Lecture 2 Flashcards
Who is covered under Medicaid?
- Low-income population
- Poor elderly
- Poor adults w/ dependents
- Disabled Medicare benefices
- Pregnant women
- Infants and children
What does CHIP stand for and who are the children eligible for it?
Children’s Health Insurance Program (CHIP)
Provided coverage for US and immigrant children up to 19
Of low and moderate income
Describe the involvement of the federal government vs. states in the Medicaid program? Who controls/spends the funding?
Medicaid Structure: How is Medicaid Structured?
A joint federal/state program
Federal government
Federal gov’t matches (federal-state funding) 50 to 78% depending on state per capita income relative to national average
Eligibility eases spending funds
Minimum Medicaid eligibility:
Mandatory group
Income % of federal poverty
Rule of thumb:
If you make 100% of FPL and are pregnant w/ children, then you are most likely to get funds (again, depending on medicaid state plan)
State
Each state has a Medicaid state plan
Each state must have a single agency to administer Medicaid-overseen by Centers for Medicare and Medicaid Services (CMS)
State participation is voluntary
Design and administer their own Medicaid programs
Beyond core requirements-flexibility regarding eligibility, benefits, provider payment, delivery systems
Seek federal waivers- research and promotion of the objectives of the program
Operated in all 50 states, DC, and each of the U.S. territories
Federal gov matches state medicaid spending on open-ended basis
Guarantee of matching funds increases state resources coverage to low-income programs and also permits medicaid programs to respond to demographic and economiship
Is medicaid government run? (structure / plan)
Medicaid is not government-run health care delivery system
States pay physicians, hospitals and other providers for Medicaid beneficiaries
Historically fee-for-service basis (FFS)- became very expensive
To conserve costs: Medicaid managed care (4 types in the following):
Managed Care Organization (MCO)- states pay premium (capitation based) MCO covers healthcare benefits/person
Primary Care Case Management (PCCM) states pay PCP
Prepaid health plan (PHP) non-comprehensive pays for certain services: outpatient (PAHP) vs. inpatient (PIHP)
Manage
What is Medicaid Expansion? Is it mandated in each state?
Medicaid Expansion: to expand medical services to people of low-income, and under “welfare” or in need of cash assistance
While it is mandated, it varies across states
What DME and assistive technology is covered under Medicaid?
DME - Durable Medical Equipment:Assistive devices used by patients
Medicaid in NY State covers basic DME such as:
Tub bench, raised toilet seat, Hoyer lift, hospital bed (semi electric), shower chair, commode
Covered for a 5 year period unless change in functional status
DME covered under medical necessity:
Rolling commode, tilt in space commode chair, adaptive cribs, higher end electric hospital bed
How is Driving Rehab covered under Medicaid?
Covers OT eval for Driving Rehab: cognition, vision, and physical assessment
Does not cover:
Behind the wheel assessment
Adaptive equipment for cars (like spinner knob, hand controls, or left foot accelerator)
Clinical reasoning: Medicaid
Clinical reasoning: what are some of the aspects you can think of when discharging/referring a patient receiving Medicaid?
Consider: DME necessary, level of function, home setup, assistance provided, living arrangement
How is home modification covered under Medicaid? Exceptions? Waivers?
Home modifications are not covered by Medicaid
There are exceptions through waiver programs
home modifications are generally not covered by medicaid but there are exceptions - medicaid waivers
waivers offer a variety of in-home support programs and financial support for home modifications that enable “aging in place”
some pay for
1. assistive tech such as special equipment for a washroom and adaptive lighting
2. physical mods to the home such as addition of wheelchair ramps, stair-lifts, walk-in, or wheelchair accessible bathtubs/showers
3. widening of internal spaces like landings/doorways for wheelchair accommodation
4. resources for both technologies & modifications (both the hardware and services to install the hardware)
5. these waivers formally referred to as Environment Accessibility Adaptors
nursing home medicaid is an entitlement, anyone eligible will receive care - however, waivers are NOT an entitlement
these programs have limited enrollments and sometimes there are waiting lists for services
Mandated services for traditional and newly eligible Medicaid adults.
Mandated Services for traditional Medicaid population
MD, input/outpt hospital services
Lab & x-rays
Early and periodic screening, diagnostic and treatment (EPSDT) for individuals under 21
Pediatric and family nurse practitioner services
Family planning services and supplies
Transportation
Nursing facility services for individuals > 21
Home health care services for persons eligible for nursing facility services
For newly eligible adults: must include 10 essential health benefits
Ambulatory patient services (outpatient)
ER
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitation and habilitation services and devices
Laboratory services
Preventive and wellness service and chronic disease management
Pediatric services, including oral and vision care (but not adult oral and vision care)
Medicaid Waivers.
Medicaid Waivers:
These allow the fed government to waive rules that normally apply - the goal is to help states accomplish goals, expand coverage and improve care
Allows those who would normally be placed in long term care to get services from the home
