George A. Ralls M.D. Health Services Department January 11 th , 2011

1. Medicaid Update 2011 George A. Ralls M.D. Health Services Department January 11th, 2011

2. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

3. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

4. Medicaid • 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 an open-ended, means-tested entitlement program financed jointly by the Federal Government and States

5. Medicaid • Omnibus Budget Reconciliation Act 1989 (SOBRA): • Mandates states to extend Medicaid coverage to children & pregnant women

6. Medicaid • Patient Protection and Affordable Care Act (PPACA); March 23, 2010 • Expands Medicaid eligibility to all individuals with incomes up to 133% of the FPL

8. Medicaid • Federal Medicaid laws mandate certain benefits for certain populations • To qualify for Federal funds states administer their programs under federally approved state plans: • A waiver is required if state plans deviated from certain provisions of the Social Security Act

9. Medicaid • State to state variability: • Optional services covered differ • Limits on mandatory and optional services differ • Provider reimbursement • Eligibility

10. Medicaid • 55 million people in low-income families • 16 million elderly and disabled people • Federal Medicaid Spending: • $290 billion in FY 2010 • 12% increase from FY 2009 • 8% of total Federal budget

11. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

12. Florida Medicaid • Florida implemented the Medicaid program in 1970 to provide medical services to low income families • SOBRA greatly expanded services to include pregnant women and children • Medicaid program administered by AHCA

13. Florida Medicaid 2010

14. Florida Medicaid Florida resident Child in home or in womb Income Limits Asset Limits

15. Florida Medicaid Medicaid Eligibility Levels by Annual Income (2010) FL: 185% of FPL US: 133% of FPL

16. Florida Medicaid Federal (FMAP) $ 20.2 Billion State Other FY10

17. Florida Medicaid • Local county funds • Cigarette excise taxes Other FY10

18. Florida Medicaid F.S. 409.915:  County contributions to Medicaid • 60 Days to pay • State will withhold revenue sharing funds if not paid

19. Florida Medicaid • Medicaid Managed Care pilot project: • Baker, Broward, Clay, Duval & Nassau counties • Expires in 2011 • Extension has been requested of CMS • Decreases costs and improves quality measures “1115 Waiver”:

20. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

21. Medicaid & the Economy

22. 97% Increase in Medicaid enrollment in 4 years Medicaid & the Economy 32% 28% 21% 16% 10% 9% 7% *Monthly case load in thousands

23. Medicaid & the Economy % Change in Enrollment, Dec 07 to Dec 09 • Florida: • 28.5 % Increase • US 13.6% • 5th largest in US

24. Medicaid & the Economy • High unemployment since beginning of current recession has resulted in: • 5 million more Medicaid/CHIP enrollees • 5 million more uninsured • Improvement in unemployment rates & Medicaid will lag behind other economic indicators

25. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

26. Local Impact Orange County Medicaid Enrollees (in thousands) 43% Increase in 2.5 Years Apr08 Apr09 Apr10 Nov10

27. Local Impact Orange County 69% increase in 3 Years Medicaid Billed/Paid FY07-10

28. Local Impact • Shortfall covered by: • $ 1.9 million from PCAN • $ 700K from DJJ • $ 500K from Health Services

29. Local Impact • Shortfall covered by: • $ 6 million Budget Amendment

30. Local Impact • Open ended program • If budget is exceeded, an end-of-year budget transfer may be required

31. Local Impact AHCA • Proposed an increase in county contribution for Medicaid nursing home care • From $ 55 to $ 202 per month per person • $ 66 Million from counties • Has not changed in 39 years Additional $ 3M to Orange County Medicaid expenditure

32. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

33. PPACA (Healthcare Reform Act) Medicaid Expansion Temporary Health Insurance Exchange PermanentHealth Insurance Exchange Pictures Insurance Reforms Accountable Care Organizations Pictures Individual Mandate

34. PPACA • Medicaid to cover all adults up to 133% of FPL • 35% increase in enrollment in FL by 2019 • Estimated $1.4B in additional state costs • Higher reimbursement for providers • Paid by Federal Govt for first 2 years

35. PPACA State Strategy to Deal with Medicaid: • Expand 1115 Waiver statewide • Extends the “Managed Care” model to all counties • Costs are capitated; more certainty in budgeting • Advisors urging Governor Scott to support the repeal of PPACA

36. Overview • History of the Medicaid Program • Florida Medicaid • Medicaid & the Economy • Local Impact • Medicaid Expansion under PPACA • Summary

37. Summary • Medicaid enrollment and costs have increased significantly • Medicaid is a mandated expenditure which has exceeded budgeted amount for last 2 fiscal years • Projected Medicaid expenditure for FY2010-11 is $15 Million • Short fall may require a budget transfer

38. Summary • State actions to increase revenue from counties will have a significant impact • Increase in nursing home “per day” rate • Sagging economy will continue to keep enrollment/costs high • Medicaid expansion under PPACA will place further pressure on County Medicaid budget

39. Medicaid Update 2011 George A. Ralls M.D. Health Services Department January 11th, 2011