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 2

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 3

State Variations in Medicaid  Feds set basic rules on eligibility and benefits; some mandatory requirements, many state options  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% 4

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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 6

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) 7

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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) 9

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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 12

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 outpatient services and RX (2006) ˗ Medicaid covers co-payments and deductibles, RX prior to 2006, and nursing home services 13

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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 21

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 22

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 23

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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 44

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 45

Penetration of Managed Care 80% 71% 70% 63% 60% 56% Percent Enrolled in Managed Care 50% 40% 29% 30% 20% 10% 10% 0% 1991 1995 2000 2005 2008 46

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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 48

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 49

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 50

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 51

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 52