Medicaid and CHIP Fundamentals. Chris Peterson Principal Analyst

Transcription

1 Medicaid and CHIP Fundamentals Chris Petersn Principal Analyst February 13, 2015

2 Overview Brief backgrund n MACPAC Medicaid and CHIP in cntext Hw Medicaid and CHIP wrk Statutry authrity and prgram administratin: What are the federal and state rles? Eligibility: Wh is cvered? Benefits and cst sharing: What is cvered? Payment and financing: Hw much? Selected plicy issues February 13,

3 MACPAC Backgrund February 13,

4 Medicaid and CHIP Payment and Access Cmmissin (MACPAC) Statutry charges include: reviewing and making recmmendatins n a range f tpics affecting Medicaid and CHIP submitting March and June reprts t Cngress Regular public meetings are held Publicatins n a variety f tpics, fr example: issue brief n emergency department use jint MACPAC/MedPAC data bk n beneficiaries wh are dually eligible fr Medicaid and Medicare state payment plicy landscapes February 13,

5 Members f the Cmmissin 17 Cmmissiners representing: Different perspectives n Medicaid and CHIP: prviders, state fficials, beneficiaries, actuaries, health plans, health services researchers Gegraphic diversity Appinted by the Cmptrller General Serve 3-year terms 6 new Cmmissiners as f January 1 February 13,

6 Medicaid and CHIP in Cntext February 13,

7 Medicaid Differs frm Other Payers Medicaid cvers peple fr whm ther insurance may nt be available r affrdable Prvides benefits ther insurance may nt (fr example, lng-term care and transprtatin) Pays premiums and cst sharing fr lwincme Medicare beneficiaries Serves as a majr surce f financing fr care delivered by safety net prviders February 13,

8 Medicaid and CHIP Beneficiaries Medicaid and CHIP cver abut a quarter f the U.S. ppulatin and abut half f all children fr at least part f the year Medicaid: 72 millin ever enrlled (FY 2013) CHIP: 8 millin ever enrlled (FY 2013) Nearly half f births natinally (46% in 2010) Mre than 16 millin age 65+ r eligible due t disability, including mre than 10 millin dually eligible fr Medicaid and Medicare February 13,

9 Medicaid Medicaid and CHIP Spending $499 billin = $303 billin federal and $195 billin state, 61% federal (FY 2014) 7.7% f federal utlays (FY 2013) 14.8% f state-funded state budgets and 23.7% f ttal state budgets (SFY 2012) 61% f lng-term services and supprts spending (2012) CHIP 26% f mental health and substance abuse spending (2009) $13 billin = $9 billin federal and $4 billin state, 70% federal (FY 2014) February 13,

10 Beneficiaries Medicaid Prjectins Cngressinal Budget Office prjects that 72 millin individuals ever enrlled in FY 2013 will rise t mre than 90 millin by FY 2018 Spending Medicaid share f natinal health expenditures prjected t rise frm 15.1% in 2012 t 17.8% ver the next decade States prject Medicaid spending f $594 billin ($358 billin federal) in FY 2015 and $614 billin ($370 billin federal) in FY 2016 February 13,

11 Hw Medicaid and CHIP Wrk: Statutry Authrity and Prgram Administratin February 13,

12 Medicaid and CHIP Legal Framewrk Medicaid is an entitlement fr eligible individuals, with pen-ended federal matching funds fr states CHIP cverage separate frm Medicaid is nt an entitlement t individuals; federal funding t states is capped, apprpriated thrugh FY 2015 Statute, regulatins, and guidance Mst statutry prvisins are cntained in Title XIX and Title XXI (CHIP) f the Scial Security Act Federal regulatins at 42 CFR 430 et seq. Subregulatry guidance includes letters t State Medicaid Directrs (SMDs); letters t State Health Officials (SHOs); Patient Prtectin and Affrdable Care Act (ACA) FAQs February 13,

13 Medicaid and CHIP State Plans and Waivers State plan is a dcument that gverns mst aspects f a state s prgram States may btain waivers f federal requirements that wuld therwise apply Sectin 1115: Experimental, pilt, r demnstratin prjects Sectin 1915(b): Managed care fr Medicaid Sectin 1915(c): Hme and cmmunity-based services fr Medicaid February 13,

14 Medicaid and CHIP Prgram Administratin States run day-t-day peratins and make plicy decisins within federal parameters Administered at federal level by Centers fr Medicare & Medicaid Services (CMS) CMS apprves (r disapprves): State plans and state plan amendments (SPAs) Waiver applicatins, renewals Claims fr federal reimbursement February 13,

15 Hw Medicaid and CHIP Wrk: Eligibility February 13,

16 Medicaid Eligibility Overview All individuals must meet financial and ther (fr example, citizenship dcumentatin) eligibility requirements Histrically, Medicaid cverage was tied t receipt f cash welfare assistance Later expanded t cver specified ppulatins withut regard t welfare receipt Adults withut dependent children were added as an eligible ppulatin by the ACA February 13,

17 General Requirements fr Medicaid Eligibility Only citizens and qualified nn-citizens can receive full Medicaid benefits Sme grups receive nly limited benefits Emergency services fr nnqualified aliens Assistance with Medicare csts Family planning and related services Cverage f lng-term services and supprts may require meeting functinal criteria (difficulties with activities f daily living) February 13,

18 Medicaid Enrllment and Spending by Majr Eligibility Grup, FY 2011 Aged 9.5% Aged Disabled 23.0% 14.7% Adults 28.3% Disabled 42.7% Children 47.4% Enrllment as a share f ttal Adults 15.3% Children 19.0% Benefit spending as a share f ttal February 13,

19 Majr Medicaid Eligibility Grups: Aged and Disabled Individuals age 65+ and thse under age 65 with a disability determinatin Mst are eligible thrugh receipt f federal Supplemental Security Incme (SSI) Incme belw abut 74% FPL fr an individual ($8,652 annually in 2014) and limited assets States may cver additinal individuals thrugh ther pathways, fr example: pverty level (up t 100% FPL) medically needy (high health care spending) special incme level (need institutinal care) February 13,

20 Majr Medicaid Eligibility Grups: Aged and Disabled (cntinued) Individuals dually eligible fr Medicaid and Medicare accunt fr: mst Medicaid enrllees age 65+ abut 40% f Medicaid enrllees under age 65 wh are eligible n the basis f a disability Fr abut ne-quarter f beneficiaries wh are dually eligible, Medicaid nly pays Medicare premiums and cst sharing Remaining three-quarters als receive full Medicaid benefits February 13,

21 Majr Medicaid Eligibility Grups: Nn-Disabled Adults and Children Nn-disabled adults age Parents (Sectin 1931 f Scial Security Act) Pregnant wmen New adult grup (thse withut dependent children and parents abve 1931 levels) Nn-disabled children under age 19 Minimum f 138% FPL Maintenance f effrt (MOE) required fr eligibility thrugh FY 2019 Sme Medicaid cverage is financed with CHIP funds (Medicaid-expansin CHIP) February 13,

22 Selected ACA Medicaid Eligibility Changes Mdified adjusted grss incme (MAGI) and n asset test fr mst eligibility determinatins New adult grup fr thse with incmes at r belw 138% FPL Expansin fr ages 6-18 at r belw 138% FPL (up frm 100% FPL) Child MOE thrugh FY 2019 Frmer fster care children until age 26 February 13,

23 Hw CHIP Differs frm Medicaid: Eligibility CHIP pays fr children abve each state s 1997 Medicaid incme-eligibility levels N federal minimum level fr CHIP Upper-incme eligibility levels range frm 175% FPL (Nrth Dakta) t 405% FPL (New Yrk) Tw ptins fr creating CHIP prgrams Medicaid-expansin CHIP (children enrlled in Medicaid, paid by CHIP) Separate CHIP (children enrlled in and paid by CHIP) Can have bth types (cmbinatin) Mst states are cmbinatin states February 13,

24 West Virginia Nn-Disabled Child and Adult 400% 350% Eligibility Levels, % 250% 200% 150% 100% 50% 0% Subsidized exchange cverage Separate CHIP Medicaid-expansin CHIP Medicaid Nte: Subsidized exchange cverage is available nly t individuals wh are nt eligible fr Medicaid, CHIP, Medicare, r affrdable emplyer-spnsred insurance, where affrdable is defined as ut-f-pcket premiums fr self-nly cverage that d nt exceed 9.5% f family incme. February 13,

25 Gergia Nn-Disabled Child and Adult 400% 350% Eligibility Levels, % 250% 200% 150% 100% 50% 0% Subsidized exchange cverage Gap Separate CHIP Medicaid-expansin CHIP Medicaid Nte: Subsidized exchange cverage is available nly t individuals wh are nt eligible fr Medicaid, CHIP, Medicare, r affrdable emplyer-spnsred insurance, where affrdable is defined as ut-f-pcket premiums fr self-nly cverage that d nt exceed 9.5% f family incme. Figure is fr citizens; lawfully present nn-citizens may als btain exchange subsidies belw 100% FPL. February 13,

26 Hw Medicaid and CHIP Wrk: Benefits and Cst Sharing February 13,

27 Mandatry Medicaid Benefits Inpatient hspital services Outpatient hspital services Physician services Early and Peridic Screening, Diagnstic, and Treatment (EPSDT) services fr individuals under age 21 (screening, visin, dental, and hearing services and any medically necessary service listed in the Medicaid statute, including ptinal services nt therwise cvered by a state) Family planning services and supplies Federally qualified health center services Freestanding birth center services Hme health services Labratry and X-ray services Nursing facility services (fr ages 21 and ver) Nurse midwife services (t the extent authrized t practice under state law r regulatin) Certified pediatric r family nurse practitiner services (t the extent authrized t practice under state law r regulatin) Rural heath clinic services Tbacc cessatin cunseling and pharmactherapy fr pregnant wmen Nn-emergency transprtatin t medical care February 13,

28 Prescribed drugs Optinal Medicaid Benefits Intermediate care facility services fr individuals with intellectual disabilities Clinic services Occupatinal therapy services Optmetry services Physical therapy services Targeted case management services Prsthetic devices Hspice services Inpatient psychiatric services fr individuals under age 21 Dental services Eyeglasses Speech, hearing, and language disrder services Inpatient hspital and nursing facility services fr thse age 65+ in institutins fr mental diseases Emergency services in a hspital nt meeting certain Medicare r Medicaid requirements Dentures Persnal care services Private duty nursing services Prgram f All-inclusive Care fr the Elderly (PACE) Chirpractic services Critical access hspital services Respiratry care fr ventilatr-dependent individuals Primary care case management services Services furnished in a religius nnmedical health care institutin Tuberculsis-related services Hme and cmmunity-based services Health hmes fr enrllees with chrnic cnditins Other licensed practitiners services Other diagnstic, screening, preventive, rehabilitative services February 13,

29 General Requirements fr Medicaid Benefits Amunt, duratin, and scpe: Services must be reasnable t achieve their purpse States have flexibility even fr mandatry benefits, except EPSDT fr children Cmparability: Same benefits fr all enrllees Statewideness: Same benefits regardless f place f residence within state Freedm f chice: Enrllees can chse amng participating prviders and managed care plans February 13,

30 Medicaid Cst-Sharing Exemptins Exempt ppulatins Exempt services At r belw 100% FPL 100%-150% FPL Abve 150% FPL N cst sharing fr mst children under age 18, pregnant wmen, beneficiaries receiving hspice care, certain beneficiaries in institutins such as nursing facilities, American Indians wh are furnished a Medicaid item r service thrugh an Indian Health Service prvider r thrugh a cntract health service referral, and individuals eligible under the Breast and Cervical Cancer Act pathway Except fr certain pregnant wmen abve 150% FPL, these ppulatins are als exempt frm premiums Emergency services, family planning services and supplies, preventive services fr children, pregnancy-related services, and services related t prvider-preventable cnditins February 13,

31 Aggregate limit Premiums Specified ppulatins Allwable Medicaid Cst Sharing At r belw 100% FPL 100%-150% FPL Abve 150% FPL Ttal premiums and cst sharing incurred by individuals in a Medicaid husehld may nt exceed 5% f family s mnthly r quarterly incme Up t $20 per mnth fr medically needy Sliding scale fr certain disability pathways (Bth may als apply abve 150% FPL) Up t 10% f incme exceeding 150% FPL fr certain pregnant wmen All thers Nt permitted N specific limit Cst sharing fr services Outpatient Up t $4.00 Up t 10% Up t 20% Inpatient Up t $75.00 Up t 10% Up t 20% Nn-emergency use f emergency dept. Up t $8.00 Drugs Preferred drugs: Up t $4.00 Nn-preferred drugs: Up t $8.00 N specific limit Preferred: Up t $4.00 Nn: Up t 20% February 13,

32 Hw CHIP Differs frm Medicaid: Benefits and Cst Sharing Medicaid-expansin CHIP prgrams These children are enrlled in Medicaid, cvering EPSDT with little r n cst sharing Separate CHIP prgrams States have flexibility t ffer benefit packages patterned after cmmercial cverage, except must cver dental Hwever, a third f separate CHIP prgrams benchmark t Medicaid benefit package Premiums and cst sharing at r belw 150 percent FPL must be nminal (very small). Mre flexibility abve 150 percent FPL, but n mre than 5% f incme February 13,

33 Hw Medicaid and CHIP Wrk: Financing and Payment February 13,

34 Federal Medicaid Financing Overview Federal Medicaid spending is determined by the amunt that states spend Federal share f service csts determined by each states federal medical assistance percentage (FMAP) Federal share f administrative csts des nt vary by state and is generally 50% States submit actual spending eligible fr federal match n the CMS-64 Quarterly Medicaid Statement f Expenditures Federal matching funds cmmnly referred t as federal financial participatin (FFP) February 13,

35 Federal Medical Assistance Percentage (FMAP) Based n a frmula that prvides higher reimbursement t states with lwer per capita incmes relative t the natinal average: 50-74% Exceptins apply in sme cases, such as: U.S. territries and D.C. (FMAPs set in statute) Special situatins (e.g., temprary state fiscal relief) Certain ppulatins, prviders, and services (e.g., Indian Health Service facilities) Federal CHIP matching rate is higher: 65 82% February 13,

36 75% State Medical Assistance Payments are Matched by Federal Gvernment Federal Medical Assistance Percentages (FY 2015) 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% AK CT MA NH NY RI WY IL SD HI DE IA TX FL LA OH OR TN NC IN AZ NM DC SC WV MS Surce: March 2014 MACStats, Table 14 February 13,

37 ACA FMAPs State Pp All states Early expansin FMAP states All states Newly eligible Already eligible childless adults All thers 100% 100% 95% 94% 93% 90% 80%- 92% 85%- 94% 86%- 92% 90%- 93% Regularly applicable FMAPs 93% 90% Newly eligible = generally nt eligible n 12/1/09 Early expansin state = cvered parents and childless adults in Medicaid/state-nly at 100%+ FPL n 3/23/10 February 13,

38 Primary Surces f Nnfederal Funding 1. State general revenue 2. Lcal gvernment cntributins Intergvernmental transfers (IGTs) Certified public expenditures (CPEs) 3. Health care related taxes Surces f the Nnfederal Share f Medicaid Payments (SFY 2012) 16% State funds 10% 5% Health care prviders 69% Lcal gvernments Other surces Surce: GAO, GAO February 13,

39 States Use f Health Care Related Taxes Nte: Example based n FMAP f 60% February 13,

40 Prvider Payment: FFS vs. MCO Fee fr service State sets amunts it will pay prviders; state is billed, pays fr services Managed care State pays premiums t plans; plans/managed care rganizatins (MCOs) pay prviders 50% f Medicaid enrllees are in managed care plans with cmprehensive benefits, which exist in mst states Hwever, nly 24% f Medicaid benefit spending is fr cmprehensive managed care February 13,

41 Prvider Payment Rates 1902(a)(30)(A) Safeguard against verutilizatin Payments cnsistent with efficiency, ecnmy, quality Sufficient t enlist enugh prviders Medicaid payments t hspitals (including supplemental payments) averaged 89% f csts in 2012 Medicaid physician fees averaged 66% f Medicare in 2012 Ranged frm 37% (RI) t 134% (ND) Medicaid managed care plans negtiate prvider rates February 13,

42 Supplemental Payments Supplemental payments are made in additin t the standard payment fr services Nt necessarily assciated with specific services Often financed by prvider taxes and IGTs Disprprtinate share hspital (DSH) payments were mre than $16 billin in FY13 Nn-DSH supplemental payments almst all based n upper payment limit (UPL) were reprted at ver $23 billin in FY13 February 13,

43 Medicaid DSH - Backgrund DSH payments are statutrily required payments t hspitals serving lw-incme patient ppulatins Intended t imprve the financial stability f safety-net hspitals and t preserve access t necessary health services fr lw-incme patients In FY 2013, DSH payments accunted fr ver $16 billin in ttal Medicaid spending February 13,

44 Medicaid DSH Reductins ACA reduced DSH alltments based n expected decline in number f uninsured Reductins were t begin in FY14 and end after FY20 Subsequent legislatin has delayed nset t FY17 and extended reductin t FY24 Under current law, FY25 reverts t pre-fy14 level February 13, 2015 Fiscal Year Annual reductin amunt (billins) 2017 $ $ $ $ $4.4 44

45 Hw CHIP Differs: Federal CHIP Funding Will Be Exhausted in FY 2016 N new CHIP alltments after FY 2015 Existing CHIP alltments are available fr 2 years Nearly all states expected t begin FY 2016 with leftver FY 2015 alltments CHIP matching rate increases by 23 percentage pints fr FY When CHIP funds are exhausted: Medicaid-expansin CHIP eligibility must cntinue thrugh FY 2019 because f MOE at higher state cst Separate CHIP prgrams can be clsed dwn February 13,

46 Percentage f States CHIP Spending fr Medicaid-Enrlled Children, FY 2016 Surce: MACPAC analysis f prjectins f FY 2016 federal CHIP spending prvided by states in Medicaid and CHIP Budget and Expenditure System as f December Includes prjected 2105(g) spending.

47 Enrllment and Uninsurance Amng Children Age 0 18 Prjected t Lse CHIP in 2016 Amng apprximately 3.7 millin children prjected t be in separate CHIP in 2016 if CHIP had cntinued. Surce: Preliminary Urban Institute analysis (Dubay, Buettgens, and Kenney) fr MACPAC f HIPSM-ACS enhanced with MEPS-IC data frm the Agency fr Healthcare Research and Quality, as f January 13, 2015.

48 Selected Plicy Issues February 13,

49 Selected CHIP Plicy Issues Shuld CHIP be extended? What wuld be the experience f children nw enrlled in CHIP if the prgram ended? Is there an nging lng-term rle fr CHIP even given the availability f new surces f cverage? 49

50 Selected Medicaid Plicy Issues Level and grwth rate f Medicaid spending and enrllment State flexibility within federal parameters and the use f waivers Adptin and diffusin f payment, delivery system, and ther innvatins Impact f state decisins regarding ACA eligibility expansin February 13,

51 Cntact Infrmatin Chris Petersn, Principal Analyst