Presentation on theme: "Medicaid A State and Federal Partnership"— Presentation transcript:
0 Florida MedicaidDyke Snipes, Assistant Deputy Secretary for Medicaid FinancePresentation to the Florida Commission on Taxation and Budget ReformAugust 17, 2007
1 Medicaid A State and Federal Partnership In 1965, the federal Social Security Act was amended to establish two major national health care programs:Title XVIII (Medicare).Title XIX (Medicaid).Medicaid is jointly financed by state and federal funds.States administer their programs under federally approved state plans.
2 The Medicaid Program Major Federal Requirements States must submit a Medicaid State Plan to the federal Centers for Medicare and Medicaid Services (CMS).Mandatory eligibility groups and services must be covered.Services must be available statewide in the same amount, duration and scope.
3 Medicaid StructureFederal Medicaid laws mandate certain benefits for certain populations.Medicaid programs vary considerably from state to state, and within states over time.State Medicaid programs vary because of differences in:optional service coverages.limits on mandatory and optional services.optional eligibility groups.income and asset limits on eligibility.provider reimbursement levels.
4 Medicaid Structure (continued) Medicaid does not cover all low income individuals.Medicaid serves the most vulnerable; in Florida:27% of children.51.2% of deliveries.60% of nursing home days.903,000 adults - parents, aged and disabled.
5 Florida Medicaid – A Snapshot Expenditures$16.0 billion estimated spending in Fiscal YearFederal-state matching program – 56.83% federal, 43.17% state.Florida will spend approximately $7,736 per eligible in Fiscal Year45% of all Medicaid expenditures cover hospitals, nursing homes, Intermediate Care Facilities for the Developmentally Disabled (ICF/DD’s); Low Income Pool and Disproportionate Share Payments.10% of all Medicaid expenditures cover drugs.Fifth largest nationwide in Medicaid expenditures.Eligibles2.0 million eligibles.Elders, disabled, families, pregnant women, children in families below poverty.Fourth largest Medicaid population in the nation.Providers/PlansApproximately 80,000 Fee-For-Service providers; 19 Medicaid Managed Care plans.
6 Who’s Eligible? Medicaid eligibility is determined by: Categorical groups, i.e., pregnant women; families and children; and aged, blind, and disabled individuals.Income.Assets.Citizenship.Residency.Cooperation with Child Support Enforcement (when one or both parents are absent from the home).Medical need for home and community-based services, and persons in nursing facilities.Level of medical bills (for Medically Needy).
7 Who Can Provide Medicaid? Any willing health care practitioner or entity who:provides one of the Medicaid covered services;submits an application to Medicaid;is licensed or certified to practice in the State of Florida;is not terminated from any government health care program; andsigns an agreement with Medicaid.Managed Care plans with appropriate provider networks.
8 Florida Medicaid Mandatory Services Physician ServicesPortable X-ray ServicesPrivate Duty NursingRespiratory, Speech, Occupational TherapyRural HealthTherapeutic Services for ChildrenTransportationAdvanced Registered Nurse Practitioner ServicesEarly & Periodic Screening, Diagnosis and Treatment of Children (EPSDT)/Child Health Check-UpFamily PlanningHome Health CareHospital InpatientHospital OutpatientIndependent LabNursing FacilityPersonal Care ServicesMandatory 41.96% of $16.0Billion
9 Florida Medicaid Optional Services* Prescribed DrugsPrimary Care Case Management (MediPass)Registered Nurse First Assistant ServicesSchool-Based ServicesState Mental Hospital ServicesSubacute Inpatient Psychiatric Program for ChildrenTargeted Case Management)Adult Dental ServicesAdult Health ScreeningAmbulatory Surgical CentersAssistive Care ServicesBirth Center ServicesChildren’s Dental ServicesHearing ServicesVision ServicesChiropractic ServicesCommunity Mental HealthCounty Health Department Clinic ServicesDialysis Facility ServicesDurable Medical EquipmentEarly Intervention ServicesHealthy Start ServicesHome and Community-Based ServicesHospice CareIntermediate Care Facilities/ Developmentally DisabledIntermediate Nursing Home CareOptometric ServicesOrthodontic ServicesPhysician Assistant ServicesPodiatry ServicesOptional 58.04% of $16.0 Billion*States are required to provide any medically necessary care required by child eligibles.
10 Institutional Providers / Other Services with automatic price level increases under current law.Examples of provider types:Inpatient HospitalsOutpatient HospitalsNursing HomesIntermediate Care Facilities for Developmentally Disabled (ICF/DD)Rural Health Clinics (RHCs)County Health DepartmentsFederally Qualified Health CentersPharmacy
11 Fee For Service Providers Services that don’t receive automatic increases under current law. Increases are determined by legislative appropriation.Examples of provider types:Physician ServicesPharmaciesHome Health ServicesDental ServicesTransportation (Emergency and Non-Emergency)DialysisNurse PractitionersLaboratory and X-Ray
12 Growth in Medicaid Total Average Monthly Caseload Source: Medicaid Services Eligibility Subsystem Reports.* FY March 2007 Social Services Estimating Conference * Budgeted Average Caseload from FY GAA
13 Growth in Medicaid Average Monthly Caseload for TANF Source: Medicaid Services Eligibility Subsystem Reports.* FY March 2007 Social Services Estimating Conference * Budgeted Average Caseload from FY GAA
14 Growth in Medicaid Average Monthly Caseload for SSI Source: Medicaid Services Eligibility Subsystem Reports.* FY March 2007 Social Services Estimating Conference * Budgeted Average Caseload from FY GAA
15 Growth in Medicaid Average Monthly Caseload including TANF and SSI
16 Title XIX Federal Medical Assistance Percentage (FMAP) Federal Fiscal YearFederal ShareState ShareTotal200856.29%43.71%100%200756.83%43.17%200658.76%41.24%200558.89%41.11%200458.90%41.10%200358.93%41.07%
17 TANF and SSI Related Eligibility Groups for 2007-08 Total BudgetAvg Monthly CaseloadPMPMSupplemental Security Income (SSI)$9,626,449,748531,806$1,508Temporary Assistance for Needy Families (TANF)$273Medically Needy$477,596,31917,772$2,239Children < = 100% of Poverty$676,466,833405,972$139Children > 100% of Poverty$147,962,64265,511$188Children – Medicaid Expansion Under Title XXI$6,023,7111,178$426Pregnant Women < = 100% of Poverty$472,094,69652,939$743Pregnant Women > 100% of Poverty$176,162,65417,959$817Family Planning Waiver$2,303,7945,155$447Categorically Eligible$228,828,85997,062$196Elderly and Disabled (MEDS AD)$400,215,45029,762$1,121Qualified Medicare Beneficiaries (QMB/SLMB/QI)$339,793,831195,950$145Refugee General Assistance$26,709,23810,369$215Other$1,342,579,910N/ATotal$16,011,911,5692,069,795$645
18 Medicaid Budget - How it is Spent Fiscal Year 2007-08 Adults*Children*Blind &DisabledElderly 65+* Adults and children refers to non disabled adults and children.
19 Growth In Medicaid Service Expenditures (Total Funds) Source: Medicaid Services' Budget Forecasting System Reports.* FY March 2007 Social Services Estimating Conference* FY Appropriations
20 Growth In Medicaid Service General Revenue Expenditures Source: Medicaid Services’ Budget Forecasting System Reports.*FY March 2007 Social Services Estimating Conference*FY Appropriations
21 Growth In Medicaid Service Expenditures and General Revenue
22 Medicaid Spending for Fiscal Year 2007-08 ServiceFY AppropriationsPercent of TotalNursing Home Care$2,636,273,99716.46%Hospital Inpatient Services$2,351,629,16014.69%Prepaid Health Plans$2,233,358,02913.95%Prescribed Medicine/Drugs & Part D$1,540,047,4869.62%Home & Community Based Services$1,053,447,6786.58%Low Income Pool$1,000,000,0006.25%Supplemental Medical Insurance$906,527,6065.66%Physician Services$718,754,6894.49%Hospital Outpatient Services$672,156,1764.20%Intermediate Care Facility/DD$338,053,8632.11%Hospice Services$288,379,8921.80%Hospital Insurance Benefits$257,768,7741.61%Nursing Home Diversion Waiver$217,550,0451.36%Home Health Services$208,643,3081.30%Disproportionate Share Hospital Payments$208,382,079Other$1,380,938,7878.62%Total$16,011,911,569100.00%
23 Estimated Fiscal Year 2007-08 Medicaid Expenditures By Appropriation Category
25 Medicaid Eligibility - A Complex System of Coverages *Coverage for infants up to 185% Federal Poverty Level is required in order for states to receive Title XXI funding.**Federal Poverty Level as of January 2007
26 Medicare vs. Medicaid Medicare Medicaid Enacted by Congress 1965 1965 MedicareMedicaidEnacted by Congress 19651965Alternate Program NameTitle XVIIITitle XIXFinancingEmployee/Employer Payroll Tax; Premiums; Federal General RevenueFederal and State Governments – Matching Rates Based on Per Capita IncomeEligibilityNot Income Based; All Persons Age 65+; Certain Younger Persons on Social Security Disability or Based on Disability and Specific Condition (ESRD); Totally and Permanently Disabled (24 months)Income Based; All Ages; Mandatory Eligibility Groups; Optional Eligibility GroupsCost SharingPart A Deductible $876/Benefit PeriodPart B Premium $66.60Part B Deductible $100/year, going up to $110 January 1, 2005Part B Coinsurance 20%Part D Coinsurance 25% / Annual Deductible $250Co-payments are variable with IncomeLow Income Subsidies are provided for the aboveNominal; Spend Down for Medically Needy IndividualsAdministering AgencyHHS/CMS/Carriers – Financed by Federal Government and Beneficiary Cost SharingStates – Jointly Financed by State and Federal Governments; Medicaid Programs Vary by StateBenefitsPart A Hospital Insurance for Hospital Care, Skilled Nursing Facilities, Hospice and Some Home Health Care (Qualifying Contributions)Part B Medical Insurance for Physician Services, Outpatient Care and Other Medical ServicesPart C Medicare+Choice – Health Maintenance Organization CoveragePart D Medicare Prescription drug InsuranceAcute and Long Term Care; Federal Mandated Services and State Optional Services