Medicaid & the Private SectorHow Private Health Plans Are

Working to Tame the Infamous Medicaid “Monster”

Toni BigbyDirector of Consumer AdvocacyToni.bigby@caresource.com

Today’s Topics

• Medicaid – What is it? Who’s Eligible?

• What Do They Get & How Do They Get It?

• How Private Plans Play A Role in Medicaid

• What Opportunities May Exist in the Future as a Result of Health Care Reform

Myth or Fact?

• Anyone who is unemployed or low income can qualify for Medicaid?

• You can’t work and get Medicaid coverage?

• Only seniors qualify for Medicaid.

• Medicare and Medicaid is the same, right?

Medicaid Today• Medicaid is Ohio’s largest health and long-term care program.

It combines state and federal funds to purchase health care coverage for low-income and medically vulnerable citizens.

• 1.7 million enrolled (average monthly)

• Spends $13.8 Billion annually

• Accounts for 23 percent of state budget

• Administered by Ohio Department of Job & Family Services (ODJFS)

– Through 6 state agencies

– 88 County Offices Determine Eligibility

• Entitlement

• Payor of Last Resort

Who’s Eligible?• Covered Families and Children (CFC)

– Children (up to 19)– Pregnant Women (any age)– Parents– Total: 1.4 million

• Aged, Blind or Disabled (ABD)– Seniors (65+)– Individuals with Disabilities– Total: ~300,000

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Medicaid Eligibility vs Spending

Eligibility Spending

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Medicaid Eligibility vs Income Thresholds

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Medicaid Income Chart (2009)Who’s

Covered?Income

Eligibility Guidelines

Gross Annual Income

Family Size

2 3 4

Children & Pregnant Women

200% $29,148 $36,624 $44,100

Parents 90% $13,116 $16,488 $19,848

Seniors & Individuals w/ Disabilities

64%Income Assets/Resources

Individual

Couple Individual Couple

$7,068 $12,132 $1,500 $2,250

Medicaid Buy-In for Workers w/Disabilities

250%Individual Resources

$27,084 $10,580

8Disregards that may reduce income may apply. These are proxy amounts.

Basic Eligibility RequirementsChildren & Families

• Income• No Resource Test • Ohio Resident• Social Security Number• Citizenship• Proof of Pregnancy (if

applicable)• Other health insurance• No face-to-face interview

required; mail in application• Must reapply every 12

months (except pregnant women)

Aged, Blind or Disabled

• In addition, must also provide proof of:– Limiting Physical Factor

(e.g., age, disability)– Resources

• Have a face-to-face interview at initial application

• Must reapply every 12 months

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Medicaid Benefit PackageMANDATORY

• Doctor Visits• Hospital*• Lab & X-rays• Healthchek (wellness

check ups to age 21)• Home Health• Nursing Facility• Transportation

OPTIONAL

• Dental*• Vision*• Mental Health• Pharmacy*• Community alcohol &

drug addiction treatment• Occupational/Physical/

Speech Therapies• Durable Medical

Equipment• Hospice

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*Co-pays may apply.

Ok, So How Do They Get Care?

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Fee-for-Service

(in community)

Managed Care

Home & Community

Based Waivers

Institutional

300,000+ 1.4 million 65,240 65,136

including

Medicaid & Managed Care• Began in 1978• Statewide enrollment became mandatory in SFY 06/07

per HB 66 for CFC and a portion of ABD consumers• 7 plans, 8 regions• Two to three plans per region• Plans accept full risk; paid on a capitated basis per

enrollee, per month• Rates determined by independent actuary• Plans must meet ODI licensure & solvency requirements• Managed care model allows budget predictability for

state

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Goals of Managed Care

• Focus on the individual needs of enrollees

• Promote and coordinate care rather than just pay for services

• Improved health outcomes for enrollees

• Increased provider access

• Cost savings and predictability for state

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Value Added MC Services• Case management • 24-hour hotline for medical advice & direction • Provider directory/Find a Doctor Search• Member handbook • Grievance resolution system • Provider network management • Member services • Preventive care reminders • Health education materials & activities• Expanded benefits with incentives (varies among MCPs) • Extended office hours (varies among MCPs)

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MC Outcomes To Date• Use of primary and outpatient care went up 57%.

• Infant emergency room visits were down 28%

• Hospital stays were down 54%

• Prenatal care increased 17%

• 20% decrease in low birth weight babies

• 14% more children got first-year check-ups

• 20% more 1-year olds and 24% more 2-year olds got tested for lead poisoning

• 98% of clean claims paid within 30 days

• Saving Ohio $368.8 million (2007-2009)

• Expected to generate $1Billion in revenue in current biennium

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Looking to The Future: A New Era in Health Care

• Medicaid Expansion To All (Under Age 65) Up to 133% of poverty– Removes categorical eligibility– Includes childless adults

• Individual Mandate w/ Subsidies• State Based Health Exchange• Insurer Reforms (not new to Medicaid plans)• Dual integration for Medicare & Medicaid

beneficiaries• Health Information Technology/Electronic Medical

Records

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Potential Challenges

• Individuals faced with poverty do not always prioritize health care in their daily lives

• Medicaid patients tend to access the health care system in spontaneous and unpredictable ways

• Transient, hard to reach population• Literacy issues or language barriers• State budget• Uncertainty of unintended consequences of

health care reform

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Review• Medicaid is a major driver of the state budget• Not everyone who is struggling with poverty is covered

by Medicaid today• Medicaid provides comprehensive benefit package with

limited cost sharing• Use of private insurers is not new to Medicaid in Ohio –

majority of population is enrolled in a plan• Managed care has proven to save $$, improves

outcomes, increases access relative to fee-for-service and offers budget predictability

• Future looks promising for managed care to be part of reform solution

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Resources

• Medicaid Web Site: www.jfs.ohio.gov/ohp– Program Info– Applications (download or order at no cost)– Brochures/Fact Sheets

• Medicaid Consumer Hotline: 800-324-8680• Ohio Association of Health Plans:

www.oahp.org• Health care reform: www.kff.org

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