Medicaid - Jan. 28 & 30 Flashcards
What is Medicaid? (Q)
Medicaid is a joint state and federal program that provides medical insurance to people in need.
How was Medicare created? (Q)
Medicaid is created by a federal statute.
What government entity establishes the requirements for the Medicaid plan? (Q)
Through the Department of Health and Human Services, or HHS, the federal government establishes the requirements for Medicaid plans.
What do the states do regarding Medicaid? (Q)
On the state side, each state creates and administers its own Medicaid plan that complies with those federal requirements.
Do the states have to fund Medicaid on their own? (Q)
No. Each state must fund part of its own plan, but the federal government matches a percentage of the state’s Medicaid spending, regardless of how much the state spends.
Traditionally, how can an individual be eligible for Medicare? (Q)
Traditionally, to be eligible for Medicaid, an individual must satisfy both a nonfinancial and a financial need requirement.
How are the dual eligibility requirements for Medicaid combined? (Q)
These dual eligibility requirements are combined in three ways.
What is the first combination for the dual eligibility requirements? (Q)
The first combination is for mandatory categorically needy people.
Must a state’s Medicaid plan cover mandatory categorically needy people? (Q)
Yes. A state’s Medicaid plan must cover mandatory categorically needy people.
How can a person meet the mandatory categorically needy people non-financial need requirement? (Q)
To meet this group’s nonfinancial-need requirement, a person must fall into one of several specific needy categories, such as being over a certain age, blind, permanently and totally disabled, pregnant, or a child in a poor family.
How can a person meet the mandatory categorically needy people financial need requirement? (Q)
To meet the group’s financial-need requirement, a person must have income low enough to qualify for other federal assistance programs, usually by falling below the federal poverty level, and the person must have limited assets.
Can someone who meets the non-financial reed requirement, but does not meet the financial need requirement give away their money to satisfy the financial need requirement? (Q)
No. If someone transfers assets for less than their full value in the five years before applying for Medicaid, the person will be denied Medicaid benefits in an amount that essentially equals the amount of that lost value.
What is the second combination for the dual eligibility requirements? (Q)
The second combination is optional categorically needy people.
Are state’s required to cover optional categorically needy people? (Q)
No. A state plan’s coverage for this group is optional.
Who is included in the optional categorically needy people category? (Q)
This group includes individuals whose income is slightly too high to qualify as mandatory categorically needy but who otherwise meet similar need requirements.
Ex: If a disabled person had only a few assets but the person’s income was too high to qualify for mandatory Medicaid, the person could still qualify for Medicaid coverage under this optional category.
What is the third combination for the dual eligibility requirements? (Q)
The third combination for the dual eligibility requirements is optional medically needy people.
Are state’s required to cover optional categorically needy people? (Q)
No. A state plan’s coverage for this group is optional.
Who is included in the optional medically needy people category? (Q)
This group includes individuals whose income is too high to qualify for the mandatory coverage group but who have significant medical expenses that bring their disposable income down to qualifying levels.
Ex: If an elderly person made well above the qualifying income level but spent most of that income on treating a chronic illness, the elderly person might qualify for Medicaid coverage under this category.
Are states allowed to provide additional coverage to some groups? (Q)
Yes.
Ex: States aren’t required to provide Medicaid to temporary lawful residents or undocumented residents, but states may opt to cover those individuals.
Are states able to restrict Medicaid coverage? (Q)
Yes, but it is very limited and to do so, a state must apply for a waiver from the Department of Health and Human Services.
Ex: Several states were granted waivers allowing the states to restrict some Medicaid benefits to individuals who worked at a paid job for a certain number of hours each month. But these work-requirement waivers were later overturned in federal court for not serving Medicaid’s intended objectives.
What expansion did the ACA add to Medicaid eligibility? (Q)
The ACA expanded Medicaid eligibility by adding a fourth eligibility group with only a single requirement, and that requirement is financial need.
What is the financial need requirement added by the ACA? (Q)
For this fourth group, anyone whose income is less than 138 percent of the federal poverty level is eligible for Medicaid.
Are states required to expand their Medicaid coverage to cover the financial needy group? (Q)
No. Following NFIB v. Sebelius, states are still allowed to voluntarily choose to expand their Medicaid coverage to include this fourth, optional financially needy group. And most states have done so.
What mandatory core benefits must be a part of any state Medicaid plan? (Q)
These mandatory core benefits include services like inpatient and outpatient hospital care, doctor and nurse-practitioner visits, health-clinic services, nursing-facility care, home-health services, laboratory and imaging services, screening and treatment services for children, midwife services, family-planning services and supplies, and transportation to and from necessary medical care.
What other things may states choose to cover under Medicaid? (Q)
States also have the option of providing additional benefits like paying for prescription drugs; inpatient psychiatric care; or occupational, physical, or speech therapy.
What is Medicaid’s freedom-of-choice provision? (Q)
Medicaid’s freedom-of-choice provision allows recipients to choose any provider that accepts Medicaid.
What is an Alternative Benefit Plan (ABP)? (Q)
These plans must still provide the same core coverage as the state’s traditional Medicaid plan. But ABPs more closely track the health-insurance plans offered to federal employees and give states flexibility in areas like limiting provider choices.
If paying the premiums for someone’s employer-sponsored healthcare plan is more cost-effective than providing Medicaid insurance for that individual, what does the ACA require? (Q)
if paying the premiums for someone’s employer-sponsored healthcare plan is more cost-effective than providing Medicaid insurance for that individual, the ACA requires states to offer an eligible person the premium-assistance option.
What happens if someone chooses the premium-assistance option? (Q)
If someone chooses the premium-assistance option, the state typically must also provide what are known as wraparound benefits to help keep the person’s overall out-of-pocket expenses the same as they would be under the state’s Medicaid plan.
