Texas Medicaid
Medical and Dental
Information Series
Module 2
Version 1.2 (6/22/2010)
2/22/2013
1
Module 2
Medicaid Curriculum Overview
Module 1: General Structure of the Texas Medicaid System
Module 2: Understanding Medicaid Clients and Health Literacy
Module 3: Texas Health Steps
Module 4: Navigating Insurance and Managed Care
Module 5: Interfacing with Medicaid as a Provider
Module 6: Special Medicaid Programs
Module 7: Special Medical Issues
Module 8: Special Dental Issues
2
Module 2
Understanding Medicaid Clients
and Health Literacy
3
Module 2
Module 2: Objectives
After completing this module, you should be able to:
Explain how poverty is defined and measured in the U.S.
List at least three characteristics of children living in
poverty
Contrast the terms generational poverty and situational
poverty
List at least five barriers to health care caused by poverty
List at least three ways that emergency department
usage is affected by poverty and unemployment
Define health literacy and its effect on health and
provision of health care
List Texas Medicaid initiatives to address adverse effects
of poverty and disability
4
Module 2
Module 2: Identifying Patterns
This module attempts to
describe poverty in terms of the
patterns observed in the research
literature– but all patterns have
exceptions. Patterns involve broad
generalizations about large
groups of people. The goal of this
presentation is to describe
poverty, its barriers and its health
implications to help providers
improve their patient care– not to
create or perpetuate stereotypes.
5
Module 2
True or False?
Test Your Knowledge about Texas Medicaid:
In 2011, nearly 1 in 20 people and 1 in 15 children
lived in poverty.
The federal government requires that state
Medicaid programs set service eligibility at 100% of
the FPL.
A family in generational Poverty is one that has
been in poverty for two or more generations.
Nationally, a 1% decrease in the employment rate
adds about 1 million new enrollees to Medicaid &
CHIP.
Only about 12% of adults have a health literacy
level that could be considered proficient.
6
Module 2
REVIEW:
What is Medicaid?
Medicaid is a federal health care program that is jointly funded by federal
and state money. Medicaid is jointly funded by the state and federal
governments:
About one-third funded by the State of Texas
About two-thirds funded by the Federal Government
In December 2011, about 1 in 7 Texans relied on Medicaid for health
insurance or long-term services (3.7 million of the 25.9 million).
Medicaid was created through Title XIX of the 1965 Social Security Act, and
established in Texas in 1967.
In Texas, Medicaid is administered by the Texas Health and Human
Services Commission (HHSC).
Medicaid is an entitlement program, which means:
The number of eligible people who can enroll cannot be limited.
Any services covered under the program must be paid.
7
Module 2
REVIEW:
Who can receive Full Medicaid Benefits?
Categories of Eligibility
Families and Children
Based on income level, depending
on age, or pregnancy
Cash Assistance Recipients
Based on receipt of Temporary
Assistance for Needy Families
(TANF) or Supplementary Security
Income (SSI)
Aged and Disabled Individuals
Based on income, age, and
physical and/or mental disability
Some Dual Eligible Individuals:
Qualified Medicare Beneficiaries
Based on age, income, and
disability status
8
Module 2
REVIEW:
Who can receive Limited Medicaid Benefits?
Categories of Eligibility
Some Dual Eligible Individuals: In the Qualified
Medicare Beneficiary, Specified Low-Income
Medicare Beneficiary, Qualified Individuals, and
the Qualified Disabled Working Individuals
Programs, Medicaid pays for some or all of
Medicare premiums
Based on income, assets, age, and/or disability
Non-Citizens
Undocumented persons who are not eligible for
Medicaid based on citizenship status may receive
emergency services
Qualified Legal Permanent Residents are eligible
for limited Medicaid services
Special programs for women (e.g., family
planning services, cervical and breast cancer
coverage, community attendant services)
Available to women and based on income level
and age
9
Module 2
REVIEW:
What Does Medicaid Cover?
Acute and preventive health care
for all ages
Physician visits
Inpatient and outpatient services
Pharmacy, lab, and radiology
costs
Long-term services for
elderly and disabled clients
Mental health and
substance abuse treatment
Dental services for patients
under the age of 21
Preventive
Therapeutic
10
Module 2
REVIEW:
How Many People Does Texas Medicaid
Serve?
At any one time, how many individuals are enrolled in
Medicaid? About 3.54 million
Texas Average Monthly
Medicaid Enrollment
SFYs 2001-2011
Millions
2.49
1.87
2001
2.68
2.88
2005
3.30
2.79
2.83
2.88
2006
2007
2008
3.54
3.00
2.10
2002
2003
2004
2009
2010
2011
11
Module 2
REVIEW:
Texas Medicaid Recipients
Unduplicated Clients
SFY 2011 = 4,567,077
State Fiscal Year 2011
Ethnicity
54%
22%
Hispanic
Age
Caucasian
36%
30%
0-5
6-14
Gender
17%
20%
30%
6%
65+
45%
Female
10%
Other
17%
21-64
55%
0%
AfricanAmerican
11%
15-20
8%
Male
40%
50%
60%
70%
80%
90%
100%
12
Module 2
REVIEW:
Who is Eligible for Medicaid Benefits?
Medicaid primarily serves:
Low-income families
People with disabilities
Foster children
Babies born to mothers receiving
benefits at time of delivery
Pregnant women
(Services available for one year)
The elderly
Texas Medicaid 2011
100%
Non-Disabled
Children
90%
80%
32%
70%
Non-Disabled
Children
60%
61%
Non-Disabled Adults
10%
30%
Non-Disabled Adults 9%
Aged & Disability
Related
20%
Aged & Disability
Related
50%
40%
10%
58%
30%
0%
Caseload
Costs
13
Module 2
Medicaid and Poverty
Medicaid serves primarily
low-income or disabled
families and individuals–
those likely to be in poverty.
Why might a family or
individual qualify for
Medicaid?
A family crisis such as death, disability
or divorce that leads to loss of income
Loss of a job or other economic distress
Long-term poverty that persists for more
than one generation
What is poverty?
This module focuses on
helping providers
understand some of the
challenges faced by their
Medicaid clients that lead to
health disparities:
What is the link between poverty and
health care?
How does health literacy affect health
care?
What Texas Medicaid programs help
reduce health disparities caused by
poverty or disability?
14
Module 2
Why Is It Important to Learn About
Poverty? Poverty and Health
% of individuals reporting poor/fair health
Research points to a strong negative relationship between Income
and Health Status: As income declines, health status also declines
Health Status of Adults at
or below 133% FPL
Income and Health
25%
45
40
20%
35
30
20%
17%
16%
15%
25
20
Uninsured
Parents
10%
15
10
5%
Medicaid
5
0
1
2
3
4
5
6
7
Income Decile
8
9
10
Uninsured
Childless
Adults
0%
Fair/Poor Health
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Module 2
Why Is It Important to Learn About
Poverty? Poverty and Dental Care
Percentage of people who visit a dentist at
least once a year, by family income
High Income (400%+ FPL)
57.9%
Middle Income (200-400% FPL)
Low Income (100-200% FPL)
Poor (≤100%FPL)
41.9%
29.9%
26.5%
16
Module 2
Why Is It Important to Learn About
Poverty? Poverty and Cultural Competency
Health providers and organizations that are culturally competent
demonstrate the ability to recognize role of cultural diversity—
including values, traditions and language preferences—in making
positive health outcomes.
Linking poverty to culture is controversial, especially explanations
that blame victims of poverty or that cast doubt on the values or
morals of the poor, but recent scholarship recognizes a link between
culture and persistent poverty.
The characteristics of socioeconomic status—income level,
educational attainment, and employment position—often also affect
traditions and language preferences.
Thus, understanding the effect of socioeconomic status and poverty
on health is a first step in achieving competency regarding the
culture of poverty.
17
Module 2
Understanding Medicaid Clients
What is poverty?
Definitions &
measurements
Children living in poverty
Poverty across the US &
Texas
Generational vs.
Situational poverty
18
Module 2
How Poverty is Defined and
Measured in the U.S.
The Census Bureau uses a set of money income, or poverty
thresholds (or Federal Poverty Level, FPL) that vary by family size
and composition (but not by region of the country) to determine who
is in poverty.
If a family's total income is less than 100% FPL, then that family
and every individual in it is considered poor or in poverty.
Families with incomes between 100-200% FPL are considered
to be low income.
In 2011, the FPL is $22,350 per year for a family of 4, or $1863
per month.
Children by Family Income, 2010
< 100%
≥ 200%
FPL
57%
FPL
21%
100199%
FPL
22%
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Module 2
In 2011, there were over
311 million people in the
United States
In 2011, more than
46 million of these
people lived in poverty
(a 15-year high)
1 in 7 people overall
1 in 5 children
20
Module 2
In 2011, more than
46 million of these
people lived in poverty
(a 15-year high)
1 in 7 people overall
1 in 5 children
21
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Children Living in Poverty
Compared with children in higher income families, poor children are more
likely than non-poor children to:
Be in single-parent families
Have parents with low educational attainment
Live in areas called “food deserts” with limited access to fresh
groceries and healthy food
Be exposed to chronic stress that is linked to chronic disease
Suffer developmental delays
Give birth during the teen years
Be in poor or fair health
The percentage of children living in low-income and
poor families has increased since 2000:
2000
2009
% Change
Low Income
26,784,244
31,298,590
17%
Poor
11,502,067
15,325,974
33%
22
Module 2
Federal Poverty Level (FPL)
Total Number of People Living in Poverty based on
Household Income (In Thousands), 2009
2012-13 US Poverty
Guidelines
Texas
4.26 million
Persons in
Family or
Household
Annual Pre-Tax Income
48 Contiguous States
and Washington DC
1
$11,170
2
15,130
3
19,090
4
23,050
5
27,010
6
30,970
7
34,930
8
38,890
>8
Add $3,960 for each
additional person
23
Module 2
Poverty in Texas
Texas (2010-2011) vs. US (2011)
By Race/Ethnicity
By Age
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
White
Black
Hispanic
Texas
Other
Total
Children
≤18
US
Adults
19-64
Elderly
65+
Texas
By Family Structure
Total
US
By Gender
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
Adults w/Kids
Adults No Kids
Texas
US
Total
Female
Male
Texas
US
Total
24
Module 2
Generational Poverty vs.
Situational Poverty
Generational Poverty
Situational Poverty
Poverty that persists for
two or more generations
Poverty that caused by
circumstance (such as
death, illness, divorce) and
has a duration of one
generation or less
Generational Poverty has its own:
• Culture
• Hidden Rules
• Belief Systems
• Approach to Language
Situational Poverty maintains an
orientation toward middle class
codes and mores.
25
Module 2
Understanding Medicaid Clients
What is the link between
poverty and health care?
Income & Medicaid eligibility
Health implications of poverty
Effects of unemployment & income fluctuations
Impact on emergency department (ED) use
26
Module 2
FPL and Social Services
The Department of Health and
Human Services develops and
publishes the Poverty Guidelines,
which are updated annually and
form the basis for eligibility for
Medicaid and other programs.
The federal government sets
minimum FPL criteria for eligibility
to federally funded programs, but
states can set higher FPL
eligibility to cover a broader range
of income levels.
Program eligibility is often
expressed as a percentage of the
FPL. The higher the percentage,
the greater the income limit, or
more generous the benefit.
Examples of Texas
Medicaid Eligibility by
FPL
Children 6-18: up to
100% FPL, or up to
$23,050/year for a
family of 4
Elderly and Disabled: 75% FPL or
$11,348/year for a family of 2
Pregnant Women:
up to 185% FPL, or
up to $35,316/year
for a family of 3
27
Module 2
Federal Poverty Levels in Use
Medicaid Eligibility in Texas, 2012
Maximum Monthly Countable Income Limit
(family of 3 unless otherwise specified)
$188
Temporary Assistance for Needy Families (TANF)
$1,591
Children ages 6-18 at up to 100% of FPL
$2,116
Children ages 1-5 at up to 133% FPL
Newborns up to age 1 at up to 185% of FPL
$2,943
Pregnant Women at up to 185% of FPL
$2,943
$698
SSI, Aged & Disabled up to 100% SSI FBR*
$2,094
Long-Term Care at up to 300% of SSI FBR*
$275
Medically Needy
$0
$500 $1,000$1,500$2,000$2,500$3,000$3,500
FPL = Federal Poverty Level
FBR = Federal Benefit Rate
* SSI is awarded to individuals and couples only
28
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Income Guidelines
www.chipmedicaid.com
29
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www.chipmedicaid.com
30
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Common Medicaid Myths
Myth
National Center for Children in
Poverty data for Texas, 2008:
Most Medicaid-eligible children
have parents who are
unemployed.
38% of children in poor families
(<100% FPL) have at least one
parent who is employed fulltime, year-round
Fact
33% of children in poor families
have at least one parent who is
employed either part-year or
part-time
Medicaid primarily serves the
working poor—families with at
least one parent who works full or
part-time but with a family income
less than 100% FPL and no other
source of insurance.
30% of children in poor families
do not have an employed
parent
In contrast, 88% of children in
families that are not poor have
at least one parent who is
employed full-time, year-round
31
Module 2
Health Implications of Poverty:
Barriers to Care
Money to pay for co-payments,
medications or other health costs
Inadequate or unreliable
transportation
Low educational levels
Food insecurity
Low literacy levels or limited
understanding of English
Poor health literacy
Conflicting priorities and needs
32
Module 2
The Face of Poverty:
Implications for a family’s health
Rhonda is a 31-year-old single mother of
Tamika (14) and Andre (10) living in Dallas.
Rhonda lives in a low income housing
development, near her mother and older
brother, who is mentally handicapped.
Rhonda’s job in a call center earns $332 per week, but offers no
benefits. She also receives $40 per week in child support from
Andre’s father, who lives in Louisiana. Her total monthly pre-tax
income is $1488 (93.5% FPL) or $17,856 per year.
Rhonda’s mother has Type 2 diabetes and hypertension. Her father,
a lifelong smoker, died of lung cancer 5 years ago.
Rhonda limits her own smoking to a half-pack of cigarettes a day.
33
Module 2
The Face of Poverty:
Rhonda’s Family
According to the
National Center for
Children in Poverty,
as a single mother
with 2 children in
Dallas, Rhonda
could expect the
following monthly
expenses, even to
be considered lowincome (132% FPL):
Expense
Monthly Cost
Rent & utilities
$871
Food
$569
Child care for Andre (He stays with
Rhonda’s mother or Tamika after school)
$0
Health insurance premiums
$0
Out-of-pocket medical
$57
Transportation
$277
Other necessities
$389
Debt
$0
Payroll taxes
$148
Income taxes (includes credits)
-$381
Total
$1930
Actual Amount Available:
$1488
34
Module 2
Linking Financial Status and
Health Care
Percent who say they or another family member living in their
household have done each of the following because of the cost
Relied on home remedies or over-the-counter drugs
instead of going to see a doctor
37%
Skipped dental care or checkups
36%
Put off or postponed getting health care needed
32%
Not filled a prescription for a medicine
26%
Skipped a recommended medical test or treatment
25%
Cut pills in half or skipped doses of medicine
Had problems getting mental health care
"Yes" to any of the above
20%
9%
54%
35
Module 2
Health Implications of Poverty
for Children
Physician Care
Physician Care Among Poor
and Non-Poor Children
(1 to 5 years)
Poor
Physician Care Among Poor
and Non-Poor Children
(6 to 17 years)
Nonpoor
Poor
35%
35%
30%
30%
25%
25%
20%
20%
14.9%
15%
10%
5%
0%
30.1%
27.0%
15%
10.6%
6.9%
10%
5%
3.0%
0%
No Usual Source of
Care
Nonpoor
No Well-Child Checkup
in Past 12 Months
8.2%
4.4%
No Usual Source of
Care
No Well-Child Checkup
in Past 12 Months
36
Module 2
Health Implications of Poverty
for Children
Overweight and Obesity
Overweight and Obesity
Among Children
(2 to 5 years)
Poor
Nonpoor
Poor
25%
20%
Overweight and Obesity
Among Children
(12 to 17 years)
Nonpoor
25%
23.8%
20%
18.6%
16.3%
15%
15%
14.0%
10.6%
10%
9.8%
5%
0%
0%
Obese
15.2%
10%
5%
Overweight
16.9%
Overweight
Obese
37
Module 2
Health Implications of Poverty
for Children
Dental Care
Dental Care Among Poor and Nonpoor Children
50%
45%
43.6%
44.1%
40%
35%
30%
25%
Poor
Nonpoor
20%
18.1%
15%
10.5%
10%
5%
0%
Never Seen a Dentist
1+ Year Since Last Dentist Visit
38
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The Face of Poverty:
Implications for a family’s health
Provider’s Concerns
Bringing in a copy of the
kids’ shot records
Setting a quit date for
smoking
Rhonda’s Concerns
Juggling competing
demands in an extended
family despite limited
resources:
Keeping appointments for
dental referrals
Keeping her kids fed
Getting regular exercise
and avoiding junk food
Keeping her car running
Filling and taking
prescriptions
Helping her extended
family
Paying her bills
Getting to work on time
39
Module 2
Percentage of labor force
Effects of Unemployment and
Income Fluctuations
12
Unemployment Rate
10
8
6
4
2
0
US
Texas
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
40
Module 2
Linking Financial Status and
Health Care
Percent of workers who become uninsured (6+ months) after leaving a
job, among workers previously insured through their employer
By Age
By Income
60%
50%
60%
52%
51%
40%
50%
40%
36%
30%
30%
24%
24%
20%
20%
10%
10%
0%
0%
19-34
35-49
50-64
<200% FPL
>200% FPL
41
Module 2
Effect of Employment Rate on
Medicaid & CHIP
1%
1 Million
National
Employment
Rate
Medicaid and
CHIP Enrollment
42
Module 2
Effects of Poverty, Unemployment
& Uninsurance on ED Usage
Key Findings from a 2009 Kaiser Family
Foundation study of Emergency Departments (EDs):
ED capacity is strained and almost all EDs report rising volume.
Many EDs observe a new “recession” population of those who have lost
jobs and insurance or those who can’t afford deductibles or cost-sharing
costs in the doctor’s office.
EDs are seeing more insured patients who come because they cannot
obtain timely or affordable primary care in the community.
Both insured and uninsured patients are refusing medically recommended
care because of cost.
ED physicians see anxiety and depression
among patients who lost their jobs.
The inability to arrange for follow-up care for
uninsured patients is a huge problem, which
impacts how ED physicians practice and
how patients fare.
43
Module 2
Characteristics of ED Users
By Insurance Status
High ED Users
28%
Low ED Users
18%
23%
12%
28%
17%
54%
14%
5%
3%
Medicare
Medicaid
Private
Non-ED Users
12% 8%
63%
15%
2%
14%
60%
15%
3%
Total Population
0%
9%
20%
40%
60%
80%
Uninsured
Mixed
100%
44
Module 2
Characteristics of ED Users
By Chronic Condition
2%
High ED Users
66%
16%
16%
1+ Physical
Conditions
2%
Low ED Users
54%
7%
36%
1+ Mental
Conditions
2%
Non-ED Users
45%
4%
Both Physical and
Mental Conditions
49%
No Physicial or
Mental Conditions
2%
Total Population
47%
0%
20%
5%
40%
46%
60%
80%
100%
45
Module 2
Characteristics of ED users
By Reason for Visit
High ED Users
31%
69%
Visit Related
to Chronic
Condition
Low ED Users
16%
84%
Visit Not
Related to
Chronic
Condition
Total Population
19%
0%
81%
20%
40%
60%
80%
100%
46
Module 2
The Link Between Poverty and Health
Care: Barriers Caused by Patient and
Provider Knowledge & Attitudes
Patient Quotes
Provider Quotes
“I didn’t know people went to
the doctor. I thought
everyone went to the
emergency room.”
“I can’t get the mother to
turn the TV off and bring her
kid in to get a checkup.”
“I never saw a dentist. Didn’t
even know you were
supposed to until you
needed false teeth.”
“My patients don’t want to
pay the $5 co-pay, so they
come to the ED and wait 6
hours to be seen for a cold.”
47
Module 2
Addressing the Link Between Poverty
and Health Care
A strong and positive provider-patient relationship has a positive
and significant effect on treatment adherence and outcome
Conflicting norms and behaviors among patients and providers of
different social groups may create barriers to effective
communication or positive relationships
Suggestions for providers:
Recognize norms as adaptive and socially constructed, and avoid
assigning positive or negative value
Do not assume that someone will see how their choices today will
affect their health tomorrow.
Learn more about the effects on health of poverty, unemployment
and uninsurance
Get to know your patients. Understanding their perspective can
improve the services you provide.
48
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Health Literacy
How does health literacy
affect health care?
Definition & importance of health literacy
Measurement and extent of health literacy
Addressing health literacy in health care settings
49
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What Is Health Literacy?
Health literacy is the degree to which individuals have
the capacity to obtain, process, and understand basic
health information and services needed to make
appropriate health decisions.
Health literacy is dependent on both individual and
systemic factors:
1.
Communication skills of lay people (such as patients) and
professionals (such as health care providers)
2.
Knowledge of lay people and professionals of health topics
3.
Culture
4.
Demands of the healthcare and public health systems
5.
Demands of the situation/context
50
Module 2
Health Literacy: A National
Priority
American Dental Association:
American Medical Association:
Limited health literacy
is a potential barrier to
effective prevention,
diagnosis and
treatment of oral
disease.
Poor health literacy is
a stronger predictor or
a person’s health than
age, income,
employment status,
education level, and
race.
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Module 2
Why Is Health Literacy Important?
Health literacy affects people’s ability to:
Navigate the healthcare system,
including locating providers and
services and keeping appointments
Fill out forms and give informed consent
Share personal and health information
with providers
Engage in self-care and chronic
disease management
Adopt health-promoting behaviors, such
as exercising and eating a healthy diet
Act on health-related news and
announcements
Costs of Low Health
Literacy:
• Poor health outcomes
• Increased health care
costs through higher
utilization of
hospitalization and
emergency services
• Reduced quality of
care
• Treatment nonadherence and
medication errors
• Poor health behavior
choices
52
Module 2
Common Reasons for Poor Health
Literacy
Lack of educational opportunity
Poor English-language skills
Low reading levels
Reading abilities are typically 3 to 5
grade levels below the last year of
school completed (i.e. a high school
graduate likely reads at a 7th or 8th
grade level).
Learning disabilities
Cognitive decline
Poor health
To accomplish health
tasks, patients may need
to be:
• Visually literate (able to
understand and read
graphs and charts)
• Computer literate (able
to operate a computer)
• Information literate (able
to obtain and apply
relevant information)
• Numerically or
computationally literate
(ability to calculate or
reason numerically)
53
Module 2
Health Literacy and Shame
People with limited health literacy often report feeling a sense of
shame about their skill level.
Individuals with poor literacy skills are often uncomfortable about
being unable to read well, and they develop strategies to
compensate.
Possible indicators of low health literacy:
Excuses for not reading: “I forgot my glasses.”
Lots of papers folded up in purse/pocket
Lack of follow-through with tests or appointments
Few questions or only simple questions
Difficulty explaining medical concerns or how to take medications
54
Module 2
Measuring Health Literacy
Literacy
Scales
• Prose (reading comprehension)
• Document (finding & using
information)
• Quantitative (performing
computations)
Health Care
Domains
2003 National Assessment of Adult Literacy
(NAAL) Survey
• Clinical
• Prevention
• Navigation of the health
care system
Literacy Levels
Proficient: Can perform complex and challenging literacy activities.
Intermediate: Can perform moderately challenging literacy activities.
Basic: Can perform simple everyday literacy activities.
Below Basic: Can perform no more than the most simple and
concrete literacy activities.
Nonliterate in English: Unable to complete a minimum number of
screening tasks or could not be tested because did not speak
English or Spanish.
55
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Difficulty of Selected Health
Literacy Tasks
Calculate an employee’s share of health insurance costs for
a year, using a table. (382)
Proficient
310-500
Intermediate
226-309
Basic
185-225
Below Basic
0-184
Use a BMI index to determine a healthy weight range for a
person of a specific height (290)
Average Score
245
Determine what time a person can take a prescription
medication, based on information on the drug label that
relates the timing of medication to eating. (253)
Give two reasons a person should be tested for a specific
disease, based on information in a clearly written pamphlet.
(202)
Circle the date of a medical appointment on a hospital
appointment slip. (101)
56
Module 2
Percentage of Adults in Each
Literacy Level
Below Basic
14%
-20%
Basic
22%
0%
Intermediate
53%
20%
40%
60%
Proficient
12%
80%
100%
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Module 2
Percentage of Adults in the
Below Basic Literacy Level
0%
10%
20%
40%
50%
60%
51%
Did not graduate from high school
15%
39%
Did not speak English before starting school
Adults reporting poor health
30%
13%
10%
4%
Hispanic adults
Black adults
Age 65+
No medical insurance
% in Below Basic Category
35%
12%
19%
12%
31%
15%
36%
18%
% in Total Population
58
Module 2
Poverty, Insurance Coverage
and Health Literacy
Poverty Threshold
Average Health
Literacy Score
Below 100% FPL
205
100-125% FPL
222
126-150% FPL
224
151-175% FPL
231
Above 175% FPL
261
Adults at poverty levels 100-125% FPL
scored in the Below Basic levels of
health literacy. Average health literacy
levels for those above 175% FPL was in
the Intermediate range.
Among adults who received Medicare
or Medicaid, 27% and 30%,
respectively, had Below Basic health
literacy. Among adults who had
employer-provided, military, or
privately purchased insurance, the
percentages with Below Basic health
literacy were 7%, 12% and 13%,
respectively.
Insurance Type
Average Health
Literacy Score
Employer-Provided
259
Military
248
Privately Purchased
243
Medicare
216
Medicaid
212
No Insurance
220
59
Module 2
Addressing Low Health Literacy
Using Plain Language
Strategies to improve patient comprehension:
Limit the amount of information provided at each visit
Begin with the most important information
“Slow down”
Avoid jargon
Provide patient education materials at the appropriate reading level
Use pictures or modules to explain important concepts
Use the “show-me” or “teach-back” methods
Encourage questions
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Module 2
Addressing Low Health Literacy
Testing for Understanding
Suggestions for providers:
Use a medically trained interpreter if necessary:
Ensure that all language access services, including translation, use
plain language
For those who do not speak English, plain English alone will not be
enough to ensure understanding
Ask open-ended questions:
Elicit cultural beliefs and attitudes: “Tell me about the problem and
what may have caused it.”
Check for understanding:
Use the “teach-back” method: Have the
person restate the information in
his or her own words.
61
Module 2
Medicaid Programs
What Texas Medicaid programs
help reduce health disparities
caused by poverty or disability?
Case Management
Outreach & Informing
Transportation Assistance
Ensuring accommodations
for the disabled
62
Module 2
Case Management
Case Management for Children and Pregnant Women (CPW)
provides services to children with a health condition/health risk, birth
through 20 years of age and to high-risk pregnant women of all
ages, in order to help them gain access to medical, social,
educational and other health-related services
Dependent upon a client’s needs, a CPW case manager may
complete a variety of tasks that include the following:
Linking a client to community resources
Coordinating medical services and supplies
Locating mental health services
Assisting with medical transportation problems
Referring a client to waiver programs, ECI and other resources
Advocating for a client at school meetings
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Module 2
Outreach and Informing Program
The Outreach and Informing Program provides
outreach, informing, and support services to THSteps
recipients.
The Outreach & Informing program seeks to improve
patients’ interactions with providers through:
Helping patients and families locate a provider
Scheduling appointments
Providing information for patients on the importance of
checkups
Performing outreach after missed appointments
Eligible recipients:
• Children birth through age 20 who are newly-certified or recertified for Medicaid
(including parents/caretakers required to have a Health Care Orientation)
• Children birth through age 20 years who are due or overdue for a medical or
dental checkup
• Pregnant women in the fourth month of pregnancy
• Special outreach groups who are at high risk for health problems (e.g., children
of migrant farm workers)
64
Module 2
Medicaid Transportation Program
Provides free rides for Texas Health
Steps and other Medicaid eligible
patients
Helps clients miss fewer appointments
Allows scheduling of multiple
appointments at one time
Results in fewer no-shows
THREE WAYS TO GET
TO THE DOCTOR
65
Module 2
Americans with Disabilities Act
(ADA)
ADA: Title III: The term "disability" means, with respect to an
individual:
(A) a physical or mental impairment that substantially limits one or
more major life activities of such individual;
(B) a record of such an impairment; or
(C) being regarded as having such an impairment.
“No individual shall be discriminated against on the basis of
disability in the full and equal enjoyment of the goods, services,
facilities, privileges, advantages, or accommodations of any place
of public accommodation by any person who owns, leases (or
leases to), or operates a place of public accommodation.”
Professional offices of a health care providers and hospitals are
included under the definition of “place[s] of public accommodation
66
Module 2
Americans with Disabilities Act
Requirements
Title VI of the Civil Rights Act requires health providers give their
limited-English-proficient patients meaningful access to their
services, which may entail offering translation services
People with disabilities must be able to access an office
building and suite. Barriers to access must be removed if alterations
are “readily achievable”
Providers have a duty to provide effective communication, including
services for vision- or hearing-impaired patients, such as:
Qualified readers, Braille or large print materials
Sign language interpreter, written forms
and information sheets, or exchange of
written notes for non-complex situations
67
Module 2
True or False?
Test Your Knowledge about Texas Medicaid:
In 2011, nearly 1 in 20 people and 1 in 20 children
lived in poverty.
The federal government requires that state
Medicaid programs set service eligibility at 100% of
the FPL.
A family in generational poverty is one that has
been in poverty for two or more generations.
Nationally, a 1% decrease in the employment rate
adds about 1 million new enrollees to Medicaid &
CHIP
Only about 12% of adults have a health literacy
level that could be considered proficient.
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Module 2
Medicaid Resources
Texas Health & Human Services Commission
www.hhsc.state.tx.us/medicaid
Texas Medicaid & Healthcare Partnership
www.tmhp.com
Texas Health Steps
www.dshs.state.tx.us/thsteps/providers.shtm
www.dshs.state.tx.us/dental/thsteps_dental.shtm
www.dshs.state.tx.us/thsteps/default.shtm
CHIP/Children’s Medicaid
www.chipmedicaid.org
69
This Texas Medicaid curriculum
was prepared by
Betsy Goebel Jones, EdD
Project Director
Tim Hayes, MAM
Project Designer
Authors: Module 2
Betsy Goebel Jones, EdD
David Trotter, MA
Department of Family & Community Medicine
Module 2
70