Medicaid Presentation at Hofstra University


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Medicaid Presentation I gave at Hofstra University.

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Medicaid Presentation at Hofstra University

  1. 1. Eligibility & Financing Presented by Steven A. Rohinsky Hofstra University MHA Program
  2. 2. Medicaid Target Groups <ul><li>Who Does Medicaid Help? </li></ul><ul><li>Low-income individuals and families who fit into an eligibility group that is recognized by federal and state law </li></ul><ul><li>Pregnant women </li></ul><ul><li>Disabled </li></ul><ul><li>Blind </li></ul><ul><li>Senior Citizens </li></ul>
  3. 3. Medicaid Services <ul><li>Treatment and Preventive Healthcare </li></ul><ul><li>Doctor Visits </li></ul><ul><li>Dental Visits </li></ul><ul><li>Hospital inpatient and outpatient services </li></ul><ul><li>Early periodic screening, diagnosis, and treatment for children under 21 years of age under the Child/Teen Health Program </li></ul><ul><li>Clinic services </li></ul><ul><li>Prenatal care </li></ul><ul><li>Diagnostic Imaging services (PET,MRI,CAT X-ray) </li></ul><ul><li>Medication </li></ul><ul><li>Laboratory Services </li></ul><ul><li>Medical Supplies , Appliances, and Equipment </li></ul><ul><li>Some insurance and Medicare premiums </li></ul>
  4. 4. Medicaid Services <ul><li>Long Term Care </li></ul><ul><li>Nursing Home (SNF) </li></ul><ul><li>Assisted Living </li></ul><ul><li>Adult Day Care (ADC) </li></ul><ul><li>Home health agency and personal care </li></ul><ul><ul><li>(Lombardi Program (Nursing home w/o walls </li></ul></ul><ul><li>Mental health Services (i.e. treatment in psychiatric hospitals ) </li></ul><ul><ul><li>Under Twenty One </li></ul></ul><ul><ul><li>Senior Citizens </li></ul></ul><ul><ul><li>Developmentally Disabled </li></ul></ul><ul><ul><li>Mentally Retarded (as defined by the NYS OMRDD) </li></ul></ul>
  5. 5. Medicaid Services <ul><li>Transportation </li></ul><ul><li>Transportation to medical appointments, including public transportation and car mileage </li></ul><ul><li>EMS to a hospital </li></ul><ul><li>Other Health Services </li></ul><ul><li>Family planning services </li></ul><ul><li>Smoking cessation agents </li></ul>
  6. 6. Medicaid Eligibility <ul><li>Who is Eligible? </li></ul><ul><ul><li>“It’s All About the Benjamin's” </li></ul></ul><ul><ul><ul><li>Resource Levels </li></ul></ul></ul><ul><ul><ul><li>Assets </li></ul></ul></ul><ul><ul><ul><li>Income </li></ul></ul></ul><ul><ul><ul><li>Number of dependants </li></ul></ul></ul>
  7. 7. Medicaid Eligibility <ul><ul><ul><li>The Four Types of Medicaid </li></ul></ul></ul><ul><ul><li>Community Medicaid </li></ul></ul><ul><ul><li>LTC Medicaid </li></ul></ul><ul><ul><li>Short term Rehabilitation </li></ul></ul><ul><ul><li>Managed Care </li></ul></ul>
  8. 8. Medicaid Eligibility <ul><li>Community Medicaid </li></ul><ul><li>Must have be below an asset level that is determined by number of dependants </li></ul><ul><ul><li>Assets include: </li></ul></ul><ul><ul><ul><li>Stocks, Bonds, Property , Vehicles, Annuities, and Cash </li></ul></ul></ul><ul><li>Must have proof of citizenship </li></ul><ul><li>Must have proof of residence of New York state and County. </li></ul><ul><li>SSI Recipients automatically approved if Disabled and below Poverty level </li></ul><ul><li>Proof of your income from sources like Social Security, Supplemental Security Income (SSI), Veteran's Benefits (VA), retirement </li></ul><ul><li>Any bank books and insurance policies that you may have </li></ul><ul><li>Insurance benefit card or the policy (if you have any other health insurance) </li></ul>
  9. 9. Medicaid Eligibility <ul><li>Long Term Care Medicaid </li></ul><ul><li>Must have under 13k in assets </li></ul><ul><ul><li>Assets include: </li></ul></ul><ul><ul><ul><li>Stocks, Bonds, Property , Vehicles, Annuities, and Cash </li></ul></ul></ul><ul><li>39 month “look back” period (will go up to 60 months by 2011) </li></ul><ul><ul><li>“ look back” period Includes </li></ul></ul><ul><ul><ul><li>Any and All bank account information </li></ul></ul></ul><ul><ul><ul><li>Any Financial Transactions (I.e. Transfer of Assets) </li></ul></ul></ul><ul><li>Must have proof of citizenship </li></ul><ul><li>Must have proof of residence of New York state and County </li></ul><ul><li>Spousal cases allowed 100k in assets and real property ownership. </li></ul><ul><li>Depending on county and Complexity of case ,approval time can take over a year </li></ul><ul><li>SSI Recipients automatically approved if Disabled and below Poverty level </li></ul>
  10. 10. Medicaid Eligibility <ul><li>Managed Care Medicaid </li></ul><ul><li>Same Eligibility requirements </li></ul><ul><ul><li>Provider bills managed care company </li></ul></ul><ul><ul><li>Set capitation rates through competitive bidding process </li></ul></ul>
  11. 11. Medicaid Eligibility <ul><li>Short-term Rehab Medicaid </li></ul><ul><li>3 to 6 Months as defined by county </li></ul><ul><li>Approval based on medical director’s approval </li></ul><ul><li>May re-apply after 1 st short term stay (non- chronic extension) </li></ul><ul><li>Allowed to keep more income </li></ul>
  12. 12. Medicaid Eligibility <ul><li>What if you are denied? </li></ul><ul><li>Fair Hearing </li></ul><ul><ul><li>ALJ presides over case </li></ul></ul><ul><li>What if you lose the Fair Hearing? </li></ul><ul><li>Article -78 Proceeding </li></ul><ul><ul><li>Supreme court presides over case </li></ul></ul>
  13. 13. Medicaid Eligibility <ul><li>If you lose the Article 78? </li></ul><ul><li>Bad news.... </li></ul><ul><li>Patient must pay out of pocket! </li></ul>
  14. 14. Medicaid Eligibility <ul><li>Permanent Residence Under Color of Law (PRUCOL) </li></ul><ul><li>Immigration status not legal status </li></ul><ul><li>Recipient must be Lawful Resident ( LPR) </li></ul><ul><li>People on temporary visas not covered </li></ul><ul><li>Refugees </li></ul><ul><li>Federal authorities aware of their presence but will not deport them - therefore NYS HRA decided to cover them </li></ul><ul><li>Funds are not matched by federal government </li></ul><ul><li>New York and California are only states that cover </li></ul>
  15. 15. Medicaid Eligibility 6 th highest 8 th highest 8 th highest Source: Kaiser Family Foundation,
  16. 16. Medicaid Financing <ul><li>Fast Facts: </li></ul><ul><li>Medicaid is jointly financed by the federal government and the states. States administer the program under federally established guidelines. </li></ul><ul><li>The federal contribution to Medicaid spending in each state ranges between 50% and 76%, depending on state per capita income. </li></ul><ul><li>Nationally, the federal government pays 57% of Medicaid costs and states pay 43%. </li></ul><ul><li>Funded through a combination of Federal , State and Local Taxes </li></ul>
  17. 17. Medicaid Financing <ul><li>Federal Medical Assistance Percentage (FMAP)- </li></ul><ul><li>Pays share of the medical assistance expenditures under each State's Medicaid program </li></ul><ul><li>Determined annually by a formula that compares the State's average per capita income level with the national income average </li></ul><ul><li>States with a higher per capita income level are reimbursed a smaller share of their costs. </li></ul><ul><li>By law, the FMAP cannot be lower than 50 percent or higher than 83 percent. </li></ul>
  18. 18. Federal Mandatory Spending Programs Source: Congressional Budget Office, January 2008
  19. 19. Medicaid-Provider Payments <ul><li>How do Providers get paid? </li></ul><ul><li>LTC </li></ul><ul><ul><li>Rate based on : </li></ul></ul><ul><ul><ul><li>Acuity of Residents </li></ul></ul></ul><ul><ul><ul><li>Cost report (Expenses) </li></ul></ul></ul><ul><li>Hospitals </li></ul><ul><ul><li>DRG’S ? </li></ul></ul><ul><li>Doctors </li></ul><ul><ul><li>Fee for service </li></ul></ul>
  20. 20. Financing-Provider Payments <ul><li>Providers are paid in two ways: </li></ul><ul><li>Checks </li></ul><ul><li>Electronic Wire Transfer </li></ul>
  21. 21. Medicaid & Medicare Relationship <ul><li>“ Dual Eligibles” </li></ul><ul><ul><li>Medicare beneficiaries who also receive Medicaid </li></ul></ul><ul><li>Medicaid “wraps around” Medicare </li></ul><ul><ul><li>Pays Medicare premiums and cost- sharing </li></ul></ul><ul><ul><li>Covers critical benefits that Medicare does not, such as long-term care. </li></ul></ul><ul><li>Dual eligibles account for 40% of Medicaid spending. </li></ul><ul><li>Medicaid accounts for nearly half of national long-term care spending and finances care for 60% of nursing home residents </li></ul>
  22. 22. Medicaid Spending – Per Enrollee 90% higher 112% higher 90% higher Source: Centers for Medicare and Medicaid Services, 2003 figures 44% higher 110% higher
  23. 23. Medicaid Utilization & Spending Source: Centers for Medicare and Medicaid Services, FY2003 figures Total savings does not include Managed Care & Drugs
  24. 24. Thank You!