Understanding Ohio's Medicaid Program: Benefits, Eligibility, and Administration

1. Ohio Medicaid March 13, 2019

2. Why We Care Ohio’s Medicaid Program is the: • Largest health insurer in the state • Largest payer of long-term care in the state • Largest state program in Ohio • Sixth largest Medicaid program in the nation

3. Historic Medicaid Spending

5. General Accounting Office’s Reporton the Ohio Medicaid Program, 1978

6. FY 2018 GRF Expenditures by Category (State and Federal Funds)

7. FY 2018 GRF Expenditures by Category (State Funds Only)

8. Agenda • Overview • Eligibility • Benefits • Delivery Systems • Budget

9. Overview Medicaid Program Description Administration Medicaid vs. Medicare

10. Medicaid Program Description • Congress established Medicaid in 1965 • Provides: • Health care services to the poor • Health care and long-term care services to the elderly and disabled • Eligible individuals entitled to receive services • Federal government sets guidelines; states administer their own Medicaid programs

11. Administration Ohio Department of Medicaid (ODM) is the single state agency administering Ohio Medicaid. ODM contracts with other state agencies • Developmental Disabilities – provides institutional and community-based services to individuals with intellectual disabilities • Aging – administers programs for older Ohioans • Education – administers the Medicaid Schools Program • Health – surveys and certifies Medicaid facilities (e.g. nursing homes) • Job and Family Services – reimburses local administration and transportation • Mental Health and Addiction Services – administers programs related to behavioral health • State Board of Pharmacy – integration of its Rx reporting system into electronic medical records

12. Administration Local Administration • County departments of job and family services • County boards of developmental disabilities • Area agencies on aging • County behavioral health boards • Schools

13. Medicaid vs. Medicare: What’s the Difference?

14. Eligibility Eligibility Requirements Eligible Populations

15. Eligibility Requirements • Be a US citizen (or meet Medicaid citizenship requirements)and an Ohio resident • Meet income requirements - different income limitations for different populations • Asset Limitation • Applies only to aged, blind, and disabled population • $2,000 for an individual and $3,000 for a couple

16. Federal Poverty Level (FPL), 2019

17. Eligibility Groups in Ohio • Children, parents, pregnant women, and adults, as well as disabled and elderly individuals at different income levels are eligible for Ohio’s Medicaid program • Three major groups receiving full benefits: • Covered Families and Children (CFC) • Aged, Blind, and Disabled (ABD) • Affordable Care Act expansion adults (Group VIII)

18. Families, Children, and Adults 2019 Monthly Financial Eligibility

19. Aged, Blind, or Disabled Individuals2019 Monthly Financial Eligibility

20. Medicaid Caseloads

21. Benefits Mandatory Benefits Optional Benefits

22. Mandatory Benefits • Certified pediatric and family nurse practitioners • EPSDT (Healthchek) • Family planning services • Federally qualified health center • Freestanding birth center • Home health • Inpatient hospital • Lab & x-ray • Nursing facility care • Nurse midwife • Outpatient hospital • Physician • Rural health clinic • Transportation to medical care • Tobacco cessation counseling for pregnant women

23. Optional Benefits • Ambulance & ambulette • Chiropractic • Community alcohol and drug addiction treatment • Community behavioral mental health • Dental • Durable medical equipment and supplies • Home & community-based service • Hospice care • Intermediate care facility • Occupational therapy • Physical therapy • Podiatry • Prescription drugs • Private duty nursing • Speech therapy • Targeted case management • Vision care

24. Delivery Systems Fee for Service Managed Care

25. Delivery Systems Fee For Service (FFS) • The state contracts directly with providers • Enrollees can receive services from any provider that contracts with Ohio Medicaid • State pays providers directly for services

26. Delivery Systems Managed Care • Managed Care Organizations (MCOs) contract with providers • Eligible enrollees must receive services from providers within their MCO’s provider network • State pays a monthly capitated rate for each enrolled individual • MCOs assume risk for each enrollee’s health care • Most of Ohio’s Medicaid population is enrolled in a managed care plan – effective July 1, 2018 behavioral health services were integrated into managed care

27. Budget Spending Funding

28. Medicaid Spending & Enrollment Aged, Blind, & Disabled (ABD), Group VIII, and Covered Families & Children (CFC), FY 2018

29. Medicaid Spending by Payment Category (FY 2018) Hospital care and other services provided to Medicaid recipients enrolled onto a Managed Care plan are accounted for in the Managed Care category.

30. Federal Funding Federal Medical Assistance Percentages (FMAP) • Percentage of Medicaid expenditures that the federal government reimburses • FMAP varies by state and type of expenditure (services vs. administration) • FMAP is based on the relative per capita income of each state • Ohio’s federal fiscal year 2019 rate is 63.09%

31. State Sources of Funding • General Revenue Fund • Provider fees and assessments • Hospitals • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) • Managed Care Organizations • Nursing Facilities • Rebates from prescription drug purchases

32. Legislative Budget OfficeHealth and Human Services Division Vern Riffe Center77 South High Street, 15th FloorColumbus, Ohio 43215