May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for...
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![Page 1: May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group William J. Scanlon Health.](https://reader036.fdocuments.net/reader036/viewer/2022070308/551c2c1a5503469e4f8b60e3/html5/thumbnails/1.jpg)
May 11, 2005 1
Overview of Medicare, Medicaid and
State Children’s Health Insurance Program
for
Citizens’ Health Care Working Group
William J. ScanlonHealth Policy R&D
National Health Policy Forum
![Page 2: May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group William J. Scanlon Health.](https://reader036.fdocuments.net/reader036/viewer/2022070308/551c2c1a5503469e4f8b60e3/html5/thumbnails/2.jpg)
May 11, 2005 2
Overview of Medicare, Medicaid and SCHIP
• Eligibility
• Services Covered
• Financing
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May 11, 2005 3
EligibilityCategories Income
Medicare
-Aged
-Disabled
-ESRD Patients
All
Medicaid
-Children
-Parents
-Aged
-Disabled
Low Income--varies by state subject to federal limits
SCHIP -Children
Low Income--varies by state subject to federal limits
![Page 4: May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group William J. Scanlon Health.](https://reader036.fdocuments.net/reader036/viewer/2022070308/551c2c1a5503469e4f8b60e3/html5/thumbnails/4.jpg)
May 11, 2005 4
Services
Acute Care Chronic Care Long-term Care
Medical, nursing and pharmaceutical services for an immediate need
Medical, nursing and pharmaceutical services for an ongoing need
Supportive services to compensate for a disability
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May 11, 2005 5
Services
Acute Care Chronic Care Long-term Care
Medicare X X
Medicaid X X X
SCHIP X X
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May 11, 2005 6
Financing
• Medicare– Open Ended Entitlement– Federal
• Payroll Taxes• General Revenues
– Beneficiary Premiums
• Medicaid– Open Ended Entitlement– Federal and State General Revenues
• SCHIP– Fixed Federal Appropriation– Federal and State General Revenues– Beneficiary Premiums
![Page 7: May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group William J. Scanlon Health.](https://reader036.fdocuments.net/reader036/viewer/2022070308/551c2c1a5503469e4f8b60e3/html5/thumbnails/7.jpg)
May 11, 2005 7
Medicare
• 41 million beneficiaries
• $301 billion in 2004– 11.7% of Federal Budget– 2.6% of GDP (2003)
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May 11, 2005 8
Medicare Program Structure
• “Original” or “Traditional” Medicare (also known as “Fee-for-Service” Medicare)
• Medicare Advantage—Private plan options
• Drug Benefit
Parts A and B
Part C
Part D
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May 11, 2005 9
Medicare BenefitsMedicare Covers Acute and Chronic Care
• Part A– Inpatient hospital– Post-hospital skilled nursing facility (SNF) services– Home health– Hospice-care
• Part B– Physician and laboratory services– Outpatient hospital– Therapy– Durable medical equipment and supplies– Home health (not-covered under Part A)
• Part D– Drugs
![Page 10: May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group William J. Scanlon Health.](https://reader036.fdocuments.net/reader036/viewer/2022070308/551c2c1a5503469e4f8b60e3/html5/thumbnails/10.jpg)
May 11, 2005 10
Medicare Cost-Sharing
• Hospital Care– Days 1-60—Deductible ($912 in 2005)– Days 61-90—Per day coinsurance ($228 in
2005)– Days 91-150—Per day coinsurance ($456 in
2005) for 60 lifetime reserve days
• SNF– Days 21-100—Per day coinsurance ($114 in
2005)
![Page 11: May 11, 20051 Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group William J. Scanlon Health.](https://reader036.fdocuments.net/reader036/viewer/2022070308/551c2c1a5503469e4f8b60e3/html5/thumbnails/11.jpg)
May 11, 2005 11
Medicare Cost SharingContinued
Part B • Deductible: $110 in 2005• Coinsurance: 20% of Medicare approved
amount• Exceptions
– Mental health: 50% co-insurance– Hospital outpatient—Fixed amounts– Home health—none
• Over-billing limit: 15 % above Medicare approved amount on unassigned claims
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May 11, 2005 12
Medicare Cost SharingContinued
Beneficiary cost sharing on Medicare
covered services can be substantial
Beneficiaries in 1998 paying more than:
Number of Beneficiaries Percent
$2,000 3.4 million 11.5 %
$5,000 736 thousand 2.5 %
$10,000 167 thousand 0.6 %
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May 11, 2005 13
Medicare Supplementary Coverage
Vast majority of beneficiaries in traditional Medicare have supplementary coverage
Supplementary Coverage in 2000
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May 11, 2005 14
Medicare Advantage—Part C
• Offers choice to join private plan
• Plan types include HMOs, PPOs, FFS, MSAs
• Plans paid monthly per enrollee fee regardless of services used
• Plan “savings” returned in extra benefits
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May 11, 2005 15
Medicare Advantage—Part C
Plan and beneficiary participation have varied over time
0
50
100
150
200
250
300
350
400
1992 1994 1996 1998 2000 2002 2004
0
1
2
3
4
5
6
7
Plans
Enrollees
Plans Enrollees (millions)
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May 11, 2005 16
Medicare Advantage—Part C
• Medicare Modernization Act changed Part C
– Increased payments to plans
– Provided for financial competition among plans and share of savings to Medicare
– Created regional PPOs to expand areas served
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May 11, 2005 17
Medicare Advantage—Part CPPO Regions for 2006
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May 11, 2005 18
Medicare Drug Benefit--Part D
• Begins January 1, 2006• Separate enrollment and premium• Monthly premium expected to average $37 nationally• Benefit provided by competing private stand-alone drug
plans or Medicare Advantage plans• Benefit
– $250 deductible– Coinsurance
• 25% from $250 to $2,250• 100% from $2,250 to $5,100• 5% on spending over $5,100
• Subsidies for premium and cost sharing for low income persons
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May 11, 2005 19
Medicaid and SCHIP
Medicaid• over 52 million beneficiaries
• $ 309 billion in 2004
• Federal share– $176 billion or .8% of federal
budget
• State share– $133 billion or 22%* of state
budgets
*2003
SCHIP• ~ 6 million beneficiaries
• $6.1 billion in 2004≈ 75 % Federal
≈ 25 % State
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May 11, 2005 20
Medicaid
Program Roles
• Primary health insurance—mostly families
• Medicare supplement—dual eligible aged and disabled beneficiaries
• Long-term care financer —beneficiaries with disabilities
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May 11, 2005 21
Medicaid
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May 11, 2005 22
Medicaid
Programs are state designed and administered subject to federal requirements
Result is 56 distinct Medicaid programs
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May 11, 2005 23
MedicaidMandatory and Optional Eligibility
Selected CategoriesMandatory
• Children– 6-18 years up to 100%
FPL– 0-5 years up to 133%
FPL– Foster care
• Pregnant women– Up to 133% FPL
• SSI cash recipients
Optional• Children and
Pregnant women– Up to 185% FPL
• Elderly and Disabled – Up to 100%FPL
• Medically Needy
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May 11, 2005 24
Medicaid Mandatory Medicare Supplementary Insurance
• Qualified Medicare Beneficiaries (QMBs)– Up to 100% FPL—Part B Premium and cost sharing
• Specified Low-Income Medicare Beneficiaries (SLMBs)– 100-120% FPL---Part B Premium
• Qualifying Individuals (QIs)– 120-135% FPL—Portion of Part B Premium
• Qualified Disabled Working Individuals (QDWIs)– Up to 200% FPL---Part A Premium
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May 11, 2005 25
MedicaidMandatory and Optional Services
Selected TypesMandatory
• Physician• Hospital inpatient and
outpatient• Nursing Facility for
persons 21 and over• Lab and X-ray• EPSDT for persons
less than 21
Optional• Prescription Drugs• Dental services• ICF/MRs• Home and
community-based services
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May 11, 2005 26
Medicaid Waivers
• Program Waivers– Mandatory managed care enrollment (1915(b))
• Section 1115 Demonstrations– Statewide experimentation with financing
mechanisms, managed care, coverage expansions– HIFA—Health Insurance Flexibility and Accountability
—tradeoff of more limited benefit packages and cost sharing for expanded coverage
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May 11, 2005 27
SCHIP
Federal-State Partnership very different• Capped appropriation—not an entitlement
$39 billion for 10 years (reauthorization 2007)
• State Flexibility– States can cap/close enrollment
• 7 states froze enrollment at least temporarily between 2001 and 2004
• 3 had freezes in effect at end of 2004
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May 11, 2005 28
SCHIPState Flexibility (Continued)
• Benefits– Medicaid Expansion– Distinct program with benefits similar to
• BC/BS plan; state employees plan; largest Medicaid HMO; or actuarially equivalent
– Combination
• Cost sharing– Very limited for children in families ≤ 150%FPL– For others, premiums and co-payments allowed if
≤ 5% of income
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May 11, 2005 29
Changes in Health Insurance Coverage for Low-Income Children and Adults, 2000-
2003Percentage Point Changes
-5.2%-4.0%
7.5%
1.2%
3.2%
-1.6%
-6%
-4%
-2%
0%
2%
4%
6%
8%
Employer Medicaid Uninsured
Children Adults
5.7 Million2.0 MillionChange in Population
3.9 Million-0.1 MillionChange in Uninsured
Note: Low-income is defined as less than <200% of poverty ($29,360 for a family of three)SOURCE: Urban Institute for the Kaiser Commission on Medicaid and the Uninsured, 2004
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May 11, 2005 30
Medicaid as LTC Financer
• Pays close to half of all LTC expenditures
• Nursing homes≈46 percent of revenues
≈1 million or 2/3 of residents partially or fully financed
• Home and community services≈48 percent of expenditures
≈850 thousand recipients
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May 11, 2005 31
Medicare and Medicaid as a Share of GDP
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May 11, 2005 32
For more information
Understanding Medicare and Medicaid: Fundamentals and Issues for the New Congress
Briefing Book — January 26, 2005
www.nhpf.org