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Briefing Book on Medicaid [1]
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51
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1
�BRIEFING BOOK
ON
MEDICAID
�MEDICAID BRIEFING BOOK
I.
BACKGROUND
A.
B.
Many Very Poor People Are Not Covered
C.
Covered Benefits Are Broad But Variable
D.
Access To Services Is Problematic
E.
Costs Are Rising Sharply
F.
States Are Experiencing Financing Problems
G.
Federal-State Govemment Relations Are Strained
H.
II.
Medicaid Program Overview
Managed Care: A State Response To Cost And Access Problems
ISSUES
A.
Medicaid Beneficiary Groups: Will Any Groups Be Integrated Into Alliance
Coverage? If So, Which Ones?
B.
Financing: What Level of Financing Effort Would Be Required Of The States
C.
Financing: How Will The Current Medicaid Underpayment
(i.e., Cost Shift) Be Financed?
D.
Changes In Covered Benefits: Would Current Medicaid Beneficiaries Have
Their Covered Benefits Decreased?
E.
Cost Sharing: Would Current Medicaid Beneficiaries Have Their Cost Sharing
Increased?
F.
Access: Would Current Medicaid Beneficiaries Experience Changes In Their
Access To Health Services?
G.
State Administrative Role Under The Reformed System
H.
The U.S. Territories
�III.
RECOMMENDATIONS AND RATIONALES
A.
Medicaid Beneficiary Groups: Will Any Groups Be Integrated Into Alliance
Coverage? If So, Which Ones?
B.
Financing: What Level of Financing Effort Would Be Required Of The States
C.
Financing: How Will The Current Medicaid Underpayment
(i.e., Cost Shift) Be Financed?
D.
Changes In Covered Benefits: Would Current Medicaid Beneficiaries Have
Their Covered Benefits Decreased?
E.
Cost Sharing: Would Current Medicaid Beneficiaries Have Their Cost Sharing
Increased?
F.
Access: Would Current Medicaid Beneficiaries Experience Changes In Their
Access To Health Services?
G.
State Administrative Role Under The Reformed System
H.
The U.S. Territories
IV.
QUESTIONS AND ANSWERS
VI.
APPENDIX
�I. BACKGROUND
A.
MEDICAID PROGRAM OVERVIEW (For additional background information,
see "Endnotes" Tab 1)
Enacted in 1965 as Title XIX of the Social Security Act, Medicaid is a Federal-State,
means-tested entitlement program that provides medical and health-related services to
certain low-income individuals.
Each state has the flexibility within broad Federal guidelines to:
•
•
•
•
1.
administer its own program;
establish eligibility standards;
determine the type, amount, duration, and scope of services; and
set payment rates.
Eligibility
a.
In 1992, it covered over 31 million eligible poor persons who were aged, blind,
disabled, pregnant, or in certain families with children.
b.
States are required to provide Medicaid coverage to most individuals who
receive federally assisted income-maintenance cash payments, and to other
related groups. These mandatory eligibility groups include:
recipients of Aid to Families with Dependent Children (AFDC);
recipients of Supplemental Security Income (SSI) for the aged, blind, or
disabled;
•
•
children born after September 30, 1992, with family incomes below 100
percent of FPL; and
•
c.
pregnant women and children up to age 6 in families with incomes at or
below 133% of the Federal poverty level (FPL) - currently $13,924 for
a family of four;
certain qualified Medicare beneficiaries with incomes up to 200% of
the FPL.
In addition to these mandated eligibility categories, states have the option to
cover other "categorically needy" groups who share characteristics of the
mandatory group. These optional categories include:
�•
•
2.
aged, blind and disabled adults with income above the SSI limit but
below the poverty level; and
•
d.
pregnant women and infants in families with incomes up to 185% of
the Federal poverty level;
certain institutionalized individuals with incomes up to 300 percent of
the SSI income limits.
States may provide coverage to "medically needy" individuals whose income or
resources exceed either the mandatory or optional categorically needy levels,
but who "spend-down" to Medicaid by incurring large medical expenses.
Coverage/Services
a.
States receiving Federal matching funds for Medicaid must provide 12
mandatory services including:
•
•
•
•
•
•
•
b.
3.
inpatient/outpatient hospital services;
physician services;
rural health clinic services;
lab and x-ray services;
early and periodic screening, diagnosis, and treatment (EPSDT) for
children under 21 years of age;
family planning services; and
nursing facility services and home health care.
In addition, states may choose to cover any of over thirty optional services
from podiatrists and optometrists to prescribed drugs and hospice care.
Payment
a.
Providers caring for Medicaid beneficiaries must accept Medicaid as full
payment and may collect only nominal additional amounts from recipients, if
states have chosen to impose copayments.
b.
Medicaid is the payor of last resort (i.e, only after all other insurance/payers
have been exhausted will Medicaid begin to pay providers).
c.
While states have broad discretion in determining payment methodologies and
rates for most services, the rates must be reasonable and adequate to assure that
services are available for the Medicaid population.
d.
The Federal govemment sets upper payment limits for some services.
�4.
Financing
The Federal govemment and the states have joint responsibility for funding the
Medicaid program.
a.
b.
Administrative costs are matched at 50 percent, however certain administrative
efforts receive an enhanced matching rate — between 75 and 100 percent.
c.
5.
The Federal share of Medicaid expenditures is inversely related to per capita
income within a state and varies from 50 percent to 83 percent. To
receive Federal funds, a state must first produce its share of payments to
providers.
Federal Medicaid program expenditures for FY 1992 were $65.9 billion and for
FY 1991 were $52.5 billion. The matching state expenditures were $48.6
billion and $40 billion for a total of $114.5 billion in FY 1992 and $92.5
billion in FY 1991.
Growth in Medicaid
The Medicaid program has been growing at an increasing rate and Medicaid
expenditures have been identified as a major cause of state budget problems
(accounting for about 14% of total state budgets).
1991-92
29%
a.
Federal Medicaid Growth Rate
(actual outlays)
1990-91 1989-90 1988-89 1987-88
28%
19%
14%
11%
A combination of factors has contributed to the growth in Medicaid expenditures.
•
The recipient population has increased.
•
Medicaid, for example, pays for nearly 40 percent of all births annually
in the U.S. and covers over 10 percent of the total population.
�Most recently, the Medicaid population grew by 11 percent in FY 1992,
after growing 12 percent in FY 1991. These increases are due to a
combination of congressionally mandated eligibility expansions, an
increase in the utilization of programs for the poor, and a slowdown of
the national economy.
Continued increase in overall health inflation.
State's use of donations and provider tax programs to raise Federal
matching funds.
6. Distinct Programs Within Medicaid
In the analysis for health care reform, Medicaid was divided into a number of distinct
programs:
a.
Acute care: Medicaid currently covers all comprehensive benefits that will
be covered in the new system, such as hospital and physician services.
However, because a number of services covered under Medicaid are optional,
not all states cunently cover all of these services. Most spending for these
services is in two major eligibility categories:
•
Low-income women and children eligible for AFDC, and pregnant
women and young children with family incomes set at certain poverty
levels, and
•
Individuals with physical and mental disabilities eligible for SSI (some
persons with disabilities will become eligible for Medicare after the 24
month waiting period, but most do not have enough work credits to
qualify for Medicare eligibility).
b.
Mental Health: Medicaid covers inpatient and outpatient mental health and
substance abuse services, but does not cover most adult residential treatment,
such as services in most state mental health facilities. The new system will
most likely provide comprehensive mental health services, without the
limitations of the current Medicaid program that excluded coverage for services
in state residential facilities.
c.
Medicare cost sharing: Medicaid pays for Medicare cost sharing for lowincome qualified Medicare beneficiaries (QMBs). Even if the Medicare
program remains outside the new system, low-income Medicare beneficiaries
will still need premium and other cost sharing subsidies.
�Long-term care: Medicaid provides services for low-income frail elderly and
physically and mentally disabled individuals in nursing facilities (post-acute
and custodial) and in some community-based settings. The comprehensive
benefit package includes services in the community and nursing homes on a
"post-acute" basis. Services beyond the post-acute stage or in a health
maintenance mode, at a minimum, would continue to be available through the
states to those currently eligible for them.
Territories: Medicaid includes a limited matching program for U.S. territories.
Puerto Rico has the largest program.
7.
Current Medicaid Spending
The following table displays preliminary estimates of the distribution of Medicaid
Federal and state spending among the distinct categories described above.
Medicaid
FY 1993 Spending Levels
(in billions)
Number of
beneficiaries
Federal
State
Total
Acute Senices-AFDC
Children/Adults
$24
$18
$42
22 million
Acute Services-SSI
Elderly/Disabled
$14
$11
$25
8 million
Acute Services-Mental HealthAFDC/SSI Disabled
$7
$5
$12
Medicare Cost Sharing-Elderly/Some Disabled
$7
$5
$12
4 million
Long-term Care-SSI
Elderly/Disabled
$26
$20
$46
2 million
Territories
$0.1
$0.5
$0.6
1 million
$78
$59
$137
|| TOTAL
Source: HCFA, Office of the Actuary
�B.
MANY VERY POOR PEOPLE ARE NOT COVERED
1.
Medicaid covers 47% of people below poverty and 28% of persons below 200% of
poverty.
2.
In 1991, of 33.6 million poor people (100% of the FPL), [see Tab 1]
40% were insured through Medicaid
13% were insured through Medicare
16% had private health insurance
29% were uninsured
2% had other insurance coverage
F.ligibility Varies Among the States
3.
Medicaid is both a categorical and an income-related eligibility program covering
more than 50 eligibility groups, [see Tab 2]
Examples
Categorical Eligibility
•
AFDC eligible children and their adult caretaker relatives
•
Aged, blind or disabled persons qualifying for Supplemental Security Income
(SSI)
Some groups are not eligible regardless of income or medical problem — because
they do not belong to any eligibility category
•
non-disabled single adults
•
non-disabled childless couples
Income Eligibility varies by family size up to State-specified limits (Examples are for
a family of 3):
•
$1,788 in Alabama
•
$2,448 in Arkansas
•
$7,956 in Califomia
•
$8,076 in Vermont
4.
35 states have AFDC/Medicaid income eligibility thresholds that are below 50% of
the Federal poverty level (FPL) for a family of 3 members.
5.
In 12 states, not all aged, blind, and disabled SSI recipients are eligible. These states
have chosen to use a more restrictive standard of income or disability.
�6.
States vary widely in covering optional eligibility groups. For example:
•
9 states have elected to cover all elderly or disabled people with incomes
below 100% of poverty.
•
For pregnant women and infants, 24 states cover all persons up to 185% of
poverty; 7 states cover all persons from 134%-184%; 19 states cover all
persons below 135%. [see Tab 3]
•
37 states cover some or all categories of medically needy.
C.
COVERED BENEFITS ARE BROAD BUT VARIABLE
1.
When compared to most commercially-available health insurance, Medicaid benefits
are more extensive by far — but availability varies significantly among the states.
a.
States must cover 12 Federally mandated services, but can impose limits on the
amount, duration or scope of those services (e.g., Florida restricts hospital
coverage to 45 days per fiscal year for those over age 20).
b.
33 optional benefits may be chosen by the states to be covered by Medicaid
and their cost can be included in the Federal-state match formula, [see Tab 4]
•
•
•
17 states cover 20 or fewer benefits
3 states cover 30 optional benefits
14 states cover these optional benefits only for people who are
categorically eligible; the other states cover at least some of those
optional services for both the categorically and medically needy
Example:
•
physical therapy - 41 states cover this benefit, but 12 cover it only for
the categorically needy.
•
c.
All but 2 states cover intermediate facility care for persons with mental
retardation and developmental disabilities: in 1988, an estimated $6
billion was paid for care of 146,000 individuals.
States may apply and receive a federal waiver to furnish non-medical, social
and supportive community-based services (e.g., minor home modification,
respite care) on certain targeted populations who are at risk of institutionalization (e.g., mentally retarded, chronically ill, disabled children, persons with
AIDS). (Average per capita expenditures may not exceed what they would
have been in the institution), [see Tab 5]
�d.
Medicaid assists low-income elderly with their Medicare costs by covering
their Medicare Part B premium, and cost sharing for Part A and Part B
services.
D.
ACCESS TO SERVICES IS PROBLEMATIC
1.
For many who are enrolled in Medicaid, being covered for benefits does not translate
into access to health care providers.
a.
Physician participation in Medicaid: [see Tab 6]
•
•
•
•
b.
34% participate in full
35% limit participation
5% participate but accept no new patients
26% do not accept Medicaid patients
Pediatrician participation in Medicaid: [see Tab 7]
•
•
30% limit participation
23% do not accept Medicaid patients
c.
Medicaid physician payments were found in 1991 to average 69% of Medicare
prevailing charges, varying among states from 30% to 120%. [see Tab 8]
d.
Hospitals report that in 1991, Medicaid payments covered only 82% of costs,
[see Tab 9]
e.
In medically underserved rural and inner city areas where access is a particular
problem, the hospital emergency room (especially in public hospitals) becomes
a source of primary care. The DHHS Inspector General has estimated that
one-half to two-thirds of Medicaid emergency room care is not for emergencies, [see Tab 10]
1,800 community and migrant health centers serve about 6 million Medicaid
and other low-income people.
f.
The effects of limited access are mixed:
•
In 1992, for 4 preventive services, Medicaid beneficiaries ages 18-64
had approximately the same utilization rate as the rest of the population
of the same age group.
•
Medicaid beneficiaries between 18-64 exhibiting one of 5 symptoms
saw physicians at higher rates than non-Medicaid individuals, [see Tab
11]
�•
Medicaid-eligible children accounted for 86% of pre-school measle
cases in Milwaukee, 75% in New York, and 60% in Los Angeles, [see
Tab 12]
•
In 1989, EPSDT screenings were estimated nationwide at 39% of
prescribed standards (ranging in the states from 7% to 92%). [see Tab
13]
E.
COSTS ARE RISING SHARPLY
1.
Through 1988, Medicaid spending increased at a rate similar to the overall growth in
medical spending.
2.
Beginning in 1989, spending in Medicaid accelerated compared to the year before:
[see Tab 14]
•
•
•
•
3.
in
in
in
in
1989
1990
1991
1992
The Federal share of Medicaid costs has increased: [see Tab 15]
•
•
4.
13%
18%
27%
30%
$35 billion in 1989
$89 billion in 1994.
The reasons for such rapid increases in spending include: [see Tab 16]
•
Enrollment growth of about 5 million (34% of cost growth)
—28% of increase was traditionally eligible low-income families
—55% of increase was pregnant women and children
—17% of increase was aged and disabled persons
(Causes are Federal legislative mandates, the recession, eased enrollment
processes, and AIDS).
•
Medical price inflation (31% of cost growth)
•
Service use and price increases above inflation (28% of cost growth)
•
Payments to Medicare and to HMOs (6.5% of cost growth)
�5.
Fund sources for much of this expansion have been aggressively used by states
through provider taxes and donations.
6.
The 4 largest service categories in Medicaid (FY 1993) are:
•
•
•
•
inpatient hospital care (20%)
nursing home care (20%)
prescription drugs (6%)
physician services (6%)
F.
STATES ARE EXPERIENCING FINANCING PROBLEMS
1.
States pay a share of Medicaid program costs: the statutory maximum state share is
50% (12 states); and, the minimum is 17% (Mississippi is lowest at 20%). 14 states
contribute less than 30%.
2.
From 1989 to 1991, the proportion of states' budgets for Medicaid has increased by
17%, from 9% to 10.5%. In 1992, it is estimated that Medicaid absorbed one-half of
all new state dollars. (For examples from 4 states, [see Tab 17])
3.
14 states require local funding of at least some portion of the provider payments. For
example, in Pennsylvania, counties pay 10% of the state's share for county nursing
homes; in New York, counties pay 20% of the state's share of long-term care, and
50% of the state's share of all other costs, [see Tab 18]
4.
These increases came just at a time when state tax revenues were declining because of
the recession and Federal mandates and recession-associated enrollment increases
were raising costs. State balanced budget requirements and limited "rainy day"
reserves restricted states'financingflexibility.
5.
Simultaneously, in 1991, hospitals and nursing homes in 21 states responded to low
Medicaid payment rates by suing states for higher payments. This occurred just when
resistance was very strong from employers and insurers to paying "surcharges" to
subsidize "free" care for the poor.
�6.
States used two techniques to artificially increase Federal Medicaid payments:
•
Provider Donations and Taxes (D&T): States taxed hospitals and other
providers, returned the funds in higher payments, then claimed increased
federal matching funds for the higher payments. States also obtained
"donations" from providers to similarly increase Federal funding. In 1990,
fewer than 10 states had D&T programs costing about $500 million; in 1993,
over 40 states have such programs costing nearly $9 billion. In 1992, CRS
reported that in 5 states, D&T payments accounted for more than 30% of the
states' Medicaid payments, [see Tab 19]
•
Disproportionate Share (DSH) Payments: States are required to make
additional payments to hospitals that serve a higher than average number of
Medicaid and other low income patients — "disproportionate share" hospitals.
This became a vehicle for returning some D&T funds to hospitals. In FY
1990, such payments totalled $831 million; in 1992, $8 billion.
•
1991 legislation limited both D&T and DSH payments.
G.
FEDERAL-STATE GOVERNMENT RELATIONS ARE STRAINED
1.
The fundamental design of the Medicaid program, as a Federal-state "partnership,"
created a situation in which there would always be a dynamic tension between the
partners.
2.
The Federal govemment sets national standards of performance with which individual
states, regardless of their particular characteristics, must comply. Then the Federal
govemment ensures compliance and imposes penalties for shortcomings.
Critics, in both the executive and legislative branches, are constantly challenging state
decisions and accusing states of lukewarm commitment to the needs of the poor,
inefficient administration, over-readiness to accommodate a narrow set of provider
and taxpayer interests, and wastefulness of federal funds. Each year, critics are
proposing to tighten or loosen (sometimes both simultaneously) Washington's direction
of the program.
3.
State governments have options — in choosing certain income and categorical
eligibility standards, and in selecting some covered benefits — and responsibility in
setting provider payment standards. They act within Federal guidelines to assess
provider qualifications, to manage program operations (including the eligibility
determination process), to assure access to, and control utilization of, needed services.
And states must raise the 20-50% of program costs for which they are responsible.
�b.
c.
3.
Currently, all but two states either have, or are implementing, some form of
managed care program for Medicaid recipients.
Managed care typically covers acute care needs of families with children.
States have adopted three models of Medicaid Managed Care:
a.
Fully Capitated Programs - (Health Maintenance Organizations (HMOs) and
Health Insuring Organizations (HIOs)).
b.
Partially Capitated Programs - (Prepaid Health Plans (PHPs)).
c.
Managed Fee-For-Service Programs - (Primary Care Case Management
(PCCM) Programs).
�n. ISSUES
A.
MEDICAID BENEFICIARY GROUPS: WILL ANY GROUPS B E
INTEGRATED INTO ALLIANCE COVERAGE? I F SO, WHICH ONES?
1.
Issues
a.
Which Medicaid beneficiaries can be "mainstreamed" into the new system?
Will the needs of those former Medicaid participants who are "mainstreamed"
differ from other low-income participants in the new system? If so, how will
those different needs be accommodated?
b.
What will be available for individuals not included in the new system? What
system will be established to meet the needs of these people? How will their
care be financed?
2. Discussion
a.
Groups for which decisions are required:
Under-65
•
•
•
AFDC-related families, poverty-related pregnant women and infants,
and poverty-related children
SSI blind and disabled on Medicaid (including QWDI, under 65 QMBs
and SLMBs)
institutionalized SSI disabled
Over-65
•
•
•
b.
Medicare/Medicaid dual eligibles
Special Medicare groups (QMBs, SLMBs)
institutionalized elderly
Criteria used for determining which Medicaid eligibility groups will be
incorporated into the new system. Note: As degree of self-sufficiency
diminishes and degree of institutionalization increases, mainstreaming appears
to become more problematic.
•
Ability to manipulate through the health alliance registration process.
•
Ability (with help) to understand differences among available health
plans and to make an informed and reasoned choice.
�•
•
Compatibility of beneficiaries' service requirements with accountable
health plans' capabilities (degree of administrative assistance, special
outreach, exceptional services required to effectively serve client).
•
c.
Ability to understand and comply with health plan rules and processes.
Impact on funding streams.
Certain assumptions were made about the design of the mainstream system.
These are:
•
Beneficiaries will be responsible for some greater or lesser share of plan
premiums, depending upon their income and/or employment status.
•
Considerable cost-sharing by beneficiaries will be required both as a
revenue source and as a utilization control device.
•
Subsidies will be available for both premiums and cost sharing for lowincome persons. These subsidies will cover:
(a)
100 percent of such costs for persons whose family income does
not exceed 100 percent of the Federal poverty level (FPL), and
(b)
a lesser amount for persons whose family income is between 100
percent and 200 percent of the FPL.
Stop loss provisions applying to cost-sharing will apply both in the
comprehensive package of benefits as well as in any supplemental
package, if the latter is not handled as part of a continuing residual
Medicaid program.
There will be no "spend-down" process under the new health care
reform system comparable to current Medicaid spend-down for the
comprehensive benefit package.
3.
Options and Implications
a.
Do not include Medicaid in the new system and retain the existing Medicaid
program.
•
This option would emphasize that the Medicaid eligible poor are going
to be treated differently than everyone else. Even if the benefits were
more generous than for those in the new system, concerns over a twotier system would be voiced. In addition, since the non-Medicaid poor
would be in the new system, administrative headaches would multiple.
�b.
Include all of these groups into the health alliance system, but retain
categorical identification. Extend the special rules on cost-sharing and other
eligibility standards to any other persons who may in the future
qualify as members of the groups as determined by historical Medicaid rules.
•
c.
This option essentially would extend current complex Medicaid rules
into the health alliances indefinitely. As the new system moves away
from a Medicaid base, such rules may become increasingly difficult to
apply.
Integrate currently eligible persons in certain Medicaid categories into the
health alliance system, but no longer retain the categorical distinctions; and
retain a number of the above groups in the residual Medicaid system and let
them continue to receive their needed services under continuing Medicaid
eligibility rules.
This option would eliminate the need for the current complex Medicaid
rules for a large segment of the poor, primarily low-income women and
children.
Retaining Medicaid for certain groups would be particularly attractive
for the SSI-related elderly.
However, special Medicaid rules designed to help certain higher income
individuals might be lost, e.g., free coverage for pregnant women and
infants with family income up to 185 percent of the Federal poverty
level, if they are included in the new system.
B.
FINANCING: WHAT L E V E L OF FINANCING EFFORT WOULD B E
REQUIRED OF THE STATES?
1.
Issues
a.
What level of current state health spending will states be required to maintain
to costs of the reformed health system?
b.
How will the global budget impact the states?
�2.
Discussion
a.
The following tables display preliminary estimates of the distribution of
Medicaid Federal and state spending among the distinct categories described
above.
Medicaid
FY 1993 Spending Levels
(in billions)
Number of
beneficiaries
Federal
State
Total
Acute Services-AFDC
Children/Adults
$24
$18
$42
22 million
Acute Services-SSI
Elderly/Disabled;
$14
$11
$25
8 million
Acute Services-Mental HealthAFDC/SSI Disabled
$7
$5
$12
Medicare Cost Sharing-Elderly/Some Disabled
$7
$5
$12
4 million
Long-term Care-SSI
Elderly/Disabled
$26
$20
$46
2 million
Territories
$0.1
$0.5
$0.6
1 million
$78
$59
$137
• ^ "
In addition to Medicaid funding, state and local governments contribute to the
funding of health services for the indigent or other population groups through a
variety of mechanisms. Examples:
•
State appropriations to public institutions explicitly to underwrite costs
of indigent care (e.g., Virginia appropriation to the Medical College of
Virginia).
•
State fee-for-service payments to health providers for services for
indigent persons covered under a state-financed program (e.g., general
medical assistance) who are not eligible for Medicaid.
Hospital district add-ons to local property tax rates to be used for
indigent care.
�State appropriations for provider payments for treatment of certain
diseases (e.g., Missouri appropriations for treatment of cystic fibrosis
and hemophilia).
b.
State Maintenance of Effort Calculations
The calculation of the state contribution to the new system or maintenance of
effort involves defining the scope of the current effort, the beginning point
(base year) and the growth factor (indexing mechanism). Each of these factors
could impact a particular state differently. The representatives of the States
have indicated that they are primarily concerned about determining a
maintenance level that, for the near term, remains as closely related to their
current level of spending as possible. In the long term, states acknowledge the
need for a more "equitable" distribution of state spending. However, if
"equity" were addressed explicitly in the legislation, everyone believes that
Congress would be tied up for a long period of time in a "formula fight"
determining exactly what factors to include and the varying impact on their
state.
c.
Global budget
Because states are likely to be at risk for some or all of the spending above the
global budget, the operating and risk-sharing elements of the global budget has
a significant impact on the states. The assumption is that the global budget
will be applied on a state-by-state basis with a target premium growth rate.
States would be given the authority/tools that would allow them to control
health spending.
3.
Options and Implications
Maintenance of Effort:
a.
State Medicaid share only with base year selected to exclude or include
effects of provider taxes and donations. Short-run and long-run indexing
mechanisms would be specified.
Developing a current effort standard could be relatively simple in the
short term. Contributions based on current spending would involve
little disruption for states in terms of changing their financing burdens.
�A current effort approach would also act as a ceiling on state
contributions. As a result, the Federal govemment and the private
sector presumably would be at risk for all subsidy costs that exceed
state current contributions.
Given the tremendous volatility in recent Medicaid spending and the
reliance of a current effort standard on continually aging data from a
fixed, historic base year, any estimate of what states would spend on
Medicaid in the future is likely to be "inaccurate."
Keying off current state spending freezes the relative distribution of
state spending. Therefore, states that have chosen to cover many or
virtually all optional services and eligibility categories under Medicaid
would pay more relative to states that have not chosen to do so. This
could penalize generous states and reward "low-effort" states. On the
other hand, states that devote relatively more state resources to health
spending would face greater financial exposure in the absence of health
care reform and, therefore, are likely to save more under these reforms.
A Medicaid-only approach also may present difficulties in terms of
States that operate all or substantial portions of their Medicaid programs
under demonstration waivers. For example, under §1115 waivers,
Oregon has used Medicaid as a vehicle for expanded access to nonMedicaid eligibles in the State. This would increase its current effort
contribution dramatically of the category of people that no other state
would be require to fund.
b.
Medicaid plus to include not only Medicaid but other current health spending
(state only or state/local Medicaid contribution).
This approach increases significantly the scope of the maintenance of effort by including the spending by the state beyond the
Medicaid program, to other state, county, and local funds.
The information needed to implement this option is very unreliable.
States vary tremendously in the size of their non-Medicaid health
spending. Data at the county and city level is incomplete.
c.
Per capita: health alliance premium for Medicaid beneficiaries multiplied by
the number of beneficiaries, and by a percentage share of the costs (e.g., 5083% based on state per capita income, the current Medicaid formula). Each
state's premium contributions would be trended forward by the annual
percentage growth in the weighted average health alliance premium in the state.
�This approach attempts to avoid many of the complications of using
current Medicaid spending noted above by using the premium costs of
Medicaid enrollees as a proxy for state spending.
On the other hand, this approach would not relate to current state
spending and would require a long debate on exactly what formula was
to be used to determine the "appropriate" state-by-state funding.
Global Budget:
a.
The global budget would be applied on a state-by-state basis with a target
premium growth rate with a "risk" band of several percentage points with the
states required to fund growth rates in the "risk" band. Above the "risk" band,
the Federal govemment would actively intervene and possible take over
management of the health system in that state.
Under this option, states would be the only group "at risk" if the
budgets are not met. This would be troublesome for states, particularly
during the early years when the budgets are set without any real data.
The authority to control spending will be politically hard to enforce.
b.
The states and the Federal govemment would share responsibility for spending
above the budget. Some of the authority to control spending would be retained
by the Federal govemment.
•
This approach would reduce the fiscal impact on states and increase
Federal spending.
•
Divided authority to control spending would increase the amount of
political conflict.
C.
FINANCING: HOW WILL THE CURRENT MEDICAID UNDERPAYMENT
(I.E., COST SHIFT) BE FINANCED?
1.
Issue:
How would any shortfalls in current Medicaid payments to health care providers be
financed under reform?
�2.
Discussion:
a.
The current Medicaid program is reported to underpay hospital and physician
charges.
•
In 1991, AHA-member community hospitals reported that Medicaid
paid 82% of their costs, an underpayment of $5 billion. 19% of
responding hospitals reported that Medicaid payments covered full costs
incurred by Medicaid beneficiaries, (see AHA Fact Sheet [see Tab 9])
•
In 1991, Medicaid physician payments were found to be on average,
69% of Medicare prevailing charges, varying among states from 30%
to 120%. (see Physician Payment Review Commission report [see Tab
26])
•
Such shortfalls are reported to affect Medicaid beneficiaries as follows:
(a)
(b)
(c)
b.
access to care (i.e., provider willingness to serve Medicaid
beneficiaries);
site of care (e.g., overuse of hospital emergency rooms); and
use of needed services (i.e., some needed care is foregone).
Current funding of these and other shortfalls includes:
•
Medicaid payment for uncompensated care;
•
State grants to hospitals for indigent and uncompensated care; and
•
Hospital-imposed surcharges on insured patients which cross-subsidize
indigent ("free") care, bad debt and payment shortfalls (e.g., Medicaid,
contractual allowances).
(Examples: New Jersey mandated until recently a 19.1% add-on to commercial
insurance payments. New York requires several payment "differentials" some
of which flow to several statewide and regional bad debt and charity pools.)
3.
Options and Implications:
a.
Explicitly finance underpayments: furnish public payments sufficient to
overcome underpayments by raising provider payments to, for example,
Medicare payment levels.
Increase the capitation payment to the health alliance to adjust
for lower than average payment rates for Medicaid eligible.
�The alliance would have sufficient funds to require provider
payments to be equal for all, so discrimination on the basis of
payment would be removed.
Since all uncompensated care would now be paid for, private
provider rates that previously included the cross-subsidy for this
uncompensated care would decrease.
b.
Implicitly finance underpayments: have capitation and premium
financing levels set to cross-subsidize Medicaid beneficiaries.
Maintain the capitated payment to the health alliance at the
current Medicaid payment level.
The alliance would not have funds to require provider payments
to be equal for all at the current rates, so discrimination on the
basis of payment would be possible.
However, since all uncompensated care would now be paid for,
rates could be lowered for all providers and still maintain a
Medicaid cross-subsidization.
c.
Do notfinancepayment shortfalls, but address it as components of
global budget ceilings.
Inclusion of shortfalls in the global budget ceilings will promote
stronger incentives for system efficiencies.
D.
CHANGES IN COVERED BENEFITS: WOULD CURRENT MEDICAID
BENEFICIARIES HAVE THEIR COVERED BENEFITS DECREASED?
1. Issues:
When Medicaid beneficiaries are shifted from current Medicaid into the new system,
could they experience a diminution in covered benefits?
2.
Discussion:
a.
Medicaid has among the most extensive package of covered benefits of any
insurance program in the United States — acute care, extended acute care,
chronic care, long-term care (both community and institution-based).
�In practice, benefits vary from state-to-state depending upon state choices to
cover optional benefits or limit the amount, duration or scope of benefits it
does cover. Therefore, beneficiaries can experience differences in benefits
depending upon state of residence, and depending (in some states) on whether
they are categorically eligible or medically needy.
b.
The standard benefit package under a reformed health program is unlikely to
include all of the benefits Medicaid currently covers in the most generous
states. Therefore, some — and perhaps most — Medicaid beneficiaries
moving into the reformed system may have benefits coverage reduced, if no
provision is made for supplementing the basic benefit package. Examples of
services which may not be included in the standard benefits package are:
•
•
3.
enabling services (e.g., transportation to medical appointments)
•
c.
eyeglasses, some adult dental (dentures and crowns)
extended care services that (a) exceed limits placed on core benefits
(e.g., mental health or substance abuse visits, extended rehabilitation
services), or (b) are not included in long-term care coverage (e.g.,
durable medical equipment, skilled or unskilled home health services)
Nature and extent of non-covered services will depend in large measure upon
the "mesh" between acute care, extended or chronic care, and long-term care
(institutional or community-based).
Options and Implications:
a.
Require states to cover and fund all currently-covered benefits that exceed the
basic benefit package.
•
•
b.
Unless benefits are made available to all low-income in the state,
inequities would exist within income groups.
State funding of such "supplemental" benefits would reduce state funds
available to support basic benefits subsidies for the low-income.
Federally mandate a standard package of supplemental benefits for Medicaid
beneficiaries; give states the option to extend such benefits to other lowincome.
•
Avoids inter-state equity considerations.
�•
•
c.
could increase costs in some currently low-benent states.
Reduces state funds available for basic benefit subsidies,
Give states unrestricted option in covering supplemental benefits.
•
In states electing to cover few or no supplemental benefits, Medicaid
beneficiaries could be exposed to substantial out-of-pocket costs and/or
denied needed services.
•
Would continue interstate inequities.
•
Is most responsive to states' expressed interests.
E.
COST SHARING: WOULD CURRENT MEDICAID BENEFICIARIES HAVE
THEIR COST-SHARING INCREASED?
1.
Issue:
When current Medicaid beneficiaries are shifted into the new system, could/should
they experience increases in their cost sharing (premiums, deductibles, co-payments,
out-of-pocket exposure)?
2.
Discussion:
a.
Medicaid beneficiaries' current cost sharing for acute care services is limited by
statute to amounts considered "nominal." Certain classes of people and
services are excluded from cost-sharing. Schedules of enrollment fees and
premiums, maximum allowable charges, and examples of charges are defined
in the regulations. [National Governor's Association, 1/1/91]
Cost sharing for nursing home residents has been redefined in recent years to
make more explicit amounts of family income and resources required to be
contributed to the costs of nursing home care and, conversely, amounts to be
retained by a spouse in the community. For example, enough of the
institutionalized spouse's income must be left with the community spouse to
raise the latter's income to at least 150% of poverty (but generally not over
$1,500 per month). The community spouse may also protect at least $12,000
in resources (up to $60,000 at state option).
�b.
The essential tensions in cost sharing are:
•
•
raising some funds to assist in program financing without making their
collection administratively costly and burdensome; and
•
c.
preventing overutilization of services while not deterring use of needed
services;
differentiating between people and services in ways that create
appropriate incentives (e.g., for in-plan versus out-of-plan use of
providers, and for prevention vs. emergency room) and equities (e.g,
compared to other plan participants).
In a draft report, the DHHS Office of the Inspector General concluded that:
•
•
states with cost sharing do not report significant impacts on utilization;
or
•
3.
states without cost sharing could save an estimated $167-335 million;
cost sharing states have not experienced excessive administrative,
recipient or provider burdens.
Options and Implications:
a.
Set special cost-sharing standards for Medicaid beneficiaries such that current
beneficiaries experience no increase in cost sharing, but phase their special
treatment out over time (i.e., don't accord that protection to newly-entering
Medicaid-eligibles).
•
Inequitable: would treat Medicaid-eligible categories of people
different from other very similar low-income people (e.g., children in
Medicaid families different from children at identical income levels in
non-eligible families).
•
Complex Administration: simultaneous management of dual systems of
subsidies for health alliances and health plans.
•
Confusing For Beneficiaries: example - when someone married or
passed a birthday, with no change in income their subsidies would
change.
�b.
Treat Medicaid beneficiaries the same as other people at their income levels:
for example, full subsidies below poverty, subsidies tapering down as income
rises above poverty, and subsidies ending at 200% of poverty (with costsharing capped by out-of-pocket maximums).
•
Equitable among low-income groups.
•
Some current beneficiaries gain: example - where a state's current
income eligibility level is at 65% of poverty, a person at 80% must
now "spend down" to obtain coverage but would not do so under a
below-poverty/full-subsidy rule.
•
Some current beneficiaries lose: examples - SSI blind and disabled
with high incomes (due to state supplementation); pregnant women and
their infants 100-185% of poverty; working disabled persons who no
longer receive SSI but need financial assistance with medical and
personal assistance costs; specified low-income Medicare beneficiaries
with incomes below 110% of poverty (120% in 1995) for whom
Medicaid pays Medicare Part B premiums; qualified working disabled
with incomes below 200% of poverty for whom Medicaid pays Medicare premiums.
F.
ACCESS: WOULD CURRENT MEDICAID BENEFICIARIES EXPERIENCE
CHANGES IN THEIR ACCESS TO HEALTH SERVICES?
1.
Issue:
In underserved areas, Medicaid beneficiaries have developed relationships with health
service providers who meet their needs (especially crucial for the chronically ill). Will
these relationships be changed under reform? Certain providers have become qualified
Medicaid providers (e.g., health centers, individual physicians); would they lose their
provider status? Specifically,
•
Should certain health provider organizations and individuals be designated as
"essential community providers?" If so, how would health alliances and health
plans be expected to integrate with them?
•
How will boundaries of health alliance regions and sub-regional service areas
be defined in a manner that protects these groups?
•
How will comparable levels of choice and access be assured?
•
Are there special standards that would have to be met by health plans serving
substantial numbers of such people?
�Would health plans be permitted to serve only these populations? If so, what
special standards would they have to meet?
What would be the requirements on health alliances and health plans regarding
assurance of access and quality for these groups?
2.
Discussion:
a.
b.
Medicaid beneficiaries have sought out combinations of providers to whom
they look for health services — hospital emergency rooms; public, philanthropic and private clinics; individual practitioners (including "informal"
healers); drug and equipment vendors. These include federally qualified health
centers (e.g., community and migrant health centers), National Health Service
Corps personnel, and professional volunteers.
c.
State Medicaid programs have increasingly enrolled beneficiaries in managed
care programs designed to overcome some access barriers, to improve
continuity of care, and to help beneficiaries obtain services in appropriate sites
in a timely manner. In 1991, 2.8 million beneficiaries were enrolled in 33
states (7 states had more than 25% of beneficiaries enrolled).
d.
3.
72 million people (including many Medicaid beneficiaries) live in areas
designated as underserved — 34 million in rural areas and 38 million in the
inner city. They face combinations of service barriers (providers who will not
serve Medicaid beneficiaries and other low-income people), geographic
hankE, organizational barriers (excessive travel, inadequate transportation,
inconvenient hours), and cultural, knowledge and language barriers.
For additional discussion, see Cluster II Working Group 8 Tollgate 5 paper
(pages 97-105).
Options and Implications:
a.
No special provision for current Medicaid arrangements:
•
some providers would become part of one or more accountable health
plans while other providers would not; and
•
some beneficiaries would be able to continue their relationships with
their current providers while others would need to be furnished by the
AHP with new arrangements.
�b.
Include transitional special requirements for certain Medicaid providers to
continue services independently, as AHPs, or as sub-contractors to AHPs.
Examples include federally-qualified health centers, public hospital clinic
systems, primary care group practices with large Medicaid patient clientele.
This may,
•
help preserve a delivery infrastructure in which the federal government
has made considerable investment to build up;
•
open doors to continued participation of groups some of which may be
delivering wasteful or low-quality care; and
•
could subject AHPs to complex and contentious actions to
oversee/control external providers.
G.
RESIDUAL MEDICAID: STATE ROLE
1.
Issue:
What policy, administrative and financing roles will the states have in the reformed
health system?
2.
Discussion:
a.
States have important roles under the current program
Policy Roles
•
•
•
•
•
•
•
•
Setting income eligibility standards
Coverage of optional eligibility groups
Coverage of optional services
Setting provider payment levels
Implementation of systems of managed care
Limitations on amount, duration or scope of covered services
Seeking Federal waivers to vary coverage among different groups or
across different parts of the state
Raising funds for the state share of program costs
Administrative Roles
•
eligibility determination
•
claims processing
•
provider certification
•
recoveries from other insurers
•
program controls (eligibility errors, computerized management information system, quality and appropriateness of care, enforcement of Federal
nursing home standards, fraud and abuse investigation)
�Financing Roles
•
3.
20-50% of program costs, averaging 43% nationwide
Options and Implications:
a.
Residual Medicaid program (acute and institutional services) would be
maintenance for long-term institutionalized disabled (e.g., physically disabled,
MR/DD) and frail elderly.
•
States would continue to pay state-owned and privately-contracted
institutions for institutional care; acute care outside the institution (e.g.,
hospital services) would be directly paid by the state.
alternative: acute care arranged through health alliance system
funded by govemment subsidy of capitation
•
Funding would continue to be federal formula matching of state
payments.
alternative: national premium tax revenues distributed to the
states to meet the institutional costs
•
b.
States would maintain quality, payment, third party liability functions.
Residual Medicaid program for supplemental services (e.g., excluded services
like adult dentures; enabling services like transportation; gap-filling basic
services like those limited in amount or duration or falling between acute and
long-term care) would be maintained. This would:
•
Require decisions about whether there would be national mandates for
these services or states would have options to select them;
•
Create an incentive for employers to lobby services out of basic benefit
coverage (knowing Medicaid would assist the poor); and
•
Encourage states to fund some portion of supplemental services creating
additional demands on maintenance of effort funds.
�c.
Residual Medicaid wrap-around for certain Medicare beneficiaries (e.g., costsharing for those with low-incomes; wrap-around benefits such as prescription
drugs; interim coverage for disabled during 2-year wait for eligibility) would
be maintained. This would,
•
Raise objections from the growing elderly population to the states as
representing an uncontrollable cost raiser.
alternative: broaden Medicare benefits and cover all of
beneficiaries' needs within Medicare
alternative: provide Medicare beneficiaries' services through the
health alliance with Medicare as a third-party resource
d.
Residual Medicaid to administer states' financing maintenance of effort would
be maintained.
H.
MEDICAID AND THE U.S. TERRITORIES
I.
Issue:
How will the U.S. Territories and the Commonwealth of Puerto Rico be treated both
financially and programmatically under the new health care reform system?
2.
Discussion:
a.
The territories have very little private insurance-based health care. They rely
heavily on public health systems and public hospitals to deliver care to
everyone — Medicaid-eligibles and others (including categorically noteligible) — and public financing flows through that system. Consequently,
such Medicaid features as "freedom of choice" of providers do not apply.
b.
These jurisdictions "overmatch" Medicaid funds. That is, they put public
subsidies into the health care system to subsidize care for all, not just Medicaid
beneficiaries. Based on fiscal year 1991-1992 estimates from the Commonwealth of Puerto Rico, the "overmatching" for Medicaid purposes adds $491
million to $79 million now being used to match an equal amount of Federal
funds under the current legislative caps.
�c.
The currently applicable fiscal caps which have not been updated since 1990
are:
$79,000,000 for the Commonwealth of Puerto Rico
$2,600,000 for the Virgin Islands
$2,500,000 for Guam
$750,000 for the Northern Marinas Islands
$1,450,000 for American Samoa
d.
e.
3.
The overall picture is influenced by the political efforts of the Commonwealth
of Puerto Rico, which has the largest jurisdiction, in deciding whether or not to
become a state. The current gubernatorial administration in Puerto Rico favors
Statehood. Various plebiscites held over several decades have up till now
always favored continuation of the Commonwealth status.
Any changes in policies in the Territories would have an impact on health care
delivered in Hawaii and the mainland states. Where health care services are
limited in quality and scope in the offshore jurisdictions, significant numbers of
individuals travel through the "air bridge" to mainland states and Hawaii to
receive needed health care. For example: people from Puerto Rico travel to
the East Coast states, and people from Guam and the other Pacific Territories
go to Hawaii.
Options and Implications:
a.
Maintenance of Effort: scope should generally be consistent with how
maintenance of effort (MOE) is defined in the states. If the MOE for states is
broad and includes Federal/state Medicaid donations, taxes, disproportionate
share funds and local funds, then presumably any territory "over-matching"
might be counted for maintenance of effort purposes.
b.
Keep fiscal caps but establish them at levels that permit only modest "catchup" with the perceived lag in the Federal share of Medicaid expenditures over
the years. (The House Energy and Commerce Reconciliation Bill has proposed
a $25 million increase in the fiscal cap for Puerto Rico and similar increases
for the other Territories). Equity (compared to the states) would be improved.
However, the limits themselves would still be essentially arbitrary.
c.
Remove the fiscal caps; set a 50/50 matching rate. This would provide a
more ample maintenance of effort base for subsidies for low income persons in
a new health alliance system. Especially in Puerto Rico, as the current
governor has proposed, this would provide a greater opportunity for making the
private health care sector more available to low-income persons. However,
such a large increase may also have an effect on the plebescite decision about
�becoming a state. Retention of the 50/50 match would recognize the special
taxation legislation that applies to these jurisdictions.
Estimates suggest that the Federal liability under a 50/50 matching in these
jurisdictions might be as high as $600 million, in contrast to present Federal
fiscal exposure of approximately $86 million.
d.
Remove the caps; calculate the Federal matching rate as with other states.
The results would be that almost all the jurisdictions, with the possible
exception of Guam, would experience a considerable increase in matching rates
above the current 50/50 level. The Commonwealth of Puerto Rico would, for
example, have its matching rate computed at 83 percent Federal funds (the
statutory maximum), instead of 50 percent. This has the potential of providing
considerable fiscal relief to that jurisdiction.
�HI. RECOMMENDATIONS AND RATIONALES
A.
Medicaid Beneficiary Groups: Will Any Groups be Integrated into Alliance
Coverage? If so, which ones?
RECOMMENDATION
a.
Groups to be integrated in health alliance coverage (financed by employer
contributions; state and federal Medicaid subsidies; and enrollee premium and
co-payments where appropriate).
•
Under age 65
AFDC-related parents and children
poverty-related pregnant women and infants
poverty-related children
non-institutionalized SSI blind and disabled (financed by
premium surcharge)
•
over age 65
frail elderly in long-term nursing home care (acute care services
only)
b.
Groups not integrated in health alliance coverage
•
Under age 65
institutionalized mentally retarded/developmentally disabled
Medicare-eligible disabled (e.g., end-stage renal disease, AIDS)
•
Over age 65
low-income Medicare beneficiaries eligible for Medicaidfinanced subsidies of Medicare cost-sharing
frail elderly in long-term nursing home care (residual Medicaid
program finances institutional care)
RATIONALE
Medicaid integrated groups should be similar in medical and economic circumstances
as other low-income people not in Medicaid.
1.
2.
Long-term institutionalized (146,000 MR/DD in 1991; 1.3 million frail elderly)
have significant non-medical needs that are not easily compatible with health
alliance management and can be better managed by states with long experience
in this field.
Medicare beneficiaries continue to have their primary insurance through that
program with Medicaid subsidies for the low-income.
�B.
Financing: What Level of Financing Effort Would be Required of the States?
RECOMMENDATION
•
States should be required to maintain level of effort equal only to their
Medicaid funding in the base year of 1993 less disproportionate share
payments. State and local support of public mental health facilities would be
maintained outside of Medicaid and the health alliances.
•
States would furnish to the health alliance(s) amounts equal to their base year
Medicaid spending minus amounts appropriate to finance (a) enabling and
extended services; (b) long-term institutional care for the SSI disabled; and (c)
subsidies for low-income Medicare beneficiaries.
•
Retained funds would be administered directly by the states or through health
alliances for supplemental and wrap-around services, and through direct vendor
purchase for long-term care.
•
In the out-years, the states' contributions would grow at the same rate as the
growth in the benchmark premium.
•
The national health board would develop a plan for phased adjustments to raise
levels of Medicaid per capita commitment from low-effort states.
•
Funding for the non-institutionalized disabled and acute care costs for the SSI
in institutions will flow from a national premium tax imposed on health
alliance and self-insured premiums. The funds will be distributed to states
based on their SSI disability population shares.
RATIONALE
Non-Medicaid state and local health funding is too variable and inter-twined
with other mechanisms to permit comprehensive and equitable disentangling.
Retained funds of this kind can be used by the states to strengthen public
health, population-based prevention, and supplemental services.
State and local support of public mental heath facilities is a significant
expenditure and must be maintained, even though it cannot be easily identified
and included in the premium calculation for the health alliances.
A national premium tax for the disabled will equitably spread the exceptionally
high costs of care for the disabled at the National level and protect states
against high expenditures for disproportionate numbers of disabled residents.
�C.
Financing: How Will the Current Medicaid Underpayment (i.e., Cost shift)
Be Financed?
RECOMMENDATION
Include shortfall in calculation of global budget. Do not make a specific adjustment to
"make up" for current Medicaid underpayments.
•
A state's global budget is set at benefit costs for non-Medicaid participants
times number of expected participants, plus the baseline Medicaid contribution.
•
Alliance-negotiated premiums multiplied times number of non-Medicaid plus
Medicaid participants may not exceed the global budget ceiling.
RATIONALE
With a fully financed premium now being paid to providers for the (formerly "free
care") indigent and former Medicaid participants, the need for provider-based
surcharges/cross-subsidies will be eliminated.
The restrained per capita payments to health plans will promote provider efficiencies
in management of care.
�D.
Changes in Covered Benefits: Would Current Medicaid Beneficiaries Have Their
Covered Benefits Decreased?
RECOMMENDATION
The residual state Medicaid program would finance supplemental services for formerly
categorically eligible beneficiaries for any services previously in the Medicaid plan but
not covered by the basic benefit.
RATIONALE
These benefits are frequently most needed by persons with chronic illnesses and
disabilities. The provision of the supplemental benefits assures that those who now
work can continue to work, and those in the community setting can continue to receive
the services necessary to keep them from institutionalization.
Loss of supplemental benefits would expose many below-poverty persons to increased
cost sharing (beyond amounts to be imposed as features of plan management).
The financing of these services through residual state Medicaid programs with the ongoing Federal/state matching formula avoids the necessity of folding the services into
the core benefit package with resulting higher premiums for employers and the nonlow income individuals.
�E.
Cost Sharing: Would Current Medicaid Beneficiaries Have Their Cost Sharing
Increased?
RECOMMENDATION
For certain current Medicaid beneficiary groups above the poverty level who may now
not pay any cost sharing, moderate, income-related levels of cost sharing would be
instituted. This could include both partial payment of premiums and service-related
co-payments.
For beneficiaries below poverty, there would not be premium cost sharing or
deductible; nominal service-related co-payments would be appropriate.
RATIONALE
Medicaid beneficiaries will have their cost sharing based on the same standards as
other (non-Medicaid) low-income persons.
Virtually any non-nominal cost sharing requirements for persons below poverty are
believed to discourage even necessary and appropriate use of services.
At levels above poverty, ability to make some contribution to costs of care rises with
income, provided that there is adequate protection through a stop-loss provision to
ensure that incremental cost sharing does not mount to unaffordable (incomedisproportionate) levels, and that the income-related cost-sharing scale is structured so
as not to provide an incentive against seeking higher earnings.
�F.
Access: Would Current Medicaid Beneficiaries Experience Changes in Their
Access to Health Services?
RECOMMENDATION
Each health alliance should be required to develop plans to (a) promote opportunities
for former Medicaid providers to participate in system of health plans especially where
such providers are designated "essential community providers;" and (b) provide for
transition periods for Medicaid beneficiaries to move from current providers to health
plan-participating providers.
RATIONALE
Former Medicaid beneficiaries (as other low-income people) will have established
provider relationships. In some cases those relationships are inappropriate and
inefficient and should be changed (e.g., dependence on hospital emergency rooms for
primary care). In other cases, and especially for persons with chronic medical
problems or disabilities, those relationships will be built on years of continuity of care
and trust. Health plans should instigate changes in these latter relationships only as a
last resort — if the provider will not cooperate with the plan, if current care is
demonstrably inappropriate in medical or cost terms.
On the other hand, health plans are required to manage the care of Medicaid
beneficiaries to secure access to a system that is comparable to that experienced by
non-low income people in the health alliance area.
�G. Residual Medicaid: State Role
RECOMMENDATION
States should administer a residual Medicaid program with the following features.
•
Programs should provide interim and transition services: examples include
identification to the health alliance of Medicaid beneficiaries and assist in
contacting them for enrollment; preparation for phase-over of provider
payment systems and settling-out of remaining billings; and assistance in
conversion of computer-based data systems.
•
Programs should provide "wraparound" supplemental services that are (a) in the
core benefit but limited in amount, duration or scope, (b) not in the core
benefit but are essential "access-enabling" services (e.g., transportation), and
(c) excluded from the core benefit but essential to some sub-population of
former Medicaid beneficiaries/low-income people (e.g., adult dentures and
crowns, adult eyeglasses).
•
Programs should provide administration and financing for institutional services
for the long-term institutionalized SSI population (mentally retarded/ developmentally disabled in ICFs/MR, and frail elderly in long-term nursing home
settings).
•
Programs should provide a base for continued certification of providers. Health
alliances/health plans may wish to contract with the state to continue to
perform this function over the long run.
•
Programs should prepare to follow baseline Medicaid program information to
the regional data authority.
RATIONALE
During the transition period, the Medicaid administrative structure should
ensure that beneficiaries and providers are adequately supported, and that
phasing into the new system occurs smoothly.
Experience and expertise should be kept together through transition.
Assure an orderly transition of employment opportunities for state employees
currently involved in Medicaid administration.
That the body of core residual functions (supplemental services, SSI
institutional care is fully supported.
�H. The U.S. Territories
RECOMMENDATION
Provide for local choice of whether or not to establish health alliances covering all low
income persons. (Puerto Rico, Virgin Islands, and Guam are likely to do so.)
Increase current fiscal caps.
RATIONALE
Increasing the caps follow the lead of the House Energy and Commerce Committee.
It would provide fiscal relief to these jurisdictions, while maintaining a limit on future Federal
expenditures.
�IV. QUESTIONS AND ANSWERS
A.
LOSS OF COVERED BENEFITS
When current Medicaid beneficiaries are moved into a new system, will some of
them find that formerly covered benefits are not included in the benefit package?
The comprehensive benefit package provide uniform, broad protection for all
Americans. Furthermore, through performance standards to be met by the
accountable health plans, former Medicaid beneficiaries are assured of effective
access to needed services, something that was not always available under the
old program.
Any former Medicaid benefits that are not a part of the basic benefit package
will be addressed through a combination of supplemental benefits, health plan
flexibility, and state initiative's.
B.
COST SHARING
Won't some current Medicaid beneficiaries be required to pay more out of their
own pockets under a new system than was true under Medicaid?
No one in families with incomes below the federal poverty level will be
required to contribute to the costs of their premiums. Nor will they be required
to meet deductible or copayment amounts that may be features of the health
plans with which they are enrolled. Those premiums and cost sharing amounts
will be fully subsidized.
For persons in families with incomes above the federal poverty level, if they
elect to participate in health plans with cost sharing features, they may be
required to pay some part of that cost sharing with the level depending upon
their family incomes. However, the cost sharing amounts will be limited when
related to their incomes, and will be small when compared to the security of
not losing coverage.
�C. FORMER MEDICAID BENEFICIARIES' CHOICE AMONG HEALTH PLANS
Will for Medicaid beneficiaries be able to choose among health plans?
"Choice" is a cornerstone concept in a new system. Everyone will have
choices to make, and they will have extensive information and assistance
available to help them.
Medicaid beneficiaries will also have choices. Premium subsidies will enable
them to choose among health plans. Within plans, they will have choices
among actual service providers.
D. PROVIDERS NOW SERVING MEDICAID BENEFICIARIES
Many Medicaid beneficiaries have limited education, making it difficult for them to
sort through the complexities of the health care delivery system.
Will Medicaid beneficiaries' long-standing provider relationships be disrupted by
the new system?
There are three clear goals for health services providers affiliated with
accountable health plans under a new system of reform:
1.
Take responsibility for ensuring that members of health plans obtain, in
an easy and timely fashion, the health and medical services they need;
2.
Practice sound prevention, maintenance, and continuity of quality care;
and
3.
Responsive to the interests of their patients within a system of prudent,
efficient, and effective management of care.
Special efforts will be made to identify health service providers who, because
of location, nature of practice, and personal commitment are important to lowincome people (including Medicaid beneficiaries), and to arrange for their
participation in the new system.
�E.
NEW SYSTEM REFORM IN MEDICALLY UNDERSERVED AREAS
An estimated 72 million Americans (including many Medicaid beneficiaries) live in
rural and inner city areas designated by the Federal Govemment as underserved —
lacking facilities and organizational support, in rural isolation, or in areas with
overwhelming urban social problems.
Will the new system of reform provide prepaid capitated health plans that can
effectively manage health service needs of people in these areas?
No system of health reform could immediately overcome decades of
maldistribution. But incremental steps can address those problems. Here are
some examples:
•
Perhaps one-fourth of physicians do not now accept Medicaid patients,
and an additional one-third limit their Medicaid participation. We
expect that, with improved payments and less administrative hassle, the
vast majority of these physicians will not begin to serve all low-income
people.
•
State and Federal governments will collaborate to increase the health
delivery infrastructure in underserved areas — perhaps by increasing
the numbers of Federally qualified health centers, and physicians and
other health professionals serving under agreements.
•
In those areas that are sparsely populated, we will expect to see interim
patterns of fee-for-service accountable health plans within which each
person will have a case manager to oversee, coordinate, and assure
access to needed care.
•
Strengthened linkages among individual and institutional providers will
facilitate access.
•
Incentives to keep people well and to provide care in the lowestintensity setting appropriate will stimulate insurer and provider attentiveness.
�F.
INSTITUTIONALIZED DISABLED AND FRAIL ELDERLY
Do you expect institutionalized disabled and frail elderly Medicaid beneficiaries to
be transferred into the new system? Will they have to choose among plans and
have their care managed by those plans?
Decisions about the most effective way to meet the needs of the institutionalized disabled and frail elderly have not been made. We expect to adopt a goslow approach so that we do not disrupt the care these vulnerable people are
receiving.
In the long run, however, we want to be certain that these people are not
disadvantaged, and that they too have the maximum possible opportunity within
their circumstances to exercise choice, to obtain the benefits of restrained costs,
and to participate in a system of care characterized by continuity, quality, and
appropriateness.
G.
THE ROLE OF THE STATES
The states now play a major role in Medicaid. What will be their roles under a
new system of reform?
The states have experience, insights, infrastructure and relationships that are priceless.
The advantages these offer us cannot be underestimated and will not be lost.
We are in a continuous discussion with the Nation's governors, asking their advice on
the role(s) they might play and how the Federal Govemment might be helpful to them.
No conclusions have yet been reached.
In addition, states are implementing Medicaid reforms at the present time. The
Department of Health and Human Services has taken steps to help the states in
designing reforms and to expedite its review and decision processes. For each broadscale reform proposal that is approve, provision is made for bringing those reforms
into congruence with national reforms when the latter are enacted.
[NOTE:SEE LATEST HCFA REPORT OF STATE REFORM INITIATIVES AT
THE END OF THE "INTEREST GROUPS — NATIONAL GOVERNORS'
ASSOCIATION SECTION]
�INTEREST GROUPS
A. THE AMERICAN MEDICAL ASSOCIATION
Source:
The AMA's National Health Policy Agenda for the American People (1989).
Author/Participants:
Chair: James Tallon (Majority Leader, N.Y. State Assembly)
Selected Other Participants:
Irene Eraser, AHA
Sara Rosenbaum, Children's Defense Fund
Robert J. Blendon
Kenneth Thorpe
Summary
1.
There should be national goals and standards.
2.
The categorical link to welfare should be broken, and income eligibility should
be set at the poverty level.
3.
All states should be required to have a "medically needy" program (i.e., a
spend-down program for those with large medical bills). Assets should only
be taken into account for the medically needy.
4.
There should be a standard, Federally-mandated benefit package.
5.
Cost effectiveness in services delivery should be emphasized.
6.
Medicaid expansion should include policies and incentives to encourage
broader health provider participation
7.
The Federal Government should bear more of the cost burden, and the formula
for matching state costs should be changed.
8.
Long term care should be continued under Medicaid or through a structurally
improved program.
Attachment:
Medicaid Committee Report "Including The Poor"
�B. THE PHYSICIAN PAYMENT REVIEW COMMISSION
Source:
The Commissions annual report to the Congress, 1991.
Author/Participants: Chair:
Philip R. Lee, M.D.
Selected Other Participants:
Karen Davis, Ph.D., Johns Hopkins University
Walter B. Maher, Chrysler Corporation
Walter J. McNemy, Northwestern University
Uwe Reinhardt, Princeton University
Summary:
Physician payment reforms should:
•
•
•
•
•
•
•
enhance access to care in physicians' offices and for primary care;
maintain or improve quality, and especially improve infant mortality and low
birthweight rates;
ensure that physicians who choose to serve Medicaid beneficiaries are not
placed at a disadvantage compared to their peers nor risk the financial viability
of their practices;
constrain expenditure growth by encouraging more appropriate and costeffective care;
improve understanding and administration of payment methods;
be flexible to meet needs of different population groups and states;
assure equitable and dignified treatment of beneficiaries.
Attachment: Chapter 16 of the report - "Physician Payment Under Medicaid: Options
for Reform"
�C. NATIONAL COMMITTEE FOR QUALITY HEALTH CARE
Source:
The Committee's report "An American Health Strategy: Ensuring the
Availability of Quality Health Care" (1988).
Authors/Participants: Chair:
Bernard Lachner, Evanston Hospital Association
Selected Other Participants: Daniel Bourque, Voluntary Hospitals of
America
Participants from hospital and health systems, medical supply and drug
manufacturers, accounting firms
Summary:
The Federal Govemment should increase flexibility for states to expand Medicaid
program eligibility and financial support (including separating Medicaid and cash
assistance eligibility, and eliminating Medicaid categorical eligibility requirements).
On long term care, the Federal Govemment should (a) offer tax advantages to promote
development of private long term care insurance, (b) allow workplace pension funds to
be spent for long term care, (c) provide Federal stop-loss protection for private long
term care insurers, (d) liberalize Medicaid eligibility and payment standards, (e)
increase the use of block grants to states for long term care, (f) improve the quality of
nursing home care through stronger standards.
Attachments:
Chapter 4: Financing Long Term and Sub-acute Care Services
Chapter 5: Providing Health Care to the Indigent and Uninsured
�D. T H E AMERICAN C O L L E G E OF PHYSICIANS
Source:
Position paper "Access to Health Care," 1990 (approved by Board of Regents).
Authors/Participants:
Robert A. Berenson, M.D.
John R. Hogness, M.D.
Other physician members of subcommittees of the Health and
Public Policy Committee
Summary
1.
Encourage individuals and employers to purchase private insurance.
2.
Mandate employer coverage.
3.
Create Health insurance risk pools.
4.
Extend Medicaid eligibility.
5.
Expand charity care.
6.
Establish a universal access to health insurance program
Attachment:
The position paper
�E. AMERICAN HOSPITAL ASSOCIATION
Source:
AHA fact sheet "Unsponsored Hospital Care and Medicaid Shortfalls, 19801991" (1992 survey of their member hospitals —- 1991 data).
Authors/Participants:
AHA staff
Summary:
1.
Medicaid payments for patient care fall very short of costs, and the shortfall is
growing very quickly.
2.
Nine out of ten hospitals are now losing money serving Medicaid patients, and
the extent of their losses is increasing each year.
3.
Medicaid shortfalls are now the most important factor driving increasing
hospital losses in caring for the poor.
Attachment:
NOTE:
THE AHA FACT SHEET IS LOCATED AT TAB 10 OF THE
ENDNOTE REFERENCES SECTION IN THIS BINDER
�F.
NATIONAL GOVERNORS' ASSOCIATION
Source:
National Governors' Association
Authors/Participants:
Ann W. Richards, Governor of Texas
Roy Romer, Chainnan of the NGA
Health Care Task Force of the NGA
Summary:
1.
Opposed to caps on Federal spending on Medicaid entitlements until another
health financing system is in place.
2.
Give states greater leeway in containing health and long-term care costs by
having HCFA issue rules on the Boren amendment (i.e., provider payment
methods).
3.
Allow states to manage costs in their (Early Periodic Screening, Detection and
Treatment — EPSDT) Program through limiting services to those in their state
Medicaid plans, and providing services in the least costly manner.
4.
Provide increased flexibility and fairness in the hospital "disproportionate
share" payment program.
5.
Expedite waivers of home- and community-based care so that the elderly and
disabled may be cared for in the community rather than in costly institutions.
6.
Raise the Federal financial matching rate.
7.
Expedite waivers.
Attachments: Letter from Governor Richards to NGA Chairman Romer
NGA resolutions on Medicaid and on health reform
April 6 summary of HCFA/NGA discussion on administrative and legislative
reforms.
HCFA May 13 report on states' Medicaid reform initiatives
�G.
HERITAGE FOUNDATION
Source:
"Critical Issues: A National Health System for America" (chapter 5).
Authors/Participants:
Editors:
Author:
Stuart Butler and Edmund Haislmaier
Terree P. Wasley
Summary:
1.
Classical critique of Medicaid performance
2.
Review of several state Medicaid experiments (Monroe County, N.Y.; New
Jersey; Missouri; Minnesota; Arizona) - advocates giving states broad
flexibility to experiment
3.
Reform recommendations for the indigent:
•
Separate the government's function of providing basic health care
services to the poor from its function as payer of last resort for middle
class patients with catastrophic medical bills.
•
Give states more flexibility to meet the health care needs of the poor
and the disadvantaged.
•
Redesign Medicaid programs at the state level to build on proposed tax
reforms (i.e., consumer choice, refundable tax credits, vouchers/tax
credits for the low-income, and tax credits for long-term care).
•
Repeal state-mandated benefit laws.
•
Separate health insurance from the workplace and establish risk pools in
every state.
•
Experiment with refundable deductibles in capitation plans for the poor.
Attachments: Chapter 5
�H.
THE KAISER COMMISSION ON THE FUTURE OF MEDICAID
Source:
Two Commission reports:
•
"Medicaid at the Crossroads" (November 1992)
•
"The Medicaid Cost Explosion: Causes and Consequences"
(February 1993)
Authors/Participants:
Commission Members:
James R. Tallon, Majority Leader, N.Y. State
Assembly
Karen Davis, Commonwealth Fund
and others (see listing, included)
Commission Staff:
Diane Rowland, Executive Director
Judith Feder, Associate Director
and others
Summary:
1.
Review of characteristics of and problems inherent in current Medicaid
program
2.
Do not contain policy reform recommendations
Attachments:
"Medicaid at the Crossroads" — commission members, table of
contents, executive summary, and final chapter "Charting a Course for
the Future"
"Medicaid Cost Explosion" — table of contents, executive summary, final
chapter "Policy Implications"
�APPENDIX
Tab 1
Kaiser Commission Report, 1992.
(Figure 4-1, "Primary Source of Health Insurance Coverage for the Poor,
1990. )
Tab 2
Health Care Financing Administration, "Characteristics of State Medicaid
Programs" Volume 1. May 1992.
Gist of Medicaid eligibility groups)
Tab 3
National Governors' Association, "State Coverage of Pregnant Women and
Children," July 1992. (Figure 1)
Tab 4
Congressional Research Service, "Medicaid Source Book: Background
Data and Analysis (A 1993 Update)," January 1993.
Tab 5
Congressional Research Service, "Medicaid Source Book: Background
Data and Analysis," January 1993. (Listing of optional Medicaid services
and number of states offering each service as of October 1, 1992 and Table
VI-4: Regular and Model Medicaid Waivers by State and Target
Population.")
Tab 6
Kaiser Commission, op. cit.
(Figure 4-6, "Physician Participation in Medicaid")
Tab 7
Kaiser Commission, op. cit.
(Figure 4-7, "Pediatrician Participation in Medicaid, 1978-1989")
Tab 8
Physician Payment Review Commission, "Annual Report to Congress,"
1991. (Table 15-13: Index of Medicaid Fees Relative to Medicare
Prevailing Charges by States).
Tab 9
American Hospital Association, "Medicaid Underpayments and Hospital
Care for the Poor: A Fact Sheet," January 1991.
Tab 10
DHHS Office of the Inspector General, "Use of Emergency Rooms by
Medicaid Recipients," March 1992.
Tab 11
Robert J. Blendon, et. al., "Medicaid Beneficiaries and Health Reform,"
Health Affairs, pp. 132-143. Summer 1993.
Tab 12
Joseph Liu and Sara Rosenbaum, "Medicaid and Childhood
Immunization, " Children's Defense Fund, January 1992.
�Tab 13
Congressional Research Service. "Medicaid Source Book: Background
Data and Analysis," January 1993.
(Tab B-8: Early and Periodic Screening, Diagnostic and Treatment
Participation Goals by state, FY 1991-1995).
Tab 14
Kaiser Commission on the Future of Medicaid, "The Medicaid Cost
Explosion: Causes and Consequences," Kaiser Foundation, February 1993.
(Table 1-5: Annual Percent Growth in Medicaid Spending, 1985-1992).
Tab 15
DHHS, Health Care Financing Administration, "Justification of Estimates
for Appropriations Committee-Fiscal Year 1994," April 1993.
(Table: Grants to states for Medicaid)
Tab 16
Kaiser Commission, Report on Costs, op. cit. (Figure 2-2: Factors
Contributing to Medicaid Expenditure Growth, 1988-1991)
Tab 17
John Holahan, et. al., "The States' Response to Medicaid Financing Crisis:
Case Studies Report," Kaiser Commission, December 1992.
Tab 18
Congressional Research Service, op. cit. (Table Vin-7: County Funding
Formula for Medicaid Vendor Payments as of September 1991).
Tab 19
Health Care Financing Administration, "Donation and Taxes Briefing
Material," 1993.
Tab 20
Tollgate Five Medicaid Integration Paper
Written Concerns
Tab 21
National Governors' Association
Tab 22
The Kaiser Commission on the Future of Medicaid
Tab 23
Heritage Foundation
Tab 24
The American Medical Association
Tab 25
The American College of Physicians
Tab 26
The Physician Payment Review Commission
Tab 27
The National Committee on Quality Health Care
�Tab 28
American Hospital Association
Tab 29
Other Papers
The Kaiser Commission on the Future of Medicaid (Memo)
United Cerebral Palsy Association
Medicare Advocacy Project
California Association of Public Hospitals
Families USA/Consumer Protection in Managed Care
Medicaid, Children and Health Reform
Homeless Health Care Los Angeles
National Multiple Sclerosis Society
The Alliance for Children's Rights
Tab 30
Legislative Proposals Addressing Medicaid
�Clinton Presidential Records
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digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�Tab 1
This section includes:
Kaiser Commission Report, 1992.
(Figure 4-1, "Primary Source of Health
Insurance Coverage for the Poor, 1990.)
�Figure 4-1
Primary Source of Health Insurance
Coverage for the Poor, 1990
Uninsured
29%
�Clinton Presidential Records
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marker by the William J. Clinton Presidential Library Staff.
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digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
3-
�Tab 2
This section includes:
Health Care Financing Administration,
"Characteristics of State Medicaid Programs"
Volume 1. May 1992.
(list of Medicaid eligibility groups)
�MEDICAID ELIGIBILITY GROUPS
MANDATORY AFDC-RELATED ELIGIBILITY GROUPS
CASH RECIPIENTS
FAMILIES W I T M UNEMPLQVED PARENTS (6-MONTHS)
OPTIONAL ADDITIONAL MONTHS
PREGNANT WOMEN WITH NO CHILDREN
AGE 18 STUDENT AFDC RECIPIENTS
DEEMED RECIPIENTS
INDIVIDUALS DENIED CASH PAVMENT OF LESS THAN $10
WORK SUPPLEMENTATION PARTICIPANTS
INDIVIDUALS WJTH ZERO PAVMENT DUE TO RECOVERIES
INDIVIDUALS RECEIVING 4-MONTH TRANSITIONAL
BENEFITS WHERE AFDC WAS LOST DUE TO CHILD
SUPPORT PAYMENTS
TITLE IV-E RECIPIENTS
NON-CASH RECIPIENTS
MEMBERS OF FAMILIES WITH UNEMPLOVED PARENTS
WORK-RELATED TRANSITIONAL MEDICAID RECIPIENTS
INDIVIDUALS DENIED AFDC DUE TO DEEMING PROHIBITED
BV MEDICAID
1972 RECIPIENTS OF OASDI INCREASE LOSING AFDC
QUALIFIED PREGNANT WOMEN AND CHILDREN
POVERTY LEVE^ PREGNANT WOMEN AND INFANTS
POVERTY LEVEL CHILDREN UNDER 6
POVERTY LEVEL CHILDREN OVER 6
WOMEN RECEIVING POSTPARTUM SERVICES
CHILDREN UNDER 1 WHOSE MOTHERS WERE ELIGIBLE
WHEN THEV WERE BORN
MANDATORY AGED, BLIND AND DISABLED ELIGIBILITY GROUPS
CASH RECIPIENTS
SSI
AGED
BLIND
DISABLED
INDIVIDUALS WHO MEET MORE RESTRICTIVE
REQUIREMENTS ( 2 0 9 ( B ) )
AGED
BL I ND
DISABLED
MANDATORY
STATE
SUPPLEMENT
RECIPIENTS
DEEMED R E C I P I E N T S OF S S I
SEVERELY D I S A B L E D I N D I V I D U A L S Q U A L I F I E D
UNDER 1 6 1 9 ( A ) OR ( B )
D I S A B L E O WIDOWERS L O S I N G S S I / S S P DUE TO
E L I M I N A T I O N OF O A S D I R E D U C T I O N
FACTOR
D I S A B L E D WIDOWERS L O S I N G S S I / S S P DUE TO E A R L Y
SSB NOT E N T I T L E D TO M E D I C A R E
NON-CASH R E C I P I E N T S
E S S E N T I A L SPOUSES ( S I N C E 1 9 7 3 )
I N S T I T U T I O N A L I Z E D I N D I V I D U A L S CONTINUOUSLY
E L I G I B L E S I N C E 1973
B L I N D AND D I S A B L E D C O N T I N U O U S L Y E L I G I B L E
SINCE 1973
INDIVIDUALS INELIGIBLE FOR SSI/SSP
INCREASES IN OASDI BENEFIT
INDIVIDUALS INELIGIBLE FOR SSI/SSP
OASDI COLAS
ADULT DISABLED CHILDREN RECIPIENTS
INCREASED OASDI BENEFITS
INDIVIDUALS INELIGIBLE F OR SSI/SSP
REASONS PROHIBITED Bv MEDICAID
QUALIFIED MEDICARE BENEFICIARIES
DUE TO 8/72
DUE TO 4/77
OF
FOR
�OPTIONAL ELIGIBILITY GROUPS
PREGNANT WOMEN AND INFANTS WITH INCOME
BELOW 185% FPL OTHER THAN MANDATORY
POVERTY LEVEL DISABLED AND AGED WITH
RESOURCES LESS THAN SSI TEST
PRESUMPTIVELY
INDIVIDUALS WHO WOULD BE AFDC I F CHILD
CARE COSTS WERE PAID FROM EARNINGS
CHILDREN UNDER (AGE)
CARETAKER RELATIVES
PREGNANT WOMEN
ELIGIBLE PREGNANT WOMEN
FINANCIALLY ELIGIBLE CHILDREN
POVERTY LEVEL INDIVIDUALS WITH COBRA
CONTINUATION COVERAGE
HMO ENROLLEES FOR MINIMUM ENROLLMENT PERIODS
COST-EFFECTIVE GROUP HEALTH PLAN ENROLLEES FOR
MINIMUM ENROLLMENT PERIODS
INDIVIDUALS WHO WOULD BE ELIGIBLE FOR CASH
IF NOT IN AN INSTITUTION
INDIVIDUALS I N HCBSWS
CHILDREN UNDER STATE ADOPTION AGREEMENTS WITH
SPECIAL MEDICAL NEEDS UNDER (AGE)
TAIN DISABLED CHILDREN !8 AND UNDER WHO
OULD BE ELIGIBLE IF IN AN INSTITUTION
INDIVIDUALS MEETING AFDC. SSI OR
SSP INCOME AND RESOURCE TEST BUT
NO CASH PAYMENT
DLSABLED
CARETAKER RELATIVES
WOMEN
H O S P I C E R E C I P I E N T S WHO WOULD BE
E L I G I B L E I N MEDICAL I N S ; T U T I O N S
T
AGED
I ND
DISABLED
CHILDREN UNDER (AGE)
CARETAKER RELATIVES
PREGNANT WOMEN
BL
INDIVIDUALS WHO WOULD BE ELIGIBLE FOR AFDC
IF AFDC PLAN wERE AS BROAD AS ALLOWED
j
i
J
;
:
.
CHILDREN UNDER (AGE)
CARETAKER RELATIVES
PREGNANT WOMEN
OPTIONAL STATE SUPPLEMENT RECIPIENTS
AGED
BLIND
DISABLED
AGED I N GROUP LIVING
BLIND IN GROUP LIVING
DISAB-ED IN GROUP LIVING
OTHER
AGED
BL IND
PREGNANT
ALL CHILDREN UNDER (AGE)
REASONABLE CLASSIFICATIONS
IN FOSTER HOMES UNDER (AGE)
IN PRIVATE INSTITUTIONS UNDER (AGE)
UNDER PRIVATE AGENCY UNDER (AGE)
IN SUBSIDIZED ADOPTIONS UNDER (AGE)
IN NFS UNDER (AGE)
IN ICFS/MR UNDER (AGE)
IN INPATIENT PSYCnlATRIC F A C I L I T I E S
UNDER (AGE)
OTnER GROUPS UNDER (AGE)
INSTITUTIONALIZED INDIVIDUALS ELIGIBLE UNDER A
SPECIAL INCOME L E V E L (UP TO 3 0 0 % S S I )
AGED
BLIND
DISABLED
CHILDREN JNDER ;AGE)
CARETAKER RELATIVES
PREGNANT WOMEN
�OPTIONAL COVERAGE OF THE MEDICALLY NEEDY
INDIVIDUALS WHO MUST BE INCLUDED
PREGNANT WOMEN
WOMEN RECEIVING POSTPARTUM SERVICES
CHILDREN UNDER 18 WHO ARE INELIGIBLE AS
MANDATORY CATEGORICALLY NEEDY
INFANTS UNDER 1 BORN TO MEDICALLY
NEEDY MOTHERS
BLIND OR DISABLED CONTINUOUSLY ELIGIBLE
SINCE 1973
INDIVIDUALS INCLUDED AT STATE OPTION
CARETAKER RELATIVES
AGED
BLIND
DISABLED
HMO ENROLLEES FOR MINIMUM PERIOD
COST-EFFECTIVE GROUP HEALTH PLAN ENROLLEES
FOR MINIMUM ENROLLMENT PERIODS
FINANCIALLY ELIGIBLE CHILDREN
ALL CHILDREN UNDER (AGE)
REASONABLE CLASSIFICATIONS
UNDER PUBLIC AGENCIES UNDER (AGE)
IN FOSTER HOMES UNDER (AGE)
IN PRIVATE INSTITUTIONS UNDER (AGE)
UNDER PRIVATE AGENCY UNDER (AGE)
IN SUBSIDIZED ADOPTIONS UNDER (AGE)
IN NFS UNDER (AGE)
IN INPATIENT PSYCHIATRIC F A C I L I T I E S
UNDER (AGE)
OTHER GROUPS UNDER (AGE)
Source: "Characteristics of State Medicaid Programs," State Profile Data System, Health Care Financing
Administration, May 1992
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�Tab 3
This section includes:
National Governors' Association, "State Coverage of
Pregnant Women and Children," July 1992. (Figure
1)
�H.,ll o l l h i
islATIONAL
GOVERNORS
ASSOCIATION
Maus
444 N " n t i ( i j p i l i ' l Street
\\jsiiliii;i"n. D.c. :i)tii)i-n::
STATE COVERAGE OF PREGNANT WOMEN
AND CHILDREN - JULY 1992
* * * *
Health Policy Studies
NGA Center for Policy Research
In our continuing effort to highlight innovative state initiatives to improve
maternal and child health, the Health Policy Studies unit of the National
Governors' Association has produced a series of MCH Updates since 1990.
As documented in this series, states have made significant progress in
expanding Medicaid coverage for pregnant women and improving the
quality of health programs for this population. Initiatives on behalf of
children have developed at a slower pace. Recently, however, a growing
emphasis at both state and national levels has led to increased activity to
improve children's health. To reflect this trend, this issue of the MCH
Update has been extensively expanded to discuss the various state
initiatives to improve health programs fbr children.
The update includes descriptions and tables on state efforts to increase
access to health care fbr both pregnant women and children, as well as
initiatives aimed to improve the quality of programs for these populations.
This issue of the MCH Update is organized into six broad sections that
reflect states' major areas of activity:
•
•
•
•
•
•
Broadening Eligibility Criteria
Streamlining the Eligibility Process
Developing Outreach Programs
Increasing Provider Participation
Enhancing Prenatal Care Services
Improving Child Health Programs
Introduction
In the l a t e 1980s and e a r l y 1990s, Congress passed a series of laws
that focused state a t t e n t i o n on improving maternal and c h i l d health
status. States responded by developing ambitious programs t o improve
access and q u a l i t y of care f o r pregnant women. Dramatic expansions
of Medicaid coverage, the streamlining of the e l i g i b i l i t y process,
the
creation
of broad
public
outreach campaigns,
and the
implementation of s t r a t e g i e s t o increase the number of o b s t e t r i c a l
providers t o serve t h i s population have a l l been adopted t o improve
access i n the vast m a j o r i t y of states. Furthermore, enhancements t o
the scope of Medicaid covered prenatal services have been implemented
i n an e f f o r t to improve the q u a l i t y of care provided t o pregnant
women.
�i- i g u re
i
STATES B R O A D E N I N G MEDICAID ELIGIBILITY
Poverty—Related Coverage of Pregnant Women and
July 1 9 9 2
Fpdprnl Poverty I evel
State Percentages
185%
134 133%
SOURCE:
NATIONAL GOVERNORS" ASSOCIATION.
1992
184%
Children
�
Dublin Core
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Title
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Health Care Reform
Identifier
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2006-0810-F
Description
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<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
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Clinton Presidential Records
Publisher
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William J. Clinton Presidential Library & Museum
Text
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Paper
Dublin Core
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Title
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Briefing Book on Medicaid [1]
Creator
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Health Care Task Force
General Files
Identifier
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2006-0810-F Segment 1
Is Part Of
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Box 53
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
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5/5/2015
Source
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42-t-2194630-20060810F-Seg1-053-008-2015
12090749