MEDICAID IN ERIE COUNTYAn Analysis of Statistical Data for the Period January 1, 2011 through June 30, 2015

Medicaid

Joint Federal – State health insurance program that assists persons with low income and limited resources.

County governments administer Medicaid and pay a portion of Medicaid costs

Presently, due to these various funding adjustments and also due to the State’s “Medicaid Cap” process, the Erie County share of total Medicaid expense ranges from 13% to 15%.

The County’s annual expense for Medicaid-MMIS is still the single-largest appropriation account in Erie County’s operating budget.

Medicaid Mandatory Services

Mandatory Services:

States Must Cover

• Inpatient and outpatient hospital services• Physician, midwife and certified nurse practitioner services• Laboratory and x-ray services• Nursing home and home health care for individuals over the age

of 21• Early and periodic screening, diagnosis, and treatment (EPSDT)

for children under 21• Family planning services and supplies• Rural health care/federally qualified health center services

Medicaid Optional Services

Optional Services:

States May Cover

• Diagnostic, screening, preventive, rehabilitative services• Clinical services• Intermediate care facilities for the mentally retarded (ICFs/MR)• Prescribed drugs and prosthetic devices• Optometrist services and eyeglasses• Nursing facility services for children under age 21• Transportation services (may be covered, must be assured)• Physical and occupational therapy• Home and community-based care to certain persons with chronic impairments• Dental services (for adults)

• New York State covers nearly all the optional services for Medicaid.

New York State Medicaid Data Warehouse

Contains the individual transaction records for all Medicaid transactions in New York State

Database is covered by the legal and regulatory provisions of the Health Insurance Portability and Accountability Act (“HIPAA”). However, amalgamations of data are allowed.

MIG Team has access to the data for Erie County. Other County personnel have access to selected portions. This access allows the MIG Team to better focus audit work.

Erie County’s Medicaid Inspector General

Audits Has completed or is in the process of completing 23

audits reviewing more than $80 million in Medicaid transactions

Works on a variety of projects and cooperate with NYS OMIG and law enforcement agencies.

Three employees and is funded through the State under a 2012 agreement.

Federal Medical Assistance Percentage

The Federal Medical Assistance Percentage (FMAP) is the federal share of Medicaid costs.

FMAP is calculated annually using a formula set forth in federal statute.

The FMAP for New York State for the federal government’s last fiscal year is 50%. New York State shares the lowest FMAP percentage in the nation with fifteen (15) other states. The highest FMAP percentage in 2015 is 73%.

Revised FMAP under the ACA

The Patient Protection and Affordable Care Act (ACA) creates a new national Medicaid minimum eligibility level: the “Medicaid Expansion.”

Income eligibility: In 2015, a family of four generally qualified with an income of $32,252.50 or less per year.

In New York State, two adults working 40 hours per week for 50 weeks a year at the Minimum Wage make $35,000 annually.

Applying for Medicaid in Erie County

Pregnant women, children, disabled persons and others may be eligible for Medicaid if they have a higher income, under certain circumstances.

Medicaid can and does cover some costs retroactively, if a person would have been eligible had they applied earlier.

Coverage generally stops at the end of the month in which a person no longer meets eligibility requirements.

Selected 2015 Annual Poverty Guidelines & Medicaid Expansion

Family Size

100% 120% 133% 150% 200%

1 11,770 14,124 15,654.10 17,655 23,540

2 15,930 19,116 21,186.90 23,895 31,860

3 20,090 24,108 26,719.70 30,135 40,180

4 24,250 29,100 32,252.50 36,375 48,500

5 28,410 34,092 37,785.00 42,615 56,820In New York State, the Minimum Wage is $8.75 per hour as of November 1, 2015, leading to an annual minimum wage of about $17,500.00.

Under the ACA Medicaid expansion, a family of 2 adults and 2 children, with both adults working at minimum wage, absent any special circumstances or additional income, would NOT qualify for Medicaid. ($35,000.00 in income.)

The above family would be able to purchase insurance through the NYS Health Plan Marketplace.

Medicaid Costs for 2013 - 2015

2013 2014* 2015#

Medicaid Costs

$1,485,449,115 $1,625,852,244

$896,559,568

Erie County’s Portion of Medicaid Costs

$217,880,408 $211,425,799 $203,276,191

The County’s final 2015 Medicaid cost is expected to be $8.1 million less than 2014. * The Medicaid Cost data for 2014 is subject to change.

# “Medicaid Costs” are for the period of January 1, 2015 through June 30, 2015. “Erie County’s Portion of Medicaid Costs” are projected for the entire Fiscal year 2015.

Medicaid Clients by Year

2012 2013 2014 2015*

221,745 230,748 258,819 252,624

The number of persons on Medicaid in Erie County has been and continues to grow at an average rate of more than four percent (4%) per year.

With the increase in Medicaid clients due to the ACA, 2014 Medicaid clients have exceeded 28% of Erie County’s population .

* 2015 Data covers the period of January 1, 2015 through June 30, 2015.

2015 Medicaid Cost and Client Summary

Race/Ethnicity Medicaid Clients Medicaid Cost

White 121,313 $513,493,591

Black/African American 73,780 $232,993,499

Hispanic/Latino 23,224 $67,405,783

Asian/Pacific Islander 12,631 $28,895,369

American Indian/Alaskan Native 1,827 $5,519,422

Not Available/More Than One Race 19,849 $48,251,905

Totals 252,624 $896,559,569

Note: 2015 data is for the period January 1, 2015 through June 30, 2015, and is incomplete. All

Medicaid clients self-identify for race and ethnicity.

There are more Whites on Medicaid in 2015 than Black/African American, Hispanic/Latino and Asian/Pacific Islander persons

combined.

2015 Medicaid Summary by Age

Age Group Medicaid Clients Medicaid Cost

65 Years of Age and Older 21,843 $148,969,159

Age 21 – 64 134,377 $575,014,828

Age 0 to 20 96,444 $172,575,582

Totals 252,624 $896,559,569

Note: 2015 data is for the period January 1, 2015 through June 30, 2015, and is incomplete.

More than one-third of the individuals on Medicaid are under the age of 21.

Medicaid Drugs in Erie County with the Most Filed Prescriptions – 2015*

Hydrocodone-Acetaminophen: Treats moderate to severe pain

Ibuprofen: Over the counter pain reliever

Omeprazole: Treats acid reflux

Lisinopril: Treats high blood pressure

Ventolin HFA: Treats asthma or allergies

Atorvastatin Calcium: Treats elevated cholesterol

Metaformin HCL: Treatment for type two diabetes

Amlodipine Besylate: Treats high blood pressure

Levothyroxine Sodium: Treats thyroid deficiency

Amoxicillin: Antibiotic

Gabapentin: Anti-epileptic medication / pain treatment

Aspirin: Over the counter pain reliever* 2015 Data covers the period of January 1, 2015 through June 30, 2015.

2014 Medicaid Clients by Race and Average Income

The US Census considers Hispanic to be an ethnicity and not a race. Hispanics may be of any race. Please see http://www.census.gov.

A monthly income of $996.81 equates to an annual income of $11,961.72, just above the Federal Poverty Guideline of $11,670 in

2014.

Race/EthnicityMedicaid Clients

in Our Study Average Monthly Income

White 38,930 $1,031.24

Black/African American 24,938 955.23

Hispanic/Latino 6,376 939.56

Asian/Pacific Islander 2,864 1,149.43

American Indian/Alaskan Native 635 978.23

Not Available/More Than One Race 7,822 950.31

Totals 81,565 $996.81

2014 Top Five Sources of Income for Medicaid Clients in our Study

No total is provided for the number of clients because clients can be counted multiple times.

About 40% of the persons in our study group have earned income (W-2 or a

1099).

Top Five Kinds Of IncomeMonthly Average

Income Number of Clients

Salaries and Wages $1,106.00 30,058

SSI Benefits 560.00 23,396

SS Disability 825.00 16,400

Child Support Payments 290.00 5,863

SS Retirement 778.00 5,486

Monthly Average Income $996.81 N/A

Summary and Conclusions

The Total number of County residents on Medicaid has risen due to the ACA, with more than 28% of residents’ health insurance now being provided by Medicaid.

More than 1/3 of all persons on Medicaid are children (Persons under the age of 21).

There are more Whites on Medicaid than Blacks/African-American, Hispanic/Latino and Asian/Pacific Islander clients combined.

Erie County’s portion of Medicaid has dropped by more than $8.1 million from 2014.

Summary and Conclusions

Hydrocodone-Acetaminophen remains the most prescribed drug in Erie County, and has been since 2008.

For the Medicaid clients in our study group, the average month income was $996.81.

About 40% of the persons in our study group have earned income (a W2 or a 1099). It is a myth that Medicaid clients don’t work.