Medicaid
What is Federal Medical Assistance Percentage (FMAP) for Medicaid?
- % rates used to determine the matching funds rate allocated annually to Medicaid and other programs - In 2013, FMAP rate for Texas was 60%
Who funds and administers Medicaid?
- Medicaid is funded jointly by the federal government and the states. - Each state administers its own Medicaid program within federal guidelines. - application process and benefits vary from state to state
If a state has a medicaid program, who must it cover?
- children under 19 who are full-time students - pregnant women who are medically needy - prenatal and delivery care for pregnant women - certain newborns for 1 year - protected blind persons - ambulatory care for children
Medicaid spending by eligibility group
- disabled, blind and elderly cost more than children (52%) - Children account for the largest percentage of Medicaid enrollees, following by adults, then disabled, and lastly elderly - Disabled account for the largest percentage of Medicaid expenditures, followed by elderly, then children, and lastly adults
What does "dual eligible" mean?
- low income seniors and people with disabilities are enrolled in both medicare and medicaid. - most costs covered for medicare/medicaid
Who is defined as "categorically needy?"
- low-income infants, pregnant women, and children age 1-5 with income below 133% FPL - low-income families who meet certain pre-welfare reform AFDC eligibility requirements - low-income children aged 6-18 with income below 100% FPL - Aged, blind and disabled individuals receiving SSI
Who is defined as "medically needy?"
- patients who would be eligible for Medicaid, except their incomes/resources are above eligibility level - individuals may qualify immediately or may "spend down" to qualify
What are some optional eligibility groups?
- pregnant women and children - tuberculosis patients
Medicaid cost sharing
- states can impose copayments, coinsurance, deductibles, and other similar charges on most medicaid-covered benefits, both inpatient and outpatient services, and the amounts that can be charged vary with income - out of pocket charges are based on the individual state's payment for that service - out of pocket cost cannot be imposed for emergency services, family planning services, pregnancy-related services, or preventive services for children
What are some Medicare resources?
-Centers for Medicare & Medicaid Services (CMS) - Social Security - Railroad Retirement Board - State Health Insurance Assistance Program (SHIPs) - Affordable Care Act
What determines the amount government will pay for Medicaid?
Federal Medical Assistance Percentage (FMAP) - amount of entire cost that medicaid will cover - matching system
What is medicaid and who does it benefit?
Federal-state health insurance program - redistributing the wealth among citizens - for people with limited income and resources - for people with certain disabilities
What is the reimbursement rate for medicaid?
Low, average about 57% of costs - discourages providers to provide service
Medicaid spending by type of service
Majority of spending for service is for acute care - followed by long-term care
What are the 3 classifications of medicaid eligibility groups?
Mandatory categorically needy Optional categorically needy Medically needy
Who is eligible?
People with the LOWEST income - not all low-income people - eligibility and services vary from state to state
What are "spend down" qualifications?
Some people may qualify for Medicaid if they spend the excess income on medical bills.
Mandatory/Required services
States are required to cover mandatory/required benefits through the Medicaid program - ex: inpatient and outpatient hospital services, home health services, ect.
Optional services
States can choose to cover optional benefits through the Medicaid program - ex: prescription, physical therapy, ect.
Who determine medicaid eligibility?
state
