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5 Things to Know About Medicaid: Getting the Facts Out

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Created in 1965, Medicaid is a public insurance program that provides health coverage to low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities; It is funded jointly by the federal government and the states. Each state operates its own Medicaid program within federal guidelines. Because the federal guidelines are broad, states have a lot of flexibility in designing and administering their programs. As a result, Medicaid eligibility and benefits can and often do vary widely from state to state.

Medicaid is the nation's public health insurance program for low-income people

Medicaid is the nation's public health insurance program for low-income people. The Medicaid program covers 1 in 5 Americans, including many with complex and expensive care needs. The program is the leading source of long-term care coverage for Americans. The vast majority of Medicaid enrollees lack access to other affordable health insurance. Medicaid covers a wide range of health services and limits members' out-of-pocket costs. Medicaid funds nearly one-fifth of all personal health care expenses in the US, providing significant funding for hospitals, community health centers, doctors, nursing homes, and health care jobs. Title XIX of the Social Security Act and a host of federal regulations govern the program, defining federal Medicaid requirements and state options and authorities. The Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS) are responsible for implementing Medicaid.

 

Medicaid is structured as a federal-state partnership

 

Subject to federal regulations, states administer Medicaid programs and have flexibility in determining covered populations, covered services, health care delivery models, and methods of paying doctors and hospitals. States may also obtain Section 1115 waivers to test and implement approaches that differ from what is required by federal statute, but for which program goals are determined in advance by the Secretary of HHS. Because of this flexibility, there is significant variation among state Medicaid programs.

 

Entitlement to Medicaid is based on two guarantees: first, all Americans who meet Medicaid eligibility requirements are guaranteed coverage, and second, states are guaranteed unlimited federal dollar matching for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for poorer states.

 

Medicaid coverage has evolved over time

 

Under the original 1965 Medicaid law, Medicaid eligibility was tied to cash assistance (either Aid for Families with Dependent Children (AFDC) or federal Supplemental Security Income (SSI) since 1972) for parents, children and the elderly, poor, blind, and disabled States may choose to provide coverage at income levels above cash assistance. Over time, Congress expanded the federal minimum requirements and provided new coverage options for states, especially for children, pregnant women, and people with disabilities. Congress also required Medicaid to help pay premiums and cost-sharing for low-income Medicare beneficiaries and allowed states to offer a Medicaid “buy-in” option for people with disabilities who work. Other coverage milestones included breaking the link between Medicaid eligibility and well-being in 1996 and the enactment of the Children's Health Insurance Program (CHIP) in 1997 to cover low-income children above the Medicaid limit with a enhanced federal match rate. Following these policy changes, for the first time states conducted outreach campaigns and streamlined enrollment procedures to enroll eligible children in both Medicaid and CHIP. Expansions in Medicaid coverage for children ushered in subsequent reforms that recast Medicaid as an income-based health coverage program.

 

In 2010, as part of a broader health coverage initiative, the Affordable Care Act (ACA) expanded Medicaid to non-elderly adults with incomes up to 138% FPL ($17,236 for one person in 2019) with enhanced federal matching funds (Figure 3). Before the ACA, people had to be categorically eligible and meet income standards to qualify for Medicaid, leaving most low-income adults without coverage options since income eligibility for parents was limited. well below the federal poverty level in most states and federal law excluded adults without dependents. children from the program no matter how poor they are. The ACA changes effectively removed categorical eligibility and allowed adults without dependent children to be covered; however, as a result of a 2012 Supreme Court ruling, the ACA Medicaid expansion is optional for states. Under the ACA, all states were required to modernize and streamline Medicaid enrollment and eligibility processes. Medicaid expansions have resulted in historic reductions in the proportion of children without coverage and, in states that adopted the ACA Medicaid expansion, sharp declines in the proportion of adults without coverage. Many Medicaid adults are working, but few have access to employer coverage, and before the ACA they had no affordable coverage options.

 

Medicaid covers 1 in 5 Americans and serves diverse populations

 

Medicaid provides medical and long-term care to millions of America's poorest and most vulnerable people, acting as a high-risk pool for the private insurance marketplace. In fiscal year 2017, Medicaid covered more than 75 million low-income Americans. As of February 2019, 37 states have adopted the Medicaid expansion. Data from fiscal year 2017 (when fewer states had adopted the expansion) show that 12.6 million were newly eligible in the expansion pool. Children represent more than four in ten (43%) of all Medicaid enrollees, and the elderly and people with disabilities account for approximately one in four enrollees.

 

Medicaid plays an especially critical role for certain populations it covers: nearly half of all births in the typical state; 83% of poor children; 48% of children with special health care needs and 45% of non-elderly adults with disabilities (such as physical disabilities, developmental disabilities such as autism, traumatic brain injury, severe mental illness, and Alzheimer's disease); and more than six in ten nursing home residents. States may choose to provide Medicaid to children with significant disabilities in higher-income families to fill gaps in private health insurance and limit the out-of-pocket financial burden. Medicaid also helps nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing, and provides many of them with benefits that Medicare doesn't cover, especially long-term care.

 

Medicaid covers a wide range of health and long-term care services

 

Medicaid covers a wide range of services to address the diverse needs of the populations it serves (Figure 5). In addition to covering services required by federal Medicaid law, many states choose to cover optional services such as prescription drugs, physical therapy, eyeglasses, and dental care. Medicaid Expansion Adult Coverage contains the ACA's ten “essential health benefits,” which include preventive services and expanded mental health and substance abuse treatment services. Medicaid plays an important role in addressing the opioid epidemic and more broadly in connecting Medicaid recipients with behavioral health services. Medicaid provides comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services. EPSDT is especially important for children with disabilities because private insurance is often inadequate to meet their needs. Unlike commercial health insurance and Medicare, Medicaid also covers long-term care, including nursing home care and many long-term services and supports in the home and community. More than half of all Medicaid spending for long-term care now goes to services provided in the home or community that enable seniors and people with disabilities to live independently rather than in institutions.

 

Because Medicaid and CHIP enrollees have limited ability to pay out-of-pocket costs due to their modest income, federal rules prohibit states from charging Medicaid premiums for recipients with incomes below 150% of the FPL, prohibit or limit cost-sharing for some towns and services, and limit total out-of-pocket expenses to no more than 5% of family income. Some states have obtained waivers to charge higher premiums and cost sharing than allowed by federal rules. Many of these waivers are geared toward expanding adults, but some also apply to other eligible groups through traditional eligibility pathways.

 

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