The Basics of Medicare and Medicaid Judith R. Lave University of Pittsburgh

Medicare Eligibility l Individuals age 65 or over l Individuals who have been on Social Security Disability for two years. l Individuals with End Stage Renal Disease (Kidney Failure) -2 year waiting period does not apply

Medicare is Made Up of Four Parts l Medicare Part A nHI- hospital insurance l Medicare Part B nSMI – Supplemental Medical Insurance l Medicare Part C n Medicare Advantage l Medicare Part D n Medicare Drug Coverage

Medicare Part A l Helps pay For nInpatient hospital care (all types) nSkilled nursing care nHospice Care nLimited home health (up to 100 days post hospital discharge ) l People are entitled to Part A if they or their spouse have paid payroll taxes for 40 quarters or more

Medicare Part A l Part A is funded primarily by a dedicated tax of 2.9% of earnings (no limit) paid by employers and employees (1.45% each) nPaid into a dedicated Trust Fund l There is some cost-sharing (2007) n Hospital: $992 deductible per spell of illness; $248 per day for days 61-90; $286 per day for days 91 – 150, 100% after day 150 nSkilled Nursing Home: $124 per day 21 through 100 each benefit period.

Medicare Part B l Pays for nPhysician services, outpatient hospital services, certain home health services and durable medical equipment l Cost Sharing (2007 nDeductible of $ per year n20% of approved charges after deductible nNo cost sharing on home health

Medicare Part B l Medicare Part B is financed through premiums (about 25%) and general revenues l 2007 Premium was $93.50 a month nPremium is higher if income is above $80,000 (individuals) or $160,000 (families)

Medicare Part C Part C provides care through managed care plans, regional PPOs and private fee for service plans. It is called Medicare Advantage About 20% of Medicare beneficiaries are currently in Medicare Advantage

Note People who do not enroll in a Medicare Advantage Plan are said to stay in Traditional Medicare or Fee-for-service Medicare

Part C l Plans must cover the same services as Part A and Part B l It is financed by fixed payments from CMS tied to the gov’t cost of traditional Medicare. l People in Part C must be enrolled in both Parts A&B.

An Issue of Controversy MA plans receive a capitated payment that is higher than the government’s average cost of covering Medicare beneficiaries that stay in traditional Medicare by about 10% These additional payments increase attractiveness of MA plans by allowing them to reduce cost-sharing or offer additional benefits.

Part D l Voluntary drug program l Provided by private stand-alone drug plans or Medicare Advantage plans l Subsidies for individuals with low income and assets l Financed by beneficiary premiums of about $22 per month, general revenues and state payments (state clawbacks) l Complicated cost-sharing structure – plans may offer actuarial equivalent coverage

Standard Medicare Drug Benefit, 2006 $386 average annual premium*** $250 Deductible $2,250 in Total Drug Costs* $5,100 in Total Drug Costs** 25% 5% $2,850 Gap: Beneficiary Pays 100% Medicare Pays 75% Medicare Pays 95% No Coverage (the “doughnut hole”) Catastrophic Coverage Partial Coverage up to Limit Beneficiary Out-of-Pocket Spending *Equivalent to $750 in out-of-pocket spending. **Equivalent to $3,600 in out-of-pocket spending. ***Based on $32.20 national average monthly beneficiary premium (CMS, 8/2005). SOURCE: KFF analysis of standard drug benefit described in Medicare Modernization Act of Exhibit 8 Return to KaiserEDU.org

Total = $374 billion Note: Does not include administrative expenses such as spending for implementation of the Medicare drug benefit and the Medicare Advantage program. SOURCE: Congressional Budget Office, Medicare Baseline, March Medicare Benefit Payments By Type of Service, 2006 (KFF) Hospice 2% Payments to Drug Plans 4% Other Facility Services 5% Hospital Outpatient 5% Physician and Other Suppliers 24% Home Health 3% Managed Care (Part C) 14% Skilled Nursing Facilities 5% Hospital Inpatient 34% Payments to Union/Employer- Sponsored Plans 1% Low-Income Subsidy Payments 3% Exhibit 11 Part A Part B Parts A and B Part D

KFF –Kaiser Family Foundation These slides were downloaded from tutorials on the Kaiser Family Foundation Web-site.

Ten Percent of All Medicare Beneficiaries Account For More than Two Thirds of Medicare Spending (KFF) SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2002 Cost and Use File. Total Number of Beneficiaries: 41.8 million Total Medicare Spending: $224.5 billion 6% 10% 69% Exhibit average = $5,370 per capita

Number of Medicare Beneficiaries 2005 l Total: 42,394,929 l % disabled (age < 65): 15.8% (Note % disabled is increasing over time: 1980, 10.4%, 1995, 11/7%)

Value of Medicare Pays for the majority of health care services for people 65 and over and the disabled. Leads to an increase in life expectancy Leads to an increase in quality of life Trusted Program

Problems With Medicare l Medicare does not cover many services – long term care, vision, hearing nAverage Medicare beneficiary has out of pocket expenditures of $3,765, Medicare paid for 46% of health care expenditures for elderly. l Payment system needs to be revised – major changes in hospital payments this year l Medicare payments per beneficiary vary widely dramatically geographically with no measurable affects on health

Some Challenges Improve payment system to promote quality and increase efficiency l Improve coverage for the chronically ill and address long term care problems l Determine balance between Traditional Medicare and Medicare Advantage nShould Medicare Advantage be Subsidized?

MAJOER CHALLENGE Medicare’s Cost Pressures

Composition of Federal Spending in FY 2007 SOURCE: OMB, Fiscal Year 2007 Budget, February Total Outlays = $2.77 trillion Exhibit 12 Medicare 14% Medicaid and SCHIP 7% Other 12% Net Interest 9% Nondefense Discretionary 18% Social Security 21% Defense Discretionary 19% Return to KaiserEDU.org

Medicare Expenditures NOTE: Per capita amounts based on July 1 Census resident based population estimates for each year. Numbers and percents may not add to totals because of rounding. $ amounts shown are in current dollars. SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Bureau of the Census.

Historical and Projected Number of Medicare Beneficiaries and Number of Workers Per Beneficiary SOURCE: 2001 and 2006 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Number of beneficiaries (in millions) Number of workers per HI beneficiary Exhibit Return to KaiserEDU.org

Key Dates for Medicare Part A Trust Funds First year outgo exceeds Income excluding interest 2007 First year outgo exceeds Income including interest 2011 Year Trust Funds are Exhausted 2019

Medicare Expenditures as a % of GDP

WHY ARE WE FOCUSING ON MEDICARE AND NOT SOCIAL SECURITY?

Social Security and Medicare Cost as a Percent of GDP

Why is Medicare Growing So Much faster than Social Security l Technological change in the absence of any effective restraining mechanism Technological change – which both increases the number of people who can get a given treatment (i.e. bypass) and the treatments available lead to increasing costs.

Questions? l Does Society want to allocate such a high proportion of its GDP to Medicare (note its somewhat limited benefits) l Does Society want to raise taxes to enable Medicare beneficiaries to get these services l Does Society want to allocate such a high proportion of its overall resources to the health of the elderly.

Medicaid l Established in 1965 l States manage the program subject to Federal guidelines l States must cover certain groups (defined by age, disability and income) and may cover other groups l State must cover certain services and may cover other services.

Medicaid Financing l The federal government shares in the cost of the Medicaid. l The Federal Match varies across the states from 50% to 78% l Federal Match in PA is 54.39%

Medicaid Eligibility & Benefits for Medicare Beneficiaries, 2005 PathwayIncome Eligibility Asset Limit Individua l/Couple Medicaid Benefits Medicare Premiums & Cost-sharing SSI Cash Assistance < 74% of poverty (SSI income eligibility) $2,000 $3,000 XX Qualified Medicare Beneficiary (QMB) < 100% of poverty$4,000 $6,000 X Specified Low-Income Beneficiary (SLMB) Copied from Medicaid % of poverty $4,000 $6,000 Premium only Mandatory Populations: (Medicaid 101. ww.kaiser.edu)

Medicaid Eligibility & Benefits for Medicare Beneficiaries, 2005 (cont’d) PathwayIncome Eligibility Asset Limit Individual/ Couple Medicaid Benefits Medicare Premiums & Cost- sharing Medically Needy Individuals who spend income down to a specified level $2,000 $3,000 X*X Poverty Level < 100% of poverty$2,000 $3,000 XX Special Income Rule for Nursing Home Residents Institutionalized individuals with income < 300% of the SSI level $2,000 $3,000 XX HCBS Waivers Must be eligible for institutional care XX Optional Populations *Medicaid benefits may be more limited than for SSI.

Eligibility and Covered Services for PA M Costlow and J. lave, Faces.

Federal Poverty Level 2007 Persons in Family Guideline 1 $10, , , ,650

Medicaid Benefits l Physician services l Laboratory and x-ray services l Inpatient hospital services l Outpatient hospital services l Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 l Family planning l Rural and federally-qualified health center (FQHC) services l Nurse midwife services l Nursing facility (NF) services for individuals 21 or over l Prescription drugs l Clinic services l Dental services, dentures l Physical therapy and rehab services l Prosthetic devices, eyeglasses l Primary care case management l Intermediate care facilities for the mentally retarded (ICF/MR) services l Inpatient psychiatric care for individuals under 21 l Home health care services l Personal care services l Hospice services “Mandatory” Items and Services“Optional” Items and Services

Total Medicare Beneficiaries = 40 million SOURCE: KCMU estimates based on CMS data and Urban Institute analysis of data from MSIS. Total Duals = 7.2 million Medicaid Status of Medicare Beneficiaries, FFY 2002

Medicaid Payments Per Enrollee by Acute and Long-Term Care, 2003 $1,700 $1,900 $12,300 $12,800 SOURCE: KCMU estimates based on CBO and Urban Institute data, Long-Term Care Acute Care

Some PA Data l Medicaid covers about 14.8% of Pennsylvanians on an average month l Medicaid covers 44% of all children l Medicaid expenditures are = $14.4 billion dollars ($7.6 Billion Federal) l It accounts for 19% of general fundspending

Figure 5: Percent of Pennsylvania Citizens Enrolled in Medicaid by Age September 2006 Note. Data provided by PA DPW: Commonwealth of Pennsylvania, Department of Public Welfare (PA DPW). (2006). Medical Assistance Eligibility Statistics, (PA DPW). Provided to authors by Director, August – December 2006.

Figure 4: Distribution of Pennsylvania Medicaid Recipients and Expenditures by Broad Eligibility Category in 2005 Note. Data provided by PA DPW: Commonwealth of Pennsylvania, Department of Public Welfare, Office of Medical Assistance Programs. (2006). 2005/2006 Annual Report. Retrieved February 22, 2007, from

Figure 6: The Proportion of Medicaid Recipients to Pennsylvania County Populations in 2006 Note. Data Provided by PA DPW. Other information from U.S. Census Bureau, 2006.[1]Pennsylvania map provided via 'Do It Yourself' Color-Coded State Maps, Texas A&M University System. Commonwealth of Pennsylvania, Department of Public Welfare (PA DPW). (2006). Medical Assistance Eligibility Statistics, (PA DPW). Provided to authors by Director, August – December, and U.S. Census Bureau. (2006). State and County QuickFacts. Retrieved November 15, 2006, from

Figure 3: Pennsylvania Medicaid Recipients from 1997–2005 Note. Data provided by PA DPW: Commonwealth of Pennsylvania, Department of Public Welfare (PA DPW). (2006). Medical Assistance Eligibility Statistics, (PA DPW). Provided to authors by Director, 1997 – 2006.

COST PROBLEMS COME TO MEDICID

Medicaid Expenditures NOTE: Per capita amounts based on July 1 Census resident based population estimates for each year. Numbers and percents may not add to totals because of rounding. $ amounts shown are in current dollars. SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Bureau of the Census.

Underlying Growth in State Tax Revenue Compared with Average Medicaid Spending Growth, NOTE: State Tax Revenue data is adjusted for inflation and legislative changes. Preliminary estimate for SOURCE: KCMU Analysis of CMS Form 64 Data for Historic Medicaid Growth Rates and KCMU / HMA Survey for 2005 Medicaid Growth Estimates; Analysis by the Rockefeller Institute of Government for State Tax Revenue.

Composition of Federal Spending in FY 2007 SOURCE: OMB, Fiscal Year 2007 Budget, February Total Outlays = $2.77 trillion Exhibit 12 Medicare 14% Medicaid and SCHIP 7% Other 12% Net Interest 9% Nondefense Discretionary 18% Social Security 21% Defense Discretionary 19% Return to KaiserEDU.org

Changes in Medicaid l Medicaid is changing due in part to the addition flexibility given to the states under the Deficit Reduction Act. l Trend did turn down this year.

What’s at Stake in Medicaid Reform (KFF) Health Insurance Coverage 25 million children and 14 million adults in low- income families; 6 million persons with disabilities State Capacity for Health Coverage 43% of federal funds to states MEDICAID Support for Health Care System 17% of national health spending Assistance to Medicare Beneficiaries 7 million aged and disabled — 18% of Medicare beneficiaries Long-Term Care Assistance 1 million nursing home residents; 43% of long- term care services