Iowa Medicaid - University of Iowa Public Policy Center



Iowa Medicaid ProgramImpact of the ACA and Health System Change on the Iowa Safety NetUniversity of Iowa Public Policy CenterDRAFTLast updated: November 5th, 2012Iowa MedicaidIntroductionMany low-income and disabled persons in Iowa receive health coverage through Iowa’s Medicaid and related waiver programs. Medicaid is a part federal, part state funded and operated program, which provides safety net insurance support to individual and also provides valuable support via service reimbursement to safety net providers such as Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). Eligibility There were 574,625 Iowans enrolled in the Medicaid program in 2010. Eligibility for Medicaid program in Iowa requires that an individual must be both income eligible and categorically eligible for the program. In general, initial eligibility screening requires that a person be an Iowa resident and either a U.S. citizen, U.S. national, or qualified alien. A monthly gross income not exceeding $1,330 and net monthly income not exceeding $361 qualifies a household with two adults and one dependent child for Medicaid. A monthly gross income not exceeding $1,824 and net monthly income not exceeding $495 would qualify a household with four adults and dependent children for Medicaid. Pregnant women and infants may have a household income up to 300 percent of the Federal Poverty Level (“FPL”). Children from ages 1 through 18 may have a household income not exceeding 133 percent FPL. Persons under 21 years of age are also eligible for Medicaid if they meet the income limits for a household with a dependent child.In addition to income, individuals can qualify for Medicaid through the Supplemental Security Income (“SSI”) program if they meet one of three eligibility criteria: they are at least 65 years of age; they are blind or disabled; or they are either blind or disabled in addition to being at least 65 years old. Eligible individuals cannot have a monthly income exceeding either $674 for a single individual or $1,011 for a couple. Further, for an individual to be eligible for SSI, he or she cannot have monthly resources exceeding $2,000 ($3,000 for a couple). The SSI benefit rate is reduced by one-third for an individual living in another person’s household and receiving support. Some individuals who are not citizens of the United States can become eligible for SSI, such as refugees (includes victims of human trafficking), asylees, and permanent residents with at least 40 qualifying quarters of earnings are possible SSI beneficiaries.In addition, some Medicare enrolled populations can also be eligible for Medicaid to cover the costs of services not covered by Medicare if they meet particular income and/or disability requirements. For example, some Medicare enrollees become eligible for Medicaid through the Medicare assistance programs including qualified Medicare beneficiaries (100 percent of FPL), specified low-income Medicare beneficiaries (120 percent of FPL), and expanded specified low-income Medicare beneficiaries (greater than 120 percent but less than 135 percent of FPL). Further, the qualified disabled and working people (200 percent of FPL) and the Medicaid for employed people with disabilities (250 percent of FPL) programs expand Medicaid coverage for additional populations.Individuals with excessively high heath care costs may be eligible for Medicaid through the Medically Needy program. There were about 11,000 Iowa Medicaid enrollees eligible because of their high health care costs in 2003. Individuals must be in one of the following categories to be eligible for the Medically Needy program: aged; blind; disabled; a member of a family with children; a pregnant woman; or a child under 21 years of age. Eligibility for the Medically Needy program is based on a combination of income and resource limits and recipients may have to spend down assets. For example, a household with one person with a monthly income equal to or less than $483 does not need to spend down in order to qualify for the Medically Needy program. In comparison a four-person household must have a monthly income equal to or less than $666 in order to avoid an income spend-down. Further, Iowa limits an individual’s resources to $10,000 in order to qualify of the Medically Needy program.Iowa’s Family Planning Waiver (“IFPN”) provides family planning services to those that don’t qualify for regular Medicaid. Effective July 2011, IFPN coverage was expanded to include women and men up to age 55, incomes up to 300 percent of FPL, and persons whose primary insurance does not cover benefits provided by IFPN. The Iowa Department of Human Services projects that 34,125 women will use IFPN services in SFY12.Medicaid and the Safety NetMedicaid, the nation’s public health insurance program for low-income people, now covers nearly 60 million Americans, including many working families, as well as many of the poorest and most fragile individuals in our society. Medicaid is the largest source of financing for nursing home and community-based long-term care, and it provides essential funding for the safety-net delivery system on which many Americans rely. Most Medicaid enrollees would be uninsured without the program. The following figure shows multiple vital roles that Medicaid plays in maintaining and supporting the health care safety net:Medicaid covers vulnerable population groups nationwide, including: 1 in 3 children in the US, especially those who are in families below poverty levels.More than 40% of all births, most of which are among low income women.8 million people with physical and mental disabilities.1 in 4 poor non elderly adults.7 in 10 nursing home residents.About 9 million low income Medicare beneficiaries.Medicaid covers comprehensive care services for children, prenatal and maternity care for low income women and a broad array of services for adults as well including long term care.Apart from providing crucial health care services to most vulnerable groups, Medicaid is the largest source of funding for most safety net providers such as health centers and public hospitals. Medicaid also provides over a quarter of all funding for mental health care. The following figure demonstrates how Medicaid plays an important role by financing safety net providers.Medicaid is one of the major items in federal (8%) and states’ (16%) budget, and the costs per enrollee are growing slower (4.6%/ year) than job coverage premiums (7.7%/ year) and national health expenditures (5.9%/ year).Funding and Expenditures in IowaIn FY 2010, total Medicaid funding in Iowa was about $3.12 billion (Table 1). The federal contribution to Medicaid included $2.26 billion in medical assistance payments and $86 million for state and local administration purposes. Table 1. Total Iowa Medicaid spending by government source for fiscal year 2010.Medicaid SpendingAmount(Millions $)PercentFederal2,25872.4State86027/6Total3,119100When comparing from 2009-2011, using a different source for the data, there was a nine percent growth in expenditures from 2009-2010 and a 5% growth from 2010 to 2011 (Table 2).Table 2. Comparison of Iowa Medicaid expenditures from state fiscal year 2009 to state fiscal year 2011.20092010Percent Change2011Percent change from 2010Total (Billions $)2.93.055%3.246%State (Millions $)793.8719.2-9%824.515%Total330,286361,3859%380,7495%Regarding expenditures for Medicaid recipients enrolled through the SSI program in Iowa, the total cost was almost 24 million in 2010 for the 48,000 enrollees eligible through the SSI program. The distribution by age and eligibility category are shown in Tables 3 and 4. Table 3. Iowa SSI beneficiaries and payments distributed by age for 2010. Age RangePayments(millions $)Percent≤174.720%18-6416.972%65+2.09%Total23.6100%Note: percentages may not equal 100 due to rounding.Most dollars were expended for those in the 18-64 age categories and those eligible through the “blind and disabled: criteria as compared to the “aged” criteria.Table 4. Distribution of Iowa SSI beneficiaries and SSI payments by eligibility category for 2010. CategoryPayments(millions $)PercentAged0.874%Blind and disabled22.796%Total23.6100%The costs for just beneficiaries in the Medically Needy program was about $40 million alone in 2003-the latest year in which data for just this program were available (Table 5)Table 5. Medically Needy expenditures in Iowa for federal fiscal year 2003.CategoryExpenditures(millions $)PercentElderly7.619Disabled/Blind18.546Children1.84Adults12.331Total40.1100Note: percentages might not sum to 100 due to rounding.The state’s contribution comes from a variety of sources. According to the Iowa Council on Human Services, $1.05 billion would come from the State General Fund for FY12. The Health Care Trust Fund (that is, the tobacco tax) contributes $107 million and other funds including the IowaCare Fund, Pharmaceutical Settlement Fund, and The Health Care Transformation Account would, combined, account for $54 million. State Resource Centers would provide another $46 million.Additionally, county and local funds would contribute approximately $227 million, while $214 million of funding comes from other revenue sources including recoveries and drug rebates. The Council also anticipates receiving $6.4 million from a Children’s Health Insurance Program Reauthorization Act of 2009 (“CHIPRA”) Performance Bonus Payment for FY2012. Finally, two recently enacted provider assessment fees, the Nursing Facility Quality Assurance Trust Fund and the Hospital Health Care Access Trust Fund, would contribute $35.7 million and $39.2 million respectively.Iowa Medicaid expenditures for primary care in 2008 included $190 million for outpatient hospital services and $56 million for clinic services. Expenditures for physician services totaled $174 million while the services for other health care practitioners totaled $17.4 million. Home health and dental services composed $108 million and $44 million of expenditures, respectively. Prescribed drugs accounted for $230 million of expenditures in 2008. Primary care case management expenditures totaled $2.9 million in 2008, and $126 million was spent on capitated care services during 2008.Enrollee characteristics in IowaEnrollment:As mentioned previously, there were 574,625 Iowans enrolled in the Medicaid program in 2010. The distribution by eligibility category is shown in Table 6. Table 6. Distribution of Iowa Medicaid beneficiaries by eligibility category for 2010.Eligibility CategoryNumber of BeneficiariesPercentAge 65 and older42,9247Blind/disabled80,90914Children265,70846Children with unemployed parent4,319<1Adults164,75829Unemployed adult4,172<1Foster Care Children11,4802Breast & Cervical Cancer Screening341<1Ineligible14<1Total574,625100There was a significant growth in Medicaid enrollment between 2009 and 2011 with the most significant growth in children and the largest one-year change between 2009 and 2010, with slower growth between 2010 and 2011 (Table 7).Table 7. Comparison of Iowa Medicaid enrollment from state fiscal year 2009 to state fiscal year 2011.20092010Percent Change2011Percent change from 2010Child180,992204,16313%217,3766%Adult52,68057,0778%61,0437%Elderly30,10030,2500.5%29,935-1%Disabled66,51469,8955%72,3954%Total330,286361,3859%380,7495%Enrollment in the Iowa Medicaid program through the SSI program, by age of the recipient, is shown in Table 8. More adults are eligible for Medicaid through this mechanism, given the requirements for eligibility.Table 8. Iowa SSI beneficiaries and payments distributed by age for 2010. Age RangeNumber of BeneficiariesPercentPayments(thousands $)Percent≤177,964174,6722018-6432,8596916,8877265+6,864142,0329Total47,68710023,591100Note: percentages may not equal 100 due to rounding.Fourteen percent (6,373) of SSI beneficiaries that are either blind or disabled worked during 2010. Among the approximately 6,000 working blind/disabled SSI beneficiaries, two percent (116) were Section 1619(a) recipients and 20 percent (1,268) were Section 1619(b) recipients. Work Incentives and Employment Support or the Section 1619(a) is the part of the Social Security Act that authorizes continued SSI eligibility even when a working SSI recipient grossed over the established income eligibility limit. This provision allows you to try working in supported or competitive employment, or self-employment without fear that your benefits will be stopped as a result of earnings. Medicaid While Working or the 1619(b) eligibility) only applies to working individuals. Once an individual has reached the earned income limit, which zeroes out his/her SSI cash benefit, he/she may be able to retain Medicaid coverage. During December 2010, SSI beneficiaries who were also 1619(a) recipients earned, on average, $1,250. In comparison, during December 2010, SSI beneficiaries who were also 1619(b) recipients earned, on average, $871.Regarding enrollment in the Medicaid through the SSI program, most are adults in the 18-64 age range (Table 9).Table 9. Iowa SSI beneficiaries by age for 2010.Age RangeNumber of BeneficiariesPercent≤177,9641718-6432,8596965+6,86414Total47,687100Note: percentages may not equal 100 due to rounding.The majority of SSI enrollees are eligible via the “blind and disabled” criteria as compared to the “aged” component (Table 10).Table 10. Distribution of Iowa SSI beneficiaries and SSI payments by eligibility category for 2010.CategoryNumber of BeneficiariesPercentPayments(thousands $)PercentAged3,22778724Blind and disabled44,4609322,71996Total47,68710023,591100The number of medically needy enrollees by their category of eligibility and associated costs for 2003 is also shown in Table 11. Most are adults as fits the criteria for eligibility for the medically need program.Table 11. Medically Needy beneficiaries in Iowa for federal fiscal year 2003.CategoryEnrolleesPercentElderly2,60023Disabled/Blind2,10019Children1,20011Adults5,10046Total11,100100Note: percentages might not sum to 100 due to rounding.There are over 85,000 seniors who are eligible for both Medicare and Medicaid (about 15% of the entire population). These enrollees are often referred to as “dual eligibles”. The distribution of dual eligibles in Iowa by their eligibility type is shown in Table 12.Table 12. Distribution of Iowa Medicaid beneficiaries by dual eligibility for 2010.Eligibility TypeNumber of BeneficiariesPercentNot dual eligible488,95785Qualified Medicare without other Medicaid7,1691Qualified Medicare with Medicaid40,2477Specified low-income Medicare without Medicaid4,767<1Specified low-income Medicare with Medicaid9,7652Qualified disabled and working00Qualifying individuals3,161<1Other duals20,5594Total574,625100Demographics:In 2010, Medicaid beneficiaries numbered 574,625. The Iowa Department of Human Services estimates that approximately 698,000 Iowans will be enrolled in Medicaid during state fiscal year 2013. Table 7 displays the distribution of Medicaid beneficiaries by eligibility basis revealing that the largest group of beneficiaries is children who are 18 years or younger and the largest adult age cohort are those ages 21-44.Table 7. Distribution of Iowa Medicaid beneficiaries by age for 2010.Beneficiary Age (years)NumberPercent< 120,35141 to 595,006176 to 1297,0711713 to 1422,754415 to 1846,977819 to 2025,180421 to 44153,0462745 to 6470,6691265 to 7416,176375 to 8414,0822≥85 13,3132Total574,625100Table 8 shows the distribution of Medicaid beneficiaries in 2010 by gender, with the majority of beneficiaries are females. While there is no gender distinction among children, adults will be predominately women due to mothers and pregnant women.Table 8. Distribution of Iowa Medicaid beneficiaries by sex for 2010.SexNumberPercentMale240,93142Female333,69458Total574,625100Regarding the distribution for Medicaid beneficiaries by race/ethnicity, the most common race was white in 2010 (48 percent) (Table 9). Table 9. Distribution of Iowa Medicaid beneficiaries by race/ethnicity for 2010.Beneficiary Race/EthnicityNumberPercentWhite282,45749Black/African American35,4356American Indian/Alaska Native2,529<1Asian4,900<1Hispanic/Latino27,8865Native Hawaiian/Pacific Islander453<1Hispanic/Latino & 1 or more races8,9412More than one race6,1481Not Identified205,87636Total574,625100Finally, the greatest proportion of Medicaid beneficiaries (46 percent) had incomes in 2008-2009 less than 100 percent of the Federal Poverty Level (Table 10).Table 10. Distribution of Iowa Medicaid beneficiaries (0-65 years old) by income (as a percent of the Federal Poverty Level) for 2008-2009.Beneficiary Income(% FPL)NumberPercent<100167,76046100-13868,11019139-25076,67021251-39932,0009≥400 20,0405Total364,580100Note: Kaiser’s beneficiary count shown here differs from the Centers for Medicare and Medicaid Services (CMS) data.Utilization:The number of Medicaid beneficiaries utilizing specific program types in 2008 included: 84,861 for early and periodic screening, diagnosis and treatment services; 57,711 for family planning services; 43,309 for federally qualified health centers; 34,342 for rural health centers; and 28,508 for home and community based waiver services.Table 11 shows the services received by beneficiaries in Medicaid in 2008. Capitated care was the service received by the most Medicaid enrollees, followed by lab and x-ray, clinical services and dental services.Table 11. Services provided to Iowa Medicaid beneficiaries for 2008. Service CategoryNumber of BeneficiariesCapitated Care425,516Lab and x-ray232,379Clinic Services187,675Dental Services138,208Inpatient hospital60,773Home Health33,274Nursing Facility19,597ICFMR2,284Mental Health Facility1,117Other services118,670The number of Medicaid enrollees utilizing different programs, including safety net FQHC, RHC and Family Planning services, are shown in Table 12. About 135,000 Medicaid enrollees utilized FQHCs, RHCs and Family Planning services through Medicaid in 2008.Table 12. Programs utilized by Iowa Medicaid beneficiaries for 2008. Program TypeNumber of BeneficiariesFederally Qualified Health Centers43,309Rural health clinics34,342Family planning services57,711Early & periodic screening, diagnosis, treatment services84,861Indian Health Services0Home and Community Based Services28,508No program specified481,801Medicaid providersThe Iowa Council on Human Services estimated 38,000 health care providers—including hospitals, physicians, dentists, pharmacies, and medical equipment providers—will help care for the Iowa Medicaid population in 2012. The distribution of participating providers by type is shown in Table 13.Table 13. Providers enrolled in Medicaid for Iowa for 2010.Provider TypeNumber EnrolledPhysician, M.D.27,922Dentist1,853Pharmacy1,233Chiropractor1,547CRNA1,640Clinical social worker281Nurse practitioner3,262Podiatrist412Optometrist993The distribution of payments to these providers are shown in Table 14. The largest expenditure in 2010 was to long term care (nursing) facilities ($500 million).Table 14. Medicaid payments (excluding administrative expenses) for Iowa during fiscal year 2010.Service CategoryTotal Expenditures ($)State Share ($)Nursing Facilities501,091,413137,772,176Prescribed drugs243,855,70166,294,711Emergency (hospital)208,142,76657,081,599Outpatient hospital189,980,43452,369,460Inpatient hospital (excluding GME)185,388,61354,308,339Physician and Surgical174,062,24247,282,388Critical Access Hospitals90,162,25524,709,955Home health88,128,86524,157,133Dental58,362,85216,018,390Mental Health35,134,2169,541,782Clinic18,100,3633,234,408Lab and Radiology8,706,8982,242,315Dual Eligibles:More than 9 million Medicaid beneficiaries nationally are ―dual eligibles – low-income seniors and younger persons with disabilities who are enrolled in both the Medicare and Medicaid programs, in 2009. Dual eligibles are among the sickest and poorest individuals covered by either the Medicaid or Medicare programs. They must navigate both Medicare and Medicaid to access services, and rely on Medicaid to pay Medicare premiums and cost-sharing and to cover critical benefits Medicare does not cover, such as long-term care. Because dual eligibles have significant medical needs and a much higher per capita cost than other beneficiaries, they are of great interest to both Medicare and Medicaid policymakers and to the state and federal governments that fund and manage the programs.Medicare beneficiaries who have low incomes and limited assets can obtain Medicaid coverage through different eligibility ―pathways, and the kind of assistance that Medicaid provides varies accordingly. Most dual eligibles qualify for Supplemental Security Income (SSI) cash assistance – generally 75% of the FPL for individuals – or have exhausted their resources paying for health and long-term care (sometimes known as ―medically needy or ―spend-down‖). These individuals receive assistance with Medicare premiums and cost sharing and coverage of Medicaid benefits. While some protections exist for spouses, those who spend down to receive assistance with nursing home care must apply all of their income, except for a small personal needs allowance, toward the costs of their care and assets must be below $2,000 for an individual and $3,000 for a couple in most states. For Medicare beneficiaries with income or resources just above the federal poverty level, Medicaid’s assistance is more limited, primarily covering Medicare premiums. This assistance is referred to as ―Medicare Savings Programs.‖ Qualified Medicare beneficiaries (QMBs) have incomes up to the poverty line (with assets up to $6,600 for an individual and $9,910 for a couple) and receive help with Medicare premium and cost sharing obligations. Specified Low-Income Beneficiaries (SLMBs) have slightly higher incomes (100-120% of FPL) and receive help with Medicare premiums only. A national snapshot of how expenditures are distributed between Medicare and Medicaid for dual eligibles is presented in the figure below:There were about 83,000 dual eligibles in Iowa in 2009. Medicaid in Iowa spent $1261 million dollars on dual eligibles which constituted 49% of their total expenditure. Nationally, Medicaid spent 39% of its expenditure on dual eligibles. This expenditure was distributed as follows (Table 15):Table 15. Medicaid payments for dual eligibles for Iowa and the US fiscal year 2010.IowaUSMedicare Premiums12%$1569%$10,899Medicare-Covered Acute9%$10915%$17,966Acute Not Covered by Medicare5%$675%$5,624Prescribed Drugs1%$101%$1,378Long-Term Care73%$92070%$84,511Total100%$1,261100%$120,520Medicaid spending per dual eligible per year, in Iowa and nationally for the year 2009 were as follows (Table 16):Table 16. Medicaid spending per dual eligible per year for Iowa and the US fiscal year 2009. ?IAUSPer Dual Eligible$19,301$16,325Per Aged Dual Eligible$19,378$16,672Per Disabled Dual Eligible$19,226$15,799In 2009, dual eligibles comprised 69% of all aged and disabled Medicaid beneficiaries in Iowa but only 60% nationally. In 2007, dual eligibles constituted about 15% of total Medicaid enrollees nationally and 17% in Iowa (16% in 2009).Table 17. Medicaid dual eligible beneficiaries for Iowa and the US fiscal year 2009. ?IA#IA%US#US%Partial Dual Eligibles13,67816%2,235,60224%Full Dual Eligibles69,26184%7,154,73876%Total Dual Eligibles82,939100%9,390.340100%Table 18 shows how they were further distributed based on the age and disability status in Iowa and the nation:Table 18. Medicaid Aged and Disabled Dual Eligibles as a Percent of Total Medicaid Beneficiaries for Iowa and the US fiscal year 2009. ?IAUSAged Duals as a % of Aged Medicaid Beneficiaries99%93%Disabled Duals as a% of Disabled Medicaid Beneficiaries52%39% ................
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