Florida Medicaid Program: An OverviewO e e

Phil WilliamsInterim Deputy Secretary for Medicaid

Presented to the Low Income Pool Council

October 29, 2009

MedicaidA State and Federal Partnershipp

In 1965, the federal Social Security Act was amended to establish two major national health care programs:

Title XVIII (Medicare).Title XIX (Medicaid).

Medicaid is jointly financed by state and federal funds.ed ca d s jo t y a ced by state a d ede a u dsStates administer their programs under federally approved state plans.

1

The Medicaid ProgramMajor Federal Requirementsj q

States must submit a Medicaid State Plan to the federal Centers for Medicare and Medicaid Services (CMS).Mandatory eligibility groups and services must be covered.Services must be available statewide in the same amount, duration and scope.p

2

Medicaid StructureFederal Medicaid laws mandate certain benefits for certainFederal Medicaid laws mandate certain benefits for certain populations.Medicaid programs vary considerably from state to state, and within states over timewithin states over time.State Medicaid programs vary because of differences in:

optional service coverages.limits on mandatory and optional services.optional eligibility groups.income and asset limits on eligibility.g yprovider reimbursement levels.

3

Medicaid Structure(continued)

Medicaid does not cover all low income individuals.Medicaid serves the most vulnerable; in Florida:

27% of children.51.2% of deliveries.63% of nursing home days63% of nursing home days.1,094,709 adults - parents, aged and disabled.

4

Medicare vs. MedicaidM di M di idMedicare Medicaid

Enacted by Congress

1965 1965

Alternate Program Name

Title XVIII Title XIX

Financing Employee/Employer Payroll Tax; Premiums; Federal General Revenue Federal and State Governments –Matching Rates Based on Per Capita Income

Eligibility Not Income Based; All Persons Age 65+; Certain Younger Persons on Social Security Disability or Based on Disability and Specific Condition (ESRD); Totally and Permanently Disabled (24 months)

Income Based; All Ages; Mandatory Eligibility Groups; Optional Eligibility Groups(ESRD); Totally and Permanently Disabled (24 months) Groups

Cost Sharing Part A Premium For most there is no premium. Buy-in available for those not otherwise qualified ($443 for 2009)

Part A Deductible $1,068/Benefit Period (2009)Part B Premium $96.40 (2009)P t B D d tibl $135 (2009)

Nominal; Spend Down for Medically Needy Individuals

Part B Deductible $135 (2009)Part B Coinsurance 20%Part D Coinsurance up to 25% / Annual Deductible $295

Co-payments are variable with IncomeLow Income Subsidies are provided for the above

Administering Agency

HHS/CMS/Carriers – Financed by Federal Government and Beneficiary Cost Sharing

States – Jointly Financed by State and Federal Governments; Medicaid Programs Vary by State

Benefits Part A Hospital Insurance for Hospital Care, Skilled Nursing Facilities, Hospice and Some Home Health Care (Qualifying Contributions)

Part B Medical Insurance for Physician Services Outpatient Care and

Acute and Long Term Care; Federal Mandated Services and State Optional ServicesPart B Medical Insurance for Physician Services, Outpatient Care and

Other Medical ServicesPart C Medicare+Choice – Health Maintenance Organization CoveragePart D Medicare Prescription drug Insurance

Services

5

Florida Medicaid – A Snapshot• $17.9 billion estimated spending in Fiscal Year 2009-10

F d l t t t hi 67 64% f d l 32 36% t t

Expenditures

• Federal-state matching program –67.64% federal, 32.36% state.• Florida will spend approximately $6,625 per eligible in Fiscal Year

2009-2010.• 36% of all Medicaid expenditures are fee for service expenditures

for institutions such as hospitals, nursing homes, Intermediate p p , g ,Care Facilities for the Developmentally Disabled (ICF/DD’s);

• 7.5 % of all Medicaid expenditures cover Home and Community Based Services (including Nursing Home Diversion)

• 10% of all Medicaid expenditures cover prescription drugs.Fifth l t ti id i M di id dit• Fifth largest nationwide in Medicaid expenditures.

Eligibles

• 2.6 million eligibles.• Elders, disabled, families, pregnant women, children in families

below povertyEligibles below poverty.• Fourth largest Medicaid population in the nation.

P id /Pl • Approximately 80,000 Fee-For-Service providersProviders/Plans pp y , p• 23 Medicaid Managed Care plans (16 HMOs and 7 PSNs).

6

Wh ’ Eli ibl ?Who’s Eligible?

Medicaid eligibility is determined by:Medicaid eligibility is determined by: Categorical groups, i.e., pregnant women; families and children; and aged, blind, and disabled individuals.IncomeIncome.Assets.Citizenship.Residency.Cooperation with Child Support Enforcement (when one or both parents are absent from the home).Medical need for home and community-based services, and persons in nursing facilities.Level of medical bills (for Medically Needy).

7

Florida Medicaid Mandatory Services

Advanced Registered Nurse Physician Services Advanced Registered Nurse Practitioner ServicesEarly & Periodic Screening, Diagnosis and Treatment of

yPortable X-ray ServicesPrivate Duty Nursing Respiratory Speechg

Children (EPSDT)/Child Health Check-Up Family Planning

Respiratory, Speech, Occupational TherapyRural HealthTherapeutic Services for

Home Health Care Hospital Inpatient Hospital Outpatient

Therapeutic Services for ChildrenTransportation

Hospital OutpatientIndependent LabNursing FacilityPersonal Care Services

Florida Medicaid Mandatory Services forAll Eligibles FY 2009-10

Mandatory40.22% of $17 9BilliPersonal Care Services $17.9Billion

8

Florida Medicaid Optional Services*

Adult Dental ServicesAdult Health Screening

Intermediate Care Facilities/

Prescribed DrugsPrimary Care Case Adult Health Screening

Ambulatory Surgical CentersAssistive Care ServicesBirth Center ServicesChildren’s Dental Services

Developmentally DisabledIntermediate Nursing Home Care O t t i S i

Management (MediPass)Registered Nurse First Assistant ServicesSchool Based ServicesChildren s Dental Services

Hearing ServicesVision ServicesChiropractic ServicesCommunity Mental Health

Optometric ServicesOrthodontic ServicesPhysician Assistant ServicesPodiatry Services

School-Based ServicesState Mental Hospital ServicesSubacute Inpatient Psychiatric Program for y

County Health Department Clinic ServicesDialysis Facility ServicesDurable Medical Equipment

Podiatry Services y gChildrenTargeted Case Management)

Early Intervention ServicesHealthy Start ServicesHome and Community-Based ServicesHospice Care

Florida Medicaid Optional Services forAll Eligibles FY 2009-10

Optional59.78% of $17 9 BillionHospice Care $17.9 Billion

*States are required to provide any medically necessary care required by child eligibles.

9

Who Can Provide Medicaid Services?

Any willing health care practitioner or entity who:provides one of the Medicaid covered services;submits an application to Medicaid;pp ;is licensed or certified to practice in the State of Florida;is not terminated from any government health care program; andsigns an agreement with Medicaidsigns an agreement with Medicaid.

Managed Care plans with appropriate provider networks.

10

Institutional Providers / OtherInstitutional Providers / OtherInstitutional Providers / Other

Examples of provider types:Inpatient HospitalsO t ti t H it lOutpatient HospitalsNursing HomesIntermediate Care Facilities for Developmentally Disabled (ICF/DD)Rural Health Clinics (RHCs)Rural Health Clinics (RHCs)County Health DepartmentsFederally Qualified Health CentersPharmacyPharmacy

11

Fee For Service ProvidersFee for Service ProvidersFee for Service Providers

Examples of provider types:Physician ServicesHome Health ServicesHome Health ServicesDental ServicesTransportation (Emergency and Non-Emergency)DialysisDialysisNurse PractitionersLaboratory and X-Ray

12

Growth in Medicaid Average Monthly Caseload

2.50

3.00

s

1 1 86 55 04 2 49 400

2.77

92.

953

1.50

2.00

2.50

d in

Mill

ions

0.49

40.

513

0.54

70.

593

0.65

60.

762

0.92

21.

176

1.49

01.

597

1.58

21.

561

1.51

81.

452

1.47

11.

608

1.81

31.

941

2.07

2.08

2.15

2.20

2.11

2.14 2.

4 2

0 00

0.50

1.00

Cas

eloa

0.00

1984

-85

1985

-86

1986

-87

1987

-88

1988

-89

1989

-90

1990

-91

1991

-92

1992

-93

1993

-94

1994

-95

1995

-96

1996

-97

1997

-98

1998

-99

1999

-00

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09*

2009

-10*

2010

-11*

Fiscal Year

13

Source: Medicaid Services Eligibility Subsystem Reports. *FY 2008-09 October 2009 Caseload Social Services Estimating Conference.*FY 2009-10 October 2009 Caseload Social Services Estimating Conference.*FY 2010-11 October 2009 Caseload Social Services Estimating Conference.

Growth in Medicaid Average Monthly Caseload for TANF

1.201.401.601.80

illio

ns

0.89

5

.789

742

.805

0.93

9

1.03

7

1.14

0

1.19

2

1.22

8

1.25

6

1.16

5

1.13

2

1.27

3

1.51

6

1.63

7

0 400.600.801.00

asel

oad

in M

0 0 0. 0

0.000.200.40C

96-9

7

97-9

8

98-9

9

99-0

0

00-0

1

01-0

2

02-0

3

03-0

4

04-0

5

05-0

6

06-0

7

07-0

8

08-0

9*

09-1

0*

0-11

*

19 19 19 19 20 20 20 20 20 20 20 20 200

200

201

Fiscal Year

S S S C SO CSource: Medicaid Services Eligibility Subsystem Reports. Caseload includes TANF and SOBRA Children*FY 2008-09 October 2009 Social Services Estimating Conference.*FY 2009-10 October 2009 Social Services Estimating Conference.*FY 2010-11 October 2009 Social Services Estimating Conference. 14

Growth in Medicaid Average Monthly Caseload for SSI

0.50

0.60

0.70

lions

0.40

2

0.41

8

0.43

2

0.43

8

0.45

2

0.46

4

0.46

8

0.48

0

0.49

0

0.50

2

0.51

9

0.53

1

0.55

1

0.57

9

0.60

5

0.20

0.30

0.40

asel

oad

in M

il

0

0.00

0.10

Ca

6-97

7-98

8-99

9-00

0-01

1-02

2-03

3-04

4-05

5-06

6-07

7-08

8-09

*

9-10

*

0-11

*

199

199

199

199 9

200

200

200 2

200

2004

200

200

200

2008

2009

2010

Fiscal Year

Source: Medicaid Services Eligibility Subsystem Reports.*FY 2008-09 October 2009 Social Services Estimating Conference.*FY 2009-10 October 2009 Social Services Estimating Conference.*FY 2010-11 October 2009 Social Services Estimating Conference. 15

Growth in Medicaid Average Monthly Caseload including

TANF and SSI

2,800,000

3,200,000

Average Caseload

1,200,000

1,600,000

2,000,000

2,400,000g

TANF

0

400,000

800,000

97 98 99 00 01 02 03 04 05 06 07 08 09 10 11

TANFSSI

1996

-

1997

-

1998

-

1999

-

2000

-

2001

-

2002

-

2003

-

2004

-

2005

-

2006

-

2007

-

2008

-

2009

-

2010

-

16

Titl XIX F d l M di lTitle XIX Federal MedicalAssistance Percentage (FMAP)

F d l Fi l F d l Sh St t Sh T t lFederal Fiscal Year

Federal Share State Share Total

2005 58.89% 41.11% 100%

2006 58.76% 41.24% 100%

2007 56.83% 43.17% 100%

2008 55.40% 44.60% 100%

2009* 67 64% 32 36% 100%2009* 67.64% 32.36% 100%

2010 60.71% 39.29% 100%

17*American Recovery and Reinvestment Act of 2009

Growth In MedicaidGrowth In Medicaid Service Expenditures

$20 000

0 ,437 $1

3,05

0

$13,

889

0 03 16,1

89

$17,

950

$18

,224

$14,000

$16,000

$18,000

$20,000

ns

6 852

5,33

2

$5,9

30$6

,139

$6,2

81

$6,6

12

$6,9

47$7

,764

$8,9

01 $10,

22 $11,

$13,

882

$14,

370

$14,

80 $

$8,000

$10,000

$12,000

$ ,

endi

ture

s in

Mill

io

$914

$1,0

35

$1,2

12

$1,5

12$1

,947

$2,4

86 $3,1

65

$3,9

86 $4,8 $5

$2,000

$4,000

$6,000Exp

e

$-

1984

-85

1985

-86

1986

-87

1987

-88

1988

-89

1989

-90

1990

-91

1991

-92

1992

-93

1993

-94

1994

-95

1995

-96

1996

-97

1997

-98

1998

-99

1999

-00

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09*

2009

-10*

2010

-11*

18

Source: Medicaid Services' Budget Forecasting System Reports.*FY 2008-09 February 2009 Social Services Estimating Conference.*FY 2009-10 August 2009 Social Services Estimating Conference.*FY 2010-11 August 2009 Social Services Estimating Conference.

TANF and SSI Related li ibili fEligibility Groups for 2009-10

Total Budget Avg Monthly Caseload Per Member

Per MonthPer Month

Supplemental Security Income (SSI) $10,067,890,630 569,947 $1,472

Temporary Assistance for Needy Families (TANF) $2,284,211,520 813,834 $234

Medically Needy $900,474,023 30,892 $2,429

Children < = 100% of Poverty $905,881,537 589,546 $128

Children > 100% of Poverty $134,416,245 65,423 $171

Children – Medicaid Expansion Under Title XXI $2,903,600 754 $321

$Pregnant Women < = 100% of Poverty $582,931,247 64,447 $754

Pregnant Women > 100% of Poverty $134,629,769 14,439 $777

Family Planning Waiver $7,761,544 60,940 $11

Categorically Eligible $479 368 960 218 447 $183Categorically Eligible $479,368,960 218,447 $183

Elderly and Disabled (MEDS AD) $465,892,486 28,861 $1,345

Qualified Medicare Beneficiaries (QMB/SLMB/QI) $390,640,215 243,373 $134

Refugee General Assistance $20,262,806 8,558 $197

Other $1,572,356,190 N/A N/A

Total $17,949,620,772 2,709,461 $552

19

Medicaid Budget - How it is Spent Fiscal Year 2008-09

90%

100% 17.34%9.06%

Adults*

60%

70%

80%

90%

50.38%

29.62%

Children*

20%

30%

40%

50%

18.04%

41.62%Blind & Disabled

0%

10%

20%

Enrollees Expenditures

14.25% 19.70%

Elderly 65+

* Adults and children refers to non disabled adults and children. 20

Medicaid Spending f Fi l Y 2009 10for Fiscal Year 2009-10

ServiceFY 2009-10 Estimated

Spending Percent of Total

Prepaid Health Plans $3 049 822 245 16 99%Prepaid Health Plans $3,049,822,245 16.99%

Nursing Home Care $2,731,595,595 15.22%

Hospital Inpatient Services $2,652,939,259 14.78%

Prescribed Medicine/Drugs & Part D $1,750,639,097 9.75%

Low Income Pool $1,123,827,163 6.26%

Supplemental Medical Insurance $1,012,090,511 5.64%

Home & Community Based Services $1,007,403,380 5.61%

Physician Services $845 256 049 4 71%Physician Services $845,256,049 4.71%

Hospital Outpatient Services $757,610,037 4.22%

Intermediate Care Facility/DD $353,147,413 1.97%

Nursing Home Diversion Waiver $338,177,730 1.88%

Hospice Services $326,477,115 1.82%

Disproportionate Share Hospital Payments $246,570,577 1.37%

Home Health Services $182,424,528 1.02%

Hospital Insurance Benefits $160,656,859 0.90%osp ta su a ce e e ts $ 60,656,859 0.90%

Other $1,410,983,214 7.86%

Total $17,949,620,772 100.00%21

Estimated Fiscal Year 2009-10 Medicaid Expenditures By Appropriation Category

Prepaid Health Plans16 99%

Hospice1 82%

Disproportionate ShareHospital Payments

1.37%

Home Health Services1.02%

Hospital InsuranceBenefits0.90%

Other7 86% 16.99%

Nursing Home Care15.22%

Intermediate Care Facility/DD

1 97%

Nursing HomeDiversion Waiver

1.88%

1.82% 7.86%

Physician Services

Hospital Outpatient Services4.22%

1.97%

Hospital Inpatient Services14.78%

Prescribed Medicine/Drugs & Supplemental Medical

Home & CommunityBased Services

5.61%

y4.71%

22

Part D9.75%

Low Income Pool 6.26%

Insurance5.64%

Top 5 Medicaid Services E dit AExpenditures on Average

$4 000 000 000

$3,000,000,000

$3,500,000,000

$4,000,000,000

Hospital

$1,500,000,000

$2,000,000,000

$2,500,000,000

Prescribed Medicine/Drugs  & Part D

Nursing Home Care

Prepaid Health Plans

$0

$500,000,000

$1,000,000,000

Home & Community Based Services

$0 FY05-06 FY06-07 FY07-08 FY08-09 FY09-10 FY10-11

23

Medicaid Budget by Fund Sourceby Fund Source

FY 2009-10 - $17.9B

General Revenue

Tobacco Settlement TF

Refugee TF0.1%

Public Med Assist TF

3 0%

Grants & Donations TF

10.2% Health Care TF

4 7%

In Millions

Medicaid (XIX) $11,394.0 Revenue15.2%

Settlement TF.3%

3.0% 4.7%General Revenue  $2,733.4

Grants & Donations $1,846.0

Health Care TF $851.0 

Other State Funds

Other State Funds $514.1

PMATF $538.2

Tobacco Settlement  $52.62.9%

Medicaid (Title XIX)

63.6%

Refugee $20.3

TOTAL                        $17,949.6

24Source:  August 2009  Social Services Estimating Conference

Medicaid Programi dGrants & Donations Trust Fund

FY 2009-10

Fraud & Abuse1%

Drug Rebates (State)11%

Sources of Funds (millions)   

Local IGT’s  $1,183.3 

Rebates (F)       $436.0 Drug Rebates

(Federal)24%

( )

Rebates (S)       $208.6

Fraud/Abuse     $19.0

TOTAL           $1,846.9

Local IGT's64%

25

Source:  August 2009 Social Services Estimating Conference

Medicaid Program gIntergovernmental Transfers (IGT’s)

FY 2009-10

Sources of Funds (millions)

H it l LIP $360 55

DSH Program9% Hospital Outpatient

8%Other26%

Hospital LIP    $360.55

Hospital IP        $310.23

DSH Program    $110.26 

Hospital OP $90 07Hospital OP       $90.07

Other                  $312.16

TOTAL              $1,183.27

Hospital Inpatient 26%

Hospital LIP31%

26

Source:  August 2009 Social Services Estimating Conference

Questions?Questions?