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Frequently Asked Questions...Medicaid
In This FAQ... · How do Medicaid service providers receive payments? · Who is eligible for Medicaid? · What services does Medicaid cover? · Doesn't the federal government make most of the Medicaid rules? · Does everyone on Medicaid join a managed care plan? · What is the difference between Medicare and Medicaid? · Why does Medicaid cost so much? · What Medicaid issues will be important in the future?
Title XIX of the Social Security Act (Medicaid) is a joint federal and state program that provides medical and medically related services to many of the most vulnerable populations in society. Medicaid was enacted in the same legislation that created Medicare-the Social Security amendments of 1965. Medicaid is a "means-tested" program-eligibility is based on a person's income and assets-for certain categories of people. Medicaid does not provide assistance to all low-income people. Traditionally, Medicaid has been available only to those in certain categories: people who receive cash assistance or welfare, members of families with children, pregnant women, and persons with disabilities or those who are aged or blind. In recent years, states have had some opportunities to extend Medicaid services through Medicaid program expansion waivers to populations beyond the traditional groups. Federal financial assistance is provided to states through federal matching payments based on the state's per capita income. The federal share of payments ranges from 50 percent to 80 percent of Medicaid expenditures. Table 1 shows matching rates for fiscal year 2000. States are not required to participate in Medicaid, although there is a large financial incentive to do so. If a state chooses to participate, Medicaid is an entitlement to the state and to those persons who are eligible for services. As long as covered services are provided to eligible people in accordance with the approved state plan or waivers, the federal government will provide its share of the match. Also, anyone who is eligible must be covered; states may not limit the program. Within broad national guidelines established by federal statutes, regulations and policies, each state establishes its own financial and categorical eligibility standards; determines the type, amount, duration and scope of services; sets the rate of payment for services; and administers its own program. Medicaid policies for eligibility, services and payment vary considerably, even among states of similar size or geographic proximity. States convey these decisions through a Medicaid state plan and through state plan amendments submitted to the federal government for approval. Increasingly, states exercise their policy options through the various waiver authorities that are available under federal law. There are essentially 56 different Medicaid programs-one for each state, territory and the District of Columbia. Thus, a person who is eligible for Medicaid in one state may not be eligible in another state, and the services provided by one state may differ considerably in amount, duration or scope from services provided in a similar or neighboring state. l
Medicaid is the single largest federal grant program to states, accounting for 40 percent of all federal grant funding given to states. Transportation grants account for 10 percent; education for 4 percent and Temporary Assistance to Needy Families (public assistance funding) for 6 percent. Policy and budgetary decisionmaking related to Medicaid typically require considerable legislative attention. Medicaid coverage has become essential to the wellbeing of a large number of citizens throughout the country. .Medicaid covered 12 percent of the total U.S. population in 1998, compared to 9.1 percent in 1978. In 1998, 41.4 million people were enrolled in Medicaid and 40.6 million accessed services. This is an increase from 35.6 million enrollees and 31.2 people served in 1992. Medicaid's role is even more important for particular groups of the population, however. Each year, more than one-third of the births in the United States are covered by Medicaid. Medicaid covers 25 percent of children under age 3, 23 percent of children between the ages of 3 and 5, and 15.5 percent of children between the ages of 12 and 17. Medicaid provides three types of critical health coverage that can not be obtained elsewhere: 1) health insurance for low-income families with children and people with disabilities who cannot obtain or afford private sector coverage; 2) supplemental coverage for low-income Medicare recipients for Medicare premiums and for services not covered by Medicare; and 3) long-term care coverage for younger people with disabilities and the elderly. In many cases, no other reliable, continuous funding source covers the services these individuals need. Medicaid enrollment increased by an average annual rate of 4 percent during the 1990s. Projections of Medicaid enrollment for the next decade show moderate growth of about 1 percent per year. Average annual enrollment growth for the blind and disabled, a group that is in particular need of the benefits offered by Medicaid and whose per person costs are relatively high, is projected to average 2 percent during the next decade. l How do Medicaid service providers receive payments? Medicaid operates as a vendor payment program. States may pay health care providers directly on a fee-for-service basis, or states may pay for Medicaid services through various prepayment arrangements, such as health maintenance organizations (HMOs). Within federally imposed upper limits and specific restrictions, each state has broad discretion to determine the payment methodology and payment rate for services. Generally, payment rates must be sufficient to enlist enough providers to make covered services available at least to the extent that comparable care and services are available to the general population within that geographic area. Providers who participate in Medicaid must agree to accept Medicaid payment rates for their services. States may impose nominal deductibles, coinsurance or copayments on some Medicaid recipients for certain services, but most recipients cannot be asked to share costs. In addition, all Medicaid recipients must be exempt from co-payments for emergency services and family planning services. States must make additional payments to qualified hospitals that provide inpatient services to a disproportionate number of Medicaid recipients and to other low-income or uninsured people under what is known as the "disproportionate share hospital" (DSH) adjustment. The federal government's share of the medical assistance expenditures, known as the Federal Medical Assistance Percentage (FMAP), is determined annually by a formula that compares the state's average per capita income level with the national income average. States with a higher per capita income level are reimbursed for a smaller share of their costs. By law, the FMAP cannot be lower than 50 percent or higher than 83 percent of the program's costs. In 1999, the FMAPs varied from 50 percent in 10 states to 77 percent in Mississippi, and averaged 57 percent overall. Most administrative costs are matched at 50 percent, although higher percentages are paid for certain activities and functions, such as family planning services or development of mechanized claims processing systems. l
Medicaid does not provide coverage for all low-income people. In general, Medicaid eligibility is based on a combination of financial and categorical eligibility requirements. Each state determines income thresholds and resource standards for its Medicaid program following federal guidelines. These thresholds and standards vary by state and may differ for each Medicaid-eligible population group within a state. In other words, a state may choose to set different standards for children, adults, the elderly and people with disabilities if it meets minimum federal requirements for each group. Historically, financial eligibility for Medicaid was linked to receipt of federally assisted income payments such as Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI). Over time, legislative changes have led to the creation of certain Medicaid groups where financial eligibility is based solely on income and resources, not on receipt of cash assistance. These groups, often referred to as "poverty-related" groups, are an increasing proportion of Medicaid beneficiaries. There has been less change in the categories of people eligible for coverage. Traditionally, Medicaid has been available only to those who are members of families with children, pregnant women, persons with disabilities, those who are blind, or the elderly. Low-income people who do not fit into one of these categories-such as childless people without disabilities-typically cannot qualify for Medicaid no matter how poor they are. In a few states, these individuals qualify for coverage under the terms of demonstration waivers that are available under federal law. However, securing these waivers can be a difficult, time-consuming and technically complex activity.
Table 1. Federal Medical Assistance Percentages (FMAP) in FY 2000
SOURCE: Department of Health and Human Services, http://aspe.hhs.gov/health/fmap00.htm
Although states have considerable discretion in determining the financial criteria for Medicaid eligibility, they must cover certain categories of people. The groups shown in Figure 1 are mandatory Medicaid "categorically needy" eligibility groups.
States also have the option of providing Medicaid coverage for other "categorically related" groups. Among these groups are the following: The medically needy (MN) option allows states to extend Medicaid eligibility to another group of people who would not otherwise be eligible. These are people who would be eligible for Medicaid except that their income and/or resources are above the eligibility level set by their state. People may qualify by incurring medical expenses that reduce their income to or below their state's medically needy income level. Benefits for the medically needy do not have to be as extensive as for these eligibility categories and may be quite restrictive. If a state chooses to have a MN program, certain groups and certain services must be included. Children under age 19 and pregnant women must be covered, and prenatal and delivery care for pregnant women, as well as ambulatory care for children, must be provided. Currently, 38 states have MN programs and are providing services to at least some MN recipients. All remaining states establish a special income level to extend Medicaid to the "near poor" in medical institutional settings. In other words, people who reside in institutions can qualify for Medicaid at a higher income level (typically 300 percent of the federal poverty level than those in the community. An individual may receive Medicaid coverage for services provided as much as three months prior to his or her date of application. Medicaid coverage generally stops at the end of the month in which a person no longer meets the criteria of any Medicaid eligibility group. States may provide 12 months of continuous Medicaid coverage (without reevaluation) for eligible children under age 19. l
What services does Medicaid cover? Title XIX of the Social Security Act allows states considerable flexibility to craft their Medicaid plans. The benefit package is defined by each state based on broad federal guidelines. There is much variation among state Medicaid programs regarding the definition of services and the amount of services provided. However, some services must be covered in order for the state to receive federal matching funds. Mandatory services for categorically needy populations include the following. · Inpatient hospital services, · Outpatient hospital services, · Physician services and medical and surgical services of a dentist, · Nursing facility services and home health services for those aged 21 or older, · Family planning services and supplies, · Rural health clinic and federally qualified health center (FQHC) services, · Laboratory and x-ray services, · Nurse practitioner services, · Nurse-midwife services, and · Early and periodic screening, diagnostic and treatment (EPSDT) services for children under age 21. States also may receive federal matching funds to provide certain optional services. Among the most common of the 33 currently approved optional Medicaid services are the following. For a complete list of optional services, see www.hcfa.gov/stats/2tchartbk.pdf · Diagnostic services, · Clinic services, · Intermediate care facilities for the mentally retarded (ICFs/MR), · Prescribed drugs and prosthetic devices, · Optometrist services and eyeglasses, · Nursing facility services for children under age 21, · Transportation services, · Rehabilitation services, · Personal care services, · Inpatient psychiatric services for those under age 21, and · Inpatient services for persons aged 65 and over in Institutions for Mental Diseases (IMDs). Within certain upper threshold limits, states determine how much to pay providers and how to set the payment levels. Payment levels and payment methodologies differ widely among the states. States can elect to cover through Section 1915c waivers certain home and community-based services that are not included in their state plan. Generally, states use these waivers to provide chore services, respite care, adult day care, homemaker, habilitation and other services to elderly or disabled people who otherwise would be in an institution. (For an excellent review of home and community-based waivers among the states, see www.hcfa.gov/medicaid) In FY 1998, prescription drugs exceeded physician services as the most utilized Medicaid service, based on the number of Medicaid beneficiaries (more than 19.3 million) who used the services. Nursing facility services were the least used service; only 1.6 million beneficiaries used nursing facility services. (See Figure 3 for additional information.) In terms of expenditures, however, nursing facility services were the most costly. During FY 1998, Medicaid spent more than $44 billion on institutional long-term care services. The Medicaid program spent $11.7 billion on prescription drugs. (See Figure 3 for additional information.) l Figure 3.
Doesn't the federal government make most of the Medicaid rules? No. If you've seen one Medicaid program, you've seen one Medicaid program. States operate from a base of federal rules, but most important decisions reside with the states. As a result, basic decisions about eligibility, benefits, reimbursement methods and delivery systems are extraordinarily diverse across the states.
An especially important set of decisions concerns the amount, duration and scope of Medicaid services. Within broad federal guidelines and certain limitations, states determine the amount and duration of services offered under their Medicaid programs. For example, states may limit the number of days of coverage for a particular service or may set medical eligibility criteria that are quite different from those in use in other states. Two restrictions apply: limits must result in a sufficient level of services to reasonably achieve the purpose of the benefits; and limits on benefits may not discriminate among beneficiaries based on medical diagnosis or condition. For services such as substance abuse and mental health services that do not have federal guidelines, states can establish their own service definitions and provider qualifications. For this reason, Medicaid services such as behavioral health, personal care and rehabilitation services, among others, vary greatly across the states. With certain exceptions, a state's Medicaid program must allow recipients to have some choice among participating providers of health care and to receive quality care that is appropriate and timely. States must guarantee choice to beneficiaries and must establish quality standards for services. In general, states are required to provide service of comparable amount, duration and scope of services to all categorically needy and categorically related eligible persons. (As noted earlier, the coverage rules may be different for medically needy persons.) There are two important exceptions. · Medically necessary health services identified through the early, periodic, screening, diagnosis and treatment (EPSDT) program for eligible children, and within the scope of services permitted under federal law, must be covered even if those services are not ordinarily covered by that state's plan. · States may request "waivers" under Section 1915c of Title XIX to pay for home and community-based services (HCBS) that otherwise are not covered for Medicaid-eligible people who might otherwise be institutionalized. As long as the services are cost effective, states have few limitations on the services covered under these waivers (except that, other than as a part of respite care, states may not provide room and board for the recipients). Virtually all states now operate several home and community-based waiver programs for persons with developmental disabilities, physical disabilities or mental illnesses, or for frail elderly persons. (Arizona, the sole exception, operates all its programs under a statewide demonstration waiver, known as an 1115 waiver.) l
Does everyone on Medicaid join a managed care plan? Since the early 1980s, state have experimented with various managed care approaches to reduce unnecessary utilization, contain costs, improve access to services, and achieve greater coordination and continuity of care. In 1991, fewer than 10 percent of all Medicaid enrollees were covered under managed care plans. By 1998, nearly 54 percent of the Medicaid population was enrolled in some type of managed care plan. Managed care is characterized by enrollment of individuals with a specific health plan, contractual agreements between the plan and the state Medicaid agency, and gatekeeping and utilization control by primary care physicians or nurses. The way managed care operates varies greatly across the states and for different populations. States use diverse managed care models, ranging from fully capitated, risk-based plans to fee-for-service primary care case management arrangements. Some states enroll most beneficiaries in "full-risk" plans in which the health plan provides all covered services for a fixed monthly payment, others use "partial-risk" plans, and still others elect to provide certain services ("carve-out") through the fee-for-service system. States may use different approaches to risk or to "carve-out" for different populations within their states. Health maintenance organization (HMOs) are the most common type of health plans used in Medicaid managed care delivery systems. In 1998, more than half of all Medicaid managed care enrollees were enrolled in HMO-type plans. Other managed care contractors include prepaid health plans and primary care case management plans. Although Medicaid managed care enrollment as a whole has grown rapidly, wide variation in penetration rates exists among the states. Two states-Alaska and Wyoming-have no managed care enrollment while twelve states-Arizona, Colorado, Delaware, Georgia, Hawaii, Iowa, Montana, New Mexico, Oregon, Tennessee, Utah and Washington-have penetration rates of more than 75 percent Most Medicaid managed care enrollment consists of children and non-disabled adults. The elderly and persons with disabilities have not yet been enrolled in large numbers in managed care. The inherent challenge of controlling costs and delivering comprehensive services to these high-need populations has deterred states from mandatorily enrolling these populations in risk-based plans. Several states have started to move non-elderly, Medicaid enrollees with disabilities into managed care. In 1998, roughly 1.6 million persons with disabilities were enrolled in Medicaid managed care programs operated in 36 different states. Often these programs are voluntary in nature or involve particular groups of persons with disabilities (such as persons with behavioral health needs or children with disabilities.) Medicaid program waivers play a significant role in supporting state efforts to manage care. The two primary mechanisms used are Section 1915(b) Freedom of Choice waivers and Section 1115 Research and Demonstration Waivers. Section 1915(b) waivers are used to require enrollment of beneficiaries in a managed care program, provide additional services via savings produced from managed care, create a "carve-out" delivery system for specialty care such as behavioral health, and create programs that are not available statewide. During FY 1998, 35 states and the District of Columbia operated 84 Section 1915(b) waivers. Section 1115 Research and Demonstration Projects provide states with flexibility to test substantially new ideas that have potential policy merit. States can test programs that range from small-scale pilot projects to test new benefits or finance mechanisms to major restructuring of the state Medicaid program. In 1998, 17 states operated statewide, comprehensive Section 1115 demonstration projects. It is unlikely that state Medicaid agencies will choose to return to an unmanaged fee-for-service environment in the foreseeable future. As states have become purchasers of care through developing and managing contracts with health care, they have gained a degree of control over both care and costs that they will want to maintain. The future configuration of managed care depends on the attraction of capitation rates or non-capitated payments to providers and the ability of Medicaid agencies to monitor access and quality to assure client satisfaction. The development of access and quality performance standards and the measurement of compliance are evolving. Among the tools being used are the HEDIS data set, the QUISMC system developed by HCFA and now in use in Medicare, and various standards developed by states. As persons with disabilities move into health plans, issues of quality become even more complex, requiring states to give attention to additional access, case management and service delivery standards for this group. l
What is the difference between Medicare and Medicaid? Medicare is a federal health insurance program for people age 65 years or older, certain people with disabilities, and people with permanent kidney failure treated with dialysis or a transplant. Medicare has two parts-Part A, which is hospital insurance; and Part B, which is medical insurance. Medicare Part A pays for care in hospitals, skilled nursing facilities for limited periods of time, and hospices, and for some home health care. Part B helps pay for covered doctor services and some other outpatient services that are medically necessary. Medicare beneficiaries who have low incomes and limited resources also receive help from the Medicaid program. l
Why does Medicaid cost so much? Medicaid spending is influenced by the number of individuals who enroll, the price of services, the volume of services used, and the effectiveness of cost containment strategies. Total Medicaid program spending reached $175 billion during FY 1998. The average annual real growth rate in total spending was 5.9 percent throughout the 1980s. During the 1990s, the average annual real growth rate increased to 9.8 percent with most of this growth occurring in the early 1990s. The slower rate of growth in recent years is caused by slower enrollment growth, lower medical price inflation, the expansion of managed care and other cost containment measures, and restrictions on growth in expenditures through the Disproportionate Share Hospitals program. It is likely that there will be a gradual return to higher growth rates in the near future. The Health Care Financing Administration projects that total Medicaid outlays will increase at an average annual rate of about 8 percent between fiscal years 1998 and 2010. Levels of growth across the states will vary considerably. States may influence the cost of their Medicaid programs by their decisions about eligibility; amount, duration and scope of services; pricing of services; and management strategies. With costs of many covered services-perhaps especially prescription drugs-increasing rapidly in private sector as well as public sector plans, states should expect increases in their Medicaid costs that are greater than the overall inflation rate. In addition, since it is far and away the primary source of long-term care coverage for the elderly and persons with disabilities, Medicaid faces cost pressures that private plans do not. Medicaid expenditures for nursing facility services accounted for almost half of all U.S. spending on nursing home care in 1998. This level of spending occurs because Medicare and private insurance provide extremely limited coverage for nursing home care (or for any other long-term care service). Medicaid also covers an array of home and community-based services in most states. The need for these services is likely to increase in the future, and there is little likelihood that either Medicare or private insurance will begin to include them in their benefit packages. A state's capacity to control costs will continue to depend upon its ability to develop creative pricing and management strategies to make the most of the available funding. See Figure 5 for a description of Medicaid expenditures across different eligibility groups. l Figure 5.
What Medicaid issues will be important in the future? Although the challenges of Medicaid vary in their relative importance across the states, several issues are receiving attention throughout the country. Among these are the following. · Assuring that qualified people stay on the Medicaid rolls as welfare to work programs are fully implemented. De-linking Medicaid from welfare has created opportunities for working families to enroll in Medicaid, but also has led some families to believe they can not enroll in Medicaid if they are employed. States will need to find creative ways to maintain enrollment of those who leave welfare for work. · Reducing administrative barriers to enrollment in Medicaid and other publicly managed health insurance programs. Many states-but not all-have shortened Medicaid application forms (at least for families with children), eliminated assets tests, reduced verification requirements, and initiated mail-in application processes. States will want to continue such creative efforts to assure the continued enrollment of eligible people. · Extending coverage to additional people. Recently, states have been authorized to increase income and asset levels for those who are categorically eligible for Medicaid. For parents and children, this authority comes from Section 1931 of the Social Security Act. For families with children and for the aged, blind and disabled, states can extend coverage under the authority of Section 1902r(2). Through these provisions, states can disregard portions of an applicant's income or assets. Thus, states can effectively set income and asset levels of their choice. (In theory, at least, states could choose to set no upper income or asset levels for particular categorical groups.) States may want to review their income and asset standards to determine appropriate financial eligibility levels for families with children, the elderly, and persons with disabilities. · Creatively using Medicaid and other state resources to develop community-based care options for disabled persons, as mandated by the Supreme Court's Olmstead decision. This Supreme Court decision says that serving disabled persons in institutions when they could receive services in the community is a civil rights violation. States are developing plans for providing comprehensive services in the community. States also are likely to make considerable use of Medicaid funds to support community-based services created as part of their Olmstead plans. l
Amount, Duration and Scope - How a Medicaid benefit is defined and limited in a state's Medicaid plan. Each state defines these parameters, thus state Medicaid plans vary in what is actually covered. Benefit Package - Services an insurer, government agency, or health plan offers to a group or individual under the terms of a contract. Capitation - A prospective payment method pays the provider of service a uniform amount for each person served usually on a monthly basis. Capitation is used in managed care alternatives such as HMOs. Comparability - In general, the state must ensure that the same Medicaid benefits are available to all people who are eligible. Exceptions include benefits approved under Medicaid waiver programs and benefits available to children through EPSDT which may not be available to adults. Cost Sharing - The generic term that includes co-payments, coinsurance, and deductibles. Co- payments are flat fees, typically modest, that insured persons must pay for a particular unit of service, such as an office visit, emergency room visit, or the filling of a drug prescription. Coinsurance is a percentage share of medical bills (e.g., 20%) which an insured person must pay out-of-pocket. Deductibles are specified caps on out-of-pocket spending which an individual or a family must incur before insurance begins to make payments. Durable Medical Equipment (DME) - Equipment which can stand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. Examples of durable medical equipment include hospital beds, wheelchairs and oxygen equipment. Disproportionate Share (DSH) - A program which provides additional reimbursement to hospitals which serve a disproportionate share of low income patients. Dual Eliglible - A person enrolled in Medicare and Medicaid. Early Periodic Screening, Diagnosis and Treatment (EPSDT) - Medicaid program for children (until age 21). EPSDT now covers any medically necessary service allowable under Medicaid regulations. 1115(a) - Section of the Social Security Act which allows states to waive provisions of Medicaid law to test new concepts which are congruent with the goals of the Medicaid program. System-wide changes are possible under this provision. Waivers must be approved by HCFA. Federal Medical Assistance Percentage (FMAP) - The percentage of federal dollars available to a state to provide Medicaid services. FMAP is calculated annually based on a formula designed to provide a higher Federal matching rate to States with lower per capita income. The federal share of Medicaid administrative costs is not based on a per capita income formula. It is a flat 50 percent for most activities. Federal Poverty Levels (FPLS) - income guidelines established annually by the federal government. Public assistance programs usually define income limits in relation to FPL. Fee-for-Service Reimbursement - The traditional health care payment system, under which physicians and other providers receive a payment for each unit of service they provide. Freedom of Choice - In general, a state must ensure that Medicaid beneficiaries are free to obtain services from any qualified provider. Exceptions are possible through waivers of Medicaid and special contract options. HCBS Waiver (Home and Community-based Services) - A waiver of the Medicaid state plan granted under Section 1915(c) of the Social Security Act which allows community-based services as an alternative to institutional care. Health Care Financing Administration (HCFA) - The federal agency responsible for administering Medicare and overseeing states's administration of Medicaid. Health Maintenance Organization (HMO) - A organization that delivers and manages health services under a risk-based arrangement. The HMO usually receives a monthly premium or capitation payment for each person enrolled which is based on a projection of what the typical patient will cost. If enrollees cost more, the HMO may suffer losses. If the enrollees cost less, the HMO profits. ICF MR (Intermediate Care Facility for Mentally Retarded Persons) - Optional Medicaid service which provides residential care and services for individuals with a developmental disabilities. Long-Term Care - Assistance and care for persons with chronic disabilities. Long term care's goal is to help people with disabilities be as independent as possible; thus it is focused more on caring than on curing. Long term care is needed by a person who requires help with the activities of daily living (ADLs) or who suffers from cognitive impairment. Managed Care - A system in which the overall care of a patient is overseen by a single provider or organization. Medicaid - A joint federal-state entitlement program that pays for medical care on behalf of certain groups of low-income persons. The program was enacted in 1965 under Title XIX of the Social Security Act. Medically Necessity - The evaluation of health care services to determine if they are: medically appropriate and necessary to meet basic health needs; consistent with the diagnosis or condition and rendered in a cost-effective manner; and consistent with national medical practice guidelines regarding type, frequency and duration of treatment. Nursing Facilities - Facilities licensed by and approved by the state in which eligible individuals receive nursing care and appropriate rehabilitative and restorative services under the Title XIX (Medicaid) long term care program. Optional Services or Benefits - Over 30 different services which a state can elect to cover under a State Medicaid plan. Part A - Medicare hospital insurance that helps pay for medically necessary inpatient hospital care, and, after a hospital stay, for inpatient care in a skilled nursing facility, for home care by a home health agency or hospice care by a licensed and certified hospice agency. Part B - Medicare medical insurance that helps pay for medically necessary physician services, outpatient hospital services, outpatient physical therapy and speech pathology services, and a number of other medical services and supplies that are not covered by the hospital insurance. Personal Care - Optional Medicaid benefit which allows a state to provide attendant services to assist functionally impaired individuals in performing the activities of daily living (e.g., bathing, dressing, feeding, grooming...). Primary Care Case Management (PCCM) - Managed care option in which each participant is assigned to a single primary care provider who must authorize most other services such as specialty physician care before they can be reimbursed by Medicaid. Prior Authorization - An authorization from the Medicaid program for the delivery of certain services. It must be obtained prior to the service for benefits to be provided Provider - A person, group or agency who provides a covered Medicaid service to a Medicaid client. Recipient - A person who received a Medicaid service while eligible for the Medicaid program. People may be Medicaid eligible without being Medicaid recipients. Risk Contract - An agreement with a managed care organization (MCO) to furnish services for enrollees for a determined, fixed payment. The MCO is then liable for services regardless of their extent, expense or degree Single State Agency - The Social Security Act requires that the state designate a single agency to administer or supervise administration of the state's Medicaid plan. Utilization - The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time. Usually expressed as the number of services used per year or per numbers of persons eligible for the services. Waiver - An exception to the usual requirements of Medicaid granted to a state by HCFA. l
The official government web site for information about Medicaid is www.hcfa.org. The site includes links to regulations, manuals and studies about Medicaid. For additional information about Medicaid eligibility and coverage, see publications by the Kaiser Commission on Medicaid and the Uninsured at www.kff.org. An especially good publication on eligibility for persons with disabilities is at www.kff.org/content/1999/2150/Pub2150.pdf. NCSL publishes the Medicaid Survival Kit, a summary of Medicaid provisions. Call NCSL to order a copy.
· The Center on Budget and Policy Priorities at www.cbpp.org · Families USA at www.familiesusa.org · The National Academy for State Health Policy at www.nashp.org · The State Medicaid Directors' Association at http://medicaid.aphsa.org
Good sources for research studies about Medicaid across the states are: · The Commonwealth Fund at www.cmwf.org · Mathematica Policy Research at www.mathematica-mpr.com · Urban Institute's New Federalism Project at http://newfederalism.urban.org · Center for Health Care Strategies at www.chcs.org
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