Medicaid, Graduate Medical Education and the State Budget Kathy Eckstein Director of Public Policy Children’s Hospital Association of Texas (CHAT )
The Significance of Medicaid • 14% of the Texas population was covered by Medicaid in 2011, and more than three- fourths of these recipients were children. • In 2011, the State of Texas spent $29.4 billion (State General Revenue (GR) plus Federal) on Medicaid, accounting for 26% of the state’s budget . 2
Medicaid History and Oversight • Established by Title XIX of the Social Security Act in 1965 • A joint state-federal entitlement program • Administered by the Centers for Medicare and Medicaid Services (CMS), part of the US Department of Health and Human Services • In Texas, the Health and Human Services Commission (HHSC) is the “single state agency” for Medicaid. 3
What Does Medicaid Provide? • Health insurance coverage to low-income – Children (all medically necessary services) – Pregnant Women – Very Low Income Parents – Persons with Disabilities • Assistance to low-income Medicare beneficiaries • Long-term care services for the elderly and persons with disabilities • Support for the health care safety net 4
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Income Caps for Texas Medicaid and CHIP, 2012 250% $25,128 $35,317 $35,317 $ 38,180 200% $25,390 150% 225% 200% $19,090 100% 185% 185% $8,376 $2,256 $3,696 50% 133% 100% 75% 19% 0% 12% Pregnant Newborns Age 1-5 Age 6-18 TANF Working SSI (aged Long CHIP Women parent of Parent of or Term 2, no 2 disabled) Care income Mandatory Optional indicates Texas choices to go ABOVE federal minimum Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, except individual incomes shown for SSI and Long Term Care 6
2012 Federal Poverty Levels Family 12% 75% 100% 133% 185% 200% Size 1 $1,340 $8,378 $11,170 $14,856 $20,665 $22,340 2 $1,816 $11,348 $15,130 $20,123 $27,991 $30,260 3 $2,291 $14,318 $19,090 $25,390 $35,317 $38,180 4 $2,766 $17,288 $23,050 $30,657 $42,643 $46,100 5 $3,241 $20,258 $27,010 $35,923 $49,969 $54,020 6 $3,716 $23,228 $30,970 $41,190 $57,295 $61,940 7 $4,192 $26,198 $34,930 $46,457 $64,621 $69,860 8 $4,667 $29,168 $38,890 $51,724 $71,947 $77,780 7
Citizenship Requirements • Medicaid does not provide health coverage to undocumented persons. • Medicaid reimbursement for undocumented persons is limited to emergency medical services. • Legal immigrant adults are not covered by Texas Medicaid. • Legal immigrant children are covered by Medicaid. 8
Texas Medicaid/CHIP: Who is Helped Today August 2012, HHSC data CHIP, 583,151 Disabled, 418,368 25.6 million Texans 7.4 million under 19 Elderly, Medicaid 320,467 Children, Poor Parents, 2,540,312 143,406 TANF Parent, 82,660 Maternity Total enrolled 8/1/2012: 3.6 million Medicaid; 583,000 CHIP 93,531 9 1 in 7 Texans, but 42% of Texas kids
Children Under 19 Enrolled in Medicaid & CHIP Texas, 2006-2012 4,000,000 3,350,860 3,500,000 3,263,571 Total Children Enrolled 3,055,691 3,000,000 2,776,802 2,571,243 2,413,363 Number Enrolled 2,325,858 2,769,173 2,500,000 2,728,628 2,519,915 2,276,341 2,000,000 Children <19 Enrolled 2,118,841 2,105,663 2,027,082 in Medicaid 1,500,000 1,000,000 CHIP 581,687 535,776 534,943 500,461 452,402 298,776 307,700 500,000 0 2006 2007 2008 2009 2010 2011 2012 Note: Counts are for May of each year. CHIP counts include the CHIP Perinatal Program. Source: Final Count – Medicaid Enrollment by Month at www.hhsc.state.tx.us/research.MedicaidEnrollment/ME-Monthly.asp. CHIP Enrollment, Renewal and Disenrollment by Month at www.hhsc.state.tx.us/research/CHIP/Disenrollment-Rate.asp. CHIP Perinatal Coverage Enrollment by Month at www.hhsc.state.tx.us/research/CHIP/perinatal.shtml. Children's Hospital Association of Texas
Texas Medicaid & CHIP Eligibles by Age May 2012 Sources: Medicaid Eligibles: HHSC 8 th Month Medicaid Eligibility File (final eligibility count); CHIP Eligibles: Maximus A010 CHIP Enrollment file. Prepared by Data Quality and Dissemination, SDS, HHSC. Children's Hospital Association of Texas
Number and Percent* of Texas Children Enrolled in Public Insurance (Medicaid or CHIP) by Age Group May 2012 =100,000 Texas Children Enrolled in Public Insurance All Others Infants and Toddlers Elementary School 5-11 Years Preschool 0-1 Years – 800,000 Children 2-4 Years – 1,200,000 Children 2,800,000 Children Public Insurance - 500,000 (63%) Public Insurance - 600,000 (50%) Public Insurance - 1,300,000 (46%) Junior High School High School 15-18 Years 12-14 Years – 1,200,000 Children 1,500,000 Children Public Insurance - 500,000 (42%) Public Insurance - 500,000 (33%) *Numbers rounded to nearest 100,000; percentages based on rounded numbers. Sources: Medicaid 8 th Month Eligibility File (final eligibility count) & Maximus A010 CHIP Enrollment File; Data Quality & Dissemination; Strategic Decision Support; HHSC. 2012 Population Projections by Age: 2010-2050, Texas State Data Center, Texas Population Estimates & Projections Program; University of Texas at San Antonio, November 2012.
Services and Providers 13
Medicaid Services: Mandatory and Optional Federal Law Requires Federal Law Allows • Inpatient/outpatient hospital • Prescription drugs • Physician services • Institutional care for developmentally disabled • Lab and x-ray • Community care for elders or • EPSDT (Texas Health Steps) people with disabilities • Ambulance • Rehabilitation and other therapies • Home health • Care by physician extenders and • Rural Health Clinics/FQHCs mental health providers • Nursing facilities • Dental care, Eyeglasses, Hearing • Immunizations/comprehensive aids care for children • Private duty nursing • Family planning • Maternity service clinics • Nurse Midwife, Nurse • Case management Practitioner • Podiatry • Medical and surgical services • Chiropractic provided by a dentist • Hospice services 14
22.6 (146,400 1-17 Years Discharges) 78.7 (758,700 18-44 Years Discharges) 105.2 (634,800 45-64 Years Discharges) 303.5 (789,700 65+ Years Discharges) 94.1 (2.3 Million Total** Discharges) 0 50 100 150 200 250 300 350 2010 Discharges Per 1,000 Population *Discharges were reported by 375 acute care hospitals. Excludes state-owned and licensed psychiatric hospitals, rehab hospitals, acute long term care hospitals, approximately 65 additional rural hospitals and other hospitals specifically exempted from reporting discharge data in 2010. **Excludes discharges under 365 days of age. Source: Texas Hospital Inpatient Discharge Public Use Data File, 2010; State Center for Health Statistics, DSHS. Children's Hospital Association of Texas
Texas Hospital Industry Serves an Adult Population Predominantly Teen Obstetrics = 0.4% (47,400 days) Normal Newborns = 4.4% (546,600 days) Adults 18+ Yrs = 82.1% Neonatal = 7.1% (10.3 million days) (890,100 days) Pediatric 0-17 Yrs = 6.0% (749,700 days) Total Inpatient Days in 375 Texas Acute Care Hospitals* = 12.5 Million *Includes acute care hospitals only: CHAT - 7; Other Urban - 285; Rural - 83. Excludes state-owned and licensed psychiatric hospitals, rehab hospitals, acute long term care hospitals, approximately 65 additional rural hospitals and other hospitals specificially not required to report discharge data in 2010. Pediatric days include inpatient data for pediatric cases age 0 -17, excluding normal newborns and teen obstetrical care. Source: Texas Hospital Inpatient Discharge Public Use Data File, 2010; State Center for Health Statistics; DSHS. Children's Hospital Association of Texas
Payment Models • As of July 2012, 82% of Medicaid clients were provided care through contracts with Managed Care Organizations that receive monthly premiums for each enrolled client. • Dental services for children on Medicaid are provided through contracts with Dental Maintenance Organizations. • Payment for Medicaid clients who are newly enrolled and most children receiving SSI (who are now voluntary for managed care) is made through fee-for-service claims. Proposed legislation mandating that children on SSI move into managed care is likely to pass. 17
Medicaid Managed Care Programs • The STAR program serves low-income families, non-disabled children and pregnant women. • The STAR+PLUS program integrates acute and long-term care services for clients who are disabled or elderly. • The STAR Health program provides care to children in foster care. • NorthSTAR is a behavioral health delivery system in the Dallas area. 18
Provider Payment Rates • HHSC develops rates for fee-for-service claims. • Medicaid provider rates are generally below rates for comparable services in Medicare and the commercial insurance marketplace. • Managed care payments must be actuarially sound; plans negotiate rates with providers to build an adequate network. • Increases occur for certain Medicaid services by primary care providers to Medicare rates (calendar years 2013 and 2014), per ACA. 19
A Look at Medicaid Spending 20
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