Health Policy and Politics

MedicaidThe Programs Purpose, Patients, and Providers

Nancy CooperCoordinator, Health Policy Fellowship OU-HCOMFebruary 5, 2013

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1Watch the debate between Cheney and Edwards last night?Access to Insurance Equals Access to Care 250 Million Americans50%Private Insurance

Employer-based group insuranceorSingle policy or

Out of Pocket50%State/Federal Gov.

MedicareMedicaidCHIPVeterans AffairsIndian Health ServiceFederal Employee Health Benefits Program

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Government InsuranceHalf of insured patients/half total health care costs

Health and Human Services Centers for Medicare and Medicaid ServicesMedicare (Entitlement >65)Medicaid (Eligibility - poor)CHIP (Eligibility near poor kids)Indian Health Service

Veterans Affairs/TriCareFederal Employee Health Benefits Program (FEHBP)

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Benefit for Randy BAlbany VFW - May 2

In March this year Randy was diagnosed with stage four prostate cancer, His family and friends are having a benefit for him to help him with medical expenses. There will be a Chinese Auction and All You Can Eat for $7 from 5:00 7:00. If you would like to donate but cant make the benefit, you can donate money at the First National Bank of Athens under the Randy B Cancer Fund.

The Athens Messenger April 27, 20094

MedicaidCoverage for 69 million eligible poor

25% of state budgets

in unemployment = in eligibility (but less state revenue)

Fairly generous benefits (mental health, dental and vision) but access problems due to low reimbursement

Happy Birthday Boomers!

12The Silver TsunamiNumber of boomers will grow from 42 to 73 millionNumber of elderly over age 80 will tripleHighest number of divorcees (live alone)Half live at or < FPL1/3 retirees have NO savings13

Congressional Budget Office 2/1/12The Elderly Poor9.2 M Dual Eligibles149.2 MAARP, Integrating Care for Dual Eligibles, 201259% are over 6541% disabledMost are very poorFills in gaps: long term care, glasses, dental, pays Medicare premiums and cost shareHospital coverage, physician visits, drugs, some post hospital careWho is not covered?17 million poor, childless men and women

Affordable Care Act expands Medicaid to this population100% FMAP for newly eligible for 3 years and 90% FMAP after 2017

SCOTUS ruling will leave decision to expand up to the states

Kaiser Health News July 201215

Will States Expand Eligibility?For those few that are slow to come in, they're going to have to answer to people why they're turning this down and why they're letting people go without coverage.

Jack Lew, Chief of Staff 6/30/12

As it stands now, theres no way we can afford to do it. Tony Keck, South Carolinas Medicaid director July 201216

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Washington Post, Medicaid expansion scorecard: 17 states say yes, 9 say no, by Sarah Cliff 12/7/12Reimbursement Set by the state NJ lowest, WA highestLower than MedicareLow fees affect access to care18

Ohio Medicaid19

Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

Gov. John KasichODJFS Director Michael ColbertIts Complicated

20DD: developmental disabilitiesMH: mental healthADAS: alcohol and drug addiction servicesHealth Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011Medicaid Delivery SystemCFC mostly Managed Care: HMO gets capitated payment per personFinancial burden is on the HMODoes not cover long term care

By law, ABD long term and home based care are Fee for Service ($$$$$).21

Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011Eligible Ohioans

22Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011Covered Families and Children (CFC)

Kids: 1,093,724 Parents: 435,742 Pregnant women: 26,195

Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

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Aged, Blind and Disabled (ABD)112,019 seniors242,091 adults with disabilities 37,989 children with disabilities392,099 patients24Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

Ohios Optional Benefits

Mandatory BenefitsEarly and Periodic Screening, Treatment and Diagnosis for kids (HEALTH-CHEK)Inpatient HospitalPhysicianLab and X RayOutpatient (rural clinics and FQHCs)Medical and surgical visionMedical and surgical dentalTransportation to servicesNurse midwife, family nurse practitioner, pediatric nurse practitionerFamily planning services and suppliesHome healthNursing home care $$$$$Medicare premium assistance

25Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011

Long Term Care ServicesFacility based long-term careNursing facilitiesIntermediate care for mentally retarded (ICF-MR)State developmental centers for mentally retarded (MR-DD)

Home and Community Based Services (HCBS)Personal care, homemaking, and nursingAdult day careDelivered mealsTransportationRespite careHospice and Program for All Inclusive Care for the Elderly (PACE) Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 201126

Providers27

Ohio Department Job and Family Services web site accessed 1/30/13Provider Organizations

28Ohio Department Job and Family Services web site accessed 1/30/13Ohio Medicaid ReimbursementPhysicians bill reasonable and customary chargeProviders cant charge the patient for the difference between their bill and the Medicaid paymentAve. wait of 41 days for reimbursementFee schedule available on ODJFS website

Health Affairs Do Reimbursement Delays Discourage Medicaid Participation By Physicians? by Cunningham and OMalley Feb 200929

Ohio Medicaid Reimbursement30% Increase in Medicaid fees 2003-2008OHUSAll services15.9%15.1%Primary Care13.6%20%Obstetrics6.8%8.8%Other services28.4%8.7%Kaiser State Health Facts/Ohio accessed 1/30/13The good newsOhio Medicaid ReimbursementMedicaid to Medicare Fee Index 2008OHUSAll services.69.72Primary care.66.66Obstetrics.84.93Other services.65.7231Kaiser State Health Facts/Ohio accessed 1/30/13 More good news ACA will pay Medicaid primary care providers 100% of the Medicare rate for evaluation, management an immunizations in 2013 and 2014 (after that reimbursement rate will be up to the state).Provider Enrollment in MedicaidEnroll via ODJFS website: Medicaid Information Technology Provider link

Ohio Department Job and Family Services web site32

Federal Changes to MedicaidACA Maintenance of Effort limits states ability to control costs by changing eligibility or benefitsHave to maintain eligibility till 2014 . . . Or lose FMAP33

Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011State Changes to MedicaidFollow the moneyIndividual-Centered Integrated Care Delivery System (CDS)Coordinate care for dual eligiblesPromote the use of health homes Promote use of home-based long term care instead of nursing home careChange hospital paymentsAdjust nursing home payment formula link $ to outcomes34Health Policy Institute of Ohio, Ohio Medicaid Basics 2011, May 2011Cradle and GraveMedicaid is a vital source of health care for 69 million vulnerable Americans

BUT . . . 35

Need to Close the GapsALBANY Randy Dewaine B., 52, of Albany, passed away at his residence Thursday, Dec. 30, 2010, after a hard-fought battle with cancer.

Born Aug. 8, 1958, in Athens, he was the son of Sharon Michael B. of Athens, and the late Robert B. Sr. He was retired from the Southeast Psychiatric Hospital and an avid sports fan, having played basketball and softball, and loved playing music with family.

The Athens Messenger, December, 2010

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Stay Informed

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WWW.Kaiserhealthnews.orgWWW.healthaffairs.org37What can you do to advocate for increased access to affordable quality care for your future patients?38

1. Medicaid fills in gaps in availability of health coverage by

Covering all people below the poverty lineCovering just low income childrenCovering certain groups of low income people392. Approximately what percent of Americans receive health insurance coverage through Medicaid at some point during the year?

Less than 10%About 20%More than 30%403. True or False: The Medicaid program is the same in all states.

TrueFalseDont know414. Of the nearly 69 million people served by Medicaid each year, approximately how many are children?

One quarterOne halfThree-quarters425. Which group accounts for most Medicaid spending?

Children under 19Unemployed adultsElderly and disabled436. How does the recent growth in Medicaid spending per person compare to the growth in private health insurance premiums per person?

Medicaid spending grew fasterMedicaid spending grew slowerMedicaid spending grew at the same rate as private insurance447. Which type of coverage is the primary payer for long-term care services and supports for elderly and disabled individuals?

MedicareMedicaidPrivate insurance458. What types of assistance does Medicaid provide for Medicare beneficiaries?

Medicaid pays for premiums and co-pays for low-income beneficiaries

Medicaid pays for health care services not covered by Medicare, such as home and community based care

Both are true469. Are Medicaid beneficiaries more likely than people with private health insurance to go to the emergency room for non-emergency care?

YesNoDont know4710. Who will become eligible to gain Medicaid coverage starting in 2014 through the Affordable Care Act?

Children up to age 26Many low income adultsUndocumented immigrants48Key32 about 20%False2 Half3 elderly and disabled2 Medicaid spending grew slower2 Medicaid3 - Both are true2 No2 many low income adults

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