Module Components

• Overview
• Assignments

Topics

• The Imperfect Health Care Market
• Market Failure, Government Regulation, and Public Policy
• Public Health Insurance - Medicare
• Public Health Insurance - Medicaid

NDNP 803 - Executive Leadership and Healthcare Economics

Module 6: Role of the Government in Health and Medical Care

public health insurance - medicaid

Medicaid was established as an entitlement program to provide financial assistance for healthcare services and long-term care services for certain low-income individuals and families who were receiving cash assistance. Medicaid is a state-federal partnership program, with administration at the state level according to federal requirements. Medicaid is financed jointly by federal and state governments, with the federal government “matching” dollars expended by the states

The federal match rate varies (minimum federal rate is 50%) and is based on average state per capita income relative to the national average.

Medicaid is administered by the states under broad federal guidelines and oversight by CMS

States have broad authority to establish eligibility criteria, benefits covered, provider payments, delivery systems, and a number of other conditions for their program. There is substantial variation in the different state Medicaid programs as a result, with the percentage of the population covered varying widely across states.

who is covered by medicaid?

Once a state has established its eligibility criteria, all individuals in the state meeting the criteria have a federal right to Medicaid coverage.The individuals are entitled to coverage, and enrollment cannot be limited by the state, nor can waiting lists be applied

More children are covered under Medicaid than any other source.

The majority of adults covered under Medicaid are in working families, holding low-paying jobs without access to employer-based health insurance

Low-income individuals on Medicare, the “dual-eligible” individuals, enroll in Medicaid.

Dual-eligible enrollees tend to have poorer health with higher rates of chronic disease, require more long-term care, and have more social risk factors than other Medicare beneficiaries.

Assists enrollees in paying their premiums for Parts B and D, to cover the cost-sharing obligations of Medicare, and cover services not covered under Medicare, especially long-term care.

Children’s Health Insurance Program provides federal matching funds to states to provide health coverage to children in families that have incomes too high to allow them to qualify for Medicaid but do not have sufficient incomes to enable them to purchase private health insurance coverage. CHIP allows states substantial flexibility in the expansion of insurance coverage to children, but every state now covers children and their families to at least 200% of the FPL.

ACA authorized states to expand Medicaid eligibility to enroll individuals under 65 and families with incomes below 138% of the FPL. States employ a number of strategies to limit utilization of services, such as concurrent and retrospective utilization review, prior authorization, restrictive definitions of medical necessity, and case management for high risk-high-cost cases.

Medicaid is the largest public payer of mental health care.

Medicaid also covers about two-thirds of all nursing home residents and about 40% of individuals with HIV.

Medicaid provides services provided in skilled and intermediate-level nursing homes, as well as such community-based services as home health, rehabilitation therapy, medical equipment, adult day care, and respite care for caregivers.