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Texas Medicaid

Texas Medicaid. Medical and Dental Information Series. Version 1.2 (6/22/2010). 2/22/2013. Medicaid Curriculum Overview. Module 1: General Structure of the Texas Medicaid System Module 2: Understanding Medicaid Clients and Health Literacy Module 3: Texas Health Steps

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Texas Medicaid

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  1. Module 2 Texas Medicaid Medical and Dental Information Series Version 1.2 (6/22/2010) 2/22/2013

  2. Module 2 Medicaid Curriculum Overview Module 1: General Structure of the Texas Medicaid System Module 2: Understanding Medicaid Clients and Health Literacy Module 3: Texas Health Steps Module 4: Navigating Insurance and Managed Care Module 5: Interfacing with Medicaid as a Provider Module 6: Special Medicaid Programs Module 7: Special Medical Issues Module 8: Special Dental Issues

  3. Module 2 Understanding Medicaid Clients and Health Literacy

  4. Module 2 Module 2: ObjectivesAfter completing this module, you should be able to: • Explain how poverty is defined and measured in the U.S. • List at least three characteristics of children living in poverty • Contrast the terms generational poverty and situational poverty • List at least five barriers to health care caused by poverty • List at least three ways that emergency department usage is affected by poverty and unemployment • Define health literacy and its effect on health and provision of health care • List Texas Medicaid initiatives to address adverse effects of poverty and disability

  5. Module 2 Module 2: Identifying Patterns This module attempts to describe poverty in terms of the patterns observed in the research literature– but all patterns have exceptions. Patterns involve broad generalizations about large groups of people. The goal of this presentation is to describe poverty, its barriers and its health implications to help providers improve their patient care– not to create or perpetuate stereotypes.

  6. Module 2 True or False?Test Your Knowledge about Texas Medicaid: • In 2011, nearly 1 in 20 people and 1 in 15 children lived in poverty. • The federal government requires that state Medicaid programs set service eligibility at 100% of the FPL. • A family in generational Poverty is one that has been in poverty for two or more generations. • Nationally, a 1% decrease in the employment rate adds about 1 million new enrollees to Medicaid & CHIP. • Only about 12% of adults have a health literacy level that could be considered proficient.

  7. Module 2 REVIEW:What is Medicaid? • Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments: • About one-third funded by the State of Texas • About two-thirds funded by the Federal Government • In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million). • Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967. • In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC). • Medicaid is an entitlement program, which means: • The number of eligible people who can enroll cannot be limited. • Any services covered under the program must be paid.

  8. Module 2 REVIEW:Who can receiveFullMedicaid Benefits?Categories of Eligibility • Families and Children • Based on income level, depending on age, or pregnancy • Cash Assistance Recipients • Based on receipt of Temporary Assistance for Needy Families (TANF) or Supplementary Security Income (SSI) • Aged and Disabled Individuals • Based on income, age, and physical and/or mental disability • Some Dual Eligible Individuals: Qualified Medicare Beneficiaries • Based on age, income, and disability status

  9. Module 2 REVIEW:Who can receiveLimitedMedicaid Benefits?Categories of Eligibility • Some Dual Eligible Individuals: In the Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, Qualified Individuals, and the Qualified Disabled Working Individuals Programs, Medicaid pays for some or all of Medicare premiums • Based on income, assets, age, and/or disability • Non-Citizens • Undocumented persons who are not eligible for Medicaid based on citizenship status may receive emergency services • Qualified Legal Permanent Residents are eligible for limited Medicaid services • Special programs for women (e.g., family planning services, cervical and breast cancer coverage, community attendant services) • Available to women and based on income level and age

  10. Module 2 REVIEW:What Does Medicaid Cover? • Long-term services for elderly and disabled clients • Mental health and substance abuse treatment • Acute and preventive health care for all ages • Physician visits • Inpatient and outpatient services • Pharmacy, lab, and radiology costs • Dental services for patients under the age of 21 • Preventive • Therapeutic

  11. Module 2 REVIEW:How Many People Does Texas Medicaid Serve? At any one time, how many individuals are enrolled in Medicaid? About 3.54 million

  12. Module 2 REVIEW:Texas Medicaid Recipients State Fiscal Year 2011 Unduplicated Clients SFY 2011 = 4,567,077 Hispanic Caucasian African-American Other 0-5 6-14 15-20 21-64 65+ Female Male

  13. Module 2 REVIEW:Who is Eligible for Medicaid Benefits? • Medicaid primarily serves: • Low-income families • Foster children • Pregnant women • The elderly • People with disabilities • Babies born to mothers receiving benefits at time of delivery (Services available for one year)

  14. Module 2 Medicaid and Poverty • Medicaid serves primarily low-income or disabled families and individuals– those likely to be in poverty. • Why might a family or individual qualify for Medicaid? • A family crisis such as death, disability or divorce that leads to loss of income • Loss of a job or other economic distress • Long-term poverty that persists for more than one generation • This module focuses on helping providers understand some of the challenges faced by their Medicaid clients that lead to health disparities: What is poverty? What is the link between poverty and health care? How does health literacy affect health care? What Texas Medicaid programs help reduce health disparities caused by poverty or disability?

  15. Module 2 Why Is It Important to Learn About Poverty? Poverty and Health Research points to a strong negative relationship between Income and Health Status: As income declines, health status also declines

  16. Module 2 Why Is It Important to Learn About Poverty? Poverty and Dental Care

  17. Module 2 Why Is It Important to Learn About Poverty? Poverty and Cultural Competency • Health providers and organizations that are culturally competent demonstrate the ability to recognize role of cultural diversity—including values, traditions and language preferences—in making positive health outcomes. • Linking poverty to culture is controversial, especially explanations that blame victims of poverty or that cast doubt on the values or morals of the poor, but recent scholarship recognizes a link between culture and persistent poverty. • The characteristics of socioeconomic status—income level, educational attainment, and employment position—often also affect traditions and language preferences. • Thus, understanding the effect of socioeconomic status and poverty on health is a first step in achieving competency regarding the culture of poverty.

  18. Module 2 Understanding Medicaid Clients What is poverty? Definitions & measurements Children living in poverty Poverty across the US & Texas Generational vs. Situational poverty

  19. Module 2 How Poverty is Defined and Measured in the U.S. The Census Bureau uses a set of money income, or poverty thresholds (or Federal Poverty Level, FPL) that vary by family size and composition (but not by region of the country) to determine who is in poverty. If a family's total income is less than 100% FPL, then that family and every individual in it is considered poor or inpoverty. Families with incomes between 100-200% FPL are considered to be low income. In 2011, the FPL is $22,350 per year for a family of 4, or $1863 per month.

  20. Module 2 In 2011, there were over 311 million people in the United States In 2011, more than 46 million of these people lived in poverty (a 15-year high) 1 in 7 people overall 1 in 5 children

  21. Module 2 In 2011, more than 46 million of these people lived in poverty (a 15-year high) 1 in 7 people overall 1 in 5 children

  22. Module 2 Children Living in Poverty Compared with children in higher income families, poor children are more likely than non-poor children to: • Be in single-parent families • Have parents with low educational attainment • Live in areas called “food deserts” with limited access to fresh groceries and healthy food • Be exposed to chronic stress that is linked to chronic disease • Suffer developmental delays • Give birth during the teen years • Be in poor or fair health The percentage of children living in low-income and poor families has increased since 2000:

  23. Module 2 Federal Poverty Level (FPL) Total Number of People Living in Poverty based on Household Income (In Thousands), 2009 2012-13 US Poverty Guidelines Texas 4.26 million

  24. Module 2 Poverty in TexasTexas (2010-2011) vs. US (2011)

  25. Generational Poverty Situational Poverty Module 2 Generational Poverty vs.Situational Poverty • Poverty that persists for two or more generations • Generational Poverty has its own: • Culture • Hidden Rules • Belief Systems • Approach to Language Poverty that caused by circumstance (such as death, illness, divorce) and has a duration of one generation or less Situational Poverty maintains an orientation toward middle class codes and mores.

  26. Module 2 Understanding Medicaid Clients • What is the link between • poverty and health care? • Income & Medicaid eligibility • Health implications of poverty • Effects of unemployment & income fluctuations • Impact on emergency department (ED) use

  27. Module 2 FPL and Social Services Examples of Texas Medicaid Eligibility by FPL Children 6-18: up to 100% FPL, or up to $23,050/year for a family of 4 Elderly and Disabled: 75% FPL or $11,348/year for a family of 2 Pregnant Women: up to 185% FPL, or up to $35,316/year for a family of 3 The Department of Health and Human Services develops and publishes the Poverty Guidelines, which are updated annually and form the basis for eligibility for Medicaid and other programs. The federal government sets minimum FPL criteria for eligibility to federally funded programs, but states can set higher FPL eligibility to cover a broader range of income levels. Program eligibility is often expressed as a percentage of the FPL. The higher the percentage, the greater the income limit, or more generous the benefit.

  28. Federal Poverty Levels in UseMedicaid Eligibility in Texas, 2012 Module 2 FPL = Federal Poverty Level FBR = Federal Benefit Rate * SSI is awarded to individuals and couples only

  29. Module 2 Income Guidelines www.chipmedicaid.com

  30. Module 2 www.chipmedicaid.com

  31. Module 2 Common Medicaid Myths • Myth • Most Medicaid-eligible children have parents who are unemployed. • Fact • Medicaid primarily serves the working poor—families with at least one parent who works full or part-time but with a family income less than 100% FPL and no other source of insurance. National Center for Children in Poverty data for Texas, 2008: 38% of children in poor families (<100% FPL) have at least one parent who is employed full-time, year-round 33% of children in poor families have at least one parent who is employed either part-year or part-time 30% of children in poor families do not have an employed parent In contrast, 88% of children in families that are not poor have at least one parent who is employed full-time, year-round

  32. Module 2 Health Implications of Poverty: Barriers to Care • Money to pay for co-payments, medications or other health costs • Inadequate or unreliable transportation • Low educational levels • Food insecurity • Low literacy levels or limited understanding of English • Poor health literacy • Conflicting priorities and needs

  33. Module 2 The Face of Poverty: Implications for a family’s health Rhonda is a 31-year-old single mother ofTamika (14) and Andre (10) living in Dallas. Rhonda lives in a low income housing development, near her mother and older brother, who is mentally handicapped. Rhonda’s job in a call center earns $332 per week, but offers no benefits. She also receives $40 per week in child support from Andre’s father, who lives in Louisiana. Her total monthly pre-tax income is $1488 (93.5% FPL) or $17,856 per year. Rhonda’s mother has Type 2 diabetes and hypertension. Her father, a lifelong smoker, died of lung cancer 5 years ago. Rhonda limits her own smoking to a half-pack of cigarettes a day.

  34. Module 2 The Face of Poverty:Rhonda’s Family According to the National Center for Children in Poverty, as a single mother with 2 children in Dallas, Rhonda could expect the following monthly expenses, even to be considered low-income (132% FPL):

  35. Module 2 Linking Financial Status and Health Care

  36. Module 2 Health Implications of Poverty for ChildrenPhysician Care

  37. Module 2 Health Implications of Poverty for ChildrenOverweight and Obesity

  38. Module 2 Health Implications of Poverty for ChildrenDental Care

  39. Module 2 The Face of Poverty: Implications for a family’s health Provider’s Concerns Rhonda’s Concerns Juggling competing demands in an extended family despite limited resources: Keeping her kids fed Paying her bills Keeping her car running Getting to work on time Helping her extended family • Bringing in a copy of the kids’ shot records • Setting a quit date for smoking • Keeping appointments for dental referrals • Getting regular exercise and avoiding junk food • Filling and taking prescriptions

  40. Module 2 Effects of Unemployment and Income Fluctuations

  41. Module 2 Linking Financial Status and Health Care Percent of workers who become uninsured (6+ months) after leaving a job, among workers previously insured through their employer

  42. Module 2 Effect of Employment Rate on Medicaid & CHIP • Medicaid and CHIP Enrollment 1% National Employment Rate 1 Million

  43. Module 2 Effects of Poverty, Unemployment & Uninsurance on ED Usage • ED physicians see anxiety and depression among patients who lost their jobs. • The inability to arrange for follow-up care for uninsured patients is a huge problem, which impacts how ED physicians practice and how patients fare. Key Findings from a 2009 Kaiser Family Foundation study of Emergency Departments (EDs): ED capacity is strained and almost all EDs report rising volume. Many EDs observe a new “recession” population of those who have lost jobs and insurance or those who can’t afford deductibles or cost-sharing costs in the doctor’s office. EDs are seeing more insured patients who come because they cannot obtain timely or affordable primary care in the community. Both insured and uninsured patients are refusing medically recommended care because of cost.

  44. Module 2 Characteristics of ED UsersBy Insurance Status

  45. Module 2 Characteristics of ED UsersBy Chronic Condition

  46. Module 2 Characteristics of ED usersBy Reason for Visit

  47. Module 2 The Link Between Poverty and Health Care: Barriers Caused by Patient and Provider Knowledge & Attitudes Patient Quotes “I didn’t know people went to the doctor. I thought everyone went to the emergency room.” “I never saw a dentist. Didn’t even know you were supposed to until you needed false teeth.” Provider Quotes “I can’t get the mother to turn the TV off and bring her kid in to get a checkup.” “My patients don’t want to pay the $5 co-pay, so they come to the ED and wait 6 hours to be seen for a cold.”

  48. Module 2 Addressing the Link Between Poverty and Health Care • A strong and positive provider-patient relationship has a positive and significant effect on treatment adherence and outcome • Conflicting norms and behaviors among patients and providers of different social groups may create barriers to effective communication or positive relationships • Suggestions for providers: • Recognize norms as adaptive and socially constructed, and avoid assigning positive or negative value • Do not assume that someone will see how their choices today will affect their health tomorrow. • Learn more about the effects on health of poverty, unemployment and uninsurance • Get to know your patients. Understanding their perspective can improve the services you provide.

  49. Module 2 Health Literacy • How does health literacy affect health care? Definition & importance of health literacy Measurement and extent of health literacy Addressing health literacy in health care settings

  50. Module 2 What Is Health Literacy? • Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. • Health literacy is dependent on both individual and systemic factors: • Communication skills of lay people (such as patients) and professionals (such as health care providers) • Knowledge of lay people and professionals of health topics • Culture • Demands of the healthcare and public health systems • Demands of the situation/context

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