Overview of the Medicaid Program Todd Gilmer, PhD Associate - - PowerPoint PPT Presentation

Overview of the Medicaid Program

Todd Gilmer, PhD Associate Professor University of California, San Diego

Overview

• History of Medicaid
• Medicaid Eligibility and Benefits
• Medicaid Populations and Expenditures
• Medicaid Today
• Medicaid Managed Care
• Medicaid and Health Reform

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History of Medicaid

• 1935 - Social Security Act - Old Age, Survivors,

and Disability Insurance Trust Fund (OASDI): retirement, widows, disability: FDR 1935

• 1965 Title XIX of the SSA created Medicare and

Medicaid: LBJ 1965

• Medicare federally funded entitlement program
• Medicaid joint state - federal social welfare

program

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State Variations in Medicaid

• Feds set basic rules on eligibility and benefits;

some mandatory requirements, many state

• ptions
• States administer the program, making many

choices on eligibility, covered services, and payment levels

• Feds pay a percentage of total Medicaid spending:

50% in CA; 85% in poor states; averages 57%

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Medicaid Eligibility

• To be eligible for Medicaid, a beneficiary must

belong to a ‘Category’ that is eligible, and meet strict financial tests

• Categories of eligibility

˗ Poor children, and their parents ˗ Disabled ˗ Elderly

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Medicaid Eligibility

• Poor children (up to 100% of FPL)

˗ Up to 133% of FPL if < age 6

• Pregnant women up to 185% of FPL
• Parents (mostly single mothers) if very low income

˗ < 100% of FPL in CA ˗ < 50% of FPL in some states

• People with disabilities and low income (SSI)
• Aged with low income (SSI)
• Disabled and aged in long term care who ‘spend down’ to

eligibility (MN)

• Children’s Health Insurance Program, enacted in 1997, covering

children up to 200%-250% of FPL (not part of Medicaid, but related)

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Restricted Benefits

• Qualified Medicare beneficiaries (QMBs) and

Selected low-income beneficiaries (SLMBs) receive Medicare premium and cost sharing assistance

• Participants in Family Planning waivers (CA, GA)

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Medicaid Eligibility

• Medicaid is categorically and financially very

restrictive (and complicated!)

• Adults without children never eligible for Medicaid,

regardless of how poor (unless disabled or elderly)

• Low income adults with children ineligible unless

very low income

• Undocumented persons ineligible, except for

emergency services

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Dual Eligibles (Medi-Medi)

• Disabled and Aged who qualify for SSDI
• Aged low-income
• Dual coverage

˗ Medicare is the primary payer for most inpatient and

• utpatient services and RX (2006)

˗ Medicaid covers co-payments and deductibles, RX prior to 2006, and nursing home services

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FACES of Medicaid II

• Provide a portrait of Medicaid beneficiaries with

multiple chronic conditions

• Prevalence of chronic conditions
• Patterns of clustering of conditions
• Patterns of expenditure

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Study Population

• Medicaid Beneficiaries in 2001 & 2002
• Excluded states with a high penetration of

managed care

˗ AZ, DE, HI, MD, TN, OR

• Excluded aid categories with a high penetration of

managed care

» Example: disabled in MI

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Study Population (continued)

• Excluded dual eligibles and aged in states where

the diagnostic data appear suspect

˗ CT, FL, GA, MI, ND, NH, PA, SD

• Excluded beneficiaries with fewer than 6 months

FFS eligibility

• Excluded beneficiaries with restricted Medicaid

eligibility and benefits

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Medicaid Managed Care

• Waivers (1915(b) and Section 1115) have allowed

states to implemented mandatory managed care programs

• Part of the state, or state-wide
• Certain or all aid categories
• MCOs provide encounter data of varying quality

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Models of Managed Care

• Risk-based: MCO is paid a fixed monthly fee per

enrollee (capitation) and assumes some (partial- risk) or all (full-risk) of the financial risk for the delivery of a range of services

• FFS Primary Care Case Management (PCCM): PC

provider is ‘gatekeeper’ to approve and monitor services provided to enrollees

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Penetration of Managed Care

10% 29% 56% 63% 71% 0% 10% 20% 30% 40% 50% 60% 70% 80% 1991 1995 2000 2005 2008 Percent Enrolled in Managed Care

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Medicaid and Health Reform

• Expands Medicaid to a national floor of 133% FPL

˗ Subsidies for individuals between 133% and 400% FPL through the State Health Exchanges

• Includes adults without children
• Income is mod-AGI without asset or resource tests
• States receive full federal match for new eligibles

for three years, then scaling down to 90%

• States are no longer required to expand Medicaid

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Medicaid and Health Reform

• Benchmark benefit package
• Increases Medicaid payment rates in FFS and

managed care for primary care services provided by primary care doctors to 100% Medicare payment rates for two years

• A new Center for Medicare and Medicaid Innovation

will test payment and service delivery models aimed to improve quality and efficiency

• Funding for pilot programs for medical homes and

accountable care organizations, demonstrations integrated / coordinated care for dual eligibles

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Congressional Budget Office Estimates

• Medicaid expansion will increase coverage by 16

million

˗ Estimates were made prior to the SCOTUS ruling

• Most of the cost will be borne by the Federal

government

˗ Federal cost of $434 billion and State cost of $20 billion from 2010 to 2019 due to coverage increases

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Medicaid Summary

• Medicaid is a primary source of coverage for the poor and

disabled

• Medicaid is financially and categorically restrictive

˗ Poor children, and sometimes their parents ˗ Disabled and poor elderly

• Medicaid coverage is fairly comprehensive

˗ Inpatient, outpatient, pharmacy, nursing home ˗ Provider payments are low

• Medicaid generosity varies across states

˗ Eligibility, enrollment, benefits, provider payments

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Uses of Medicaid Data

• Large sample sizes
• Ability to study young women and children
• Identify more severe, less common conditions

among the disabled

• Study variations in state program characteristics
• Pharmacy studies

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