Eligibility & Financing Presented by

Steven A. Rohinsky Hofstra University MHA Program

Medicaid Target Groups

Who Does Medicaid Help?

Low-income individuals and families who fit into an eligibility group that is recognized by federal and state law

Pregnant women Disabled Blind Senior Citizens

Medicaid ServicesTreatment and Preventive Healthcare Doctor Visits Dental Visits Hospital inpatient and outpatient services Early periodic screening, diagnosis, and treatment for children under 21

years of age under the Child/Teen Health Program Clinic services Prenatal care Diagnostic Imaging services (PET,MRI,CAT X-ray) Medication Laboratory Services Medical Supplies , Appliances, and Equipment Some insurance and Medicare premiums

Medicaid Services

Long Term Care Nursing Home (SNF) Assisted Living Adult Day Care (ADC) Home health agency and personal care

(Lombardi Program (Nursing home w/o walls Mental health Services (i.e. treatment in psychiatric hospitals )

Under Twenty One Senior Citizens Developmentally Disabled Mentally Retarded (as defined by the NYS OMRDD)

Medicaid Services

Transportation Transportation to medical appointments, including public transportation and

car mileage EMS to a hospital

Other Health Services Family planning services Smoking cessation agents

Medicaid Eligibility

Who is Eligible? “It’s All About the Benjamin's”

Resource Levels Assets Income Number of dependants

Medicaid Eligibility

The Four Types of Medicaid Community Medicaid LTC Medicaid Short term Rehabilitation Managed Care

Medicaid Eligibility

Community Medicaid Must have be below an asset level that is determined by number of

dependants Assets include:

Stocks, Bonds, Property , Vehicles, Annuities, and Cash Must have proof of citizenship Must have proof of residence of New York state and County. SSI Recipients automatically approved if Disabled and below Poverty

level Proof of your income from sources like Social Security, Supplemental

Security Income (SSI), Veteran's Benefits (VA), retirement Any bank books and insurance policies that you may have Insurance benefit card or the policy (if you have any other health

insurance)

Medicaid Eligibility

Long Term Care Medicaid Must have under 13k in assets

Assets include: Stocks, Bonds, Property , Vehicles, Annuities, and Cash

39 month “look back” period (will go up to 60 months by 2011) “look back” period Includes

Any and All bank account information Any Financial Transactions (I.e. Transfer of Assets)

Must have proof of citizenship Must have proof of residence of New York state and County Spousal cases allowed 100k in assets and real property ownership. Depending on county and Complexity of case ,approval time can take over

a year SSI Recipients automatically approved if Disabled and below Poverty

level

Medicaid EligibilityManaged Care Medicaid

Same Eligibility requirements Provider bills managed care company Set capitation rates through competitive bidding process

Medicaid Eligibility

Short-term Rehab Medicaid 3 to 6 Months as defined by county Approval based on medical director’s approval May re-apply after 1st short term stay (non- chronic extension) Allowed to keep more income

Medicaid Eligibility

What if you are denied? Fair Hearing

ALJ presides over case

What if you lose the Fair Hearing? Article -78 Proceeding

Supreme court presides over case

Medicaid EligibilityIf you lose the Article 78?

Bad news....

Patient must pay out of pocket!

Medicaid Eligibility

Permanent Residence Under Color of Law (PRUCOL)

Immigration status not legal status Recipient must be Lawful Resident ( LPR) People on temporary visas not covered Refugees Federal authorities aware of their presence but will not deport them -

therefore NYS HRA decided to cover them Funds are not matched by federal government New York and California are only states that cover

Medicaid Eligibility

211%

87% 73%

250%

150% 150%

0%

50%

100%

150%

200%

250%

Children Parents - Working Parents - Non-working

Fede

ral P

over

ty L

imit

.

Average State

New York

6th highest

8th highest

8th highest

Source: Kaiser Family Foundation, StateHealthFacts.org

Medicaid Financing

Fast Facts: Medicaid is jointly financed by the federal government and the states.

States administer the program under federally established guidelines. The federal contribution to Medicaid spending in each state ranges

between 50% and 76%, depending on state per capita income. Nationally, the federal government pays 57% of Medicaid costs and

states pay 43%. Funded through a combination of Federal , State and Local Taxes

Medicaid FinancingFederal Medical Assistance Percentage (FMAP)- Pays share of the medical assistance expenditures under each

State's Medicaid program Determined annually by a formula that compares the State's average

per capita income level with the national income average States with a higher per capita income level are reimbursed a smaller

share of their costs. By law, the FMAP cannot be lower than 50 percent or higher than 83

percent.

Federal Mandatory Spending Programs

$0

$100

$200

$300

$400

$500

$600

$700

$ B

illio

ns

SocialSecurity

Medicare Medicaid FederalRetirement& Disability

Unemploy-ment

Comp.

EarnedIncome &Child TaxCredits

FoodStamps

FamilySupport

ChildNutrition

Source: Congressional Budget Office, January 2008

Medicaid-Provider Payments

How do Providers get paid? LTC

Rate based on : Acuity of Residents Cost report (Expenses)

Hospitals DRG’S ?

Doctors Fee for service

Financing-Provider Payments

Providers are paid in two ways: Checks Electronic Wire Transfer

Medicaid & Medicare Relationship “Dual Eligibles”

Medicare beneficiaries who also receive Medicaid Medicaid “wraps around” Medicare

Pays Medicare premiums and cost- sharing Covers critical benefits that Medicare does not, such as

long-term care. Dual eligibles account for 40% of Medicaid spending. Medicaid accounts for nearly half of national long-term care

spending and finances care for 60% of nursing home residents

$4,1

67

$12,

464

$12,

164

$1,4

19

$2,0

84

$7,9

12

$26,

384

$25,

553

$2,0

49

$3,9

53

$0

$10,000

$20,000

$30,000

Total Elderly Disabled Children Adults

Category

Spen

ding

per

Enr

olle

e

.

US Average (less NY)

New York

Medicaid Spending – Per Enrollee

90% higher

112% higher

90% higher

Source: Centers for Medicare and Medicaid Services, 2003 figures

44% higher

110% higher

Medicaid Utilization & Spending

Source: Centers for Medicare and Medicaid Services, FY2003 figures

Managed Care 2,424,251 $4,177,113,409 $1,065,581,042 $440Clinic 991,157 1,562,337,089 $1,023,922,146 $1,033Dental 989,424 410,325,782Home Health 302,029 1,032,934,130 $717,272,812 $2,375ICF/MR (Institution) 11,257 2,729,280,514 $1,967,794,824 $174,806Inpatient Hospital 636,455 5,520,662,249 $3,083,317,699 $4,845Lab and X-Ray 1,121,949 132,475,580Mental Health Srvcs 17,967 470,659,672Nursing Facilities 183,240 6,184,593,542 $2,982,403,514 $16,276Other Services 975,695 3,624,587,811 $1,921,755,745 $1,970Outpatient Hospital 1,743,076 1,305,218,273Other Provider 439,142 32,171,974Drugs 2,623,805 4,000,289,361 $1,217,836,382 $464Physician 1,537,876 390,816,386Personal Support 436,799 3,614,463,881 $2,338,050,124 $5,353TOTAL 4,449,939 $35,206,760,472 $14,034,516,864

Savings per User

Total New York Medicaid Spending

Category of ServiceNew York Medicaid

Users

Savings if New York had US Average

(less NY) for Costs and Utilization

Total savings does not include Managed Care & Drugs

Thank You!