Chapter 10: Government Health Insurance Programs: Medicaid, CHIP, and Medicare

Benchmarks

provide a state with a standard to follow when designing its Medicaid package of benefits

DSH Payments

hospitals that serve a high number of low-income patients may receive additional medicaid payments called this

To qualify for Medicare under the elderly category,

individuals must be at least 65 years old and be eligible for Social Security for at least 10 years; individuals who are 65 but do not meet the work requirements may become eligible for Medicare on the basis of their spouses eligibility

To qualify for Medicare as a person with disabilities,

individuals must be totally and permanently disabled and receive Social Security Disability Insurance for at least 24 months, or have a diagnosis of either end-stage renal disease or amyotrophic lateral sclerosis - no age requirement

CHIP Waivers

states may apply to the secretary of HHS to waive CHIP program requirements; may use to expand eligibility or create premium assistance programs

Immigrants

the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 restricted immigrant eligibility; states now have the option to cover legal immigrant children and/or pregnant women from Medicaid and CHIP in the first five years they are in the US

Medicaid is a

entitlement program

Medicare Spending

Medicare expenditures are expected to reach $504.3 billion, or 12% of the total federal budget

Medicare Part D

Prescription drug benefit

States have 3 options regarding CHIPs structure

- States may incorporate CHIP into their existing Medicaid program by using CHIP children as an expansion population - States may create an entirely separate CHIP program - States may create a hybrid program with lower-income children part of Medicaid and higher-income children in a separate CHIP program.

Optional Long-Term Care Benefits

- intermediate care facility services for the mentally retarded - inpatient/nursing facility services for -individuals aged 65 years or older in an institution for mental disease - inpatient psychiatric hospital services for individuals under 21 - home and community based waiver services -other home health care -targeted case management - respiratory care services for ventilator dependent individuals - personal care services - hospice services - services furnished under a PACE program

ACA and Medicaid

- medicaid eligibility expansion - covering low-income childless adults without a waiver - cover legal immigrant pregnant women and children -only have to meet income threshold

CHIP Benefits

- must provide "basic" benefits including inpatient and outpatient hospital care, physician services, lab and x-ray services, well-baby and well-child care, and age appropriate immunizations, dental coverage (CHIPRA), - additional benefits include mental health or substance abuse services.

Mandatory Benefits

Acute Care Long Term Care New benefits in ACA

New Optional Benefits

- new state option for community based care - new state option for home health care - new state option for family planning services

Medicare Part B

Supplemental Medical Insurance - physician, outpatient hospital, x-ray, labs, emergency room, and other ambulatory services; medical equipment; limited preventive services, including: one preventive physical exam, mammography, pelvic exam, prostrate exam, colorectal cancer screening, glaucoma screening, prostrate cancer screening, cardiovascular screening blood test, diabetes screening and outpatient self-management; bone-mass measurement for high-risk patients; pap smear; and pneumococcal and flue vaccinations

CHIP Eligibility

- allowed states to cover up to 300% FPL (due to CHIPRA) - eligibility begins where medicaid ends (based on state) - coverage for pregnant women - lawfully residing immigrant pregnant women and children, even if they haven't been in the US for longer than 5 years -Has performance bonuses

Part C Financing

plans to provide services from parts A and B and receive their funding from the sources described above

The federal government and Medicaid

sets certain requirements and policies for the Medicaid program through statue, regulations, a State Medicaid Manual, and policy guidance.

New Mandatory Benefits

tobacco cessation program for pregnant women

CHIP Benchmarks

- The health insurance plan that is offered by the HMO that has the largest commercial, non-Medicaid enrollment in the state. - the standard BCBS preferred provider plan for federal employees - a health plan that is available to state employees - a package that is actuarially equivalent to one of the above plans - a coverage package that is approved by the HHS secretary.

ACA and Medicare

- new benefits: cost sharing eliminated for select preventative services; coverage for personalized prevention plan, including comprehensive health assessment. - Independent Payment Advisory Board - increases the rate of mandatory payroll tax for higher income tax payers - reduces reimbursement for hospitals and other medicare providers, including skilled nursing facilities and hospices -reducing in Medicare Advantage payments

the Centers for Medicare and Medicaid Services

is the federal agency in charge of administering the medicaid program

Medicaid financing

About 57% of the total program costs are paid for by the federal government and the rest by the states.

Mandatory Long-Term Care Benefits

Nursing facility services for individuals 21 and over home healthcare services for individuals entitled to nursing facility care

Medicaid Managed Care Reimbursement

These organizations that enroll Medicaid beneficiaries receive a monthly captivated rate per member and assume financial risk for providing services; states and MCOs agree upon a set of services the MCOs will provide for the captivated rate.

Program financing occurs through

a matching payment system that divides the amount paid by the federal and state governments. The matching rate for most medical services is called the FMAP, and is determined by a formula

Medicare Advantage Reimbursement

paid and captivated rate by the federal government to provide parts A, B, and D benefits to each enrollee in their plan. Plans submit a bid to the federal government that estimates their cost per enrollee and these bids are compared to benchmarks established by statue and that can vary by county

Medicaid FFS Reimbursement

states are required to set their payment rates to physicians at levels that are "sufficient" to ensure Medicaid patients have "equal access" to providers compared to the general population; medicaid reimbursement is low; the ACA includes a temporary bump in primary care rates in both reimbursement settings.

Part D Financing

through an annual deductible, mostly premiums, general revenues, and state payments for dual enrollees.

Medicaid spending

$366 billion - 16%

Optional Acute Care Benefits

- prescription drugs - medical care or remedial care furnished by non-physician licensed practitioners - rehabilitation and other therapies - clinic services - dental services, including dentures - prosthetic devices, eyeglasses, and durable medical equipment - primary care case management - TB related services - Other specified or remedial care

Medicaid Enrollees

Traditionally, Medicaid has covered low-income pregnant women, children, and adults in families with dependent children, individuals with disabilities, and the elderly.

Part A Financing

paid from the HI trust fund, funded through a mandatory payroll tax. Employers and employees pay a tax of 1.45% of a worker's earnings, which is set aside for this fund.

Medicaid

the country's federal-state public health insurance program for the indigent. available to provide healthcare services to poorer and generally less-health beneficiaries operated by the federal and state governments

Medicaid requirements

amount, duration, scope, and reasonableness; intended to ensure that all medicaid beneficiaries in a state received adequate, comparable, and nondiscriminatory coverage.

CHIP Funds

are disbursed on a matching basis, and the matching formula is set by law. State allotments will increase in the number of children in the state, and state program expansions.

Medicaid is also partially financed through

beneficiary co-payments, co-insurance, and premiums

Chip is a

block grant

CHIP and Private Insurance

congress feared that medicaid-eligible children would sign up for CHIP instead of Medicaid, so they have to be checked to see if eligible for Medicaid; in addition, congress wanted to make sure that the government did not start funding health insurance coverage that was previously being paid for in the private sector

CHIP ___________ have the same standards regarding reasonableness, benefit definitions, medical necessity, or nondiscrimination coverage on the basis of illness.

does not

Medicare

federally funded health insurance program for the elderly and some persons with disabilities

Part B Financing

financed through general federal tax revenues and monthly premiums, deductibles, and cost-sharing paid by beneficiaries

Medically needy

intended to cover individuals who have extremely high medical expenses. these have both income and asset requirements

State Children's Health Insurance Plan

is designed to provide health insurance to low income children whose family income is above the eligibility level for Medicaid in their state; it is an optional program for the states but all 50 have chosen to participate

The federal and state governments

jointly set rules concerning who is covered and which services Medicaid provides.

Health Policy and Public Programs

policy makers must choose between state flexibility, and national uniformity, determine the appropriate role for government, the private sector, and individuals in health care financing and delivery.

_____ states receive more federal money

poorer

Medicaid Waivers

provide another level of flexibility for states; several states have implemented managed care programs, created tiered benefit systems in exchange for covering new populations, altered federal financing, or expanded coverage to low-income adults

Medicare Financing

- It is a federally funded program, state governments do not contribute to spending, so a matching system is not required. - Beneficiary contributions in the form of premiums, deductibles, and co-payments contribute to financing Medicare expenditures.

Mandatory Acute Care Benefits

- physician services - lab and x-ray services - inpatient and outpatient hospital services - early and periodic screening, diagnostic and treatment services for beneficiaries under 21 - family planning services and supplies - federally qualified health center services -rural health clinic services -nurse midwife services - certified pediatric and family nurse practitioner services

ACA and CHIP

- states must cover all children aged 6-29 up to 133% poverty level that are in CHIP and move them to Medicaid - states will bear increased cost - most children who are dropped from CHIP will be required to obtain coverage through another source

Three benchmark packages:

- the Federal Employee Health Benefits Plan - A state's health plan for its own employees - The state's largest commercial non-Medicaid HMO

Eligibility for Medicaid

-Categorical: and individual must fit within a category covered by the program - Income: and individual/family must earn no more than the relevant income limits which are expressed as an FPL percentage - Resources: an individual/family must not have nonage assets that exceed eligibility limits - Residency: An individual must be a U.S. resident of a state in which they are seeking benefits - Immigration status: immigrants must meet certain requirements, including having been in the country for at least five years

Premium assistance

means that public subsidies are available to help beneficiaries cover the cost of private health insurance premiums for employer sponsored coverage or other health insurance plans that are available to them.

Medicare Hospital Reimbursement

paid for acute inpatient services on a prospective bases using "diagnostic related groups." - for outpatient care, hospitals are reimbursed by Medicare, using a different prospective system

Medicare benefits

Part A Part B Part C Part D

CHIPRA

Children's Health Insurance Program Reauthorization Act

Medicare Part A

Hospital Insurance - inpatient hospital, 100 days at skilled nursing facility, limited home health following hospital, or SNF stay, and hospice care

Medicare Physician Reimbursement

Managed care - follow the same general rules as managed care reimbursement FFS - paid according to the Medicare fee schedule

Medicare Part C

Medicare Advantage - managed care plans, private FFS plans, special needs plans, and medical savings accounts. The plans provide all services in Part A and B and generally must offer additional benefits or services as well