Medicaid Overview

  • Medicaid was started by Title 19 of the Social Security Act in 1965
    • OBRA ’90 required DUR be performed for all Medicaid patients
  • Medicaid provides HC coverage for:
    • Poor
    • Entitled people- if you meet certain criteria (newborns etc)
    • *Medicaid covers about ~19% of U.S. population*
  • Medicaid is administered by the state and federal governments together
    • Different states get varying levels of support from the federal government for their medicaid programs depending on how wealthy they are
  • In order for a state to receive federal funds Medicaid must cover the following groups:
    • TANF- money to support minor children
    • People on SSI (social security), poor people who either old, blind or just plain poor
    • Women who don’t fall under the above but are poor
    • Children who don’t fall under the above but are poor
  • Can only get medicaid benefits in a given state for 5 years
  • Administration of Medicaid
    • Federal- HCFA
      • Portion paid by the federal government is known as FMAP (federal medical assistance program)
    • State- single agencies that go by a variety of names
  • The federal government doesn’t require medicaid programs to cover Rx drugs, but all state programs do
  • Requirements mandated by federal government
    • Program must be state wide
    • Patient must have the choice of a provider
    • All eligible patients are entitled to equal levels of service
  • States are responsible for eligibility, type & scope of service, set payment rates, administering the program
  • Medicaid waivers can be obtained in order to provide a new experimental therapy for a patient which isn’t usually specified by HCFA
    • Section 1115 waiver
      • 5 year demonstration
      • Budget neutral (the proposed waiver can’t raise costs)
      • Helped home health and community service (1970s)
    • Section 1915b
      • Managed care waiver (ex. Primary care physician manages a patient’s care for a fixed fee and arranges for care)
  • Medicaid is an entitlement program, in which the states determine who is eligible
  • There is no limit on spending for the enrolled
  • Over the last 30 years, the % of medicaid spending on hospitals & doctors are down, but spending on prescriptions, home health care, and outpatient spending has increased (b/c of increasing drug prices & people living longer.)
  • Managed care is a characteristic of Medicaid now (~57% of enrollees)
    • Managed care was allowed via the waiver process
  • Block grant—Federal Government makes a large payment for the states to use as they see fit
  • Medicaid has more comprehensive coverage for infusion therapy
    • Home care is a required benefit
    • Parenteral nutrition is covered

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