Government Financed Health Care: Medicaid, CHIP, the VA, and the IHS

Question 1

Health Insurance coverage nationally

Answer 1

• Quick review of current status of how Americans get health care paid for
• Does not show how much people pay out of pocket – in addition to coverage.
• For individuals, historicially Medicaid has been a bad deal
• But under the marketplace, the governemtn became kind of the group part of the plan – this was through the affordable care act
• Why do we have 7% who are uninsured? Financially, they are making a risk assessment and saying it is not worth it for them to pay for insurance

Question 2

Medicaid: basic background

Answer 2

• Enacted in 1965 (Title XIX) as companion legislation to Medicare
• Originally focused on the welfare population:
  
  • Single parents with dependent children
  • Aged, blind, disabled
• Guarantees entitlement to individuals and federal financing to states
• Includes mandatory services and gives states options for broader coverage
• Brief hx
• Enacted with Medicare, in 1965, as addition to Social Security Act
• The greatest number of people served by what are sometimes referred to as “entitlement programs” (a government program that guarantees certain benefits to a particular group or segment of the population, also including Medicare and social security, most Veterans’ Administration programs, federal employee and military retirement plans, unemployment compensation, food stamps, and agricultural price support programs)
• Numbers served by top 10 “entitlement” programs:
  
  • 1. Medicaid/CHIP: 63.2 million
  • 2. Social Security: 55.8 million
  • 3. Medicare: 49.9 million
  • 4. Food stamps: 46.6 million
  • 5. Child nutrition: 35 million
  • 6. College loans: 11.3 million
  • 7. Unemployment insurance: 8.9 million
  • 8. Supplemental Security Income: 7.9 million
  • 9. Veterans compensation: 3.8 million
  • 10. Civil service retirement: 2.5 million
• What does it mean if something is an entitelemnt program? If you meet the requirement for something you will get the help from the government. For medicare, the big one is age: 65
• For Medicaid the requirement is to be poor

Question 3

Medicaid: federal-state partnership

Answer 3

• Partnership of state and federal governments:
• Oversight by federal govt; direct management and admin by states
• Standards and requirements set by feds
• Although participation is optional, all 50 states participate in the Medicaid program.
• However, eligibility for Medicaid benefits varies widely among the states - all states must meet federal minimum requirements, but they have options for expanding Medicaid beyond the minimum federal guidelines,
• ½ to ¾ of financing comes from federal government, states pay for remainder. Depends on the Federal Medical Assistance Percentage (FMAP) - a formula that takes into account the average per capita income for each State relative to the national average. The FMAP is always at least 50%.
• States can apply for waivers from federal standards.
• Part A comes out of taxes
• Part B is a premium that you have to pay for
• Medicare is pretty much 100% federal cost (not state)
• Medicaid is a joint partnership between federal and state

Question 4

The ACA modernized the Medicaid applicaiton and enrollment experience in all states

Answer 4

Why would the state not want this? Its administered by the state – they have to deal with the paperwork/etc.

Question 5

Medicaid and the affordable care act prior to the ACA

Answer 5

• ACA sought to remedy some of the vast differences in who was covered by states
• Adults that weren’t taking care of children weren’t eligible

Question 6

Medicaid expansion with ACA

Answer 6

• One of the primary mechanisms through which the ACA sought to reduce the number of uninsured Americans was through expansion of Medicaid. When the law was passed in March 2010, states were required to expand Medicaid to all adults with income up to 138% of FPL by 2014. If they did not, states would lose Medicaid funds. States were authorized to begin implementation of the expansion as early as April 2010.
• Several states sued the federal government over the expansion requirement, and in 2011 the Supreme Court held that states could not be required to accept the expansion. Rather, Medicaid expansion had to be optional for each state. As a result, 19 states have refused to expand Medicaid
• Instead of the patchwork of eligibility rules that existed around the country, there would be national standard in which anyone with income up to 138 percent of the federal poverty level could qualify.
• That expectation ended in 2012, when the Supreme Court, as part of a ruling that upheld the law’s constitutionality overall, gave each state the latitude to decide whether to participate in the ACA Medicaid expansion.
• As of now, 31 states and the District of Columbia have.
• For states that expanded Medicaid, the federal government paid 100 percent of the cost for newly eligible enrollees for the first few years, and the federal share is now ratcheting down to an eventual 90 percent.
• While some states with Republican governors have expanded Medicaid under the ACA, the Trump administration and many GOP leaders in Congress oppose it. The president has recently indicated that he supports an idea, long popular in conservative circles, that would fundamentally change Medicaid, transforming it from an entitlement (meaning that everyone who is eligible can get into the program and the government spends whatever is needed to provide its benefits) to a program of block grants, in which the government allots to each state a fixed amount of money each year and frees states from many of the program’s rules about what health services must be covered.
• Block grant proponents say that they would give states more flexibility to run their programs as they see fit; detractors say they are a smokescreen to curb federal spending and ultimately would hurt poor people.

Question 7

unanticipated gap for poor in some states

Answer 7

• And, unfortunately, the ACA did not anticipate that some states would not expand Medicaid, and the law does not have provisions for poor people who do not qualify for Medicaid. So they are also not eligible for Market place plans and subsidies, and are thus left with no options under ACA to get health insurance coverage (in the 19 states that did not expand Medicaid, despite the fact that the federal govt paid 100% initially, and would then cover 90%, for people with up to 138% of FPL)

Question 8

For which populations does medicare play a critical role?

Answer 8

Question 9

What is Medicaids highest expense?

Answer 9

• Elderly and people with disabilities!
• Current estimates are that Medicaid pays for health care for more than 74.5 million people nationally.
• Those with most serious – and costly – conditions, require greater expenditures
• Disabled and elderly, are ~ ¼, but need almost 2/3 of funding for their care

Question 10

Majority of medicaid expenditures

Answer 10

• ACUTE CARE! Not long term care
• Acute care = 2/3

Question 11

Medicaid benefits - “mandatory” items and services

Answer 11

• •Physicians services
• •Laboratory and x-ray services
• •Inpatient hospital services
• •Outpatient hospital services
• •Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21
• •Family planning and supplies
• •Federally-qualified health center (FQHC) services
• •Rural health clinic services
• •Nurse midwife services
• •Certified nurse practitioner services
• •Nursing facility (NF) services for individuals 21 or over

Question 12

Medicaid benefits - “optional” items and services

Answer 12

• •Prescription drugs
• •Medical care or remedial care furnished by licensed practitioners
• •Diagnostic, screening, preventive, and rehab services
• •Clinic services
• •Dental services, dentures
• •Physical therapy
• •Prosthetic devices, eyeglasses
• •TB-related services
• •Primary care case management
• •ICF/MR services
• •Inpatient/nursing facility services for individuals 65 and over in an institution for mental diseases (IMD)
• •Inpatient psychiatric hospital services for individuals under age 21
• •Home health care services
• •Respiratory care services for ventilator-dependent individuals
• •Personal care services
• •Private duty nursing services
• •Hospice services

Question 13

medicaid financing

Answer 13

• The federal government matches state Medicaid spending on an open-ended basis (the Federal Medical Assistance Percentage, FMAP)
• The current matching rate ranges from 50% to 75.65%, based on a state’s per capita income
• Enrollees who are newly eligible under health reform qualify for higher match, starting at 100% in 2014-16 and phasing down to 90% in 2020 and beyond
• ½ to ¾ of financing comes from federal government, states pay for remainder. Depends on the Federal Medical Assistance Percentage (FMAP) - a formula that takes into account the average per capita income for each State relative to the national average. The FMAP is always at least 50%.
• TEST QUESTION:
  
  • Is this a state program or federal? BOTH!!!

Question 14

Federal Medical Assitance Percentage (FMAP)

Answer 14

• The Federal Medical Assistance Percentage (FMAP) is computed from a formula that takes into account the average per capita income for each State relative to the national average. The FMAP cannot be less than 50%.
• The multiplier is based on the FMAP. For every dollar the state spends on Medicaid, the federal government matches at a rate that varies year to year. For example, in FY2004, the rate for Alabama was 1:2.80 (73.70%).
• FMAPs displayed here apply to the federal fiscal year indicated unless otherwise noted, which runs from October 1 through September 30. For example, FY 2018 refers to the period from October 1, 2017 through September 30, 2018.
• US federal minimum FMAP is 50%.

Question 15

Is medicaid budget item or a revenue item in state budgets?

Answer 15

• Medicaid is both a budget item and a revenue item in state budgets.
• States receive federal dollars, and expend revenue for services to Medicaid resipients

Question 16

ACA medicaid expansion to low-income adults

Answer 16

• 32 states cover parents and other adults with incomes up to 138% FPL ($28,676 per year for a family of three and $16,753 per year for an individual in 2018) under the ACA Medicaid expansion to low-income adults
• “…Other adults…” – not pregnant or parents with children in the household

Question 17

States that have not expanded Medicaid

Answer 17

• In the 19 states that have not expanded Medicaid, the median eligibility limit for parents is 43% FPL ($8,935 per year for a family of three in 2018) and other adults remain ineligible, except in Wisconsin (Figure 5).
• In 11 of these states, parent eligibility is at less than half of the poverty level, and only two of these states (ME and WI) cover parents at or above poverty. Wisconsin is the only non-expansion state that provides full Medicaid coverage to other adults, although eligibility at 100% FPL remains below the expansion level and the state does not receive the enhanced match available for expansion adults for this coverage.2
• In the non-expansion states, 2.4 million adults with incomes above the Medicaid eligibility limit but below poverty fall into a coverage gap; they are ineligible for Medicaid and do not qualify for subsidies for Marketplace coverage, which become available at 100% FPL

Question 18

income eligibility levels for children in Medicaid/CHIP

Answer 18

• As of January 2018, 49 states cover children of parents with incomes up to at least 200% of the federal poverty level (FPL, $41,560 per year for a family of three in 2018) through Medicaid and CHIP (Figure 1, Table 1and 1A).
• This count includes 19 states that cover children with incomes at or above 300% FPL.
• Only two states (ID and ND) limit children’s eligibility to below 200% FPL.
• Across states, the upper Medicaid/CHIP eligibility limit for children ranges from 175% FPL in North Dakota to 405% FPL.

Question 19

INcome eligibility levels for pregnant women in medicaid/CHIP

Answer 19

• Most states extend coverage to pregnant women beyond the federal minimum of 138% FPL through Medicaid and CHIP.
• As of January 2018, 34 states cover pregnant women with incomes at or above 200% FPL ($41,560 per year for a family of three in 2018), including 12 states (including DC) that cover pregnant women with family incomes above 250% FPL.
• Five states extend coverage for pregnant women through CHIP and 16 states use CHIP funding to provide coverage through the unborn child option, under which states cover income-eligible pregnant women regardless of immigration status

Question 20

Medicaid income eligibility levels for parents

Answer 20

• As of January 2018, 32 states cover parents and other adults with incomes up to 138% FPL ($28,676 per year for a family of three and $16,753 per year for an individual in 2018) under the ACA Medicaid expansion to low-income adults (Figures 3 and 4, Table 3).
• The District of Columbia extends eligibility beyond the expansion limit to parents with incomes up to 221% FPL and other adults with incomes up to 215%, and Alaska covers parents with incomes up to 139% FPL.
  *

Question 21

how do most beneficiaries receive care

Answer 21

• Most beneficiaries receive care through some type of managed care arrangement.

Question 22

policy issues for medicaid

Answer 22

• Coverage for low-income families
  
  • Reduces uninsured
  • Improves access to care
  • Per enrollee costs low
  • Responds to economic downturn
• Assistance for the elderly and disabled
  
  • Helps poorest and sickest Medicare beneficiaries
  • Essential supplement to Medicare
  • Primary users of prescription drugs and long-term care
  • Per enrollee costs high
• Fiscal Pressure
  
  • Pressure from declining state revenue and growing health costs
  • Need to keep pace with private sector to assure access
  • Most dollars in elderly/disabled and long-term care
  • Fiscal tension between federal government and states
  • Restructuring proposals/state flexibility

Question 23

what is CHIP

Answer 23

• Children’s Health Insurance Program
  
  • •Enacted in 1997
  • •8.1 million children ever enrolled in FY 2013 (compare to 72 million people covered by Medicaid)
  • •$13 billion ($9 billion federal and $4 billion state) in FY
  • 2014 (compare to >$400 billion for Medicaid)
  • •Similar state-federal partnership design
  • •Can be operated as Medicaid expansion or separate program (or both)
• It is kind of a companion to Medicaid
• Higher income eligibility is a great thing!!

Question 24

How does CHIP differ from Medicaid

Answer 24

• From the perspective of the enrollee:
  
  • •Not an entitlement to individuals: states can establish waiting periods, waiting lists
  • •Income eligibility is higher; upper limit ranges from 175% of federal poverty level (FPL) (North Dakota) to 405% FPL (New York)
  • •Modeled on private insurance with options for:
  • •Monthly premiums
  • •Benefits may be pegged to commercial benchmark
  • •Branding
• From the perspective of the state:
  
  • •Funding is capped and allotments to states set in statute
  • •Matching rate is enhanced at 65–82% (compared to Medicaid’s match of 50-74%)
  • •Choice of design (Medicaid expansion, separate CHIP)

Question 25

CHIP basic background

Answer 25

• Enacted in 1997 to encourage states to expand coverage for children; reauthorized in 2009 through 2013 (CHIPRA)
• States can use funds to expand Medicaid or cover children in a separate program
• States have more discretion regarding eligibility and benefits if they establish a separate program
• Block grant with capped annual allotments
• No entitlement to coverage and children must be uninsured

Question 26

CHIP: federal-state partnership

Answer 26

Question 27

CHIP financing

Answer 27

• The federal government pays for 65% to 81% of each state’s CHIP program (depending on the state)
• Block grant with capped annual allotments, although states facing funding shortfalls can tap the child enrollment contingency fund
• ACA extended CHIP funding through FY2015 and increases each state’s matching rate by 23 percentage points starting in FY2016

Question 28

Current CHIP debate

Answer 28

• •Congress last considered CHIP as part of ACA
• •Extended CHIP funding until FY 2015
• •Created maintenance of effort requirement through FY
• 2019
• •Increased CHIP matching rate by 23 percentage points for FY 2016 to FY 2019
• •Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended to 2017

Question 29

2018 CHIP funding extension

Answer 29

• 2018 CHIP Funding Extension On January 22, 2018, Congress passed a six-year extension of CHIP funding as part of a broader continuing resolution to fund the federal government.
• Federal funding for CHIP had expired on September 30, 2017. Without additional funding available, states operated their CHIP programs using remaining funds from previous years. However, some states came close to exhausting funding, leading them to make contingency plans to reduce coverage and notify families of potential coverage reductions.
• In late December 2017, Congress provided some short-term funding for early 2018, but some states still expected to exhaust funds by March 2018. The six-year funding extension provides stable funding for states to continue their CHIP coverage.
• It provides federal funding for CHIP for six years, from FY2018 through FY2023.
  
  • ·Continues the 23 percentage point enhanced federal match rate for CHIP that was established by the Affordable Care Act, but reduces the federal match rate to the regular CHIP rate over time.
  • ·Extends the requirement for states to maintain for coverage for children from 2019 through 2023; after October 1, 2019, the requirement is limited to children in families with incomes at or below 300% FPL.

Question 30

Implications of the CHIP funding extnesion for children

Answer 30

• •Kids with Medicaid expansion CHIP remain covered
• through FY 2019
• •3.7 million children will need new source of coverage (exchange or employer)
• •1.1 million projected to be uninsured due to high premium costs
• •Kids that get covered elsewhere will experience much higher cost sharing and slimmer benefits (particularly dental)

Question 31

Other direct impacts on children and families

Answer 31

• Prohibits the use of asset tests or face-to-face interviews
• Limits CHIP waiting periods to 90 days and requires certain exceptions
• Requires parents to enroll uninsured children before enrolling themselves
• Creates a “welcome mat” effect that will bring currently eligible people

Question 32

premiums and cost-sharing

Answer 32

• State flexibility within limits -
• Premiums limited below 150% FPL
  
  • None in Medicaid
  • Maximum of $19/enrollee in CHIP, depending on income/family size
• Total cost-sharing cannot exceed five percent of family income
• Cannot favor higher-income families over lower-income families
• No cost sharing for well-baby and well-child care, including immunizations.
• Know: every state has set up their own criteria and details.

Question 33

Outreach

Answer 33

• Use messages that are welcoming and easy to understand
• Provide a reference (families earning up to $64,000 per year may qualify)
• Target specific populations (adolescents, children of color)
• Engage trusted messengers (doctors, real people who look like me)
• Be persistent: hardest to reach families require significant follow-up

Question 34

Improving Children’s coverage going forward

Answer 34

• Medicaid expansion for adults in all states
• Eliminate CHIP waiting periods
• Cover lawfully residing immigrant children (or all kids)
• Use data and feedback to assess how reform is working and identify areas that need improvement
• Transparency in reporting key enrollment and quality indicators

Question 35

SPAs

Answer 35

• States submit their Medicaid or CHIP State Plan to CMS for federal approval
• Details eligibility, policy options, procedures and other operating information
  
  • •To make a change, the state submits a “State Plan Amendment” or SPA
  • •Templates may be offered by CMS for states to fill out to enact specific policy options

Question 36

Waivers

Answer 36

• Section 1115 Waivers provide flexibility to design and improve state programs in order to “demonstrate and evaluate policy approaches”
  
  • Expand eligibility to individuals not otherwise eligible
  • Provide services not covered
  • Improve care, increase efficiency or reduce costs
• New public process and transparency rules

Question 37

Medicare Access and CHIP reauthorization act (MACRA)

Answer 37

• Update on CHIP - as well as Medicare payments…
• Medicare Access and CHIP Reauthorization Act (MACRA), law passed in 2015:
• MACRA created the Quality Payment Program that:
  
  • Repeals the Sustainable Growth Rate (SGR) formula
  • Changes the way that Medicare rewards clinicians for value over volume
  • Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS) Gives bonus payments for participation in eligible alternative payment models (APMs)
  • MACRA also required us to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019.
• Physicians who participate in “advanced alternative payment models” (advanced APMs) will be eligible for automatic 5-percent bonuses on their Medicare payments, starting in 2019.
• They include:
  
  • certain types of ACOs,
  • certain bundled payment modes,
  • Comprehensive Primary Care Plus (CPC+) medical home model
• CMS estimated that for 2017, between 70,000 and 120,000 providers (under 10% of all Medicare clinicians billing Part B) will be affiliated with advanced APMs, but more are anticipated in future years as the number of advanced APMs continues to increase.
• repealed the Sustainable Growth Rate formula and combined various quality and reporting programs into one:
• the Quality Payment Program (QPP).
• Beginning in 2017, Eligible Clinicians (ECs), which include PAs, follow one of two reporting tracks under the Quality Payment Program.
  
  • The first is the Merit-based Incentive Payments System (MIPS).
  • The second track is Advanced Alternative Payment Models (Advanced APMs). The 2017 reported data will affect reimbursement in 2019. The 2018 reported data will affect reimbursement in 2020.

Question 38

VA health care services

Answer 38

• Eligible veterans can get preventive and specialized health care at 168 VA Medical Centers (VAMCs), 1,053 community-based outpatient clinics (CBOCs), and other facilities.
• hospital and outpatient services, including preventive and primary care.
• Created in 1930
• the largest integrated health care system in the United States, providing care at 1,233 health care facilities, including 168 VA Medical Centers and 1,053 outpatient sites of care of varying complexity (VHA outpatient clinics), serving more than 8.9 million Veterans each year.
• For those who served in the active military, naval or air service and are separated under any condition other than dishonorable, …may qualify for VA health care benefits.
• Employs many PAs…

Question 39

the military health system

Answer 39

• Health care for active duty and retired U.S. Military personnel and their dependents
• Within the Department of Defense
• $50 billion budget*
• Serves approximately 10 million beneficiaries**
• Over 137,000 employees across the nation and around the world
• 65 hospitals,
• 412 clinics,
• 414 dental clinics at facilities
• The Military Health System is the enterprise within the United States Department of Defense that provides health care to active duty and retired U.S. Military personnel and their dependents.
• Its primary mission is to maintain the health of military personnel, so they can carry out their military missions; and to deliver health care during wartime. This involves medical testing and screening of recruits, emergency medical treatment of troops involved in hostilities, and the maintenance of physical standards of those in the armed services.
• The MHS also provides health care to dependents of active duty service members, to retirees and their dependents, and to some former spouses. Such care has been made available since 1966, (with certain limitations and co-payments), through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and its successor, TRICARE.
• In October 2001, TRICARE benefits were extended to retirees and their dependents aged 65 and over.
• *The actual cost of having a government-run health care system for the military is higher because the wages and benefits paid for military personnel who work for the MHS and the retirees who formerly worked for it, is not included in the budget.
• **including active duty personnel and their families and retirees and their families.
• More than combat medicine.
  
  • Health care delivery
  • Medical education
  • Public health
  • Private sector partnerships
  • Medical research and development

Question 40

Tricare

Answer 40

• The health care program for uniformed service members
• Active duty and retired:
• U.S. Army, U.S. Air Force,
• U.S. Navy,
• U.S. Marine Corps,
• U.S. Coast Guard,
• Commissioned Corps of the U.S. Public Health Service
• Commissioned Corps of the National Oceanic and Atmospheric Association, and their families, around the world.
• TRICARE provides comprehensive coverage to all beneficiaries, including:
  
  • Health plans
  • Special programs
  • Prescriptions
  • Dental plans
  • Most TRICARE health plans meet the requirements for minimum essential coverage under the Affordable Care Act.
• Managed by the Defense Health Agency under leadership of the Assistant Secretary of Defense (Health Affairs).

Question 41

Indian health service mission, goal and foundation

Answer 41

• Mission: In partnership with American Indian and Alaska Native (AI/AN) people, is to raise their physical, mental, social and spiritual health to the highest level.
• Goal: To ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all AI/AN people.
• Foundation: To uphold the Federal Government’s obligation to promote healthy AI/AN people, communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.
• Historically, various treaties exchanged Indian lands for federal trust responsibilities and benefits. Those treaties between tribes and the United States established a unique federal-tribal relationship establishing the federal government’s obligation to promote healthy American Indian and Alaska Native people, communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.
  
  • •Snyder Act authorized health services for Indians (1921)
  • •Transfer Act placed Indian health programs in the PHS (1955)
  • •Indian Health Care Improvement Act and amendments - permanently reauthorized under the Affordable Care Act in 2008.
• IHS hospitals are certified by CMS and many are accredited by Joint Commission.
• IHS hospitals have approximately 50,000 inpatient admissions per year, 11 million outpatient visits per year and 3.5 million dental services per year.
• Thirteen IHS are maternity hospitals – all of which have been designated as Baby Friendly.

Question 42

Funding of IHS services

Answer 42

• IHS services historically have been underfunded to meet the needs of AIANs. The services provided through the IHS consist largely of primary care, and include some ancillary and specialty services. If facilities are unable to provide needed care, the IHS and Tribes may contract for health services from private providers through the Purchased/Referred Care (PRC) program. However, urban Indian health organizations do not participate in the PRC program. Although the IHS budget has increased over time, funds are not equally distributed across facilities and remain insufficient to meet health care needs. 3 As such, access to services through IHS varies significantly across locations, and AIANs who rely solely on IHS for services often lack access to needed care. Moreover, referrals through the PRC program are often limited to emergency services due to funding limitations.
• AIANs who meet state eligibility standards are entitled to Medicaid coverage in the state in which they reside.
• Medicaid provides coverage to more than one in four (27%) nonelderly AIAN adults and half of AIAN children
• Medicaid also provides a key source of revenue for IHS and Tribal facilities.
• The federal government covers 100% of costs for services provided to AIAN Medicaid enrollees through an IHS- or Tribally-operated facility. This 100% matching rate reflects a policy judgment that states should not have to contribute state general funds to the cost of care provided by a federal facility, whether operated by the IHS or on its behalf by a Tribe.
• Expansion of Medicaid has particularly benefitted American Indians

Question 43

Indian health payer system

Answer 43

• In any state, for native americans to get healthcare, the federal government pays in 100%