1 / 32

Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group

Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group. William J. Scanlon Health Policy R&D National Health Policy Forum. Overview of Medicare, Medicaid and SCHIP. Eligibility Services Covered Financing. Eligibility.

gloria
Download Presentation

Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Overview of Medicare, Medicaid and State Children’s Health Insurance ProgramforCitizens’ Health Care Working Group William J. Scanlon Health Policy R&D National Health Policy Forum

  2. Overview of Medicare, Medicaid and SCHIP • Eligibility • Services Covered • Financing

  3. Eligibility

  4. Services

  5. Services

  6. Financing • Medicare • Open Ended Entitlement • Federal • Payroll Taxes • General Revenues • Beneficiary Premiums • Medicaid • Open Ended Entitlement • Federal and State General Revenues • SCHIP • Fixed Federal Appropriation • Federal and State General Revenues • Beneficiary Premiums

  7. Medicare • 41 million beneficiaries • $301 billion in 2004 • 11.7% of Federal Budget • 2.6% of GDP (2003)

  8. “Original” or “Traditional” Medicare (also known as “Fee-for-Service” Medicare) Medicare Advantage—Private plan options Drug Benefit Parts A and B Medicare Program Structure Part C Part D

  9. Medicare Benefits Medicare Covers Acute and Chronic Care • Part A • Inpatient hospital • Post-hospital skilled nursing facility (SNF) services • Home health • Hospice-care • Part B • Physician and laboratory services • Outpatient hospital • Therapy • Durable medical equipment and supplies • Home health (not-covered under Part A) • Part D • Drugs

  10. Medicare Cost-Sharing • Hospital Care • Days 1-60—Deductible ($912 in 2005) • Days 61-90—Per day coinsurance ($228 in 2005) • Days 91-150—Per day coinsurance ($456 in 2005) for 60 lifetime reserve days • SNF • Days 21-100—Per day coinsurance ($114 in 2005)

  11. Medicare Cost SharingContinued Part B • Deductible: $110 in 2005 • Coinsurance: 20% of Medicare approved amount • Exceptions • Mental health: 50% co-insurance • Hospital outpatient—Fixed amounts • Home health—none • Over-billing limit: 15 % above Medicare approved amount on unassigned claims

  12. Medicare Cost SharingContinued Beneficiary cost sharing on Medicare covered services can be substantial Beneficiaries in 1998 paying more than:

  13. Medicare Supplementary Coverage Vast majority of beneficiaries in traditional Medicare have supplementary coverage Supplementary Coverage in 2000

  14. Medicare Advantage—Part C • Offers choice to join private plan • Plan types include HMOs, PPOs, FFS, MSAs • Plans paid monthly per enrollee fee regardless of services used • Plan “savings” returned in extra benefits

  15. Medicare Advantage—Part C Plan and beneficiary participation have varied over time Plans Enrollees (millions)

  16. Medicare Advantage—Part C • Medicare Modernization Act changed Part C • Increased payments to plans • Provided for financial competition among plans and share of savings to Medicare • Created regional PPOs to expand areas served

  17. Medicare Advantage—Part C PPO Regions for 2006

  18. Medicare Drug Benefit--Part D • Begins January 1, 2006 • Separate enrollment and premium • Monthly premium expected to average $37 nationally • Benefit provided by competing private stand-alone drug plans or Medicare Advantage plans • Benefit • $250 deductible • Coinsurance • 25% from $250 to $2,250 • 100% from $2,250 to $5,100 • 5% on spending over $5,100 • Subsidies for premium and cost sharing for low income persons

  19. Medicaid over 52 million beneficiaries $ 309 billion in 2004 Federal share $176 billion or .8% of federal budget State share $133 billion or 22%* of state budgets *2003 SCHIP ~ 6 million beneficiaries $6.1 billion in 2004 ≈ 75 % Federal ≈ 25 % State Medicaid and SCHIP

  20. Medicaid Program Roles • Primary health insurance—mostly families • Medicare supplement—dual eligible aged and disabled beneficiaries • Long-term care financer — beneficiaries with disabilities

  21. Medicaid

  22. Medicaid Programs are state designed and administered subject to federal requirements Result is 56 distinct Medicaid programs

  23. Mandatory Children 6-18 years up to 100% FPL 0-5 years up to 133% FPL Foster care Pregnant women Up to 133% FPL SSI cash recipients Optional Children and Pregnant women Up to 185% FPL Elderly and Disabled Up to 100%FPL Medically Needy MedicaidMandatory and Optional EligibilitySelected Categories

  24. Medicaid Mandatory Medicare Supplementary Insurance • Qualified Medicare Beneficiaries (QMBs) • Up to 100% FPL—Part B Premium and cost sharing • Specified Low-Income Medicare Beneficiaries (SLMBs) • 100-120% FPL---Part B Premium • Qualifying Individuals (QIs) • 120-135% FPL—Portion of Part B Premium • Qualified Disabled Working Individuals (QDWIs) • Up to 200% FPL---Part A Premium

  25. Mandatory Physician Hospital inpatient and outpatient Nursing Facility for persons 21 and over Lab and X-ray EPSDT for persons less than 21 Optional Prescription Drugs Dental services ICF/MRs Home and community-based services MedicaidMandatory and Optional ServicesSelected Types

  26. Medicaid Waivers • Program Waivers • Mandatory managed care enrollment (1915(b)) • Section 1115 Demonstrations • Statewide experimentation with financing mechanisms, managed care, coverage expansions • HIFA—Health Insurance Flexibility and Accountability—tradeoff of more limited benefit packages and cost sharing for expanded coverage

  27. SCHIP Federal-State Partnership very different • Capped appropriation—not an entitlement $39 billion for 10 years (reauthorization 2007) • State Flexibility • States can cap/close enrollment • 7 states froze enrollment at least temporarily between 2001 and 2004 • 3 had freezes in effect at end of 2004

  28. SCHIPState Flexibility (Continued) • Benefits • Medicaid Expansion • Distinct program with benefits similar to • BC/BS plan; state employees plan; largest Medicaid HMO; or actuarially equivalent • Combination • Cost sharing • Very limited for children in families ≤ 150%FPL • For others, premiums and co-payments allowed if ≤ 5% of income

  29. 5.7 Million 2.0 Million 3.9 Million -0.1 Million Changes in Health Insurance Coverage for Low-Income Children and Adults, 2000-2003Percentage Point Changes Children Adults Change in Population Change in Uninsured Note: Low-income is defined as less than <200% of poverty ($29,360 for a family of three) SOURCE: Urban Institute for the Kaiser Commission on Medicaid and the Uninsured, 2004

  30. Medicaid as LTC Financer • Pays close to half of all LTC expenditures • Nursing homes ≈46 percent of revenues ≈1 million or 2/3 of residents partially or fully financed • Home and community services ≈48 percent of expenditures ≈850 thousand recipients

  31. Medicare and Medicaid as a Share of GDP

  32. For more informationUnderstanding Medicare and Medicaid: Fundamentals and Issues for the New CongressBriefing Book — January 26, 2005www.nhpf.org

More Related