Lecture 2: Medicaid

Question 1

What is the SCHIP?

Answer 1

State Children’s Health Insurance Program (SCHIP)
Extends health coverage to children in families with incomes too high for Medicaid but too low to afford private insurance (middle class)

Question 2

Who adminsters SCHIP and then who funded SCHIP?

Answer 2

Administered by states but funded jointly by federal and state governments

**In Ohio, SCHIP is an expansion of Medicaid

Question 3

What is the Medicaid Program?

Answer 3

Medical assistance provided to Americans with low incomes and other eligibility catergories:
1. Cannot afford health services on their own (can’t afford private insurance)
2. An “Entitlemetn Program: If eligible, benefits are guaranteed and state must pay for these benefits

Question 4

Can a person be enrolled in both Medicare and Medicaid?

Answer 4

Yes, remember Medicaid can be used as a secondary insurance to reduce out-of-pocket costs for patients with Medicare

Question 5

Is state participation in Medicaid mandatory?

Answer 5

No, state participation is voluntary (all states don’t have to participate)

Question 6

How is Medicaid paid for? Explain role of federal and state government in Medicaid

Answer 6

Joint Federal-State governments program: funding and administration is shared between federal and state governments

Federal government matches a percentage of state spending on Medicaid (federal government sends money to states); then states must manage costs of the program

Question 7

What is the federal responsibility in Medicaid?

Answer 7

Establishes broad guidelines and minimum standards under which states must design and operate their individual programs

Question 8

What is the state responsibility in Medicaid?

Answer 8

Single state agency desigated responsible for the program
States determine criteria for
1. eligibility
2. benefits
3. provider payments rates
*within federal guidelines

It is the states capacity to address health challenges: sates have flexibility to design Medicaid program based on the needs of their communities

Question 9

What does it mean when we say that Medicaid is an “entitlement” program?

Answer 9

**Eligible Individuals are entitled to a defined set of benefits
**States are entitled to federal matching funds

When Medicaid is described as an “entitlement” program, it means that the program provides benefits to all eligible individuals who apply, and there is a legal guarantee that those benefits will be provided as long as the eligibility criteria are met

1. Legal Guarantee: Eligible individuals have a legal right to receive Medicaid benefits if they meet the eligibility criteria.
2. No Enrollment Caps: There is no limit on the number of people who can be covered by Medicaid as long as they qualify.
3. Joint Funding: Medicaid is funded through a combination of federal and state resources, with federal funds matching state expenditures.
4. Comprehensive Coverage: Medicaid provides extensive health coverage, ensuring access to necessary medical services for those who qualify.

In essence, Medicaid’s status as an entitlement program means that it is designed to ensure that eligible individuals have access to essential healthcare services without limitations on the number of beneficiaries or the scope of coverage based on federal and state guidelines.

Question 10

Who is eligible for Medicaid?

Answer 10

1. US citizen
2. Ohio resident
3. Social Security Number
4. Meet certain income and categorical requirements

Income: Varies by eligibility group and state; linked to the Federal Poverty Level (FPL).
Eligibility Groups: Includes children, pregnant women, parents, elderly, and disabled individuals.
Citizenship: U.S. citizens and certain lawfully present immigrants are eligible.
Residency: Must be a resident of the state where applying.
State Variability: States have flexibility in setting income limits and additional eligibility criteria, particularly in non-expansion states.
In summary, Medicaid eligibility is based on a combination of income, household size, specific eligibility categories, and residency, with variations based on state-specific rules and whether a state has opted for Medicaid expansion under the ACA.

Eligibility for Medicaid is determined by a combination of federal and state guidelines. It includes:
Low-income families with children
Pregnant women
Individuals with disabilities
Elderly individuals (65 and older)
Children

Question 11

Difference between Medicaid and Affordable Care Act?

Answer 11

• Medicaid is a federal and state program designed to provide health coverage to low-income individuals and families. It aims to ensure access to essential medical services for vulnerable populations. In states that expanded Medicaid under the ACA, coverage extends to low-income adults without children.
• The ACA, also known as Obamacare, was enacted to reform the U.S. healthcare system. Its primary goals include reducing the number of uninsured Americans, controlling healthcare costs, and improving the quality of care. he ACA allowed states to expand Medicaid eligibility to cover adults with incomes up to 138% of the FPL. This expansion aimed to provide health coverage to more low-income individuals.Affects a broader range of people, including those who may not qualify for Medicaid but need assistance with purchasing private health insurance. The ACA itself does not provide direct health coverage but facilitates access to private insurance and expands Medicaid.

Question 12

What are sample of “mandated needy” eligibility groups?

Answer 12

1. low income families
2. Children
3. Low-income persons who are elderly, blind or disabled (Recieve Supplemental Security Income)
4. People over less than or equal to age of 65 with a disability

(low income faimiles, individuals with disabilities, elderly and children)

Question 13

Does Medicaid use patient cost sharing techniques?

Answer 13

Yes HOWEVER, cost-sharing must NOT present a serious barrier to receiving needed services. Certain services cannot require cost-sharing

***Many states require Medicaid recipients to pay in the form of: deductibles, copayments and coinsurance

Question 14

Is it true for Medicaid that certain services cannot require cost-sharing?

Answer 14

Yes, Medicaid has a list of services that cannot require cost-sharing

Question 15

What type of care delivery programs are the majority of mediciaid beneficiaries enrolled in?

Answer 15

Medicaid Managed Care Programs

(can do fee-for-service because private health insurance companies contract with Medicaid)

Question 16

What are some emerging care delivery and/or financing models in Medicaid?

Answer 16

1. Patient-Centered Medical Home (PCMH)
2. Accountable Care Organization (ACO)
3. Pay-for-Performance (P4P)

Question 17

Who is eligible for Ohio Medicaid?

Answer 17

1. Low income
2. Children, infants, pregnant women
3. Disability (blindness)
4. Older persons with disabilities (ABD: Aged, Blind and Disabled)
5. Must be a US citizen or meet non-citizen requirements set up by Medicaid

Question 18

What is the main way Medicaid is delivered?

Answer 18

Managed Care

Question 19

what are new initiatives is Ohio Medicaid working on to improve quality?

Answer 19

1. “Next Generation of Managed Care”: goals are improves wellness and health outcomes (keep people healthy), emphasizes a personalized care experience, supports providers in better patient care, improves care for children and adults with complex needs
2. Single Pharmacy Benefit Manager: increase program transparency and accountability; single pharmacy benefit manager manages prescription drugs for Ohio Managed Care plans effective 7/1/2023

Question 20

Does Ohio Medicaid cover prescription drugs?

Answer 20

yes (Ohio has a federal and state supported program that provides prescription drug coverage to eligibile people in Ohio Medicaid; over 46k different drugs, very large formulary)

Question 21

Is the majority of care provided under Ohio Medicaid managed care or fee-for-service?

Answer 21

managed care (ohio currently has 7 managed care programs and patients ahve the option to choose their managed care plan network)

Question 22

Who are key resources to help patients access medicaid programs?

Answer 22

Pharmacists

Question 23

What is the purpose of Medicaid?

Answer 23

To assist low-income individuals and other patient groups in affording and accessing their health care

Question 24

What are some resources pharmacists can use to help patients?

Answer 24

1. Medicaid.ohio.gov
2. Ohio Medicaid Consumer Hotline
3. healthcare.gov (help to see if patients might be qualified for Medicaid)

Question 25

Difference between Medicaid and Medicare in terms of who is eligible?

Answer 25

• Medicaid: Low-income individuals and families, pregnant women, elderly, disabled, varies by state; Medicaid expansion under ACA
• Medicare: Individuals aged 65+, disabled individuals, ESRD, ALS

Question 26

Difference between Medicaid and Medicare in terms of how these programs are funded?

Answer 26

• Medicaid: Joint federal and state funding; federal matching rate based on state spending
• Medicare: Federal funding through payroll taxes, general revenue, and trust funds

Question 27

Difference between Medicaid and Medicare in terms of how these programs are administered?

Answer 27

Medicaid: State-administered with federal guidelines; states have flexibility in program design; The federal government provides guidelines and funding but allows states to manage eligibility, benefits, and service delivery.

Medicare: Federally administered by CMS; Medicare provides uniform benefits and coverage rules across the country, though it allows for different plan options (e.g., Medicare Advantage and Medigap) and regional variations in provider networks.; The federal government manages enrollment, benefits, and service delivery for Medicare.