Upload
raymundo-bayley
View
212
Download
0
Embed Size (px)
Citation preview
May 11, 2005 1
Overview of Medicare, Medicaid and
State Children’s Health Insurance Program
for
Citizens’ Health Care Working Group
William J. ScanlonHealth Policy R&D
National Health Policy Forum
May 11, 2005 2
Overview of Medicare, Medicaid and SCHIP
• Eligibility
• Services Covered
• Financing
May 11, 2005 3
EligibilityCategories Income
Medicare
-Aged
-Disabled
-ESRD Patients
All
Medicaid
-Children
-Parents
-Aged
-Disabled
Low Income--varies by state subject to federal limits
SCHIP -Children
Low Income--varies by state subject to federal limits
May 11, 2005 4
Services
Acute Care Chronic Care Long-term Care
Medical, nursing and pharmaceutical services for an immediate need
Medical, nursing and pharmaceutical services for an ongoing need
Supportive services to compensate for a disability
May 11, 2005 5
Services
Acute Care Chronic Care Long-term Care
Medicare X X
Medicaid X X X
SCHIP X X
May 11, 2005 6
Financing
• Medicare– Open Ended Entitlement– Federal
• Payroll Taxes• General Revenues
– Beneficiary Premiums
• Medicaid– Open Ended Entitlement– Federal and State General Revenues
• SCHIP– Fixed Federal Appropriation– Federal and State General Revenues– Beneficiary Premiums
May 11, 2005 7
Medicare
• 41 million beneficiaries
• $301 billion in 2004– 11.7% of Federal Budget– 2.6% of GDP (2003)
May 11, 2005 8
Medicare Program Structure
• “Original” or “Traditional” Medicare (also known as “Fee-for-Service” Medicare)
• Medicare Advantage—Private plan options
• Drug Benefit
Parts A and B
Part C
Part D
May 11, 2005 9
Medicare BenefitsMedicare Covers Acute and Chronic Care
• Part A– Inpatient hospital– Post-hospital skilled nursing facility (SNF) services– Home health– Hospice-care
• Part B– Physician and laboratory services– Outpatient hospital– Therapy– Durable medical equipment and supplies– Home health (not-covered under Part A)
• Part D– Drugs
May 11, 2005 10
Medicare Cost-Sharing
• Hospital Care– Days 1-60—Deductible ($912 in 2005)– Days 61-90—Per day coinsurance ($228 in
2005)– Days 91-150—Per day coinsurance ($456 in
2005) for 60 lifetime reserve days
• SNF– Days 21-100—Per day coinsurance ($114 in
2005)
May 11, 2005 11
Medicare Cost SharingContinued
Part B • Deductible: $110 in 2005• Coinsurance: 20% of Medicare approved
amount• Exceptions
– Mental health: 50% co-insurance– Hospital outpatient—Fixed amounts– Home health—none
• Over-billing limit: 15 % above Medicare approved amount on unassigned claims
May 11, 2005 12
Medicare Cost SharingContinued
Beneficiary cost sharing on Medicare
covered services can be substantial
Beneficiaries in 1998 paying more than:
Number of Beneficiaries Percent
$2,000 3.4 million 11.5 %
$5,000 736 thousand 2.5 %
$10,000 167 thousand 0.6 %
May 11, 2005 13
Medicare Supplementary Coverage
Vast majority of beneficiaries in traditional Medicare have supplementary coverage
Supplementary Coverage in 2000
May 11, 2005 14
Medicare Advantage—Part C
• Offers choice to join private plan
• Plan types include HMOs, PPOs, FFS, MSAs
• Plans paid monthly per enrollee fee regardless of services used
• Plan “savings” returned in extra benefits
May 11, 2005 15
Medicare Advantage—Part C
Plan and beneficiary participation have varied over time
0
50
100
150
200
250
300
350
400
1992 1994 1996 1998 2000 2002 2004
0
1
2
3
4
5
6
7
Plans
Enrollees
Plans Enrollees (millions)
May 11, 2005 16
Medicare Advantage—Part C
• Medicare Modernization Act changed Part C
– Increased payments to plans
– Provided for financial competition among plans and share of savings to Medicare
– Created regional PPOs to expand areas served
May 11, 2005 17
Medicare Advantage—Part CPPO Regions for 2006
May 11, 2005 18
Medicare Drug Benefit--Part D
• Begins January 1, 2006• Separate enrollment and premium• Monthly premium expected to average $37 nationally• Benefit provided by competing private stand-alone drug
plans or Medicare Advantage plans• Benefit
– $250 deductible– Coinsurance
• 25% from $250 to $2,250• 100% from $2,250 to $5,100• 5% on spending over $5,100
• Subsidies for premium and cost sharing for low income persons
May 11, 2005 19
Medicaid and SCHIP
Medicaid• over 52 million beneficiaries
• $ 309 billion in 2004
• Federal share– $176 billion or .8% of federal
budget
• State share– $133 billion or 22%* of state
budgets
*2003
SCHIP• ~ 6 million beneficiaries
• $6.1 billion in 2004≈ 75 % Federal
≈ 25 % State
May 11, 2005 20
Medicaid
Program Roles
• Primary health insurance—mostly families
• Medicare supplement—dual eligible aged and disabled beneficiaries
• Long-term care financer —beneficiaries with disabilities
May 11, 2005 21
Medicaid
May 11, 2005 22
Medicaid
Programs are state designed and administered subject to federal requirements
Result is 56 distinct Medicaid programs
May 11, 2005 23
MedicaidMandatory and Optional Eligibility
Selected CategoriesMandatory
• Children– 6-18 years up to 100%
FPL– 0-5 years up to 133%
FPL– Foster care
• Pregnant women– Up to 133% FPL
• SSI cash recipients
Optional• Children and
Pregnant women– Up to 185% FPL
• Elderly and Disabled – Up to 100%FPL
• Medically Needy
May 11, 2005 24
Medicaid Mandatory Medicare Supplementary Insurance
• Qualified Medicare Beneficiaries (QMBs)– Up to 100% FPL—Part B Premium and cost sharing
• Specified Low-Income Medicare Beneficiaries (SLMBs)– 100-120% FPL---Part B Premium
• Qualifying Individuals (QIs)– 120-135% FPL—Portion of Part B Premium
• Qualified Disabled Working Individuals (QDWIs)– Up to 200% FPL---Part A Premium
May 11, 2005 25
MedicaidMandatory and Optional Services
Selected TypesMandatory
• Physician• Hospital inpatient and
outpatient• Nursing Facility for
persons 21 and over• Lab and X-ray• EPSDT for persons
less than 21
Optional• Prescription Drugs• Dental services• ICF/MRs• Home and
community-based services
May 11, 2005 26
Medicaid Waivers
• Program Waivers– Mandatory managed care enrollment (1915(b))
• Section 1115 Demonstrations– Statewide experimentation with financing
mechanisms, managed care, coverage expansions– HIFA—Health Insurance Flexibility and Accountability
—tradeoff of more limited benefit packages and cost sharing for expanded coverage
May 11, 2005 27
SCHIP
Federal-State Partnership very different• Capped appropriation—not an entitlement
$39 billion for 10 years (reauthorization 2007)
• State Flexibility– States can cap/close enrollment
• 7 states froze enrollment at least temporarily between 2001 and 2004
• 3 had freezes in effect at end of 2004
May 11, 2005 28
SCHIPState Flexibility (Continued)
• Benefits– Medicaid Expansion– Distinct program with benefits similar to
• BC/BS plan; state employees plan; largest Medicaid HMO; or actuarially equivalent
– Combination
• Cost sharing– Very limited for children in families ≤ 150%FPL– For others, premiums and co-payments allowed if
≤ 5% of income
May 11, 2005 29
Changes in Health Insurance Coverage for Low-Income Children and Adults, 2000-
2003Percentage Point Changes
-5.2%-4.0%
7.5%
1.2%
3.2%
-1.6%
-6%
-4%
-2%
0%
2%
4%
6%
8%
Employer Medicaid Uninsured
Children Adults
5.7 Million2.0 MillionChange in Population
3.9 Million-0.1 MillionChange in Uninsured
Note: Low-income is defined as less than <200% of poverty ($29,360 for a family of three)SOURCE: Urban Institute for the Kaiser Commission on Medicaid and the Uninsured, 2004
May 11, 2005 30
Medicaid as LTC Financer
• Pays close to half of all LTC expenditures
• Nursing homes≈46 percent of revenues
≈1 million or 2/3 of residents partially or fully financed
• Home and community services≈48 percent of expenditures
≈850 thousand recipients
May 11, 2005 31
Medicare and Medicaid as a Share of GDP
May 11, 2005 32
For more information
Understanding Medicare and Medicaid: Fundamentals and Issues for the New Congress
Briefing Book — January 26, 2005
www.nhpf.org