10/15/2012
What is Medicaid?
Texas Medicaid Basics
Barry S. Lachman, MD, MPH
October, 2012
Jointly funded state-federal program providing
health coverage to low-income and disabled
individuals.
Federal agency: Centers for Medicare and
Medicaid Services (CMS)
State agency: Health and Human Services
Commission (HHSC)
Medicaid is entitlement
program
Federal law requires coverage for certain
populations and services.
States are allowed to cover additional populations.
Eligibility is based on income, age and certain
eligibility categories
Guaranteed coverage for eligible services to eligible
individuals.
Medicaid Eligibility
Medicaid serves:
Eligibility criteria:
Low-income families
Residency in Texas
Children
U.S. citizen or qualified
Related caretakers of
dependent children
Pregnant women
Elderly
Individuals with
disabilities
aliens legally admitted
for permanent residency
Income and resource
limits
Functional and medical
criteria for long-term
services and support
Most child applicants
must be under age of 19
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10/15/2012
Medicaid Caseload
Federal Poverty Level
currently serves about 3.3 million people
is the definition of poverty used by the federal government as
the reference point to determine Medicaid eligibility
FPL
66% are children
50% of all enrollees are in FFS & PCCM models that
were not designed to manage costs.
is the income level below which a person
is officially considered to lack adequate financial resources and to be
living in poverty
Services for the aged, blind, and disabled are the largest share
of program costs
U. S. Dept. Of HHS 2011 Poverty Guidelines
Federal Poverty Level Based on Family Income
FPL Income Examples
Individual
Family of 3
$20,147
$37,060
$34,281
(based on U.S. Dept. of HHS poverty guidelines for 2011)
Family Size
Income
1
$10,890
2
$14,710
3
$18,530
4
$22,350
5
$26,170
6
$29,990
$14,484
$24,645
$10,890
100%
FPL
$18,530
133%
FPL
185%
FPL
100%
FPL
133%
FPL
185%
FPL
200%
FPL
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10/15/2012
Eligibility by Income
200%
Texas FPL Eligibility
*Annual income based on a family of 3 except
for SSI and nursing home clients which are
based on individual income
Texas Medicaid Caseload Growth
Sept. 1978 – Sept. 2020 Source: HHSC
Texas Medicaid Beneficiaries & Expenditures
SFY 2010 (Source: HHSC)
Non-Disabled
Children
66%
Other Adults 9%
Aged, Blind
and Disabled
25%
Caseload
Non-Disabled
Children
32%
Other Adults 10%
Aged, Blind
and Disabled
58%
Expenditures
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10/15/2012
Texas Medicaid Expenditures
SFY 2009
Medicaid Benefits
Mandatory Benefits
The services states are federally required
to offer as part of state program
Optional Benefits
Federally approved additional services that states
can offer under Medicaid program
Services Covered
How is Medicaid Funded?
Medicaid is funded by both state and federal
Covers basic health care services
physician services
inpatient, outpatient care
pharmacy, lab and x-ray
long term care services for the aged and disabled
governments.
Federal share is based on Federal Medical
Assistance Percentage (FMAP)
FMAP is based on state’’ s per capita personal
income compared to the U. S. average.
Texas receives FMAP of approximately 60%
meaning 60/40 split for most client services.
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10/15/2012
Supplemental Federal Funding
Upper Payment Limit (UPL) – payments made to
hospitals and physicians to make up the difference
between what Medicaid pays for services and what
Medicare would have paid for the same care.
Disproporionate Share Hospital Program (DSH) –
Health Reform: Myth and
Truth
Barry S. Lachman, MD, MPH
special payments made to hospitals that serve a
disproportionately large number of Medicaid and lowincome patients.
Why is Medicaid Important
Safety Net for the underserved and vulnerable
Key cog in assuring universal coverage for those
under 133% of poverty
Medicaid Myths and Reality
Myth: Federal Program – actually much State control
Benefits are very generous – true, more than any
commercial insurance or Medicare. However, covers
those with disabilities who are more expensive.
Fiscally unsustainable – State budgets are challenged;
however, we are already paying for these services. 40%
of health expenditures are wasted (IOM, 2012)
Medicaid is a failure – fales. It has narrowed gap on
health disparities. Multiple good studies show improved
health outcomes in those served
Could just move them into commercial insurance –
false. Has been tried. It does not work.
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10/15/2012
The State of the Healthcare
System
The Uninsured
Over 40 million uninsured (US Census Bureau, New York Times,
Costs out of control
Austin American Statesman, Lubbock Times
Over 40 million uninsured
Texas highest uninsured rate in US (same)
Poor quality – Overall Texas is at or near the bottom on
Texas highest number of uninsured children (KFF, US Census
almost all measures
Bureau) Over 1 million uninsured children in Texas (Kids Count
Survey)
Ration based on income
Dallas has second most uninsured of any city – 1.4 million (TMA)
Employer based model in rapid decline
Over 90% of uninsured in Dallas are US citizens (CPPP)
Insurance unaffordable for many
1 in 5 women in Dallas uninsured (Dallas Women’s Foundation)
Very inefficient system
Most are low income (Census Bureau, CPPP, Dallas Women’s
Multiple problems not just access
Foundation, KFF)
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Texas Health Statistics
47th in % of insured children (KFF)
47th in % of insured adults (KFF)
2nd in number of uninsured adults (KFF)
2nd in Total Uninsured (KFF)
1st in number of uninsured children (KFF)
Public Mental Health expenditures (48th)
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Affordable or Not
Texas cost cover 80% of uninsured for 1% increase
in State Health Care Spending CPPP
CMS (DMN 6/14/2012) – cover 30 million (75%)
for 0.1% increase per year in costs
Does not include any savings from bill
Does not look at NPV of investment – what is the cost
of not doing it over time
Infectious Disease – 46th
Lack of Health Insurance – 50th
Early Prenatal Care – 50th
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10/15/2012
Supreme Court Ruling
ACA Highlights
Near universal coverage through Medicaid,
Upholds all challenged parts of ACA except
Exchanges, Medicare, private health insurance
Medicaid Expansion to 133% of poverty level (it is
Eliminates preexisting condition for coverage and
optional)
continuation
Eliminates ending coverage for honest errors on
application
Extends dependent coverage to age 27
Clinical trials coverage
Small employer tax credits
Making Medicare
Stronger
More ACA Highlights
Grants available to states: (1) to set up an Office of Health
2010: Closing the Rx “ Doughnut Hole”
” : Shrinks Doughnut Hole by $250 in 2010
(rebate), 50% discount on brand-name drugs in the remaining gap; closes
doughnut hole entirely by 2020
Jan. 2011: New preventive benefits: adds comprehensive annual check-up plus
other prevention benefits, with no out-of-pocket costs.
Insurance Consumer Assistance (2) to establish health
insurance exchanges. TX applied and will get both!
Begins new $11 billion investment in Community Health
Centers.
New funding for training primary care docs, nurses, other
professionals.
No copays on preventive services
Minimum and essential benefits
Medicaid payments to doctors must be equal to Medicare
Limits excessive profits by insurers
Adds 12 more years to Medicare Trust Fund Solvency: Not by cutting current
Medicare benefits or doctor fees, but slowing growth in Medicare spending from
2010 to 2019.
New Access to Community-Based Services and Supports: Medicare today does
not cover community-based services to help seniors remain in their homes. A new
voluntary insurance program (CLASS) will provide community-based assistance
services and support. Starts in 2012 or 2013; 5 years to qualify for benefits.
The “cuts” are largely limits on insurer profits in ACA whereas cuts in the “Ryan Budget” are real
cuts to benefits and payments
.
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10/15/2012
Health Reform Coverage Options by Income
Family Income
>$88,400 for a
family of four;
>400% of FPL
• Job-based coverage, or
• Full-cost coverage in the exchange
$66,200-$88,400;
300-400% of FPL
• Job-based coverage, or
• Subsidized exchange coverage: premiums capped
at 9.5% of income
$44,100-$66,200;
200-300% of FPL
• Job-based coverage, or
• Subsidized exchange coverage: premiums capped
at 6.3 – 9.5% of income
Medicaid and Faith
$29,300-$44,100;
133-200% of FPL
CHIP
• Job-based coverage, or
• Subsidized exchange coverage:
premiums capped at 3% - 6.3%
of income
<$29,300 for a
family of four;
< 133% FPL
Medicaid
Medicaid
Children
Adults
(non-disabled adults,
not eligible for Medicare)
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Family income based on 2009 federal poverty income levels for a family of four
Tikkun Olam (Healing the
World)
Christian and Moslem
Jewish theologic concept dating to early Rabbinic Period
Jesus ministry to the poor
Maimonides expanded to society as a whole
Islam –
Luria expounded the concept most clearly as part of the
mystic tradition (Kabbalah)
Zakah –
clearly linked to social justice
Jewish tradition celebrates and honors our obligations
to the community
Maimonides – Hierarchy of charitable acts
Seventh Noachite commandment links Jewish tradition
to social justice
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