Medicaid The Program’s Purpose, Patients, and Providers

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

2. Access to Insurance Equals Access to Care 250 Million Americans 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

3. Government InsuranceHalf of insured patients/half total health care costs • 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)

4. Benefit for Randy B 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, 2009

5. Financial Eligibility MedicaidCoverage for 69 million eligiblepoor <133% Federal Poverty Level (FPL)

6. Categorical Eligibility • 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 18-26 who age out of foster care

7. National Medicaid Profile69 million people 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 2012

8. Who Pays for Medicaid? • 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 2012

9. What Does Medicaid Pay For?Federally mandated 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 Congressional Research Service, Medicaid: A Primer July 2012

10. States’ Flexibility Congressional Research Service, Medicaid: A Primer July 2012 • 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

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. Happy Birthday Boomers!

13. The Silver Tsunami • 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 Congressional Budget Office 2/1/12

14. The Elderly Poor9.2 M “Dual Eligibles” 59% are over 65 41% disabled Most are very poor 9.2 M Hospital coverage, physician visits, drugs, some post hospital care Fills in gaps: long term care, glasses, dental, pays Medicare premiums and cost share AARP, Integrating Care for Dual Eligibles, 2012

15. Who is not covered? • 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 2012

16. Will States Expand Eligibility? “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 2012

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

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

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

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

21. Medicaid Delivery System Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011 • 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 ($$$$$).

22. Eligible Ohioans Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

23. Covered Families and Children (CFC) Kids: 1,093,724 Parents: 435,742 Pregnant women: 26,195 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

24. Aged, Blind and Disabled (ABD) Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011 112,019 seniors 242,091 adults with disabilities 37,989 children with disabilities 392,099 patients

25. Ohio’s Optional Benefits 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 Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

26. Long Term Care Services • 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 2011

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

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

29. Ohio Medicaid Reimbursement 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 2009

30. Ohio Medicaid Reimbursement The good news Kaiser State Health Facts/Ohio accessed 1/30/13

31. Ohio Medicaid Reimbursement 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). Kaiser State Health Facts/Ohio accessed 1/30/13

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

33. Federal Changes to Medicaid Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011 ACA Maintenance of Effort limits states’ ability to control costs by changing eligibility or benefits Have to maintain eligibility till 2014 . . . Or lose FMAP

34. State Changes to MedicaidFollow the money Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011 • 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

35. “Cradle and Grave” Medicaid is a vital source of health care for 69 million vulnerable Americans BUT . . .

36. Need to Close the Gaps ALBANY — Randy DewaineB., 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, 2010

37. Stay Informed WWW.Kaiserhealthnews.org WWW.healthaffairs.org

39. 1. Medicaid fills in gaps in availability of health coverage by • Covering all people below the poverty line • Covering just low income children • Covering certain groups of low income people

40. 2. Approximately what percent of Americans receive health insurance coverage through Medicaid at some point during the year? • Less than 10% • About 20% • More than 30%

41. 3. True or False: The Medicaid program is the same in all states. • True • False • Don’t know

42. 4. Of the nearly 69 million people served by Medicaid each year, approximately how many are children? • One quarter • One half • Three-quarters

43. 5. Which group accounts for most Medicaid spending? • Children under 19 • Unemployed adults • Elderly and disabled

44. 6. How does the recent growth in Medicaid spending per person compare to the growth in private health insurance premiums per person? • Medicaid spending grew faster • Medicaid spending grew slower • Medicaid spending grew at the same rate as private insurance

45. 7. Which type of coverage is the primary payer for long-term care services and supports for elderly and disabled individuals? • Medicare • Medicaid • Private insurance

46. 8. What types of assistance does Medicaid provide for Medicare beneficiaries? • Medicaid pays for premiums and co-pays for low-income beneficiaries • Medicaid pays for health care services not covered by Medicare, such as home and community based care • Both are true

47. 9. Are Medicaid beneficiaries more likely than people with private health insurance to go to the emergency room for non-emergency care? • Yes • No • Don’t know

48. 10. Who will become eligible to gain Medicaid coverage starting in 2014 through the Affordable Care Act? • Children up to age 26 • Many low income adults • Undocumented immigrants

49. Key 3 2 – about 20% False 2 – Half 3 – elderly and disabled 2 – Medicaid spending grew slower 2 – Medicaid 3 - Both are true 2 – No 2 – many low income adults