 1. One quarter 2. One half 3. Three-quarters 42

43 1. Children under Unemployed adults 3. Elderly and disabled 43

44 1. Medicaid spending grew faster 2. Medicaid spending grew slower 3. Medicaid spending grew at the same rate as private insurance 44

45 1. Medicare 2. Medicaid 3. Private insurance 45

46 1. Medicaid pays for premiums and co-pays for low-income beneficiaries 2. Medicaid pays for health care services not covered by Medicare, such as home and community based care 3. Both are true 46

47 1. Yes 2. No 3. Don’t know 47

48 1. Children up to age Many low income adults 3. Undocumented immigrants 48

49 – about 20% 3. False 4. 2 – Half 5. 3 – elderly and disabled 6. 2 – Medicaid spending grew slower 7. 2 – Medicaid Both are true 9. 2 – No – many low income adults 49


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