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Briefing Book on Medicaid [2]
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51
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�Clinton Presidential Records
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Divider Title:
^
�Tab 4
This section includes:
Congressional Research Service, "Medicaid Source
Book: Background Data and Analysis (A 1993
Update)," January 1993.
�CHAPTER I. OVERVIEW
Medicaid is a joint Federal-State entitlement program that pays for medical
gervicef on behalf of certain groups of low-income persons. The program was
enacted in 1965, in the same legislation that created the Federal Medicare
program for the aged and disabled. Medicaid is estimated to have served 31.4
million persons in FY 1992, at a combined cost to the Federal, State, and local
governments of $11 S.8 billion, about 15 percent of total national health
spending. (Figure 1-1 shows the relative size of Medicaid and other public and
private sources of health spending in calendar year 1990J
The Federal share of Medicaid spending in FY 1992 is estimated to have
been $67.8 billion, about 57 percent of the total, with State and local
governments paying the remainder. Medicaid is the third largest social program
in the Federal budget, exceeded only by Social Security and Medicare. It is also
one of the fastest growing components of Federal and State budgets.
This overview begins with a basic explanation of how Medicaid works: who
is covered, what services they may receive, and how the program operates and
is financed. This is followed by a history of the program and a more detailed
look at the program's performance in serving its targeted populations. The last
section summarizes trends that may affect the program in the near future.
I. BASIC PROGRAM DESCRIPTION
Medicaid is administered by the States with partial Federal funding. Each
State designs its own program within Federal guidelines. States must provide
Medicaid to certain population groups and have the option of covering others.
Similarly, a State must cover certain basic services and may cover additional
services if it chooses. States set their own payment rates for services, with some
limitations. There is thus considerable variation in Medicaid programs; some
are relatively limited, others very generous. Over the last decade, Congress has
gradually expanded the minimum standards that all States must meet. Still, the
program is by no means uniform across States.
2
'This chapter was written by Mark Merlis.
2
Arizona is the only State without a Medicaid program. Since 1982, it has
received Federal funds under a demonstration waiver for an alternative medical
assistance program for low-income persons, the Arizona Health Care Cost
Containment System, or AHCCCS.
�FIGURE 1-1. National Health Expenditures
by Payer, CY 1990
Total spending = $666.2 billion
Private Insurance
$216.8 billion
32.6%
Out-of-Pocket and
Other Private
$166.7 billion
25.0%
P
r
fai
qu
th
ca
Medicaid
/ $75.2 billion
11.3%
Medicare
$111.2 billion
16.7%
re?
am
wit
ver
On
du:
ap;
an
su':
Other Public
$96.3 billion
14. 5%
P'
w
rr
P
a
h
8
r
}
c
c
)
Source: Figure prepared by Congressional Research Service
based on data from HCFA.
�The following discussion provides basic information about program
eligibility, covered services, payment for services, and alternative delivery and
payment systems. It also provides an overview of Medicaid administration and
financing.
A. Eligibility for Medicaid Benefits
Medicaid is a means-tested program. Applicants' income and other
resources must be within program financial standards. These standards vary
among States, and different standards apply to different population groups
within a State. With some exceptions, Medicaid is available only to persons with
verv low incomes. However, Medicaid does not cover everyone who is poor.
Only 47 percent of persons in poverty received Medicaid benefits at any time
during 1990. There are two basic reasons for this. First, many types of
applicants must meet income limits that are based on cash welfare standards
and are usually well below the poverty level. Second. Medicaid eligibility is
subject to categorical restrictions.
3
Medicaid is available only to members of families with children and
pregnant women, and to persons who are aged, blind, or disabled. Persons not
falling into those categories-such as single adults and childless couples-cannot
qualify, no matter how low their income is. Even within the covered groups
there are categorical distinctions that are based on those traditionally used in
cash assistance (welfare) programs. For example, all the members of a singleparent family may receive Medicaid. In a two-parent family with one parent
working full time, only the children may receive continuous coverage; the
mother is eligible only during pregnancy, and the father is never eligible.
The Medicaid statute defines over 50 distinct population groups as
potentially eligible, including those for which coverage is mandatory in all States
and those that may be covered at a State's option. The various eligibility groups
have traditionally been divided into two basic classes, the "categorically needy"
and the "medically needy." The two terms once distinguished between welfarerelated beneficiaries and those qualifying only under special Medicaid rules.
However, nonwelfare groups have been added to the "categorically needy" list
over the years. As a result, the terms are no longer especially helpful in sorting
out the various populations for whom mandatory or optional Medicaid coverage
has been made available, and some analysts believe they should be abandoned.
However, the distinction between the categorically and medically needy is still
an important one, because the scope of covered services that States must provide
to the categorically needy is much broader than the minimum scope of services
for the medically needy (see the discussion of service requirements in the next
section).
Despite the complexity of Medicaid eligibility, most of the coverage
categories fall into six basic groups:
�Current and some former recipients of cash assistance, either Aid to
Families with Dependent Children (AFDC). which covers single-parent
families and two-parent families with an unemployed principal earner,
or Supplemental Security Income (SSI), which covers low-income
persons who are aged, blind, or disabled. All recipients of AFDC
receive Medicaid automatically, as do SSI recipients in all but a few
States. AFDC and SSI recipients account for 61 percent of Medicaid
beneficiaries. Medicaid is also available to some persons whose cash
assistance has been terminated or who fail to receive cash assistance
for technical reasons.
Low-income pregnant women and children who do not qualify for
AFDC, either because their income is too high or because they fail to
meet the program's categorical restrictions. Coverage of some children
in this category (the "RibicofT children") was made optional when
Medicaid was first enacted in 1965. As will be discussed below,
expansion of mandatory and optional coverage for non-AFDC pregnant
women and children was a major theme of Medicaid legislation in the
1980s.
The medically needy, persons who do not meet the financial standards
for cash assistance programs but meet the categorical standards and
have income and resources within special medically needy limits
established by the States. Persons whose incomes or resources are
above those standards may qualify by "spending down," incurring
medical bills that reduce their income and/or resources to the
necessary levels. Coverage of the medically needy is optional; as of
October 1991, 41 States and other jurisdictions covered at least some
groups of the medically needy.
Persons requiring institutional care. Special eligibility rules apply to
persons receiving care in nursing facilities (NFs) or intermediate care
facilities for the mentally retarded (ICFs/MR) or who are participating
in alternative community care programs for the aged and disabled.
Many of these persons may have incomes well above the poverty level
but qualify for Medicaid because of the very high cost of their care.
Low-income Medicare beneficiaries. Medicaid pays required Medicare
premiums, deductibles, and coinsurance on behalf of low-income aged
and disabled Medicare beneficiaries. (Coverage is restricted to
Medicare cost-sharing unless the beneficiary also qualifies for Medicaid
in some other way.)
Low-income persons losing employer coverage and entitled to purchase
continuation coverage through the employer's group health plan under
the provisions of the Consolidated Omnibus Budget Reconciliation Act
of 1985 (COBRA, Public Law 99-272). At the State's option, Medicaid
may pay the premiums for continued private coverage on behalf of
certain individuals.
�Figures 1-2 and 1-3 show two different ways of grouping the 28.3 million
raons receiving Medicaid benefits in FY 1991. Because of limitations in the
Iteta reported by States, neither corresponds to the groupings listed above (or
to those in Medicaid law). Figure 1-2 classes beneficiaries into those receiving
AFDC or SSI, the medically needy, and non-AFDC or SSI groups. The latter
would include low-income pregnant women and children and low-income
Medicare beneficiaries qualifying under recent Medicaid expansions, as well as
persons eligible under the special rules for institutional care. Figure 1-3 classes
beneficiaries by demographic group.'
4
The following discussion provides a more detailed look at the various
populations eligible for Medicaid. It describes the mandatory and optional
coverage groups under four broad headings (families, pregnant women, and
children; aged and disabled; the medically needy; and persons receiving
institutional or other long-term care), along with the COBRA premium payment
option.
1. Families,
Pregnant
Women and
Children
Medicaid-eligible families, pregnant women, and children fall into two basic
groups: those receiving AFDC or meeting AFDC standards, and those qualifying
under the series of targeted Medicaid expansions that began in the 1980s.
a. AFDC-Related
Groups
States must provide Medicaid to families receiving AFDC benefits, and
eligibility for some other groups is tied to AFDC standards. Each State sets its
own income limits for AFDC. As of January 1992, limits on countable income
for a family of three ranged from $1,440 per year in Alabama to $11,088 per
year in Alaska. The median State's limit was $4,464, or 38 percent of the
Federal poverty level for a family of three.
6
Mandatory. States must provide Medicaid to all persons receiving cash
assistance under AFDC, as well as to additional AFDC-related groups who are
not actually receiving cash payments. (Examples include persons who do not
receive a payment because the amount would be less than $10 and persons
whose payments are reduced to zero because of recovery of previous
overpayments.)
4
The large number of beneficiaries shown as "other/unknown" in both figures
is the result of inconsistencies in State reporting practices. Many of the
beneficiaries in this group are Ribicoff children.
r * .vVfl
i •":$
�FIGURE 1-2. Medicaid Beneficiaries
by Assistance Status, FY 1991
Total beneficiaries = 28.3 million
AFDC
45%
Other/
Unknown
SSI
16%
2%
Medically
Needy
12%
N o n - A F D C Families,
Non-SSI Aged,
Pregnant Women,
Blind, Disabled
Children
7%
18%
NOTE: The total number of beneficiaries shown is an unduplicated total.
Source: Figure prepared by Congressional Research Service based on data from HCFA.
NC
Sc
�FIGURE 1-3. 'Medicaid Beneficiaries
by Basis of Eligibility, FY 1991
Total beneficiaries = 28.3 million
Children
46%
Adults,
Families with
Children
24%
Other/
Unknown
4%
Disabled
14%
NOTE: The total number of beneficiaries shown is an unduplicated total.
Source: Figure prepared by Congressional Research Service based on data from HCFA.
�P
Ml
8
States are required to continue Medicaid for specified periods for certain
families losing AFDC benefits after receiving them in at least. 3 of the preceding
6 months. If the family loses AFDC benefits because of increased earnings or
hours of employment, Medicaid coverage must be extended for 12 months.
(During the second 6 months a premium may be imposed, the scope of benefits
may be limited, or alternate delivery systems may be used.) If the family loses
AFDC because of increased child or spousal support, coverage must be extended
for 4 months. States are also required to furnish Medicaid to certain two-parent
families whose principal earner is unemployed and who are not receiving cash
assistance because the State is one of those permitted (under the Family
Support Act of 1988) to set a time limit on AFDC coverage for such families.
Optional. States are permitted, but not required, to provide coverage to
additional AFDC-related groups. The most important of these are the "Ribicoff
children." whose income and resources are within AFDC standards but who do
not meet the AFDC definition of "dependent child." For example, the child may
be in a two-parent family where the principal breadwinner is not unemployed.
States may cover these children up to a maximum age of 18, 19, 20, or 21, at the
State's option, and may limit coverage to reasonable subgroups, such as children
in two-parent families, those in privately subsidized foster care, or those who
live in certain institutional settings. (This group will become largely obsolete
as States are required to phase in coverage of children under age 19 with
incomes below poverty. However, some States may still choose to cover Ribicoff
children aged 19 and 20.) States may also furnish Medicaid to persons who
would receive AFDC i f the State's AFDC program were as broad as permitted
under Federal law.
6. Non-AFDC
Pregnant
Women and
Children
Beginning in 1984, Congress gradually extended Medicaid coverage to
groups of pregnant women and children who are defined in terms of family
income and resources, rather than in terms of their ties to the AFDC program.
Mandatory. States are required to cover pregnant women and children
under age 6 with family incomes below 133 percent of the Federal poverty
income guidelines. (The State may impose a resource standard that is no more
restrictive than that for SSI, in the case of pregnant women, or AFDC, in the
case of children.) Coverage for pregnant women is limited to services related to
the pregnancy or complications of the pregnancy; children receive full Medicaid
coverage.
Effective July 1, 1991, States are also required to cover all children who are
under age 19, who were born after September 30, 1983, and whose family
income is below 100 percent of the Federal poverty level. (Coverage of such
children through age 7 has been optional since Omnibus Budget Reconciliation
Act of 1987 (OBRA 87).) The 1983 start date means that coverage of 18 year
olds will take effect during FY 2002.
Optional. States are permitted, but not required, to cover pregnant women
and infants under 1 year old with incomes below a State-established maximum
�ods for certain
."the preceding
ed earnings or
or 12 months,
ope of benefits
he family loses
ist be extended
ain two-parent
receiving cash
er the Family
;uch families.
de coverage to
re the "Ribicoff
rds but who do
. *'
'iid may
n
iloyed.
20,o. ...atthe
uch as children
-. or those who
argely obsolete
T age 19 with
J cover RibicofT
o persons who
id as permitted
n
iid coverage to
erms of family
\PDC program.
n and children
"ederal poverty
that is no more
r AFDC, in the
-vices related to
. e full Medicaid
hilai . .i who are
j whose family
•jverage of such
: Reconciliation
rage of 18 year
above 133 percent of the poverty level but no more than 185 percent. As
I f j ' uary 1992, 30 States had made use of this option; 23 had set their income
l,mit« at the maximum of 185 percent.*
Figure 1-4 shows the maximum income eligibility thresholds for children
through age 192. Aged and Disabled
a. SSI-Related
Persons
Groups
SSI was established in 1972, replacing previous federally funded cash
assistance programs for the aged, blind, and disabled. Income and resource
standards are defined by Federal law. For 1992 the maximum income is $442
per month for an individual and $653 for a couple (higher limits apply to
persons with wage income). However, States have the option of supplementing
SSI payments for aged persons living independently, resulting in income
maximums above the Federal limits. All but nine States or jurisdictions do so.
In the States with supplements, the median resulting increase in 1992 income
limits was $32 per month for an individual.
7
Mandatory. States are generally required to cover recipients of SSI.
However, States may use more restrictive eligibility standards for Medicaid than
those for SSI if they were using those standards on January 1, 1972 (before the
implementation of SSD. States that have chosen to apply more restrictive
standards are known as "section 209(b)" States, after the section of the Social
Security Amendments of 1972 (Public Law 92-603) that established the option.
There are 12 section 209(b) States:
Connecticut
Hawaii
Illinois
Indiana
Minnesota
Missouri
New Hampshire
North Carolina
North Dakota
Ohio
Oklahoma
Virginia
These States may use different definitions of disability, more restrictive income
and resource limits, or methodologies for determining income and resources
different from those used under SSI. States using more restrictive income
standards must allow applicants to "spend down": deduct incurred medical
expenses from income before determining eligibility. For example, if an
applicant has a monthly income of $600 (not including any SSI or State
supplement payment (SSP)) and the State's maximum allowable income is $500,
the applicant would be required to incur $100 in medical expenses before
qualifying for Medicaid. As will be discussed below, the spend-down process is
also used in establishing medically needy eligibility.
�10
Mm
FIGURE 1-4. Income Eligibility Thresholds for
Medicaid Coverage of Non-AFDC Children. July 1992
Percent of Federal Poverty Guidelines
200%
Optional coverage for
infants under 1 in tamilies
with income up to 185% of poverty
150%
Mandatory coverage
for children under 6
Mandatory coverage
for children 10 to 18
phased in by FY 2002*
Mandatory coverage
for children 6 to 9
100% -
50%-
!
<1 1 2 3 4
5 6
7
8
!
I
Age of Child
•Phased in coverage for children bom after September 30. 1983.
Source.
I
'
i
l
l
9 10 11 12 13 14 15 16 17 18
Figure prepared by Congressional Research Service.
�11
38'
is for
July 1992
must continue Medicaid coverage for several defined groups of
U who have lost SSI or SSP eligibility. The "qualified severely
U***^.*
disabled persons who have returned to work and have lost
WP** , ^ result of employment earnings, but still have the condition that
i ^ * * ^ ! * rendered them disabled and meet all nondisability criteria for SSI
^ '
inc°m<
Medicaid must be continued if such an individual needs
«* *P , jflpdjcal assistance to continue employment and the individual's
e not sufficient to provide the equivalent of SSI, Medicaid, and
** '!if*t care benefits the individual would qualify for in the absence of
*
States must also continue Medicaid coverage for persons who were
* * eligible for both SSI and Social Security payments and who lose SSI
""^u** of a cost of living adjustment (COLA) in their Social Security benefits.
ilar Medicaid continuations have been provided for certain other persons
^ho lose SSI as a result of eligibility for or increases in Social Security or
"urans' benefits. Finally, States must continue Medicaid for certain SSI"""liited groups who received benefits in 1973, including "essential persons"
^ertons who care for a disabled individual).
8 U t
B r e
a
1
, n B
c
t
l
r n t l t l T l X >
ar
f11
l t P n
rn
y coverage
•n 10 to 18
by FY 2002*
Optional. States are permitted to provide Medicaid to individuals who are
oot receiving SSI but are receiving State-only supplementary cash payments.
6. Qualified
Medicare
Beneficiaries
States must provide limited Medicaid coverage for "qualified Medicare
beneficiaries" (QMBs). These are aged and disabled persons who are receiving
Medicare, whose income is below 100 percent of the Federal poverty level, and
whose resources do not exceed twice the allowable amount under SSI.
Mandatory. States must pay Medicare Part B premiums (and, if applicable,
Part A premiums) for QMBs, along with required Medicare coinsurance and
deductible amounts. Coverage is restricted to Medicare cost-sharing unless the
beneficiary also qualifies for Medicaid in some other way.
5 16 17 18
Effective January 1, 1993, all States must pay Part B premiums (but not
Part A premiums or Part A or B coinsurance and deductibles) for beneficiaries
who would be QMBs except that their incomes are between 100 percent and 110
percent of the poverty level; the upper limit rises to 120 percent on January 1,
1995.
States are also required to pay Part A premiums, but no other expenses, for
•qualified disabled and working individuals." These are persons who formerly
received Social Security disability benefits and hence Medicare, have lost
eligibility for both programs, but are permitted under Medicare law to continue
to receive Medicare in return for payment of the Part A premium. Medicaid
must pay this premium on behalf of such individuals who have incomes below
200 percent of poverty and resources no greater than twice the SSI standard.
Optional. States are permitted to provide full Medicaid benefits, rather
than just Medicare premiums and cost-sharing, to QMBs who meet a State-
�12
established income standard that is no higher than 100 percent of the Federa!
poverty level.
3. The Medically
Needy
As of October 1991, 41 States and other jurisdictions provided Medicaid to
at least some groups of "medically needy" persons. These are persons who meet
the nonfinancial standards for inclusion in one of the groups covered under
Medicaid, but who do not meet the applicable income or resource requirements
for categorically needy eligibility. The State may establish higher income or
resource standards for the medically needy. In addition, individuals may spend
down to the medically needy standard by incurring medical expenses, in the
same way that SSI recipients in section 209(b) States may spend down tc
Medicaid eligibility.
The State may set its separate medically needy income standard for a family
of a given size at any level up to 133 1/3 percent of the maximum payment for
a similar family under the State's AFDC program. States may limit the groups
of individuals who may receive medically needy coverage. I f the State provides
any medically needy coverage, however, it must include all children under 18
who would qualify under one of the mandatory categorically needy groups, and
all pregnant women who wou'd qualify under either a mandatory or optional
group, i f their income or resources were lower.
4. Persona
Receiving
Institutional
or Other Long-Term
Care
States may provide Medicaid to certain otherwise ineligible groups of
persons who are in Nfs or other institutions, or who would require institutional
care if they were not receiving alternative semces at home or in the community.
States may establish a special income standard for institutionalized persons,
not to exceed 300 percent of the basic SSI benefit that would be payable to a
person who was living at home and had no other income ($1,266 per month in
1992). In States without a medically needy program, this "300 percent rule" is
an alternative way of providing NF coverage to persons with incomes above SSI
or SSP levels. (Unlike the medically needy, however, persons with incomes
above the 300 percent limit cannot spend down to Medicaid eligibility, even if
their income is insufficient to cover the costs of their care.)
Both the medically needy and those becoming eligible under the 300 percent
rule must contribute their available income to the costs of their care, retaining
only a small personal needs allowance ($30 to $75 per month in 1991, depending
on the State) for clothing and other incidental expenses. Medicaid has distinct
post-eligibility rules to determine how much of a beneficiary's income must bt
applied to the cost of care before Medicaid makes its payment. Special rule.'
exist for the treatment of income and resources of married couples when one o;
the spouses requires nursing home care and the other remains in the
community. These rules are referred to as the "spousal impoverishment'
protections of Medicaid law, because they are intended to prevent th(
impoverishment of the spouse remaining in the community.
�•a
rcent of the Federal
13
the
gtate may obtain a waiver under section 1915ic) of th( Act to provide
. J -nmmunity-based
defined
of indivic
and community-based services to a aeiinea group ot individuals who would
^ h ^ " se require institutional care. Persons served under such a waiver may
Jude persons who would be eligible under the 300 percent rule if they were
^ • n institution. Such individuals may also be covered in a State that
*infltes its waiver program in order to take advantage of a new, no-waiver
home and community-based services option created by OBRA 90.
8
, n
provided Medicaid tore persons who meet
oups covered under"
source requirementa
?h higher income or
dividuals may spend
cal expenses, in the
may spend down to
stanuard for a family
iximum payment for
may limit the groups
If the State provides
!1 children under 18
iv needy groups, and
indatory or optional
ng-Term
Care
ineligible groups of
require institutional
or in the community.
tutionalized persons,
ould be payable to a
$1,266 per month in
"300 percent rule" is)
,h incomes above SSI •
with incomes
ers
^ B i b i l i t y , even if
inder the 300 percent
their care, retaining
h in 1991. depending
'.1. r - ' l
'\c\
hr.c d i s t i n c t
A State may also provide Medicaid to several other classes of persons who
eed the level of care provided by an institution and would be eligible if they
e in an institution. These include children who are being cared for at home,
persons of any age who are ventilator-dependent, and persons receiving hospice
benefits in lieu of institutional services.
w e r
5. Medicaid
Purchase
of COBRA
Coverage
The COBRA 85 (COBRA, provides that employees or dependents leaving an
employee health insurance group in a firm with 20 or more employees must, be
offered an opportunity to continue buying insurance through the group for 18
to 36 months (depending on the reason for leaving the group). The employer
may charge a premium of no more than 102 percent of the average plan cost
(150 percent for months 19 to 29 for certain disabled persons).
The OBRA 90 permits State Medicaid programs to pay the premiums for
COBRA continuation coverage when it is cost-effective to do so. States may paypremiums for individuals with incomes below 100 percent of poverty and
resources less than twice the SSI limit who are eligible for continuation coverage
under a group health plan offered by an employer with 75 or more employees.
As of March 1992, only two States, Montana and Washington, were reported by
Health Care Financing Administration (HCFA) to be making use of this option.
B. Covered Services
1. Mandatory
and Optional
Services
Each State defines its own package of covered medical services within broad
Federal guidelines. Thus, there is considerable variation among the States in
types of services covered and the amount of care provided under specific service
categories.
Federal Medicaid law draws a distinction between mandatory services
ithose States are required to cover) and optional services (those they may elect
to cover). The mandatory' services for the categorically needy are as follows:
�14
inpatient and outpatient hospital services.
8
NF services for individuals 21 or older,
physicians' services,
laboratory and X-ray services,
early and periodic screening, diagnostic and treatment (EPSDT)
services for individuals under age 21,
family planning services,
home health services for any individual entitled to NF care,
rural health clinic and federally qualified health center (FQHC)
services, and
services of nurse-midwives, certified pediatric nurse practitioners, and
certified family nurse practitioners (to the extent these individuals are
authorized to practice under State law).
(As will be discussed below, EPSDT services for beneficiaries under age 21
include both screening examinations and follow-up services required to treat
problems uncovered during a screening. As a result, States may be required to
cover services for children that would be optional for adults )
States may also offer any of a broad range of optional services. Among the
most important, in terms of program expenditure, are prescribed drugs, dental
and optical services, clinic services, and care in ICFs/MR and in institutions for
mental diseases (IMDs). Many of the optional services are listed in law or
regulations; coverage of any other medical service may be approved at the
request of a State.
States that have chosen to cover the medically needy may offer more
restricted benefits to these beneficiaries than to the categorically needy (the
reverse is not true). States having medically needy programs are required, at
a minimum, to offer the following:
•
prenatal and delivery services for pregnant women;
•
ambulatory services for individuals under 18 and individuals entitled
to institutional semces; and
home health services for individuals entitled to N'F services.
�15
der requirements apply if a State has chosen to provide coverage for
needy persons in ICFs/MR jr in IMDs. In this case the State is
" " ^ ' ^ d to cover either the same services as those which are mandatory for the
* ^ ^ g i i y needy or alternatively the care and services listed in 7 of the 21
'"n!^?^
^ '
* *" ' £
^ mandatory and optional services.
,
0 1
i n
tment (EPSDT)
>IF care.
center (FQHC)
ra
ers, and
e in^. .,duals are
ies under age 21
squired to treat
y be required to
:ces. Among the
ed drugs, dental
institutions for
listed in law or
pproved at the
may offer mon.ally needy (the
are required, at
V]
-rvices.
entitled
t
e
a W t
e
in n
c o v e r e c
Table M bsts the mandatory and optional services currently defined in
Medicaid law and regulations. It should be noted that the Secretary has
roved coverage of additional services at the request of individual States.
Ajnong those not listed in table 1-1 but covered in one or more States are adult
dav care, blood and blood products, durable medical equipment, ambulatory
surgical centers, and various types of mental health and substance abuse clinics.
Figure 1-5 shows FY 1991 Medicaid spending by major service category.
Four mandatory services (inpatient and outpatient hospital, NF, and physician)
accounted for 52 percent of total program spending. Two optional services,
prescription drugs and ICF/MR, accounted for another 17 percent.
States may place certain limits on the coverage of all services. For
example, they may place limits on the number of covered hospital days or
the number of covered physician visits. States are also permitted to impose
nominal cost-sharing charges, with certain major exceptions, in connection with
the use of covered services.
10
2. Other Coverage
Rules
In addition to covering the mandatory services specified in law, States
must meet four basic requirements in designing their benefit packages:
Amount, duration, and scope Each covered service must be
sufficient in amount, duration, and scope to reasonably achieve its
purpose. The State may not arbitrarily deny or reduce the amount,
duration, or scope of services solely because of the type of illness or
condition. The State may place appropriate limits on a service
based on such criteria as medical necessity.
Comparability. The services available to any categorically needy
beneficiary in a State must generally be equal in amount, duration,
and scope to those available to any other categorically needy
beneficiary in the State.
Similarly, services available to an
individual in a covered medically needy group must be equal in
amount, duration, and scope to those available to all persons in the
covered medically needy group.
�T A R L R 1-1
M i a d a l o r y • a d O p l l o . m l M t d i c a i d S e r n c e t for C m U t m i c m l l f • • < ! M r d k . I l T Needy P n p . U l l o . .
CATEGORICAIXY NKEDY
MANDATORY
MEDICALLY NEEDY
SHKVICKS
•
Inpaiirnt hncpiul M r v i c d
•
P r r n a U l aad delivery • r r v i c n
4
O u l p i t i c n l h m p i u l •ervic**
•
Ambulatory aervioet ( i n d i v i d u a h under age Ifl and
•
K u r i l health Hrnic t r r v l c r t
•
hftfrnlbf qu»lifi«l hctUh crater •enHcn
4
Home health aervioes ( i n d i v f d t n t i entiiled lo N F a e r v l c r a )
•
O i h r t l i N . n t o r y i n d i - r t j r Krvicea
•
In Stitie» chnnaing to cover the raedlcalty needy In I C F i / M R or
4
N u n j n | facility ( N F ) i c r v i o r » ( a g t 21 or o w r )
•
Home health • r r v i c n for i n d i v i d u s b entitled to N F a r c
•
f l i r t y i n d Periodic Scrrcning, [>ia|nn»iic and T r t a i m e n t (HP-SLIT)
4
Family p l a n n l n | Krvicra
individuab e m u led to iniiitutlonalaervicea)
i n t t i l u t l o n i for mental diaeaaea ( I M D a V hmader r e q u i r r m e n n appty.
v i v i c n (under i f t 21)
•
N u r w - midwife arrvicc*
•
IIPTIONALSI:RVK
Phytidani' •ervian
•
O m f t t d prdialrtc and f a m i t y n u n e p r » r l i i i o n c r i ' • r r v i c n
C A T K O O R I C A I X Y A N D M T . n i C A l J - Y NF.F.DY
i:s
•
PodlaiHiti trrvioM
•
Inpatient hoapltal a r r ^ m Cage * 5 of over In ror n La I InatltQtlon)
•
()pi>>nM-(ritu acrvion
•
N u m n g facility a e i ^ ' r i { «gr 6 V r m e t tn mental Inatllulion)
•
C h l r i - p i a n u n ' acrvicca
•
I M D ( n v r i age
•
Oiher p n r t l r i n ^ r ^ • • arrvicra
•
Inpatient paychialric huspital aervtcra (under age 21)
•
Privaie dtiiy n u i n n i
•
f h r i t t u n Vience nur»ra
•
( limr w r v j t r i
•
( . h n m a n Science l a n i t o r i *
•
Denial •en.-icn
•
Nuraing facility •ervirr^ (under age21)
•
P h « i f a l thrrapy
•
Fm^rgency hf>«pital arrvicea
•
Orcupational I h e n p y
•
Per«)nal rare • r r v i c n
•
Speci.h. h f a n n g . anrl l a n | u a | r diaordrr
•
Tramportatinn a r r v i c n
r»f under age 21) and H.'F/MH aervirra •*
•
Prrifrihrd dru|i
•
T a i r management •ervtcn
•
tVniuir*
•
Hoapice aervicea
•
Prmthene decora
•
Re»pir»lnry m r r aervicn
•
Ryeglaian
•
Other aervicet approved by (he Secretary
•
Oiher d i i g m r t t t c . a c n r r i n g , p r r
live, and rrh«t.|li'iti\<aervic*M
N( i T H : S t a i n may " f l e r optional aervirra i n thr meg<wic»lfy needy onlv. '>r lo hmh the rairgnrically and medkallv needy.
* " l f a .State cowrra the*- arrvicea. il n required io cover in their medically needy p m f r * m e i l h e r the aame a e r v i . n aa !h«>«e which are mandatory for the categorically needy ( e i c r p f r e n i n e d nur«
pr»ititn>nera" and certined f a m i t v n u r w pranninrtert' a e r v u n i. or ihe care and aervire* tialed in 1 ol ihe
Sourer- TaMe p r r p a n - d W the ( V n g r r n ' o n a l Reaeanrh Service
paragraph! In the law defining covered mandatory and optional aervjeet.
�17
FIGURE 1-5. Medicaid Payments by
Type of Service, FY 1991
I
f
1
Total payments = $77.0 billion
Other Services
$8.0 billion
5
| .
10.4%
J !
i
t
Prescription
Drugs
$5.4 billion
7.0%
! <
:
£
.3 t
? E
Outpatient
Hospital
H.3 billion
5.6%
1 i
>. s
s I
-
b
11
Physician
Services
$5.0 billion
6.4%
1II
1
-. t £ •
V
=
X
*
"it
i 9
_
C 5
i
-
f
Inpatient Hospital
$21.9 billion
28.4%
c. t
t
« »!! "
*
is !
r
Home Health
$4.1 billion
5.3%
ICF/MR
$7.7 billion
10.0%
Nursing Homes
$20.7 billion
26.9%
II
n
NOTE. "Oiher Services' category i n c l u d e s dental, clinic, and lab and x-ray services a m o n g others.
Source. Figure p r e p a r e d by Congressional Resea/ch Service based on data from HCFA Form 2082.
�18
Statewideness.
Generally, a State plan must bt in effect
throughout an entire State; that is the amount, duration, and scope
of coverage must be the same statewide.
Freedom-of-Choice. Beneficiaries must be free to obtain services
from any institution, agency, pharmacy, person, or organization that
undertakes to provide the services and is qualified to perform the
services.
The Secretary may waive applicability of these requirements under certain
circumstances."
3.
EPSDT
Under the EPSDT benefit, a State must provide screening, vision, hearing
and dental services at intervals which meet recognized standards of medical and
dental practice, and at other intervals as necessary to determine the existence
of certain physical or mental illnesses or conditions. Any service that a State
is permitted to cover under Medicaid and that is necessary to treat an illness or
condition identified by a screen must be provided to EPSDT participants,
regardless of whether the service is otherwise included under the State's
Medicaid plan. The effect of this rule is to require States to offer the full range
of mandatory and optional Medicaid benefits to categorically needy beneficiaries
under age 21 (and to the medically needy, if the State has made EPSDT
available to the medically needy).
4. Purchase
of Private
Coverage
Effective January 1, 1991, the States are required to pay premiums for
group health plans for which Medicaid beneficiaries are eligible, when it is costeffective to do so instead of covering services directly. Guidelines for
determining cost-effectiveness are to be issued by the Secretary, and this
provision has not yet been implemented. States will pay any cost-sharing
required by a plan and continue to furnish any Medicaid benefits not covered
under the plan. Providers under group health plans will be required to accept
plan payment as payment in full for Medicaid enrollees.
C. Payment for Services
Under Medicaid law, States now have considerable freedom to develop
their own methods and standards for reimbursement of Medicaid services. This
section reviews States' methods for determining provider payment and for
collecting amounts due from other potential sources of payment for Medicaid
beneficiaries.
�19
effect
scope
j rvices
in that
rm the
nder certain
sion. hearing
" medical and
:h
'tence
t
tate
an
ss or
participants,
the State's
he full range
beneficiaries
lade EPSDT
Dremiums for
hen it is costuidelines for
iry, and this
cost-sharing
? not covered
ired to accept
m to develop
=e-. This
n
d for
foj
.dicaid
1. Institutional
Services
Before 1980. Medicaid programs were required to use the same methods
Medicare in paying for hospital and NF services. Facilities were paid on the
f the actual costs they incurred in providing care Legislative changes in
1980 and 1981 (the Boren amendment) permitted States to develop their own
bursement methodologies for these services. Most States have now moved
*oro8pective" payment systems, under which the amount of payment for a
defined unit of service (such as a day of care in a NF or full treatment of an
moatient hospital case) is established in advance. Some of these systems are
comparable to Medicare's prospective payment system (PPS) for hospital
Bervices, under which reimbursement varies according to the classification of
each case into a diagnosis related group, or DRG. I n other States, hospitals are
Mid a flat rate, for each day of care or for total care for each patient, without
regard to diagnosis. Finally, States may develop rates through negotiation with
hoapitals. In a number of States, the Medicaid program participates in an "allpayer" system, under which most insurers i n the State agree to a single method
for paying hospitals. States are required to make additional payment to
"disproportionate share" hospitals, those that serve a higher than average
number of Medicaid and other low-income patients.
0
12
Data collected by the American Hospital Association (AHAt indicate that,
at least until recently, most States have been paying less than the f u l l cost
incurred by hospitals in serving Medicaid beneficiaries. In the median State in
1989, Medicaid covered 81.6 percent of estimated costs; in the aggregate, AHA
estimates that Medicaid nationally covered 78.3 percent of hospita] costs.
Courts have found Medicaid reimbursement inadequate in several States, and
hospitals have filed suit for higher reimbursement in several more. Data for
more recent years show dramatic growth in Medicaid inpatient spending, a
matter that will be discussed further below.
For NF services, Medicaid law formerly distinguished between two types
of facilities: SNFs and ICFs. The distinction between the two types of care was
eliminated effective October 1, 1990. Nearly all States have adopted prospective
payment systems for N F services, although they may pay on a retrospective
basis for certain cost components. Rates may be set for individual facilities or
for peer groups (based on such factors as size and location). As of 1989, twelve
States had adopted "case mix" reimbursement systems, under which higher
payments are made to facilities that accept more severely ill patients.
2.
Physician
and Outpatient
Services
For services of physicians or other individual practitioners, payment
amounts are usually the lesser of the provider's actual charge for the service or
a maximum allowable charge established by the State. Payments may be
determined through "prevailing charge" screens, under which the maximum is
�20
set at a fixed percentile of the customary charges of area providers fo
comparable services. Or the State may use a fee schedule, specifying a flat
maximum payment amount for each service. In 1989, 41 States and the District
of Columbia used fixed fee schedules.
The Physician Payment Review
Commission has estimated that State payment rates for physician services in
that year averaged 73.7 percent of what would have been allowed under
Medicare for the same services.
r
States use a wide variety of methods for reimbursing hospital outpatient
services. Hospitals may be paid their actual costs for providing outpatient care,
or the State may pa}- Hxed rates. These may be based on a hospital's historic
costs or may involve a fee schedule comparable to those used for physician
services. As of 1989, only 10 States were still paying on the basis of actual
costs; the rest had adopted some form of prospective rates or a fee schedule.
3. Prescription
Drugs
For prescription drugs, States are required to establish a system that pays
a pharmacy's cost for acquiring a drug plus a fixed dispensing fee. Payment for
drugs that exist in both brand-name and generic versions is generally limited to
the price of the least expensive readily available generic equivalent. The
pharmacy thus has an incentive to substitute the generic drug unless the
physician specifically requests that the brand-name version be furnished. OBRA
90 requires pharmaceutical manufacturers to grant rebates to Medicaid
programs for the drugs they purchase, thus giving Medicaid discounts
comparable to those ofTered to other high-volume purchasers.
4. Other
Services
Although Medicaid programs cover numerous other kinds of services, the
law establishes specific payment rules for only a few of them. Payment to rural
health clinics, hospices, and clinical laboratories must generally follow Medicare
rules. For some services, including laboratory services, durable medical
equipment, and eyeglasses, States are permitted to establish "volume purchasing"
programs, selecting a sole source for the service through competitive bidding or
other means.
1
VA
••ti.
5. Medicaid
and Other
Payers
With minor exceptions, Medicaid is the "payer of last resort," secondary to
any other insurance coverage a beneficiary may have or to any other third party
who mav be liable for medical payments or medical support on the beneficiary's
behalf. "
Some Medicaid beneficiaries may also have private health insurance, or
may be eligible for payments through automobile or liability insurance or
workers' comnc-n?p.tion. FinalK . an absent psrrnt mav be reFnonsibk- for
-
�20
set at a fixed percentile of the customary charges of area providers for
comparable services. Or the State may use a fee schedule, specifying a flat
maximum payment amount for each service. In 1989, 41 States and the District
of Columbia used fixed fee schedules
The Physician Payment Review
Commission has estimated that State payment rates for physician services in
that year averaged 73.7 percent of what would have been allowed under
Medicare for the same services.
States use a wide variety of methods for rewnbursing hospital outpatient
services. Hospitals may be paid their actual cosu? for providing outpatient rare,
or the State may pay fixed rates. These may be based on a hospital'? historic
costa or may involve a fee schedule comparable to those used for physician
services. As of 1989, only 10 States were still paying on the basis of actual
costa; the rest had adopted some form of prospective rates or a fee schedule.
3. Prescription
Drugs
For prescription drugs. States are required to establish a system that pays
a pharmacy's cost for acquiring a drug plus a fixed dispensing fee. Payment for
drugs that exist in both brand-name and generic versions is generally limited to
the price of the least expensive readily available generic equivalent. The
pharmacy thus has an incentive to substitute the generic drug unless the
physician specifically requests that the brand-name version be furnished. OBRA
90 requires pharmaceutical manufacturers to grant rebates to Medicaid
programs for the drugs they purchase, thus giving Medicaid discounts
comparable to those offered to other high-volume purchasers.
4. Other
Services
Although Medicaid programs cover numerous other kinds of services, the
law establishes specific payment rules for only a few of them. Payment, to rural
health clinics, hospices, and clinical laboratories must generally follow Medicare
rules.
For some services, including laboratory services, durable medical
equipment, and eyeglasses, States are permitted to establish "volume purchasing"
programs, selecting a sole source for the service through competitive bidding or
other means
5. Medicaid
and Other
Payers
With minor exceptions, Medicaid is the "payer of iast resort," secondary to
any other insurance coverage a beneficiary may have or to any other third party
who may be liable for medical payments or medical support on the beneficM-v's
behalf.
Some Medicaia beneficiaries may also have private health insurance, or
may be eligible for payments through automobile or liability insurance or
workers' compensation. Finally, an absent parent may be responsible f r
medical support payments. Applicants for Medicaid benefits are required to
diBcloae any potential payment sources, and Medicaid programs must have a
system for pursuing third party claims. For most services, States have adopted
�°1
providers f
|
icifying a flat »
id the District
ment Review
an services in
.llowed under
21
0 r
#
V O
»co* •
dance" system, denying payment, of claims for which third party
J
to'exist. For a few types of services, Medicaid programs pay
n o w n
^ a i l i n * an
d t h e n
t 0
c o l l e c l
f r o m
t h e
r e s
P
o n 8 i b l e
art
P >'-
1 ged Medicaid beneficiaries and many of the disabled are also eligible
M dicare benefits. States enter into "buy-in" agreements with the
far M* ^ ^
j
j Human Services (DHHS) for these dual eligibles.
^ t ^ * pay Medicare premiums on the beneficiaries' behalf. Medicare pays
^ l l o w e d amounts for the services it covers, with Medicaid paying beneficiary
* u-nng the deductibles and coinsurance required under Medicare. For
beneficiaries fully eligible under both programs, Medicaid also pays for services
that Medicare does not cover but that are included in the State's Medicaid plan,
'uch a* prescription drugs and most NF care. For QMBs (see above), Medicaid
'^yt only the Medicare cost-sharing amounts.
8
c
H
l > r P
tal outpatient
itpatient care,
lital's historic
for physician
'asis of actual
ee schedule.
s e e k
I
e
a
t
h
a n £
8
13
D. Alternative Delivery and Payment Systems
1
•ti
pays
. P.
ntfor
ally limited to
ivalent. The
ig unless the
ushed. OBRA
to Medicaid
aid discounts
'f services, the
ment to rural
How Medicare
rabie medical
ie purchasing"
ive bidding or
" secondan,' to
er
-I party
iary's
insurance, or
insurance or
sponsible for
•e reauired to
•
Medicaid law provides a number of options for States wishing to use
innovative methods for delivering or paying for Medicaid services. Since the
rnrliest years of the Medicaid program, States have arranged for the voluntary
enrollment of Medicaid beneficiaries under contracts with health maintenance
organizations (HMOs) or comparable organizations. OBRA 81 established two
new options, the section 19150)1 (freedom-of-choice) and section 1915(c) (home
grid community-based services) waiver programs. Under these provisions, the
Secretary mav waive certain statutory requirements, on application by a State,
in order to allow the State to develop cost-effective alternative methods of
wrvice delivery or reimbursement. The purpose of these provisions was to give
States greater flexibility in managing their Medicaid programs.
f
14
In the case of the 1915(b) waiver option, the greater flexibility was
intended to offset the temporary reductions in Federal Medicaid funding
imposed by the same Act. The waivers allow States to require beneficiaries to
enroll in HMOs or other managed care programs, or to select cost-effective
providers from whom beneficiaries must obtain all nonemergency care. The
1915(c) option was intended to correct a perceived "institutional bias" in
Medicaid services for the chronically ill by providing States an alternative of
offering a broad range of home and community-based care to persons at risk of
institutionalization. Two other home and community-based care waiver
programs were subsequently established in Medicaid-one to allow States to
serve elderly persons at risk of needing nursing home care and a second to allow
them to provide services to certain children infected with the acquired immune
deficiency syndrome (AIDS) virus or who are drug dependent at birth.
'^Sorne States pay less than the full cost-sharing amounts if the sum of
Medicare and Medicaid payment would be greater than the maximum payable
by Medicaid alone.
1
�22
Most recently, OBRA 90 established two new optional Medicaid benefits,
home and community-based care for functionally disabled elderly persons and
community supported living arrangements for the developm jntally disabled.
These benefits may be provided at a State's option, without waivers. However,
total Federal contributions are subject to national caps ($70 million for the
elderly and $10 million for the developmentally disabled in 1992). In addition,
no more than 8 States may furnish community supported living arrangements.
Finally, States have periodically been granted waivers of Medicaid
requirements in order to conduct demonstration projects. Some of these projects
have been authorized by the Secretary under general statutory provisions
allowing for tests of possible program improvements. Others have been
speciflcally authorized by Federal legislation.
Arizona's medical assistance program, under which beneficiaries receive
all services through HMO-like contractors, has been operated under
demonstration waivers since 1982.
E . Administration
At the Federal level, Medicaid is administered by the HCFA in DHHS, the
same agency that administers the Medicare program. In 1990, a separate
Medicaid bureau was established within HCFA, and most Medicaid functions
were shifted to the new bureau.
Each State operates its Medicaid program through a single state agency,
usually the department responsible for welfare and social services programs, the
health department, or a combination of the two. (Eligibility determination must
be performed by the agency that manages the State's AFDC and SSI programs.)
The program in each State is operated in accordance with a State plan for
medical assistance, which describes the State's basic eligibility, coverage,
reimbursement, and administrative policies. The State plan must be approved
by HCFA and is periodically updated to reflect changes in State policy or to
conform to new Federal requirements. HCFA may use several mechanisms to
insure State compliance with Federal requirements. The method generally
chosen is the disallowance action, under which HCFA retrospectively disallows
and recovers Federal matching payments for State expenditures made in
violation of Federal requirements. An alternative process is the compliance
action, under which HCFA could prospectively withhold Federal funds if it
makes a determination that the State plan no longer complies with Federal
requirements or that the administration of the plan is noncompliant; this
process has never yet been carried to the point of actual withholding of funds.
A Medicaid program pays claims for medically necessary covered services
rendered by qualified providers to eligible beneficiaries. This basic program
description defines the chief functions performed by the single State agency.
�23
1. Eligibility
Determination
Many Medicaid beneficiaries qualify automatically as a result of their
Ii bility for cash assistance. Determination of Medicaid eligibility for persons
Reiving AFDC must be performed by the same agency that determines AFDC
| i bility In States where recipients of SSI are automatically eligible, the State
mav contract with the Social Security Administration to determine eligibility for
these beneficiaries, as well as for other aged, blind, or disabled applicants, or it
may perform its own determinations. A State that uses more restrictive
standards for Medicaid eligibility than for SSI (so-called "209(b) States"; see
Chapter I I I Eligibility) must conduct its own Medicaid determinations. States
generally conduct their own determinations for the medically needy. The State
must verify the information furnished on applications, largely through data
exchange with other agencies.
r
1
-
-
-
~
ra^
Establishment of eligibility for Medicaid is not permanent. The State
must conduct periodic redetermination of eligibility and must also take action
between redeterminations if it learns of changes in a beneficiary's circumstances.
The Secretary has established by regulation that redetermination must occur at
least every 12 months; longer intervals are permissible for blind or disabled
beneficiaries. Redetermination intervals for recipients of AFDC and SSI are set
by the regulations for those programs; the interval is 6 months for AFDC and
varies for different groups of SSI beneficiaries. Applicants who are denied
eligibility must be given notice and an opportunity for a fair hearing.
States have the option to establish "presumptive eligibility" for low-income
pregnant women, in order to ensure that prenatal care is not delayed by the
process of establishing Medicaid eligibility. Certain providers of care may make
a preliminary determination that a pregnant woman may be financially eligible
for Medicaid benefits. The woman may then receive ambulator}- prenatal care
while the State is reviewing her Medicaid application. States are also now
required to "outstation" eligibility workers, to give individuals the opportunity
to apply for Medicaid at the sites where they receive health care.
2. Claims
Processing
Most Medicaid payments must be issued directly to the provider furnishing
the service, not to the beneficiary. Many States use outside fiscal agents to
process claims. Three States have entered into arrangements under which the
fiscal agent assumes direct financial responsibility for payment of some services.
The State issues a fixed monthly payment to the agent, known as a "health
insuring organization" or HIO, for each eligible beneficiary. The HIO uses the
funds to reimburse providers, and may retain some of the savings-or suffer a
loss-if amounts paid to providers differ from the tota! payment received from
the State.
3. Provider
Certification
States must determine which providers of services are eligible to
participate in the program. Federal law is specific about the standards and
�24
certification procedures for institutional providers, such as hospitals and NFs.
For certain other kinds of providers, such as physicians and pharmacies, States
generally follow their own laws on licensure and monitoring. (OBRA 1990
established minimum Federal standards for physicians furnishing Medicaidcovered pediatric or obstetric services.)
Both Medicare and Medicaid use State certification agencies to determine
compliance by institutional providers with program standards. (The Secretary
also conducts direct reviews of some facilities.) For hospital certification, both
Medicare and Medicaid may rely on the findings of one of two organizations (the
Joint Commission on the Accreditation of Health Care Organizations or the
American Osteopathic Association, whichever is appropriate) for determining
whether an institution meets the majority of program requirements. A State
may terminate the certification of a facility that no longer meets the
requirements for participation. If the deficiencies do not immediately jeopardize
the health and safety of patients, the provider may be granted a reasonable
period of time to achieve compliance and may be subject to other sanctions.
States generally follow their own procedures for certifying physicians and
other health care practitioners and certain other noninstitutional providers such
as pharmacies. The Medicare and Medicaid Patient and Program Protection Act
of 1987 (Public Law 100-93) established a data exchange system to disseminate
information on adverse licensing actions among the States, Federal agencies, and
other parties.
16
4. Program
Controls
A Medicaid agency must engage in a variety of activities to ensure that the
program is properly administered:
•
•
Most States are required to operate a computerized Medicaid
Management Information System (MMIS), which maintains
information on beneficiaries and providers, processes claims, and
produces program reports. As of January 1991, only one StateRhode Island-was exempt from the requirement to have an
operational MMIS.
•
16
Medicaid, like other federally funded, State administered programs,
has quality control systems, under which each State identifies
eligibility errors that may result in improper Federal payments.
States with high error rates may be subject to financial penalties.
Medicaid law and regulations include detailed provisions relating
to the quality and appropriateness of care rendered to Medicaid
beneficiaries. Required State activities include development of a
utilization review plan and provision for external reviews of
Thi8 system is coordinated with the National Practitioner Data Bank,
established by the Health Care Quality Improvement Act of 1986 (P.L. 99-660),
which collects data on malpractice awards.
�25
certain facilities. Activities conducted by the facilities themselves
include initial and periodic recertification of each patient's need for
care, development of plans for the care of each patient, and
operation of an approved utilization review (UR) program.
ita.. ..id NFs.
macies, States
(OBRA 1990
ing Medicaid-
to determine
The Secretary
fication, both
lizations (the
ations or the
determining
nts. A State
r meets the
lyjeopardize
a reasonable
sanctions.
ysicians and
oviders such
otection Act
disseminate
gencies, and
ure that the
i programs,
e identifies
payments.
J penalties.
i Medicaid
maintains
aims, and
)ne State-have an
1
is relating
Medicaid
ment of a
eviews of
it.
. 9b
The "nursing home reform" provisions of OBRA 87 established new
minimum standards for nursing homes participating in Medicaid,
restructured the survey and certification process, and included new
sanctions and enforcement actions for noncompliant facilities. The
new standards address such issues as levels of staffing in the
facility, the qualifications of staff, and residents' rights. NFs must
also now conduct periodic assessments of residents' functional
capacity.
«
Each State is required to establish methods for identifying and
investigating cases of potential fraud and abuse. Special Federal
funding is available for State Medicaid fraud control units
(MFCUs), which investigate State law fraud violations. Federal
agencies may also act on their own to pursue Medicaid fraud or
abuse cases.
F. Program Financing
Medicaid services and associated administrative costs are jointly financed
by the Federal Government and the States. The Federal share of a State's
payments for services is known as the Federal medical assistance percentage
(FMAP).
FMAPs are calculated annually based on a formula designed to
provide a higher Federal matching rate to States with lower per capita incomes.
No State may have an FMAP lower than 50 percent or higher than 83 percent.
In FY 1992, 11 States and the District of Columbia received the minimum 50
percent FMAP, while Mississippi received the highest FMAP, 79.99 percent.
(FMAPs for the territories are fixed at 50 percent; there are also overall caps on
Federal funding for the territories' Medicaid programs.) The Federal share of
administrative costs is 50 percent for all States, though higher rates are
applicable for specific items. Overall, the Federal share of Medicaid payments
is an estimated 57 percent in FY 1992.
Participating States are responsible for the nonfederal share of Medicaid
payments. (Some States require local governments to share a part of the cost.)
Like the Federal Government, States usually rely on general funds for Medicaid
spending. In recent years, however, many States have developed special revenue
sources for Medicaid, some of them controversial. In the face of rising Medicaid
costs, States have used funds donated by health care providers or taxes paid by
those providers to draw greater Federal matching payments. For example,
hospitals might donate funds to the State. The State would use these funds as
the State share of Medicaid spending, receive Federal matching funds, then
repay the hospitals their donations plus the Federal funds. Similar increases in
Federal funds could be generated through taxes or mandatory assessments on
providers. The Medicaid Voluntary Contribution and Provider-Specific Tax
�26
Amendments of 1991 (P.L. 102-234) prohibit the use of provider donations after
1992 (or mid-1993, in certain States) and limit the use of provider-specific taxes.
G. Medicaid and the Federal Budget
From a Federal budget perspective, Medicaid is viewed as an entitlement
program. Entitlement programs provide benefits to all people or jurisdictions
who are eligible and receive benefits. Spending levels for entitlements tire
determined, not by the annual appropriation process, but by the number of
persons who participate in the program and program benefit levels. However,
Medicaid spending is still drawn from Federal general funds. There is no trust
fund like that established for some other entitlement programs (such as Social
Security and Part A of Medicare).
Under the Budget Enforcement Act of 1990 (Title X m of OBRA 90, P.L.
101-508), Medicaid spending falls into the "pay-as-you-go" category with other
entitlement programs. The budget law requires that for fiscal years 1991
through 1995 any legislation affecting these programs should be deficit neutral
for the whole class of entitlement programs. That is, any legislative change in
one of these programs that would increase spending over current law levels
must by offset by changes in the same program or other "pay-as-you-go"
programs, in order to avoid increasing the size of the Federal deficit.
. 1
�*
0
2 f
'
3
0)
S
a
2 o oo '4
*
S P £
P
< • -a 2
>
Q D
O
c
7
3 ST re £ i _
CD
to
»—r-
W
C
TO
to
^ S' ^ 3 a i
a
o 9 BS
rt- ^ _ B "
O r » (t>
—
2. C < ^ p o g
EL R * o 5 g 3
T A B L E 1-2.
1965
2.3
C
D
O
-a 3
J £
?
5 5
>
n
3
f5
M » j o r M e d i c a i d L c g i i l a t i o n , 1965 l o 1 9 9 1
Social S c c u r l i r A m e n d m e n t t o f 1965 (P.L. 8 9 - 9 7 )
Eu«hli«hed ihe Medicaid program
1967
Social Security AroeBdmeoU o f 1967 ( P L. 9 0 - 2 4 S )
Limited flnancial Xandsrdi ror the medical!)' needy
Euablithed the Earlyand Periodic Screening, Diagnowicand Treatment (EPSDT) program to improve child health
Permitted Medicaid beneflciariel to u»e provider! of their choice
1971
Act o f O e c c n b e r U , 1971 ( P . L . 9 1 - 2 2 3 )
Altoved Statei to cover icrvlcei In Intermediate care facilltiet (ICFi)and ICFt lor the mentally retarded (ICFs/MR)
1972
SocUl Securlly A m e n d m e n t i o f 1972 ( P . L . 9 2 - « 0 J )
Repealed 196? proviiion requiring Statei to move toward comprehensive Medicaid coverage
Allowed Statei to cover care for benertciariei under age 22 in psychiatric hospitali
1977
M e d i c a r e - M e d i c a i d A n t l - P r a n d and Abuae A m e n d m e o t i of 1977 (P.L. 9 5 - 1 4 2 )
Euabliihed Medicaid Fraud Control U n i u
1980
M e n t a l Healih Syalema Act ( P L. 9 6 - 3 9 8 )
Required moit Statei to developa computeriied Medicaid Management Information SyKem ( M M I S )
O m n l b u t RecoDciliatloii Act o f 1980 ( P L
9*-499)
Boren amendment permitted Staiet to eMahlish payment systems lor nunlng home care in lieu of Medicare's rules
1981
Omnibus Budget R e c o n c i l i a t i o n Act o f 19*1 ( O B R A M l . P L. 9 7 - 1 5 )
r.nacled 1-yrnr rediKliins In l-'cderal matching prrccmage*
Slates whose spending ricerded growth targris
r'stahli^hetl seciiin 191 5(h) and IVI 5<c) waiver pfngrnmi (freedom - of-choice and home and community-hHsed services)
l-:sieniied ihe lloren amendment io inpatient hospital services
Lliminatcd special penal)ies for noncompliance with KI'SDT requirements and gave States with medically needy program! broader authority lo limit coverage
1984
Oeflcil Reducltoo Act of I9S4 ( D R F R A , P I.. 9*1-1*9)
Fliminaled categorical tests for certain pregnant wumcn and young children
r o m i n u e d o n nen page.
�T A B L E 1-2.
1986
M a j o r M e d i c a i d L e g i s l a t i o n , 1965 t o 1991 - - C o n t i n u e d
C o u o l l d i l e d O m n i b u i Budget Reconclltatlon A c t o f 198S ( C O B R A , P L. 99 - 272)
Eitended coverage lo all pregnant women meeting A F D C financial ttandards
O n n l b B i Budget Reconclltatlon A c t o f I9S6 ( O B R A 86, P . L 9 9 - 3 0 9 )
Allowed coverage of pregnant women and young children to 100 percent of poverty
Euabliihed a new optional category of 'qualified Medicare beneficiariei' ( Q M B i )
1987
Medicare t o d Medicaid Patient and Program Protecltoa Act o f 1987 ( P . L . 1 0 0 - 9 3 )
Strengthened authoritlci to unction and eiclude provider!
O m o l b u Budget R e c o n c i l i a t i o n Aet o f 1987 ( O B R A 87, P L. 1 0 0 - 2 0 3 )
Allowed coverage of pregnant women and infanti to 105 percent of poverty
Strengthened quality of care uandardt and monitoring of nurilng homei
Strengthened O B R A 81 requirement that States provide additional payment to hoipitali treailrg a dlaproportbnate t h a n of low-Income patien
1988
Medicare C a t a u r o p h l c Coverage Act o f 1 9 M ( M C C A , P.L. 1 0 0 - 3 6 0 )
Mandated coverage of pregnant women and Infant! to 100 percent of poverty
Expanded coverage of low-Income Medicare beneflciariel
Euabliihed ipeclal eligibility rules tor i n u i t u t b n a l i s d perioni whose spouse remained in tbe community to prevent 'spousal impoverishment'
Family Support Act o f 1988 ( P . L . 1 0 0 - 485)
Extended work transition coverage Ibr families losing AFDC because of increaaed earnings and expanded coverage for two-parent familrs
whose principal earner was unemployed
1989
Omnibus Budget R e c o n c i l i a t i o n Act o f 1989 ( O B R A 89, P L
101-239)
Mandated coverage of pregnant women and children under age 6 to 133 percent of poverty
Expanded EPSDT program requirements
Mandated coverage and f u l l - o o u reimbursement of federally qua lifted health centers (FQHCs)
1990
O m n i b u s Budget R e c o n c i l t a l i o n A c l o f 1990 ( O B R A 90, P L
101-508)
Phased in coverage of children ages 6 through 18 to 100 percent of poverty
Expanded coverage of low-income Medicare beneficiaries
Euablished Medicaid prescription drug rebate program
1991
M e d i c a i d V o l u n t a r y C o n l h b u t i o n aad P r o v i d e r - S p e c i f i c Tax Amendments o f 1991 ( P . L . 102 - 234)
Reuricted use of provider donations and taxes as State share of Medicaid spending; limited disproportionate share hospital payments
Source: Table prepared by the Congressional Research Service
�Table A-2
Medicaid Beneficiaries and Expenditures, by State, 1990
State
United States Total
Alabama
Alaska
Arizona
Arkansas
California
Total
Beneficiaries
I'm thousands)
Total
Expenditures
(m millions)
Expenditures
Per
Beneficiary
25,255
S64,859
S 2,568
352
39
N.A.
264
3,624
609
139
N.A.
599
6,507
1,730
3.564
N.A
2,269
1,796
191
250
2,702
4,820
3,000
2,645
2.275
Colorado
Connecticut
Delaware
District of Columbia
Florida
93
1,038
516
1.205
123
246
2,361
Georgia
Hawaii
Idaho
Illinois
Indiana
651
85
55
1,067
348
2,076
191
162
2.424
1.343
3,189
2.247
2,945
2.272
3,859
240
194
468
585
133
620
491
977
1.315
432
2,583
2,531
2,088
2,248
3.248
330
591
1,048
380
433
1,090
2,730
2,195
1,410
586
3,303
4,619
2,094
3,711
1,353
448
61
119
47
45
897
171
309
149
243
2,002
2,803
2,597
3,170
5,400
New Jersey
New Mexico
New York
North Carolina
North Dakota
567
130
2,329
563
49
2,298
275
11,877
1,426
194
" 4,053
2,115
5,100
2,533
3,959
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
1,221"
273
227
1,177
117
3,132
688
519
2,883
442
2,565
2,520
2,286
2,449
3,778
South Carolina
South Dakota
Tennessee
Texas
Utah
317
49
613
1,442
108
743
166
1,163
2,781
247
2,344
3,388
1,897
1,929
2,287
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico and Virgin Islands
~60"
379
448
250
393
29
1,291
153
985
952
361
1,248
59
150
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Jevada
New Hampshire
4]
"
" 2,550
2,599
2,125
1,444
3,176
2,034
116
Note: Arizona uses the Arizona Health Care Cost Containment System as an alternative to Medicaid
and is not included m the HCFA Form 2082.
N.A. = Not applicable.
SOURCE: Health Care Financing Administration, 1991.
�Table A-3
Annualized Medicaid Eligibility Standards for a Family of Three, 1992
.ite
Maximum
AFDC Payment
United States Average
Alabama
Alaska*
Arizona
Arkansas
California
S 5,106
Percent ot
Poverty
Pregnant
Women
and Infants
44%
S 18.521
Percent of
Poverty
Medically
Needy
Percent of
Poverty
S 6,191
53%
0
159 x
1,788
11,076
4,008
2,448
7,956
16
77
35
21
69
15.388
19,232
16,198
21,405
21.405
133
133
140
185
185
Colorado
Connecticut
Delaware
District of Columbia
Florida
5,052
6,972
4.056
4,908
3.636
44
60
35
42
31
15.388
21.405
18.512
21.405
17,355
133
185
160
185
150
Georgia
Hawaii*
Idaho
Illinois
Indiana
5,088
7,992
3,780
•1.404
3.456
44
60
33
38
30
15.388
24,624
15.388
15.388
17.355
133
185
133
Iowa
Kansas
Kentucky
Louisiana
Maine
5.112
4,752
6,312
2.280
6.876
44
41
55
20
59
21.405
17,355
21.405
15.388
21.405
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
39
60
61
55
38
Missouri
Montana
Nebraska
Nevada
New Hampshire
4.524
6.948
7.044
6,384
4.416
3.504
4,680
4,368
4.176
6.192
New Jersey
'ew Mexico
w York
,rth Carolina
jorth Dakota
3,300
11,208
29
97
9,276
80
6.540
3,636
57
31
4.500
7.992
39
50
5.904
51
185
150
185
133
185
6,792
5,640
3,696
3,096
5.496
59
J9
27
48
21.405
21.405
21.405
21.405
21.405
185
185
185
185
185
5.304
9,300
6,804
8,508
46
30
59
74
30
40
38
36
54
15.388
15.388
15.388
15.388
15.388
133
133
133
133
133
5,316
5,904
46
51
5.008
3.888
6.924
3.264
4,812
43
34
60
28
42
21,405
21.405
21,405
21,405
15,388
185
185
185
185
133
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
4.008
5,652
5,520
5,052
6,648
35
49
48
44
57
15,388
15,388
15,388
15,388
21,405
133
133
133
133
185
South Carolina
South Dakota
Tennessee
Texas
Utah
5.280
4.848
5,112
2,208
6,444
46
42
44
19
56
21,405
15,388
21,405
21.405
15,388
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
8.076
3.492
6,372
2,988
6.216
4.320
70
30
55
26
54
37
21,405
15,388
21,405
17,355
17,934
15,388
150
7,392
64
6,792
59
9,000
4 404
5,220
78
38
45
5.508
7,356
5,604
8,892
48
64
48
77
185
133
185
185
133
3,396
29
3,000
3.204
6,432
26
28
56
185
133
185
150
155
133
10.800
4,296
7,800
3,480
8,268
93
37
67
30
71
Note: The 1992 federal poverty level for a family of three is S11,570.
* Poverty levels for Alaska IS14,460I and Hawaii (313,310) differ from other states.
SOURCE: National Governors Association. 1992.
tvi
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�Tab 5
This section includes:
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
Table VI-4: Regular and Model Medicaid Waivers
by State and Target Population.")
�256
T
T
T A B L E rV'-l. Optional Medicaid Services and Number of
Statea* Offering Each Service aa of October 1, 1W1
Service
Podiatriau' servicee
Optometnat£' servicee
. . ..
Chiropractors' services
Other practitioners' servicee .
Private duty nursing
Clinic services
Dental servicee
Physical therapy
Occupational therapy
Speech, hearing and language
disorder
Prescribed drugs
Dentures
Prosthetic devices
Eyegiaasee
Diagnostic servicee
Screening aervices
Preventive services
Rehabilitative servicee
Services for age 65 or older in
mental institution:
A. Inpatient hospital services
B. NT services
ICF servicee for
mentally retarded
inpatient psychiatric aervices for
under age 21
Chriatian Science nurses
Chriatian Science sanitoria
NF for under age 21
Emergency hospital services
Personal care services
Tranaponation servicee
Case management servicee
Hospice servicee
Respiratory care services
Stales offering
eervice to
ca Lego n cally
needy only
Statee offerinp
service to both
categorically
and medically
needy
TotAJ
AS
12
14
?
13
8
15
12
11
8
33
36
19
32
20
40
36
31
26
11
16
8
14
16
5
4
3
12
2S
3?
31
38
33
2i
19
20
33
40
14
11
26
22
40
2!
28
10
1
4
20
14
9
14
10
9
3
11
30
28
19
37
33
24
II
•Includes the temtonee Thus, maximum number LB 56.
Source: U S Dept. of Health and Human Services. 1991
.V.
<t*
•t;
:^
4$
t.
;
�390
391
operation at the end of 1991
In
JIT than ]
?
185.000 penon.."
TABLE Vl-4. 1916(c) Regular and Model Waiver*,
by State and Target Population, December 2, 1981
Sutes with regular waivers served t h .
retarded/develop entaJlv d.sabTd
£
M waiver programs servmg the aged and
Regular waivers
Model waivers
m
m
Population
Total
Population
1 A/D
1 MR/DD
2
1 A/D
1 C/D
2
Alaska
None
0
None
0
Arizona
None
0
None
0
Arkansas
1 A/D
1 MR/DD
2
None
0
2 A/D
1 P/D
1 AIDS
1 MR/DD
5
1 A/D
1
1 A/D
1 MR/DD
1 DD
1 AIDS
4
1 C/D
1
1 A/D
1 MR/DD
1 DD
3
1 MR/DD and D
1
1 A/D
1 MR/DD
2
1 AIDS
1
Dist. of Columbia
None
0
None
0
Florida
2 A/D
1 MR/DD
1 AIDS
4
1D
1
1 AT}
1 MR/DD
2
1 C/D
1
2 A/D
1 MR/DD
1 AIDS
4
None
0
1 A/D and MR/DD
1
None
0
e
eo Z r ^ ^
^ i - v retarded a^d
W j e d a program servmg both of thesp
Total
6
Alabama
a C t i V i t y
1
'
C O n t a , n e d
at
l n
^
VI-6
d,8abled c h i l d r e n
S E m^T
«5
w a ] v e r
roM
,
to serve the
«ll y -tarded/developmentaJly d.sabled a
"l
d
e
0
"?3 L
W a i V e r S
8 e r V e d
r
a
PP-x,matel
y
Califomia
Colorado
Connecticut
Delaware
.'CFA Form 372s that States
-rso ^ . on served, services used and
ri
S
from 4, States that operated 136
a b 0 U t
^ a ^ T ^
'^i-abled
a.sabled be.ng served. In only a few
S
e
t
h
e
P h
V 8
e T m L
7
- '
y tabled
'
'"ferences about the age of
W
m
a
k
Georgia
c a , 1
e
a ^ i s ofHCFA Form 3723. The totals
1 * regular and model waivers in FY
-onal 3.800 persons who i„ 1991 weVe
^ t two difTeren, population groups
-arded/devviopinenully d.sabled For
ofparticpanis.neach group was not
Hawaii
Idaho
See not«6 at end of table
�392
T A B L E Vl-4. 1916<c) Regular and Model Walvera,
by SUte and Target Population, December 2. 1991 -Continued
Mode! waivers
Regular waivers
Population
Total
Population
Total
1 D
1 A
1 MR/DD
1 AIDS
4
1 C/D and AIDS
Indiana
1 AT)
1
1 DD
Iowa
2 ME
1 AIDS
3
1 A/D, C/D, MR/DD
1 A/D
1 AT)
1 MR/DD
2
1 D
1 C/D
1 A/D
1 MR/DD
2
1 C/D
1 D
1 AT)
1 MR/DD
2
None
1 A
1 P/D
1 MR/DD
3
None
0
Maryland
2 MR/DD
2
1 C/D
1
Massachusetts
1 .VD
1 MR/DD
o
None
0
Michigan
1 MR/DD
1
1 MR/DD
Minneeota
1 A
1 P/D
2 MR/DD
4
1 D
1 A/D
1
None
Illinois
Kansas
Kentucky
Louisiana
Maine
I..
Mississippi
1
1
0
Missouri
Montana
2 A/D
2 MR/DD
1 AIDS
5
None
1 A
1 A/D
1 MR/DD
3
None
See notes at end of table.
�393
TABLE V M . 1916(c) Regular and Model Waivers,
by State and Target Population, December 2, 1991-Continued
Model Waivers.
er 2. 1 M l - C o n t i n u e d
Population
Model waivers
Regular waivers
Model waivers
Population
Total
Total
Population
Total
1 A/D
1 MR/DD
2
1 MR/DD
1
1 A/D •
1 MR/DD
2
1 P/D
1
1 A/D
1 MR/DD
2
None
0
1 A/D
1 MR/DD
1 AIDS
3
3 B and D
3
1 A/D
1 D
1 MR/DD
1 AIDS
4
None
0
1 A/D
1 MR/DD
2
1 C/DD
2 C/D
3
1 A/D
1 MR/DD
2
1 C/B, C/D,
and C/ATDS
1
1 A/D
1 MR/DD
2
None
0
1 A
1 D
1 C/D
1 AIDS
2 MR/DD
6
2 MR/DD
2
Oklahoma
2 MR
2
None
0
Oregon
1 B and D
1 MR/DD
2
None
0
I MR/DD
2 MR
1 AIDS
4
1 C/D
1
Nebraska
1 C/D and AIDS
1
1 DD
Nevada
1
New Hampabire
1 A/D, C/D, MR/DD
1 A/D
2
New Jersey
1D
1 C/D
2
1 C/D
1D
2
New Mexico
None
vi ••.'pi
I'- 'r?
0
New York
0
1 L,^
North Carolina
1
North Dakota
None
0
1 MR/DD
1
1D
1
None
0
Ohio
None
None
0
Pennaytvania
0
See notes at end of table
�T A B L E Vl-4 1916(c) Regular and Model Waivers,
by State and Target Population. December 2, 1991-Contlnued
Modei waivers
Regular waivers
Population
Total
Population
Total
2 A/D
1 MS/DD
3
1 P/D
1 C/D
2
1 A/D
1 AIDS
1 MR
3
1 C/D
1
1 A
1 MR/DD
2
None
0
1 A/D
1 MR/DD
2
1 MR/DD
1
1 C/D
1 MR/DD
2 MR
4
None
0
Utah
1 MR/DD
1
None
0
Vermont
1 A/D
2 MR/DD
1 Ml
4
None
0
1 A/D
2 MR/DD
3
1 D
1 AIDS
2
1
1
1
1
A/D
MR/DD
MR
AIDS
4
1 B and D
1
1 A/D
1 MR/DD
2
None
0
1 A/D
2 DD
3
None
0
1 DD
1
None
0
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Virginia
Washington
West Virginia
Wismnsin
Wyoming
129
TOTAL
KEY:
A/D
A
includes aged/disabled persons.
includes aged persons
38
�395
and Mode) Waivers,
jernber 2, 1981 -Continued
T A B L E VI-4. 1916(c) Regular and Model Waivers,
by State and Target Population. December 2, 1991-Contlnued
Model waivers
Population
KEY (continued):
Total
1 P/D
1 C/D
1 C/D
None
P/D
C/D
C/DD
B and D
D
MR/DD
MR
DD
MI
AIDS
indudes physically disabled persons.
includes disabled children.
includes developmentally disabled children
includes blind and disabled persona.
includes disabled persons.
includes mentally retarded and/or developmentally disabled persons.
includes mentally retarded persons.
includes developmentally disabled persons.
includes mentally ill persons
includes persons diagnosed with acquired immunodeficiency
syndrome (AIDS), AIDS-related complex, or human
immunodeficiency virus (HTV) infection.
Source Table prepared by the Congressional Research Service based on analysis
of unpublished HCFA reports
1 MR/DD
None
None
D
1 AIDS
1 B and D
None
US
None
0
None
0
38
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(
o
�Tab 6
This section includes:
Kaiser Commission Report (Figure 4-6, "Physician
Participation in Medicaid")
�Figure 4-6
Physician Participation in Medicaid
Limit
participation
.35%
Accept no
new patients
5%
Full
participation
34%
Do not accept
Medicaid
26%
SOURCE: American Medical Association, 1991.
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�Tab 7
This section includes:
Kaiser Commission, op. cit.
(Figure 4-7, "Pediatrician Participation in Medicaid,
1978-1989")
�Figure 4-7
Pediatrician Participation in
Medicaid, 1978-1989
Percentage of Pediatricians Limitinq Practice
53%
50
"^- • /t
• •"rs
1978
1983
1989
3 Percentage limiting Medicaid caseload
• Percentage not participating in Medicaid
SOURCE: Yudkowsky, B., Cartlami. J. • •<•
Flint, S., 1990.
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�Tab 8
This section includes:
Physician Payment Review Commission, "Annual
Report to Congress," 1991. (Table 15-13: Index of
Medicaid Fees Relative to Medicare Prevailing
Charges by States).
�PHYSICIAN
PAYMENT
REVIEW
COMMISSION
ANNUAL REPORT
TO
CONGRESS
1991
�Table 15-13.
Index ot Medicaid Fees Relative to Medicare Prevailing Charges by State
State
Index
.72
1.06
1.20
St
.81
J6
JO
Jl
.71
1.12
.79
.76
.48
1.02
.91
.79
.63
66
62
Jl
94
.62
.86
.66
.57
.74
99
.79
.67
40
.69
JO
.93
.75
60
.78
.66
.51
.55
81
.85
.92
.77
-89
71
.73
69
J5
.76
Alabanu
Aluka
Arkaiuai
C*lifomu
Colorado
Connecticut
Delaware
Diftria of Columbia
Florida
Georgia
Hawaii
Idaho
Olinoii
Iowa
Kansaa
Kentucky
Louisiana
Maine
Maryland
MasiachuMfu
Michigan
Minnesota
Miasauppi
Miisouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Menco
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsytvania
Rhode Island
South Carolina
South Dakota
Tennc»»e«
Tcxaa
Utah - <
Vermont
Virginia
Wuhil^ron
West Virginia
Wisconsin
Source.
National Governors' Association and Physician Payment Review Commission, 1990. Health Care
Financing Administration, BMAD, 1988, and Medicaid Statistical Information System. 1989.
Note:
The index measures Medicaid fees relative to Medicare prevailing charges. For example,
Alabama's Medicaid fee* are, on average, 72 percent of Medicare prevailing charges in the state.
290
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�Tab 9
This section includes:
American Hospital Association, "Medicaid
Underpayments and Hospital Care for the Poor: A
Fact Sheet," January 1991.
�UNSPONSORED HOSPITAL CARE AND MEDICAID SHORTFALLS, 1980-1991:
A FACT SHEET UPDATE
Questions regarding the information presented in this fact sheet should be directed to Sarah
Thomas (312/280-4471) or Carmela Dyer (312/280-6635) ofAHA's Division of Health Policy.
Questions regarding state Medicaid reimbursement policy should be directed to Pat Meersman
(312/280-6074) of AHA's Division of Financial Policy.
�Key Findings
Over the decade, the cost of uncompensated and unsponsored hospital care has grown at
a faster pace than overall hospital costs. In 1980, uncompensated care cost hospitals less
than $4 billion; the cost was over $13 billion in 1991. As a percentage of total hospital
costs, uncompensated care climbed from slightly more than five percent to six percent
during this period. Between 1980 and 1991, unsponsored care costs increased from less
than 3 billion to $10.8 billion. While such carerepresentedless than four percent of
hospital costs in 1980, it accounted for almost five percent of costs by 1991.
A significant number of hospitals are providing very high levels of unsponsored care.
More than 1500 hospitals (almost 29 percent of hospitals) provided unsponsored care
exceeding 5 percent of their costs. More than 300 (approximately 6 percent of hospitals)
provided unsponsored care totaling more than 10 percent of their costs.
Govemment assistance to hospitals to help subsidize the cost of uncompensated care is
not keeping pace with the growth in these costs. In 1980, state and local tax
appropriations covered more than 28 percent of the cost of uncompensated care. In
1991, state and local tax appropriations covered less than 20 percent of uncompensated
care costs.
Medicaid payments for patient care fall very short of costs, and the shortfall is growing
very quickly. In 1980, hospital losses from Medicaid underpayment were $0.7 billion.
By 1991, these losses hadrisento $5 billion. Four out of five hospitals are now losing
money serving Medicaid patients.
Medicaid shortfalls now account for almost one-third of hospital losses in caring for the
poor ~ up from one-fifth in 1980 ~ and have been the fastest growing component of such
losses.
American Hospital Association
Revised November 1992
�Because of their mission, the vital nature of the services they provide, and community
expectations, hospitals historically have provided care to some patients without charge or at
reduced charges. This fact sheet, based on data from the American Hospital Association's
Annual Survey of Hospitals, examines trends in hospital provision of uncompensated care and
Medicaid shortfalls from 1980 to 1991.
UNCOMPENSATED AND UNSPONSORED CARE
WHAT IS UNCOMPENSATED CARE?
Uncompensated care is an overall measure of hospital care provided for which no
payment was received from the patient or insurer. It is the sum of a hospital's "bad
debt" and the charity care it provides. A hospital incurs bad debt when it cannot obtain
reimbursement for care provided. This happens when patients are unable or unwilling
to pay their bills. Charity care is care for which hospitals never expected to be
reimbursed. Most hospitals budget annually to provide a certain level of charity care to
poor patients based on the individual hospital's mission and financial situation.
Uncompensated care excludes other voluntary or involuntary discounts or "reductions in
revenue," such as underpayment from Medicaid and Medicare or discounts to private
payers.
Unsponsored care is that portion of uncompensated care thatremainsunpaid even after
government subsidies-that portion of uncompensated care that must be absorbed by
hospitals or passed on to other patients. It is the difference between uncompensated care
and what governments give to hospitals to either help with overall expenses, in the case
of govemment hospitals, or to offset charity care costs through special programs, such
as uncompensated care pools.
Both measures include the costs accounted for as bad debt and charity care. While effons
occasionally are made to present bad debt and charity care figures separately, such analysis
conveys a sense of precision not warranted by the data. For accounting purposes, bad debt
consists of services for which hospitals anticipated, but did not receive, payment. In contrast,
charity care is services for which hospitals neitherreceived,nor expected to receive, payment.
In practice, however, it is very difficult for a hospital to distinguish bad debt from charity care.
Depending on mission, financial condition, and other factors, hospitals provide varying levels
of charity care which must be budgeted for and financed by the hospital. Thus, the care
delivered to a patient may be classified as charity care by one hospital, but bad debt by another.
This does not mean, however, that care classified as bad debt was provided to patients who can
afford to pay. On the contrary, bad debt can be generated by people with limited resources,
making the distinction between the two categories virtually meaningless. Recent studies of
American Hospital Association
Revised November 1992
�medical indigence in Florida and North Carolina, for example, found that about 90 percent of
the uncompensated care, both bad debt and charity care, was attributable to people who were
poor, near-poor, or uninsured. No national data are available, however, on the characteristics
of patients whose expenses are classified as hospital bad debt. For these reasons, bad debt for
hospitals is not comparable to bad debt in other industries. Additional information on the
difference between bad debt and charity care, and changes in financial reporting requirements
is presented as an appendix to this fact sheet.
The difference between uncompensated and unsponsored care is important. For most purposes,
unsponsored care figures provide a better measure of a hospital'sfinancialburden in caring for
the medically indigent, because they are "net" of govemment appropriations, and therefore
indicate the cost that must either be absorbed by the hospital or passed on to private-pay patients.
Uncompensated care data generally are expressed in terms of hospital charges, but charge data
can be misleading, particularly when comparisons are being made among types of hospitals, or
hospitals with very different payer mixes. For this reason, AHA data are expressed in terms of
costs.
Finally, because figures on uncompensated and unsponsored care do not take into account the
cost of contractual adjustments for public or private payers, any effort to weigh hospital burdens
in caring for the medically indigent would also have to factor in Medicaid shortfalls-the
difference between Medicaidreimbursementsand the cost of providing hospital care to Medicaid
patients. This issue is addressed in the second section of this fact sheet.
WHY IS UNCOMPENSATED CARE A PROBLEM?
While hospitals always have provided some free care to those unable to pay, uncompensated care
currently is creating a large problem not only for hospitals but for insurers and employers as
well because of the confluence of three trends: the growth in uncompensated and unsponsored
care, the uneven distribution of such care, and the declining ability of providers to shift
uncompensated care costs to other payers.
Increasing Volume
The first and most readily-apparent aspect of the problem is the fact that levels of
uncompensated and unsponsored care have increased rapidly. Table 1 illustrates trends in
hospital uncompensated and unsponsored care from 1980 to 1991. The greatest period of growth
was between 1980 and 1986; since that time unsponsored care as a percent of total expenses
appears to have stabilized somewhat.
American Hospital Association
Revised November 1992
�Table 1
National Uncompensated and Unsponsored Care:
1980 - 1991 (in Billions), Registered
Uiuponiored Cirt
Uncompenuted C«re
Chirgebiied
* of
Grou
Pitient
Revenue
Coit-btied
Cott-biied
it i % of
Toul
Expenie*
Coit-bued
Con-btted
*• • * of
Total
Expense*
Yeir
Hoipi
Toul
Expense!
Grou
Pitiant
Revenue
1980
5828
$76.8
$89.5
$4.6
5.2*
$3.9
5.1%
$2.8
3.7*
1981
5812
$90.6
$106.3
$5.6
5.2%
$4.7
5.2%
$3.5
3.8%
1982
5796
$104.8
$126.0
$6.5
5.2*
$5.3
5.1%
$4.1
3.9*
1983
5782
$116.4
$145.1
$7.8
5.4*
$6.1
5.3%
$4.8
4.1*
1984
5757
$123.3
$155.8
$9.5
6.1%
$7.4
6.0%
$5.6
4.6*
1985
5729
$130.5
$163.3
$9.9
5.8*
$7.6
5.8%
$6.0
4.6*
1986
5676
$140.6
$178.4
$11.7
6.5*
$8.9
6.4*
$6.9
4.9*
1987
5597
$152.2
$198.1
$12.6
6.4%
$9.5
6.2%
$7.2
4.7*
1988
5499
$168.0
$224.8
$14.2
6.3%
$10.4
6.2%
$8.1
4.8%
1989
5448
$184.6
$275.9
$15.6
6.0%
$11.1
6.0%
$8.9
4.8*
1990
5370
$203.2
$297.4
$17.9
6.0%
$12.1
6.0%
$9.5
4.7%
$224.5
$343.4
$20.5
6.0%
$13.4
6.0*
$10.8
4.8%
1991
5329
Source: AHA Annual Survey Dau, 1980-1991
In 1980, uncompensated care cost hospitals $3.9 billion; the cost was $13.4 billion in
1991. As a percentage of total hospital costs, uncompensated care climbedfrom5.1
percent to 6.0 percent during this period.
Between 1980 and 1991, unsponsored care costs increasedfrom$2.8 billion to $10.8
billion. While such care represented only 3.7 percent of hospital costs in 1980, it
accounted for 4.8 percent of costs by 1991.
American Hospital Association
Revised November 1992
�Uneven Distribution
A second aspect of the problem is the fact that levels of uncompensated and unsponsored care
are very uneven, with some hospitals providing very large amounts of such care relative to their
costs. The heavy burdens bome by some hospitals can be seen by looking at unsponsored care
levels, that is the net costs of care that are neitherreimbursed(by patients or third party payers)
nor covered through state and local tax appropriations. In 1991, for example, AHA annual
survey data show that:
1537 hospitals (28.8 percent of hospitab) provided unsponsored care exceeding 5.0
percent of their costs.
307 hospitals (5.8 percent of hospitals) provided unsponsored care totaling more than
10.0 percent of their costs.
Declining Ability to Shift Costs
The third trend affecting the uncompensated care problem is the declining ability of all
providers, and the dramatically declining ability of some, to successfully shift unsponsored care
costs to other payers. Traditionally, hospitals have been able to subsidize some of the cost of
care provided to the medically indigent by increasing charges to privately insured patients and
to patients able to pay their own bills. To the extent that cost shifting occurs, unsponsored care
becomes an implicit or "shadow" tax on private payers. There have always been limits on the
ability of hospitals to shift costs in this way, but the competitive environment and
reimbursement changes in private insurance programs are making this practice increasingly
difficult. In a price competitive environment, private payers are increasingly able to escape such
a tax by taking their business elsewhere.
Some hospitals, those with a large volume of Medicare and Medicaid patients, are particularly
limited in thisregardbecause they have few patients to whom costs can be shifted. These same
hospitals generally face an additional burden: to the extent that Medicare and Medicaid
reimbursements fall below costs, any dollars generated through cost shifts to private payers also
must be used to cross-subsidize care for these publicly insured patients. For this reason,
unsponsored care percentages alone do not provide a complete picture of a hospital's ability to
suppon indigent care. Unsponsored care levels of six percent might be very difficult for some
hospitals to maintain andrelativelyeasy for others. For example, states with large numbers of
Medicaid patients, but low Medicaid payment levels, may still be allocating a sizable proportion
of its costs to the provision of care for the medically indigent, but find it very difficult to finance
additional unsponsored care.
American Hospital Association
Revised November 1992
�In short, hospitals with large unsponsored care burdens cannot withstand a payer mix with few
private pay patients, and particularly cannot withstand a high-volume, undercompensated
Medicaid load.
WHOSE PROBLEM IS IT?
The growing uncompensated care problem, like the broader indigent care crisis, is obviously a
very serious concern for hospitals. Hospitals that continue to provide large amounts of
unsponsored care are at a competitive disadvantage in an increasingly price-driven payment
environment; for hospitals with an unfavorable payer mix, even moderate levels of unsponsored
care can be devastating. In addition, however, uncompensated care has serious effects on
others. For example:
Employers. Employers who sponsor insurance plans for their employees and families
face higher rates as a result of the implicit uncompensated care "tax." In very
competitive areas, large employers and insurers may be able to avoid this implicit tax
through negotiated discounts; but many employers, particularly smaller employers, will
not be able to do so. The self-insured and the non-poor uninsured who pay for their own
health insurance are similarly disadvantaged.
The community. Most importantly, the growing uncompensated care problem can
restrict access to health care, particularly for the uninsured, but in some cases for the
insured as well, by threatening the viability of hospitals that provide such care. In the
next several years, many of the hospitals currently providing large volumes of
unsponsored care may be forced to choose between closure and a drastic reduction in
service to the poor. Particularly in the case of sole community providers, either choice
could severely restrict access to care.
\fF.mr ATP UNDERPAYMENT AND HOSPITAL CARE FOR THE POOR
WHAT ARE MEDICAID SHORTFALLS?
The growing indigent care problem reveals itself in many ways ~ increasing numbers of
uninsured and underinsured, rising uncompensated care burdens for hospitals, cost shifts to
private payers and, most critically, limited access to primary and preventive care. A growing
problem for hospitals is Medicaid payment shortfalls, the difference between what it costs a
hospital to take care of Medicaid patients and what state Medicaid programs pay hospitals to take
care of those patients. Table 2 illustrates trends in Medicaid shortfalls from 1980 to 1991.
American Hospital Association
Revised November 1992
�Analysis of data from the American Hospital Association's Annual Survey of Hospitals shows
clear trends in Medicaid payment:
Medicaid payments for patient care fall very short of costs, and the shortfall has grown
quickly since 1980.
Four out offive hospitals are now losing money serving Medicaid patients.
Medicaid shortfalls now account for almost one-third of hospital losses in caring for the
poor - up from one-fifth in 1980 -- and have been the fastest growing component of such
losses.
AHA survey data show that aggregate Medicaid payments consistently lag behind costs, and that
the gap has widened rapidly since 1985. Between 1980 and 1985, Medicaid paid about 90
percent of the cost of hospital care for its beneficiaries - about three-quarters of hospital charges
for the patients. During the second half of the decade, however, payments fell further behind.
There appears to have been some stabilization in the rate of decline from 1989 to 1991. In
1991, payments covered 82 percent of hospital costs.
In 1980, hospital losses from Medicaid underpayment were $0.7 billion; by 1991, these
losses had risen to $5 billion.
While some of the increase in Medicaid shortfalls was due to inflation, the gap between
Medicaid payments and costs has been growing twice as fast as costs themselves.
Medicaid underpayment amounted to only 1 percent of hospital expenses in 1985, but 2.2
percent in 1991 -- a greater than two-fold increase in six years.
The impact of Medicaid shortfalls varies considerably from one hospital to another, depending
on a multitude of factors, including the individual hospital's costs, payer mix, and patient mix:
the particularreimbursementrate and mechanism established by the state; and whether the
hospital is a disproportionate share provider. The overall impact, however, is clear from
aggregate level analysis ~ the number of hospitals losing money on Medicaid grew very quickly
from the mid-1980s to late-1980s and appears to have stabilized somewhat from 1989 to 1991.
In 1984, 39.1 percent of hospitals were receiving Medicaid payment that met their costs
and, therefore, had no Medicaid shortfall. By 1991, payments were covering costs in
only 19 percent of hospitals. In other words, by 1991, four out of five hospitals lost
money caring for Medicaid patients.
American Hospital Association
Revised November 1992
�Table 2
National Medicaid (MCD) Payments: 1980 - 1991
(In Billions)
Registered Community Hospitals
OroH Revenue
Yr
e
,
1
#of
Hoapi.
Toul
Grou
Pitient
Revenue
Net Revenue
Orou
MCD
Piliem
Revenue
MCD i t
• * of
Toul
Toul
Net
Pilient
Revenue
Cotti
MCD
P.ymenu
Shonfill between M C D C o m ind
M C D Piymenti
MCD n
• % of
Toul
Toul
Expense!
MCD
Cost
M C D is
1 % of
Toul
% of
MCD
Co»U
Plid
Shortfill
1
|
Shortfill
IS 1 % of
Toul
Expenses
1980
5828
$89.5
$8.8
9 8*
$73.8
$6.7
90%
$76 8
$7.4
9 6%
90 5%
$07
09%
1981
5812
$.06.3
$.08
102%
$87.2
$8 5
9 8%
$906
$92
10 1%
92 9%
$07
0 7%
1982
5796
$.26.0
$124
99%
$101 8
$92
9 1
%
$104 8
$10.2
9 7%
90 8%
$0 9
1983
5782
$145 1
$142
98%
$.13 5
$10 0
8 8%
$.164
$111
9 5%
90 1%
$11
09%
1984
5757
$155 8
$153
98%
$12. 3
$105
86%
$123 3
$119
96%
88.2%
$14
I98S
5729
$163 3
$165
10 1%
$129.7
$116
90%
$130 5
$12 8
9 8%
90 7%
$12
11%
0 9%
09%
1986
5676
$178.4
$186
10.4%
$137 9
$12 6
9 1
%
$.406
$143
10 2%
88 2%
$17
12%
1987
5597
$198 1
$206
104%
$147 3
$.2 9
8.7%
$1522
$15.5
102%
83.3%
$2.6
17%
1988
5499
$224.8
$23 4
104%
$161 1
$13 7
8.5%
$168.0
$17.2
102%
79 7%
$3 5
2 1%
1989
5448
$275.9
$27.5
100%
$176 9
$152
8.6%
$1846
$19.4
10.5%
78.3%
$4.2
2.3% |
1990
5370
$297.4
$34 0
114%
$195 5
$18 4
9.4%
$203.2
$23 0
11.3%
80 .%
$4 6
2.3% |
.99.
5329
$343 4
$42 6
12.4%
$217 2
$22 8
10 5%
$224 5
$27.8
12 4%
82 0%
$5 0
Source: AHA Annual Survey dsti, 1980 1991
American Hospital Association
Revised November 1992
2.2%
•
|
�Perhaps even more significant, the number of heavy losers increased during this period.
Between 1984 and 1991, the proportion of hospitals with loses representing more than
2.5 percent of total expenses rose from just over 10 percent to 32.9 percent.
While the Medicaid shortfall has grown significantly since 1980, there is evidence that the trend
of annually declining cost coverage may have begun to level off. The 1990 and 1991 data
actually indicate a slight annual improvement in the percent of Medicaid costs covered by
payment rates (2 percent increase each year). Slightly more hospitals were paid rates that
covered the cost of caring for their Medicaid patients (3.7 percent increase between 1989 and
1990 and 2.4 percent increase between 1990 and 1991). Slightly fewer hospitals experienced
loses representing more than 2.5 percent of total expenses (3.1 percent decrease between 1989
and 1990; no change between 1990 and 1991).
It is not yet clear whether these changes represent a temporary stabilization or a long-term shift
in the trend of declining Medicaid reimbursement levels. In light of recent changes in Medicaid
funding and reimbursement, 1990 may be viewed as a transitional year - a time when states
were modifying their programs in anticipation of the influences now changing the entire system
(e.g., provider tax and donation program design, Medicaid disproportionate share hospital
payment mechanisms, and litigation based on the Medicaidrequirementfor reasonable and
adequatereimbursement).With the Medicaid program in transition on so many different fronts,
any inferences made about the long term implications of the changes observed in 1990 can only
be speculative. AHA will continue to study any fundamental changes in the underlying trend
of Medicaid undeipayment.
TOTAL UNREIMBURSED CARE FOR THE POOR
Any assessment of hospital burdens in caring for the poor must consider Medicaid underpayment
as well as losses incurred from patients with limited or no payment source. In fact, our analysis
indicates that most of the growth in unreimbursed hospital costs as a percent of total costs over
the decade due to care for the poor has been caused by rising Medicaid losses rather than
increased unsponsored care, although the cost of unsponsored care continues to contribute most
to the totai. Table 3 illustrates the combined effect of uncompensated care and Medicaid
shortfalls between 1980 and 1991.
In 1980, the combined losses from unsponsored care and Medicaid shortfalls was $3.5
billion, with about one fifth due to Medicaid shortfalls.
By 1991, unreimbursed hospital care for the poor cost $15.8 billion, and almost a third
of these losses were due to Medicaid underpayment.
American Hospital Association
Revised November 1992
�The growing role of Medicaid shortfalls as a factor in hospital losses incurred from care to the
poor is particularly significant because Medicaid is not a large payer source for most hospitals.
In 1991, Medicaid patients accounted for only 12.4 percent of total hospital expenses-but almost
a third of hospital losses in caring for the poor.
It is also important to note that Medicare underpayment has also been increasing in recent years.
In 1991, overall Medicare reimbursement was 88.6 percent of Medicare costs.
For many reasons -- sharp differences in community needs, differences in hospital resources,
differences in hospital mission and specialty -- thefinancialburden of unreimbursed care to the
poor varies from one hospital to another. Yet, the cost of care for the poor affects the vast
majority of providers, a number of which endure substantial losses as aresultof their care to
the poor.
60 percent of all registered community hospitals are now allocanng more than five
percent of total hospital expenses to the provision of unreimbursed care to the poor. In
1980, only about a quarter of hospitals had burdens this high.
In 1991, 33.1 percent of all registered community hospitals allocated more than 7.5
percent of hospital expenses to unreimbursed care for the poor. In 1980, only 11 percent
of hospitals had losses at this level.
Discussion and Implications of the Data
It is important from a policy perspective that both losses from Medicaid and from unsponsored
care are significant factors accounting for hospitals' financial burden in caring for the poor. The
growth in Medicaid shortfalls took place in the middle of the decade, concurrent with expansions
in Medicaid eligibility criteria. At the same time, increasing unemployment may have resulted
in more people qualifying for Medicaid coverage. The very early 1980s were a period of
retrenchment in Medicaid eligibility, whereas the late 1980s have been a period of selective
expansion in eligibility. As aresultof more stringent eligibility rules under the 1981 Medicare
and Medicaid amendments, the number of recipients declined from 22.0 million in 1981 to 21.6
million in 1982, 1983, and 1984. But the number ofrecipientsbegan to climb at mid-decade,
and reached 25.2 million by 1990.
American Hospital Association
Revised November 1992
10
�Table 3
National Medicaid (MCD) Payment Shortfalls and Uncompensated/Unsponsored Care 1980 - 1991
(in Billions)
Registered Community Hospitals
Shortfall Between M C D
Co til and Paymentt
Unsponsored Care
Uncompensated Ctre
Cost Based
Cost Based
at s * of
Toul
Expenses
Cost-Based
as s * of
Toul
Expenses
Ye«r
#of
Hntpt
Toul
Expeniei
Shortfall
Shortfall
at a % of
Toul
Expeniei
1980
S828
$76.8
$07
09*
$3.9
5.1*
$28
3 7*
1981
S8I2
$90.6
$07
0.7*
$4 7
5.2*
$3 5
1982
5796
$104 8
$09
0.9%
$53
S.I*
1983
5782
$116 4
$11
0 9*
$6 1
1984
5757
$123 3
$14
11*
198S
5729
$130 5
$12
1986
5676
$1406
1987
5597
1988
Unsponsored Care
plus M C D Shortfall
1
M C D Shortfall
as a * of
Toul
$3 5
4 6%
20 0 *
3.8%
$4.1
4.6*
17 1 *
$4 1
3 9*
$5 0
4.8%
18 0 *
5.3*
$48
4 1%
$5 9
50%
18 6 *
$7.4
60*
$5 6
4 6%
$7 0
5 7%
20 0 *
09*
$76
5.8*
$60
4 6*
$7.2
5.5%
16 7 *
$17
12*
$8.9
6.4*
$69
4 9*
$86
6 1%
198*
$152 2
$2 6
1.7*
$95
6 2*
$7.2
4.7*
$9 9
6 5%
26 3 *
5499
$1680
$35
2.1*
$10 4
6 2*
$8 1
4 8*
$116
6 9%
302*
1989
5448
$1846
$42
2.3*
$111
6.0*
$8.9
4 8%
$13 1
7.1*
32.1*
1990
5370
$203 2
$4 6
2 3*
$12 1
60*
$95
4 7%
$14 1
6 9%
32 4%
1991
]
as a * of
Toul
Expenses
5329
$224.5
$5 0
2.2*
$134
6.0*
$10 8
4 8%
$15 8
70%
318*
Cost Based
CostBased
iource: AHA Annua Survey, 1980 1991
Revised November 1992
American Hospital Association
II
�As the number of Medicaid recipients increased, simultaneous changes in hospital utilization
were observed. Between 1983 and 1991, the overall number of inpatient discharges was
declining, yet AHA survey data show that the number of Medicaid inpatient discharges actually
grew-from 3.7 million in 1983 to 4.75 million in 1991. Medicaid has become a bigger share
of hospital charges-from 9.8 percent to 12.4 percent of the total charges over this time period-at the same time there has been an overall decline in the proportion of its costs Medicaid pays.
The net effect for hospitals has been an increase in the losses incurred by hospitals in caring for
the poor.
It is important to note that in 1991 and 1992 the Medicaid program underwent a series of
importantfinancialchanges in both program funding and hospitalreimbursementthat are not
reflected in the 1990 data. Specifically, there was a tremendous increase in the use of provider
tax and donation programs to fund the Medicaid program and there were expansions in the use
of the Medicaid disproportionate share hospital (DSH) payment mechanism. It is not yet clear
whether the combined impact of changes in Medicaidfinancingwill result in a net increase in
the Medicaid shortfall (from the additional cost to hospitals of provider taxes and donations) or
a net decrease in the Medicaid shortfall (from additionalreimbursementto hospitals through
DSH payments). There was some inconsistency in the way states reponed taxes and donations
in 1991, which may make the 1991 data on Medicaid shortfalls somewhat unreliable; these
inconsistencies should beresolvedin the 1992 survey.
Further complicating the future picture of Medicaidfinancingis the enactment of the Medicaid
Voluntary Contribution and Provider-Specific Tax Amendments of 1991 in November 1991.
This recent federal legislation includes three significant changes in Medicaidfinancingthat will
affect the shortfall: the exclusion of provider donation funds from qualification for federal
matching funds, the restriction of provider taxes in qualifying for federal matching funds, and
the limitation of the dollar amount of DSH payments. Any gains in the level of Medicaid
payments that may be experienced from the 1991 and 1992 expansions in these financing
mechanisms may be lost in 1993 after these statutory changes become effective.
Regardless of the uncertainty in the implications of future Medicaid shortfalls, what is clearly
established in the analyses is that Medicaid shortfalls will remain a significant portion of
hospitals' unsponsored care burden. With the likelihood of continued growth in Medicaid losses,
hospitals will find it more and more difficult to provide care to patients with no insurance at all.
Current estimates are that 36 million people were uninsured in 1990 - up from 31 million just
three years earlier. Every dollar a hospital loses through Medicaid underpayment is a dollar not
available to provide care to the uninsured.
American Hospital Association
Revised November 1992
12
�ST ATT DATA ON MEDICAID SHORTFALLS AND UNCOMPENSATED CARE
In most cases, state-level trends in Medicaid shortfalls and unsponsored care parallel national
trends. In some cases, however, specific state-level policies have had significantly different
influences on both Medicaid and unsponsored care. Tables 4a and 4b present state-level detail
on Medicaid shortfalls and unsponsored care for 1990 and 1991. More specific information
regarding selected state experiences follows.
Forty states show an overall growth in the share of total hospital costs devoted to Medicaid
patients between 1989 and 1990. This may be explained by policy changes and changes in the
economy. For example, the Omnibus Budget Reconciliation Act of 1989 mandated that states
expand coverage to include all pregnant women and children in families with incomes equal to
or less than 133% of the federal poverty level. And, as unemployment has increased during the
recession and incomes have dropped, more families qualify for Aid to Families with Dependent
Children payments and Medicaid coverage.
A number of other states have also seen deterioration in their Medicaidreimbursement.For
example, North Carolina's hospitalreimbursementmethodology uses an annual inflation factor
that has not kept up with real cost increases. Many states with significant reductions in the
percent of Medicaid costs covered by payments, including New Hampshire (11% decrease
between 1989 and 1990), experienced budget problems in the late 1980s and early 1990s. Faced
with budgetary constraints, some states have decreased Medicaid hospitalreimbursementto
reduce govemment spending. Another state with low Medicaid cost coverage is Alabama, whose
large hospitals'reimbursementrateswere lowered to the 60th percentile of costs in 1990 because
of budget problems in 1989.
States experiencing an improvement in Medicaidreimbursementfrom 1989 generally attribute
the changes to improvements in thereimbursementmethodology. Examples include a change
from a per diem to a DRG system in Kansas, a law suit settlement over fiscal closure claims and
aretroactiverate increase in Massachusetts, and an adjustment to the utilization factor in
Georgia's reimbursement system.
Maryland and New Jersey use complexreimbursementsystems that are set up to ensure that
hospital uncompensated care costs are minimized, if not totally eliminated. In both states, most
payers, including Medicaid, pay cost plus an additional percentage calculated to offset hospitals'
uncompensated care. This explains why Medicaid payment as a percent of Medicaid cost is
greater than 100 percent in these two states for 1990 and 1991.
In Mississippi, the proportion of Medicaid payment to Medicaid cost is higher than 100 percent
because thereimbursementrateformula is designed to include enhanced payments for hospitals'
capital costs as well as direct patient care costs.
American Hospital Association
Revised November 1992
13
�Table 4a
1990 Medicaid (MCD) Cost, Uncompensated Care (UCC) Cost, and Unsponsored Care (USC)
Ai • % of Toul Hoipiul Expeniei
Ai t * of Toul Hospiul Expenie*
Sute
MCD
Cor
UCC
Co*
MCD and
UCC Coit
MCD Payment at
i % of COM
MCD
Shortfall
MCD
Shortfall
plui USC
USC
7.5
9.7
17.2
73.1
2.0
7.1
9.1
ALASKA
15.0
6.1
21.1
87.8
1.8
5.2
7.0
ARIZONA
10.2
7.3
17.5
98.8
0.1
5.4
5.5
9.6
7.1
16.7
72.0
2.7
7.1
9.8
CALIFORNIA
16.2
4.6
20.8
66.7
5.4
3.9
9.3
COLORADO
7.8
5.3
13.1
56.4
3.4
4.5
7.9
CONNECTICUT
9.2
4.7
13.9
71.1
2.7
4.7
7.4
DELAWARE
9.0
9.5
18.5
80.8
1.7
9.5
11.2
11.9
9.1
21.0
69.5
3.6
6.6
10.2
FLORIDA
8.6
8.7
17.3
82.6
1.5
7.7
9.2
GEORGIA
11.0
10.9
21.9
86.1
1.5
7.7
9.2
HAW AD
14.1
3.1
17.2
73.6
3.7
3
6.7
IDAHO
6.3
4.7
11.0
82.1
I.I
4.3
5.4
ILLINOIS
13.3
4.8
18.1
56.8
5.8
3.4
9.2
INDIANA
7.6
5.8
13.4
95.1
0.4
4.8
5.2
IOWA
8.2
4.3
12.5
88.1
1.0
1.6
2.6
KANSAS
7.5
4.3
11.8
87.0
1.0
3.7
4.7
KENTUCKY
11.6
5.7
17.3
93.7
0.7
5.2
59
LOUISIANA
11.1
6.9
18.0
88.4
1.3
6.2
7.5
MAINE
11.4
5.1
16.5
85.0
1.7
5.1
68
MARYLAND
11.7
6.9
18.6
106.3
-0.7
6.7
6.0
8.2
6.0
14.2
87.1
1.1
6
7.1
MICHIGAN
12.3
3.1
15.4
86.2
1.7
2.9
4.6
MINNESOTA
10.5
2.5
13.0
88.0
1.3
1.9
3.2
MISSISSIPPI
11.7
9.5
21.2
104.1
-0.5
8.7
8.2
8.5
5.7
14.2
68.3
2.7
5.1
7.8
ALABAMA
ARKANSAS
DC
MASSACHUSETTS
MISSOURI
American Hospital Association
Revised November 1992
14
�Ai • * of Toul Hotpiui Expeniei
At • * of Toul Hotpiui Expeniei
Sute
MCD
Cost
UCC
COM
MCD tnd
UCC Cost
MCD Piyment i i
i % of Cott
MCD
Shortfill
USC
MCD
Shontill
plui USC
MONTANA
10.2
3.8
14.0
90.6
1.0
NEBRASKA
7.1
2.7
9.8
73.4
1.9
NEVADA
6.8
8.5
15.3
46.8
3.6
8.4
12.0
NEW HAMPSHIRE
46
5.3
9.9
84.5
0.7
5.3
6.0
NEW JERSEY
8.4
6.3
14.7
104.8
-0.4
6.3
5.9
NEW MEXICO
9.5
79
17.4
96.2
0.4
49
5.3
NEW YORK
19.3
4.8
24.1
88.9
2.1
3.3
5.4
NORTH
CAROLINA
9.3
6.2
15.5
61.7
3.6
6.2
9.8
NORTH DAKOTA
9.2
2.1
11.3
95.9
0.4
2.1
2.5
OHIO
11.3
4.8
16.1
94.4
0.6
4.3
49
OKLAHOMA
10.6
7.0
17.6
83.3
1.8
4.6
6.4
OREGON
8.4
6.5
14.9
62.5
3.1
5.7
8.8
PENNSYLVANIA
94
2.7
12.1
65.6
3.2
2.7
5.9
RHODE ISLAND
98
3.6
13.4
94.6
0.5
3.6
4.1
10.3
8.3
18.6
83.5
1.7
7.2
8.9
7.7
2.8
10.5
91.1
0.7
2.8
3.5
11.8
8.5
20.3
93.5
0.8
8.3
9.1
TEXAS
9.5
13.4
22.9
82.1
1.7
6.2
7.9
UTAH
10.2
4.3
14.5
78.7
3.9
6.1
VERMONT
8.2
3.8
12.0
75.5
2.0
3.8
5.8
VIRGINIA
7.8
7.6
15.4
79.5
1.6
4.8
6.4
WASHINGTON
14.0
4.3
18.3
81.6
2.6
3.5
6.1
WEST VIRGINIA
10.7
7.5
18.2
84.8
1.6
7.7
9.3
WISCONSIN
5.6
2.3
7.9
77.6
1.3
2.3
3.6
WYOMING
9.0
70
16.0
92.8
0.7
4.8
5.5
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
3.8
48
4.1
Source: AHA Annual Survey of Hospitals, reported data only
American Hospital Association
Revised November 1992
15
�Table 4b
1991 Medicaid (MCD) Cost, Uncompensated Care (UCC), and Unsponsored Care (USC) Cost
As i * of Toul Hospiul Expense!
At i % of Toul Hoipiul Expeniei
Sute
MCD
Coit
UCC
Coit
MCD ind
UCC Coit
MCD Piyment
i i i * of Coit
MCD
Shortfill
USC
Coit
MCD
Shortfill
Plui USC
9.5
10.1
19.6
80.9
1.8
7.5
9.3
ALASKA
17.1
5.9
23.0
72.4
4.7
4.6
94
ARIZONA
17.7
7.1
24.9
87.5
2.2
4.9
7.1
ARKANSAS
10.4
8.4
18.8
80.3
2.1
8.3
10 4
CALIFORNIA
19.3
5.3
24.6
65.7
6.6
3.6
10.2
COLORADO
9.8
55
15.3
78.9
2.1
4.3
64
11.1
5.0
16.1
67.0
3.7
4.9
85
9.7
9.2
19.0
77.4
-> n
9.2
11.4
14.2
12.9
27.0
82.1
2.5
6.7
9.2
FLORIDA
9.5
8.2
17.8
81.3
1.8
7.3
9.1
GEORQIA
12.6
11.3
23.9
100.0
0.0
7.6
7.6
HAWAII
13.8
3.8
17.7
84.3
2.2
3.6
5.8
IDAHO
8.0
4.7
12.7
77.1
1.8
4.3
6.2
ILLINOIS
14.1
5.0
19.1
56.8
6.1
3.5
9.6
INDIANA
7.7
5.8
13.5
94.7
0.4
4.8
5.2
IOWA
8.5
4.2
12.6
93.8
0.5
1.6
2.1
KANSAS
7.8
4.1
11.9
81.6
1.4
3.4
4.9
KENTUCKY
11.9
5.4
17.3
97.9
0.3
4.9
5.2
LOUISIANA
10.9
4.7
15.6
85.9
1.5
4.3
58
MAINE
12.4
5.0
17.4
87.1
1.6
5.0
6.6
MARYLAND
14.2
7.3
21.6
107.5
-1.1
7.2
6.1
9.1
6.0
15.1
91.5
0.8
5.9
6.7
MICHIGAN
12.5
3.0
15.5
87.0
1.6
2.8
4.5
MINNESOTA
11.7
2.6
14.2
82.9
2.0
1.9
3.9
MISSISSIPPI
13.3
10.1
23.4
107.2
-1.0
94
8.4
9.8
5.9
15.6
80.4
1.9
5.4
7.3
ALABAMA
CONNECTICUT
DELAWARE
DC
MASSACHUstrrs
MISSOURI
American Hospital Association
Revised November 1992
16
�A i i % of T o u l H o i p i u l Expenses
Aj i % of Toul Hoipiul Expeniei
Suie
MCD
Coit
UCC
Coit
MCD ind
UCC Coit
M C D Piyment
• i i % of Coit
MCD
Shontill
USC
Cost
MCD
Shortfill
Plus USC
MONTANA
11.0
3.8
14.7
87.9
1.3
3.6
5.0
NEBRASKA
8.4
2.4
10.8
73.1
:.3
2.0
4.2
NEVADA
8.2
8.3
16.5
62.2
3.1
8.2
11.3
NEW HAMPSHIRE
5.9
5.9
11.8
88.6
0.7
5 9
6.6
NEW JERSEY
8.7
10.6
19.3
116.7
-1.5
9.3
7.8
NEW MEXICO
9.8
8.8
18.6
85.3
1.4
6.0
7.4
NEW YORK
22.6
5.6
28.2
92.1
1.8
3 9
5.7
NORTH CAROLINA
12.0
6.6
18.6
83.4
2.0
5.8
7.8
11.4
96.1
0.4
NORTH DAKOTA
9.2
2.6
OHIO
11.4
4.7
16.0
91.9
0.9
4 3
5.:
OKLAHOMA
12.0
7.9
19.9
93.3
0.8
5.8
6.6
OREGON
9.0
6.3
15.3
65.7
3.1
5.2
8.3
PENNSYLVANIA
9 9
2.7
12.6
74.9
2.5
2.6
5.1
RHODE ISLAND
10.8
3.4
14.2
92.0
0.9
3.4
4.3
SOUTH CAROLINA
12.4
7.8
20.1
101.0
-0.1
6.9
6.8
7.5
2.8
10.4
86.8
1.0
2.8
3.8
TENNESSEE
1 1.8
6.5
18.3
86.1
1.6
6.4
8.1
TEXAS
10.8
12.3
23.1
81.2
2.0
6.5
8.5
UTAH
10.5
4.2
14.7
88.4
1.2
3.9
5.1
VERMONT
11.5
4.3
15.9
71.6
3.3
4.3
7.6
VIRGINIA
9.0
7.9
16.9
79.2
1.9
6.8
8.7
WASHINGTON
16.0
3.9
19.9
82.1
2.9
3.1
6.0
WEST VIRGINIA
11.4
7.3
18.7
92.1
0.9
7.3
8.2
WISCONSIN
6.4
2.8
9.2
76.3
1.5
2.8
4.3
WYOMING
10.4
6.6
17.0
90.7
1.0
4.5
5.4
SOUTH D A K O T A
American Hospital Association
Revised November 1992
17
�APPENDIX: METHODS
Each year, the American Hospital Association (AHA) publishes aggregate information on the
level of uncompensated and unsponsored care delivered in U.S. hospitals. The data used to
generate these numbers come from the AHA's Annual Survey of hospitals, which is the single
most comprehensive source of hospital financial data. This appendix provides technical
information on how uncompensated and unsponsored care are calculated. It also describes how
the recent American Institute of Certified Public Accountants (AICPA) accounting changes to
bad debt and free care were handled in the Survey to ensure continuity of uncompensated and
unsponsored numbers.
Calculating Uncompensated and Unsponsored Care
Uncompensated care is calculated on a hospital by hospital basis. Bad debt and charity care are
reported as charges in the Annual Survey. These two numbers are added together and then
multiplied by "the cost to charge ratio," or the ratio of total expenses to gross patient and other
operating revenue. Unsponsored care is the difference between uncompensated care and state
and local govemment tax appropriations.
•
Bad debt charges + charity care charges = uncompensated care charges
•
Uncompensated care charges - tax appropriations = unsponsored care charges
•
Unsponsored care charges x [Total expenses/(gross patientrevenue+ other operating
revenue)] = unsponsored care costs
Use of the total facility cost to charge ratio does not take into account the fact that some
of these costs, which are allowable under generally accepted accounting principals
(GAAP), would not be allowable under Medicare or Medicaid definitions.
Two adjustments to the data must be made before unsponsored and uncompensated care are
summed across hospitals. First, some hospitals receive greater tax appropriations than provide
uncompensated care. In these cases, unsponsored care is set to zero. Uncompensated care is
not adjusted.
Second, a small number of hospitals each year do not earn gross patientrevenue(e.g. Shriner s
hospitals). Without gross patientrevenue,it is impossible to calculate the cost to charge ratio
and thus calculate the cost-based figures for uncompensated and unsponsored care, and no
percentages can be calculated. These hospitals have been deleted from the analysis.
American Hospital Association
Revised November 1992
18
�Bad Debt and Charity Care
For accounting purposes, bad debt consists of services for which hospitals anticipated, but did
not receive payment. In contrast, charity care is defined as services for which hospitals neither
received, nor expected to receive, payment because they had determined the patient's inability
to pay. In practice, however, the distinction is not very clear-cut. Some hospitals use a formal
process to identify who can and cannot afford to pay in advance of billing in order to antipate
whether the patient's care should be funded through the charity care fund. On the other hand,
some hospitals use the billing and collection process to identify those patients who are unable
to pay. Thus, the care delivered to a patient may be classified as charity care by one hospital,
but bad debt by another.
In addition to the fact that bad debt and charity care are not strictly comparable across facilities
due to institutional practice, several studies suggest that health care bad debt is more often than
not accounted for by care to people who cannot afford to pay their hospital bills. Thus, it is
reasonable to consider bad debt as a component of hospitals' total burden of care to the
medically indigent and underinsured.
The combined total of bad debt and charity care is comparable across hospitals. This sum is
equal to the provider's total uncompensated care; neither bad debt nor charity care costs are
compensated. New accounting changes used to classify these costs (described below) will result
in some shifting between bad debt and charity care, but will not influence the totalreportedcost
of uncompensated care. Thus, the preceding analyses of AHA Annual Survey data focus on the
total cost of uncompensated care and do not further split this cost into the components of bad
debt and charity care expenses.
AICPA Changg? and the Anmial Survgy
In 1990, the American Institute of Certified Public Accountants (AICPA) made important
changes to its Audit and Accounting Guide, which impact bad debt and charity care. The Guide
is the industry standard for health care financial reporting and audits. The changes were made
in an effort to bring health care organization financial statements andreportingcloser to general
industry practice.
Prior to 1990, hospitalsreportedboth bad debt and charity care as deductions from revenue.
In many cases, the hospitals did not carefully distinguish between bad debt and charity care.
The new rulesrequiredifferentreportingof the two items. Hospitals continue to internally
account for charity care as a deduction from gross revenue. Grossrevenue,with charity care
subtracted as a line item, is no longer reported in external financial statements, however;
hospitals must now report only net revenue.
American Hospital Association
Revised November 1992
19
�Bad debt, in contrast, must now be reponed as an expense item (it may be either separately
reported or reported with administrative services or other adjustments) and is thus no longer
deducted from gross revenue.
1990 AHA data on uncompensated and unsponsored care is comparable to data presented before
the AICPA changes. The changes have been incorporated into the Annual Survey, but enough
detail has been maintained in the Survey so that the methodology of calculating uncompensated
and unsponsored care from yean before the changes can be replicated. The 1990 figures on
uncompensated and unsponsored care are thus directly comparable to figures reported for earlier
years.
American Hospital Association
Revised November 1992
20
�
Dublin Core
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Title
A name given to the resource
Health Care Reform
Identifier
An unambiguous reference to the resource within a given context
2006-0810-F
Description
An account of the resource
<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
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records
Publisher
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William J. Clinton Presidential Library & Museum
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Briefing Book on Medicaid [2]
Creator
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Health Care Task Force
General Files
Identifier
An unambiguous reference to the resource within a given context
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
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
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5/5/2015
Source
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42-t-2194630-20060810F-Seg1-053-009-2015
12090749