What is Medicaid?

- serves large, vulnerable pop (poor disabled, low income women, & children)

- state/federal partnership w specific eligibility criteria

- means-tested program: beneficiary must qualify by demonstrating level of need based on income, assets or excessive medical expenses

- insures more americans than any other insruances

- Medicaid established in 1965 as Title XIX of the Social Security Act

- Significant expansion of Medicaid coverage w the Patient Protection and Affordable Care ACt of 2010 (Obama Care)

- all 50 states participate in Medicaid, each state has its own plan that sets eligibility criteria & benefits within fed guidelines

- the cost is shared btwn federal (50-74%) and state (poorer states pay less) gov

- total cost of medicaid: 2016 grew 3.9% to 565.5 billion

Who receives Medicaid?

- children: 50% of medicaid beneficiary pop (50.4%)

- pop served include those w severe intellectual disabilities, physical disabilities, and elderly who are poor

- 5% enrollees account for 1/2 the programs expenditure (this means very small amnt spend the most amnt of $, usually older w less disabilities)

- Medicaid: largest purchasers of LTC in the US funding the "safety net" for the health care system

- 2 sets of criteris:

1. Categorical

2. Medically needy eligibility

- income assessed as a % of the federal poverty level (FPL)

*set annually assets include personal investments or savings & must be very low to qualify for medicaid

*FPL for fam of 4 in 2016 $24,300; 2017 $24,600; 2018 $25,100

> income btwn 100% & 400% FPL= qualify for premium tax credits; can get marketplace insurance plan

>income below 138% FPL: based on state; if Medicaid has expanded in the state= qualify for medicaid based on income

> income below 100% FPL: if state hasn't expanded Medicaid, will not qualify for income-based Medicaid or savings on marketplace health insurance plan

- every state expected to exhaust funds this year

- will move to states instead of federal

*help further legislation for policy changes (bc $ has to come from somehwerE)

- pregnant women

- low income 65+

- ppl w disabilties

- SSI for those w annual income below 75% FPL, citizens w disabilities, and persons over age 65

- 2017: $735/month (single), $1,103 (couple), 2018: $750 & $1,125

- must meet both income & asset limits

- income not exceeding 100% FPL & w assets < $6,600 to qualify for Medicare Part B covered by Medicaid

- Dual eligible individuals are among the sickest & poorest individuals covered by Medicare or Medicaid

- 65+

- kidney failure or LT kidney disease

- ppl currently disabled/can't work

- low income

- pregnant women

- children under 19

- ppl 65+

- ppl who are blind

- ppl who are disabled

- ppl who need nursing home care

Medically needy:

- exceed income & assets but has catastrophic medical event that results in expensive care & qualify

- qualify but have to "spend down" assets to meet criteria

- Spousal Impoverishment Protection: portion of jointly held assets is protected for the community dwelling spouse

* 2018: minimum resource standard $24,720, maximum resource standard $123,600

- Medicaid= Egalitarian Gov Program

- 3 tier package benefits:

1. basic packages (states that offer Medicaid benefits to categorically eligible pops)

2. package for states that offer medically needy programs

3. states that include several optional benefits at their discretion

- Medically necessary OT & PT are optional but all states must cover therapy services to children in early & periodic screening, dx & tx programs & to categorically eligible ppl 21+ who reside in a SNF

Home & community-based waiver program:

- alternative to expensive SNF care

- comprehensive state plan to provide benefit package to those w disabilities living in the community

- many provide therapy services to keep individuals functional in the comm

- personal care services are an optional benefit

- managed care: dominant form of health care delivery in state medicaid programs

- 70% Medicaid beneficiaries enrolled in managed care plans

- 2 forms of medicaid managed care:

1. primary care case management: fee for service, contract w physicians for routine care & referrals

2. Capitation: contracts w manage care organizations to provide all services needed at a predetermined monthly fee

- many states have multiple programs

- managed care in medicaid has allowed reduction of health disparities, improved access to primary care & dec unnecessary hospitalizations

- Eligibility

*min 2 years of service & an honorable dc from the military

* veterans w service related injury or dsiability are given highest enrollment priority

*impoverished veterans also receive priority enrollment in the VA

*non-service connected veterans have to meet income/asset req or pay deductibles/co-pays

- Health care benefits package:

*rich benefits for LTC & support for those w disabilities (more so than Medicare or Medicaid)

*PT & OT mandated benefits

*prosthetic & orthotics routinely covered

*serving since 9-11 can provide edu, personal support, respite, and in some cases payment to caregivers for providing care to an injured veteran

- benefits packages vary each veteran:

*established co-pays for prescription drugs, inpatient/outpatient hospital service s& nursing home care

- for active military personnel: 2018 changes

- certain services for eligible dependents are provided in the civiian health care sys

- TRICARE covers 9.6 million Americans worldwide 2017

- 3 insurance options:

1. Prime

*active military req to enroll in prime

*utilized Health Maintenance Organization model (HMO)

*use in-network

2. Extra

*available to nonactive military

*utilizes fee for servie

3. Standard

- criteria coverage of OT& PT that is "medically necessary & considered proven"

Nationally accepted medical practice:

1. clinically meaningful endpoints published

2. formal tech assessments

3. reports of professional medcial associations

4. medical policy positions

5. reports of national expert opinions

- what do they all have in common? EBP!

- Agency of federal gov to provide health care to 2.2 million american indian & alaskan natives

*form 1 of the 566 recognized tribes (2016: 567)

- provided thorugh 1 or 2 mechanisms:

1. direct delivery by the Indian Health Service

2. health care dev & administered by the tribes (Tribal Self determination)

- both use global budgeting system

*resources come from direct appropriations by the congress

*per person expenditure 2015: $3,688

- OT & PT= provided since 1960s as a civilian or as a commissioned member of the public health service

-       Combined w Medicare all the plans of this chapter fund ½ of the US health care system

-       Eligibility programs supports the public’s idea that the gov should cover health care for those that are poor, children, have disabilities, & military/veterans

-       Lack of consistenct Medicaid policy across states/nationally leaves room for health care gaps such as OT/PT

-       Rehab is mandated for Military & Veterans