10.13.11.Medicaid.Doshi - HCMG 101 Jalpa Doshi October 13,...

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Unformatted text preview: HCMG 101 Jalpa Doshi October 13, 2011 History Eligibility and Enrollment Coverage and Cost-sharing Expenditures and Payments Medicaid and Managed Care Dual-Eligibles Summary of Differences ◦ Medicaid vs. Medicare 1965: Medicaid bill (Title 19; Social Security Act) ◦ Low-income families with dependent children (AFDC) ◦ Low-income elderly, blind, and individuals with disabilities Late 1980s: Expansion to pregnant women and infants ◦ Coverage for women and children <6 years of age (<=133% of FPL) ◦ Phase-in of children ages 6-18 years (<=100% of FPL) Mid 1990s: Medicaid HMOs & Welfare Reform ◦ Many states choose mandatory Medicaid enrollment with HMOs ◦ 1996 Clinton replaces AFDC with TANF (no welfare link to Medicaid) 1997: BBA creates expanded access for children ◦ SCHIP (State Children’s Health Insurance Program) Administered by each State within broad national guidelines established by Federal statutes, regulations, and policies. Each State: ◦ establishes its own eligibility standards; ◦ determines the type, amount, duration, and scope of services; ◦ sets the rate of payment for services; and ◦ administers its own program. Medicaid policies for eligibility, services, and payment are complex and vary considerably across States State Budgets (15-30% of budget) Federal Matching (50-76% rates) • Medicaid is a top budget item for state governments (education, public works) • States qualify for federal match if they agree to provide coverage for: • Low-income families • Poor elderly, disabled • Children, pregnant women • Match based on state per capita income • Mississippi (76% rate: $1:$3.17) • NJ, NY, CT, DE (50% rate: $1:$1) SOURCE: CBO, Baseline Budget Outlook , January 2005; National Association of State Budget Officers, 2003 State Expenditure Report, 2004. State General Fund Spending Total = $499 Billion Total = $2.3 Trillion Federal Outlays Medicaid is a Primary Source of Health Insurance For People Below Poverty Level 2010 Poverty Guidelines Persons in Family or Household 48 Contiguous States and D.C. Alaska Hawaii 1 $10,830 $13,530 $12,460 2 14,570 18,210 16,760 3 18,310 22,890 21,060 4 22,050 27,570 25,360 5 25,790 32,250 29,660 6 29,530 36,930 33,960 7 33,270 41,610 38,260 8 37,010 46,290 42,560 For each additional person, add 3,740 4,680 4,300 SOURCE: CMS. Eligibility Rules • Mandatory Eligibility – Certain pregnant women, children, and parents with dependent children; – Disabled and elderly receiving SSI; children in foster care • Optional Eligibility – Persons with disabilities – Individuals with high health care expenses (“medically needy”) – Persons living in nursing homes; – “Buy-in” population; – Individuals with breast and cervical cancer In 2009, Medicaid provided coverage to about 46.9 million low-income Americans To provide a sense of how this breaks down, in 2005 Medicaid enrollment was...
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This note was uploaded on 10/26/2011 for the course ASDF 2342 taught by Professor 2adga during the Spring '11 term at Mansfield University of Pennsylvania.

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10.13.11.Medicaid.Doshi - HCMG 101 Jalpa Doshi October 13,...

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