Medicaid and CHIP

Implementation Briefs

The Center for Medicare and Medicaid Innovation: A Year’s Progress

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicaid and CHIP, Medicare

Posted on January 26, 2012

Improving the quality of care delivery and reducing explosive growth in healthcare costs is a cornerstone of The Patient Protection and Affordable Care Act (ACA). It reflects the shared understanding that the current silo-based approaches to care delivery that focus on settings of care (e.g., physician office, hospital) rather than care delivery across multiple providers and setting (e.g., episodic) are not working. Costs are increasing at an unsustainable pace, and evidence from leading researchers collectively points to serious deficiencies in health care quality and the disconnect between high spending and health care quality. To foster the development of more collaborative and...

Update to Health Insurance Exchanges–Exchange Functions in the Individual Market: Eligibility Determinations and Exchange Standards for Employers

Categories: Health Insurance, Implementation Update, Medicaid and CHIP

Posted on September 1, 2011

This Update to the health insurance Exchange Implementation Brief examines a proposed regulation issued on August 17, 2011 as part of three proposed rules to implement provisions of the Affordable Care Act related to health insurance affordability. Companion Updates explain the proposed Medicaid eligibility rule and the proposed rule related to health insurance premium tax credits; this Update focuses on Exchange functions related to determinations of eligibility for “Exchange participation and insurance affordability programs,” as well as standards for employer participation.

Update: Medicaid Program Eligibility Changes under the Affordable Care Act

Categories: Implementation Update, Medicaid and CHIP

Posted on August 31, 2011

This update to the Medicaid Implementation and health insurance Exchange Briefs reviews a Notice of Proposed Rulemaking (NPRM) implementing the Medicaid and CHIP eligibility, enrollment simplification, and coordination provisions of the Affordable Care Act. Issued by the United States Department of Health and Human Services on August 17, 2011, the rule is comprehensive in scope; its public comment period ends October 31, 2011. The Medicaid NPRM is part of a group of three regulations, all of which are summarized at HealthReformGPS.org. Together the rules are designed to implement both the Medicaid eligibility expansions, the process of determining eligibility for premium tax credits and cost sharing assistance in the Exchange individual market, and standards for employers purchasing coverage in Exchanges. Collectively, the rules are designed to allow individuals and families to acquire and keep coverage and move more seamlessly among publicly-supported sources of health insurance as family income and circumstances change.

Dual-eligible Medicare/Medicaid Beneficiaries

Categories: Implementation Update, Long Term Care, Medicaid and CHIP, Medicare

Posted on August 10, 2011

According to the Centers for Medicare and Medicaid Services (CMS), in 2008 there were an estimated 9.2 million individuals who were eligible for and enrolled in both the Medicare and Medicaid programs (commonly referred to as “dual eligibles”). Two-thirds of dual eligibles qualify because they are over age 65, while the other third qualify because of a disability. Dual-eligible beneficiaries typically have multiple chronic conditions that require a higher level of care and result in increased spending relative to other Medicare and Medicaid beneficiaries; however, their care is not usually coordinated. Policymakers have expressed concern that the lack of coordination between the two programs results in higher costs and poorer health outcomes than would be achieved if Medicare and Medicaid services were better integrated.

The Basic Health Program

Categories: Centers for Medicare & Medicaid Services, Disparities, Health Insurance, Medicaid and CHIP

Posted on June 29, 2011

An important issue in implementing the Affordable Care Act (ACA) is how to address the needs of uninsured low-income individuals and families whose incomes exceed Medicaid eligibility levels but are less than twice the federal poverty level (about $37,000 for a family of 3 in 2011). Under the ACA, the basic approach to assisting such individuals and families is the state health insurance Exchange, which enables qualified individuals to secure coverage and provides access to premium assistance and cost-sharing subsidies aimed at making coverage and care affordable.

Medicaid Payment Adjustment for Health Care-Acquired Conditions

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicaid and CHIP, Medicare

Posted on June 8, 2011

A high number of deaths occur every year due to potentially preventable adverse events, including medical errors, in the hospital setting. The most commonly cited research on this topic was published by the Institute of Medicine (IOM) in 1999. The IOM report, "To Err is Human: Building a Safer Health System" stated that hospital acquired conditions (HACs) caused by medical errors are a leading cause of morbidity and mortality in the United States.^[1] More recently, a 2007 study found that of 1.7 million infections acquired while a patient was receiving treatment in a hospital, 99,000 resulted in death in 2002.^[2] In addition, there is also a significant cost burden associated with potentially preventable HACs. In 2000, the Centers for Disease Control and Prevention (CDC) published a report estimating the cost burden of HACs to be almost $5 billion.^[3]

Medicaid Access Rule

Categories: Medicaid and CHIP

Posted on May 26, 2011

Access to health care has been a prime focus of the Medicaid program since it’s enactment in 1965. A key aim of the Medicaid statute has been to integrate Medicaid beneficiaries into the general health care system, affording them insurance coverage that would enable them to secure care from the participating provider of their choice in a manner similar to that enjoyed by privately insured individuals and Medicare beneficiaries. It is evident, however, that despite Medicaid’s enormous achievements, access to “mainstream” medical care has remained elusive.

Update: Medicaid Maintenance of Effort

Categories: Implementation Update, Medicaid and CHIP

Posted on May 13, 2011

House and Senate Republicans introduced legislation to permit states, effective on the date of enactment, to repeal both the ARRA MOE provisions and the Medicaid and CHIP MOE provisions included in the ACA. The State Flexibility Act (H.R. 1683) was introduced in the House of Representatives by Rep. Phil Gingrey (R-GA). The Senate companion legislation (S. 868) was introduced by Senator Orrin Hatch (R-UT), ranking member of the Senate Finance Committee. Supporters of the State Flexibility Act argue that the MOE limits the ability of states to lower Medicaid spending and balance state budgets.

Medicaid Benefit Changes

Categories: Medicaid and CHIP

Posted on April 6, 2011

Medicaid provides health insurance to the poorest and most medically vulnerable populations. Low-income pregnant women, children, and very poor parents of minor children are the majority of beneficiaries; Medicaid also provides coverage for children and adults with severe disabilities, as well as “wrap-around” coverage for low-income Medicare beneficiaries who cannot pay for services and cost-sharing that Medicare does not cover, particularly institutional and home- and community-based long-term care. Medicaid is jointly funded by states and the federal government and administered by states under broad federal standards.

Essential Community Providers

Categories: Health Care Quality and Delivery System Reform, Medicaid and CHIP

Posted on March 11, 2011

A recurring health reform theme over the years has been the “essential community provider.” Originated as an aspect of President Clinton’s health reform plan, the term has been used by policymakers and researchers alike to denote health care providers that through legal obligation or mission, organizational and service structure, and patient population characteristics, play a significant role in health care for patients and populations at disparate risk for inadequate access. Examples of patient populations reached by essential community providers include uninsured and underinsured persons, residents of medically underserved urban and rural communities that experience primary health care shortages, children with special health care needs and serious and chronic conditions, adults with mental illness and substance use disorders, disadvantaged patients who seek family planning and primary reproductive health services, seriously and chronically ill and disabled low-income populations including Medicare/Medicaid “dual enrollees,” homeless individuals, persons with HIV/AIDS, high risk pregnant women and newborns, and farm workers and their families.

Medicaid and CHIP Maintenance of Effort Provisions Under the Affordable Care Act

Categories: Medicaid and CHIP

Posted on March 9, 2011

In recessionary times, states seek to reduce Medicaid spending; paradoxically, this is when the need for public insurance may be the highest. During the recession that occurred in the early 2000s, two-thirds of all states reduced Medicaid eligibility, removing between 1.2 and 1.6 million children and adults from the program before Congress enacted legislation barring further cuts as a condition of additional federal assistance. The current recession is far more serious, and state budget shortfalls, far greater.

The Medicaid Family Planning Coverage Expansion Option

Categories: Medicaid and CHIP

Posted on March 7, 2011

Family planning services and supplies for individuals of childbearing age (including sexually active minors) who desire such services is a required benefit under federal Medicaid law. Although all state Medicaid programs must cover family planning services, many states’ Medicaid eligibility standards for adults of childbearing age are so low that family planning (and other essential) Medicaid benefits reach only a fraction of the poor. Simply being low-income is not a recognized eligibility category for adults as it has been for children since Medicaid’s 1965 enactment. Beginning several years ago, a number of states began to build on Medicaid eligibility expansions for pregnant women in order to extend this expanded eligibility to non-pregnant women for family planning and related services, rather than the full Medicaid benefit package.

Chronic Disease Management

Categories: Health Care Quality and Delivery System Reform, Long Term Care, Medicaid and CHIP, Medicare, Public Health

Posted on February 23, 2011

More than 40% of the U.S. population has one or more chronic condition. Although the likelihood of having a chronic disease increases with age, approximately half of working-age Americans has at least one chronic condition. The prevalence of chronic diseases is increasing in both the elderly and non-elderly populations, with a significant increase in the number of people with multiple chronic diseases. Increased spending on chronic diseases in Medicare is a significant driver of the overall increase in Medicare spending over the last twenty years. Nevertheless, given the high cost of treating chronic diseases, the Affordable Care Act (ACA) includes many provisions to encourage chronic disease management as part of the overall emphasis on improving the efficiency of health care.

Health Reform and Community Living Assistance Services and Supports (CLASS)

Categories: Medicaid and CHIP, Medicare

Posted on February 18, 2011

Approximately 10 million American seniors and individuals with disabilities need long-term services and supports (LTSS), and the number is expected to increase to nearly 21 million by 2040. Private long-term care insurance represents only a fraction of long-term care financing, due to a host of issues ranging from the high cost of insurance premiums to concerns about the high rate of coverage denials. Medicare only covers short-term skilled nursing care services and home health services, and Medicaid, the primary payer of LTSS (almost 50%), covers a range of services, but is only available to low-income individuals with disabilities. In the Patient Protection and Affordable Care Act (ACA), Congress addressed the long-term care needs of the elderly and disabled by making a number of changes in Medicaid coverage of home and community based services, and by establishing the Community Living Assistance Services and Support (CLASS) program, a voluntary, federally administered health insurance program designed to assist eligible individuals in purchasing long-term community living services and supports.

Bundled Payments – Medicaid Demonstration Project

Categories: Health Care Quality and Delivery System Reform, Medicaid and CHIP

Posted on July 7, 2010

The health reform law requires the Secretary of HHS to establish a Medicaid demonstration project “to evaluate integrated care around a hospitalization.” Specifically, this project aims “to evaluate the use of bundled payments for the provision of integrated care for a Medicaid beneficiary . . . with respect to an episode of care that includes a hospitalization . . . and for concurrent physicians services provided during a hospitalization.”

Medicaid Accountable Care Organization Demonstration Project

Categories: Health Care Quality and Delivery System Reform, Medicaid and CHIP

Posted on June 27, 2010

The law introduces ACOs on a voluntary basis by directing the Secretary of Health and Human Services to establish a “Pediatric Accountable Care Organization Demonstration Project.” This demonstration project would authorize a participating state to allow certain qualified Medicaid providers to organize themselves into an ACO for the purposes of receiving incentive payments “in the same manner as an accountable care organization is recognized and provided with incentive payments” under the health reform law’s Medicare ACO pilot program. The Medicaid ACO demonstration, akin to the Medicare ACO pilot, is aimed at reducing expenditure growth and improving health outcomes.

Medicaid and CHIP – Outreach and Enrollment

Categories: Medicaid and CHIP

Posted on June 21, 2010

This brief provides an in-depth look at the outreach and enrollment provisions in the Patient Protection and Affordable Care Act affecting Medicaid and CHIP.

Center for Medicare and Medicaid Innovation

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicaid and CHIP, Medicare

Posted on May 13, 2010

Health reform establishes a Center for Medicare and Medicaid Innovation (CMI) and empowering and directing the CMI to “test innovative payment and service delivery models to reduce program expenditures under the applicable titles [Medicare and Medicaid] while preserving or enhancing the quality of care furnished to individuals under such titles.”

Medicaid Eligibility Changes

Categories: Medicaid and CHIP

Posted on April 15, 2010

Expands Medicaid to provide uniform coverage to all U.S. citizens and legal immigrants with incomes below 133 percent of the Federal Poverty Level.

Medicaid: Federal Matching Assistance Percentage (FMAP)

Categories: Medicaid and CHIP

Posted on April 13, 2010

Increases the federal matching rate to states for individuals newly eligible for Medicaid.