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- 1. Analysis of Statutes, Regulations, and Policies COMPARING THE NATIONAL ISSUES TO ALABAMA AND KENTUCKY
- 2. HEALTHCARE DELIVERY SYSTEM ▪ Medicare ▪ Medicaid ▪ Children’s Health Insurance Program (CHIP) ▪ Private insurance/Employer insurance ▪ And people with no insurance
- 3. MEDICARE
- 4. MEDICARE ▪ Federal health insurance ▪ For people 65 and over ▪ For some disabled people ▪ For people with end- stage renal disease (ESRD) ▪ Medicare Part A ▪ Medicare Part B ▪ Medicare Part C ▪ Medicare Part D
- 5. MEDICARE PARTS A AND B PART A ·Hospital Services (Inpatient) ·Skilled Nursing Facility ·Hospice ·Some home health care PART B ·Medical Insurance ·Doctors Services ·Preventive Services ·Outpatient Care ·Medical Supplies
- 6. MEDICARE PARTS C AND D PART C ·Medicare Advantage Plan ·Private Companies Contracting with Medicare ·Provides Part A and Part B Benefits ·Most Offer Prescription Coverage PART D ·Prescription Coverage ·Functions as an Add-On to Original Medicare
- 7. ELIGIBILITY – AGE ▪ There are a lot of rules and regulations that determine eligibility, if and how much a person has to pay in premiums, etc., but the most important requirements for age-based Medicare are: ▪ Must be eligible based on own earnings or those of a spouse, parent, or child ▪ Must have 40 quarters vested (about 10 years of full-time work) to qualify for free Medicare Part A. ▪ Must have applied for Social Security or Railroad Retirement Board benefits. Four months later, you can enroll in Part A, then in Part B.
- 8. ELIGIBILITY -- DISABILITY ▪ Disabled persons may enroll in Part A after drawing Social Security or Railroad Retirement Board benefits for 24 months. ▪ If the disability is Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease) there is no waiting period. ▪ Disabled children may apply for Part A at age 20 (18 for ALS). They are covered under a children’s plan prior to age 20.
- 9. ELIGIBILITY -- ESRD ▪ End stage renal disease (ESRD) is also a qualifier for Medicare. ▪ Regular dialysis or a kidney transplant allow a person to enroll in Medicare. Timing is based on the particular circumstances of the treatment. ▪ Must be eligible for Social Security or Railroad Retirement Benefits to enroll.
- 10. ALABAMA AND KENTUCKY MEDICARE 960,848 enrolled in Original Medicare and Medicare Advantage 681,722 enrolled in Part D 857,316 enrolled in Original Medicare and Medicare Advantage 630,711 enrolled in Part D
- 11. 55 MILLION ENROLLED NATIONALLY
- 12. MEDICAID
- 13. MEDICAID ▪ Medicaid is a government-funded health insurance program for lower-income and disabled people ▪ There are many federally-mandated services (inpatient, outpatient, labs, well-child services, nursing facility and home health, etc.) ▪ States must provide the mandated services, and can provide additional services, too (vision, dental, prescriptions, hospice and respite care, and others)
- 14. MEDICAID EXPANSION UNDER THE ACA ▪ The ACA is the Patient Protection and Affordable Care Act (ACA for short, or Obamacare) introduced in 2010 ▪ 32 states and DC expanded Medicaid under the ACA, affording more people insurance. With the expansion, people can qualify on their income alone, instead of income plus a set of circumstances.
- 15. MEDICAID IN ALABAMA AND KENTUCKY ·Alabama has not expanded Medicaid. ·435,000 more would be eligible through Medicaid expansion ·139,000 with no way to get coverage ·Pre-ACA monthly average enrollment 799,176 ·November 2016 monthly enrollment 883,030 ·That's a gain of only 11% in people insured through Medicaid and CHIP ·Kentucky has expanded Medicaid. ·399,000 more people became eligible with new income-only rules ·63% reduction in uninsured 2013 to 2015 ·Pre-ACA monthly average enrollment 606,805 ·November 2016 monthly enrollment 1,229,387 ·That's a gain of 103% in people insured through Medicaid and CHIP
- 16. MEDICAID IN ALABAMA AND KENTUCKY Children up to 141% of federal poverty level (FPL) are eligible for Medicaid ·Children up to 312% of FPL are eligible for CHIP ·Pregnant women up to 141% FPL ·Parents up to 13% of FPL ·Certain elderly and disabled who meet income requirements Infants up to 195% of federal poverty level (FPL) are eligible for Medicaid ·Children up to 218% of FPL are eligible for CHIP ·Pregnant women up to 195% FPL ·All other adults up to 133% FPL ·Certain elderly and disabled may be eligible for higher income limits.
- 17. NATIONAL FIGURES Early roll-out of expansion Official roll-out
- 18. CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
- 19. CHIP ▪ CHIP is a federal insurance program that covers children whose families make too much for Medicaid. ▪ It’s a low-cost program, and sometimes is free ▪ 26 million enrolled nationally ▪ CHIP insures kids whose families make up to as much as 400% of the Federal Poverty Level
- 20. CHIP MANDATORY COVERAGE ▪ CHIP includes well-child care ▪ Hospitalization and outpatient care ▪ Prescriptions ▪ Emergency services ▪ Other services
- 21. CHIP IN ALABAMA AND KENTUCKY ▪ ·ALL Kids is for children under age 19 who do not have insurance ▪ Children whose families are at 300% of Federal Poverty Levels qualify ▪ ·Doctor visits, including check-ups ▪ ·Mental health/substance abuse services ▪ Hospital and physician care ▪ ·Immunizations ▪ ·Prescriptions ▪ ·Dental and vision care ▪ ·461,000 insured by Medicaid and CHIP combined ▪ ·KCHIP is for children under age 19 who do not have insurance ▪ ·Children whose families are at 213% of Federal Poverty Levels (FPL) qualify ▪ ·Glasses ▪ ·Immunizations ▪ ·Physical therapy ▪ ·Speech therapy ▪ ·Dental services ▪ ·Other services ▪ ·392,000 insured by Medicaid and Chip combined
- 22. COST OF CHIP BASED ON INCOME https://www.upmchealthplan.com/individuals/learn/plans-and-services/coverage-for-children.aspx
- 24. MANDATORY COVERAGE FOR ALL PLANS ▪ Offered through employers ▪ Available on the open market ▪ You must have a plan with essential minimum coverage or you pay a tax ▪ All plans must offer basic care ▪ Cost assistance is available on the Marketplace for those whose income falls between 100% and 400% of Federal Poverty Levels (FPL)
- 25. IMPROVEMENTS FOR CONSUMERS ▪ Can’t be denied coverage ▪ Can’t be charged more because of sex ▪ Can’t be charged more because of health status ▪ Can’t be dropped for being sick ▪ Can’t be denied for pre-existing conditions ▪ Kids can stay on parent’s plan until age 26 ▪ Improved women’s care ▪ Improved care for seniors
- 26. FINANCIAL CHANGES ▪ Preventative services covered 100% ▪ Essential coverage must count toward out-of- pocket limit ▪ No annual or lifetime limits ▪ Out-of-network emergency services won’t have a higher co-pay ▪ Out-of-pocket costs are capped ▪ More companies required to provide insurance to full-time employees
- 27. THE INSURANCE COMPANIES ▪ Insurance companies must be more transparent in how they are spending ▪ 85% of premiums paid in must be paid out in claims ▪ Rules for appeals and summaries are simplified for consumer’s ease ▪ Rules put in place to cut back wasteful spending
- 28. REQUIRED ESSENTIAL COVERAGE ▪ Hospitalizations ▪ Outpatient care ▪ Labs ▪ Prescriptions ▪ Emergency services ▪ Rehabilitation ▪ Pre- and Post-natal care ▪ Maternity care ▪ Pediatrics ▪ Pediatric dentistry ▪ Pediatric vision ▪ Mental health care
- 29. THE UNINSURED AND THE UNDERINSURED
- 30. Appalachian Citizens' Law Center. How to apply for black lung benefits. Retrieved from https://appalachianlawcenter.org/black-lung-benefits/how-to-apply-for-black-lung-benefits/ http://adph.org/allkids/index.asp?id=588 Cooper. L. (2016 May 10). Even with Obamacare, 29 million people are uninsured: Here's why. The Fiscal Times. Retrieved from http://www.thefiscaltimes.com/2016/05/10/Even-Obamacare-29-Million-People-Are- Uninsured-Here-s-Why http://datacenter.kidscount.org/data/tables/6546-children-who-have-health-insurance-by-health-insurance- type?loc=2&loct=2#detailed/ http://files.constantcontact.com/1b4946a6001/b8d36476-16b5-4875-9a2d-f1178cf55002.pdf https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/ http://kff.org/other/state-indicator/total-population/ http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment http://kidshealth.ky.gov/en/kchip/ http://obamacarefacts.com/affordablecareact-summary/ http://obamacarefacts.com/benefitsofobamacare/ http://obamacarefacts.com/obamacare-top-10/ https://www.cff.org/Assistance-Services/Insurance/Medicaid/Medicaid-and-CF-An-Overview/ https://www.cms.gov/medicare/eligibility-and-enrollment/origmedicarepartabeligenrol/index.html https://www.cms.gov/newsroom/mediareleasedatabase/press-releases/2015-press-releases-items/2015-07- 28.html http://www.cnn.com/2016/01/11/politics/joe-biden-barack-obama-financial-help/ http://www.countyhealthrankings.org/app/alabama/2016/measure/factors/85/map https://www.healthinsurance.org/alabama-medicaid/
- 31. https://www.healthinsurance.org/kentucky-medicaid/ https://www.healthinsurance.org/medicaid/ https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is- medicare.html Shanker, R. (1983). Occupational Disease, Workers' Compensation, and the Social Work Advocate. Social Work, 28(1), 24-27. Retrieved from http://www.jstor.org/stable/23714184 The Commonwealth Fund (2014). The problem of underinsurance and how rising deductibles will make it worse. Findings from the Commonwealth Biennial Health Insurance Survey, 2014 [Issue Brief]. Retrieved from http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance Webb, R. A. (2010 June). National Association of Social Workers Practice Update. Social workers: A bridge to language access services. [PDF] Retrieved fromhttps://www.socialworkers.org/assets/secured/documents/practice/clinical/WKF-MISC- 47310.DiversityPU.pdf West, R. L. (2017 February 11). Social work must be political [blog post]. Retrieved fromhttp://www.politicalsocialworker.org/social-workers-must-be-political/ https://www.ssa.gov/disabilityresearch/wi/medicaid.htm Yurkanin, A. (2017 January 18). Alabamians covered under Obamacare worry about repeal. AL.com. Retrieved from http://www.al.com/news/index.ssf/2017/01/alabamians_covered_under_obama.html
Editor's Notes
- So you can see that the health care system in the U.S is big and cumbersome and in several parts. I didn’t include the VA and Tricare because they are a pretty small piece of the pie, so just keep it in the back of your mind that in addition to the following parts of the healthcare delivery system, there are a couple of other small parts, too. And even with all of this, there are still people who are unable (and in some cases unwilling) to get insurance, or they have insurance but it’s not cost-effective for them to use it.
- Let’s talk about Medicare first.
- To get part B, you have to have Part A.
- From what I can tell, Part C is beneficial, especially to people who get Part A for free, because you get more choices and maybe some extra services by purchasing the supplement plan. When my grandmother needs to change the company she orders her diabetes supplies through, her part C gives her more choices on who to order from. It doesn’t make any difference to Medicare because all of the companies they approve for that particular service are managed care companies and the cheapest ones win, but my grandma can pick one that has better reviews for faster service, or the one that sells the lancing device that she likes.
- I have a friend who had a baby in 2012, before our state expanded Medicaid. It took her three years to pay off the visits to the pediatrician for the first month of her child’s life. And her kid was completely healthy! If this had been after the expansion, the baby’s well-child care and first case of the sniffles would have been covered and my friend wouldn’t have impoverished herself keeping her kid healthy.
- There is a big movement to keep kid’s teeth healthy in Kentucky, because we have, overall, terrible oral health in this state. So dental visits are really pushed once you get on Kchip.
- Without the sex-protection laws, women are charged higher rates because of pregnancy and childbirth
- So even with all of what I just talked about, we still have people with no health insurance, or whose health insurance is really just a catastrophic policy because the deductible is so high.