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Medicaid Eligibility

Medicaid Eligibility . Low-income by federal poverty level (FPL) $17,960 for family of 1 (2003) Us citizen or lawful immigrant Pregnant Women and newborn Children 18 years and younger (some states cover up to 21 yrs of age) Aged, Blind, and/or Disabled.

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Medicaid Eligibility

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  1. Medicaid Eligibility • Low-income by federal poverty level (FPL) • $17,960 for family of 1 (2003) • Us citizen or lawful immigrant • Pregnant Women and newborn • Children 18 years and younger (some states cover up to 21 yrs of age) • Aged, Blind, and/or Disabled

  2. NC Financial Eligibility(April 1, 2003)

  3. Limitations on Services • 24 visits per yr. to practitioner, clinics, & outpatient departments • Limit of 6 prescriptions per month • Exceptions • Preventive care for pregnant women • People with life threatening conditions • Some services require a co-pay

  4. NC Medicaid Co-payment Amounts

  5. Medicaid Recipients and Managed Care • Carolina Access • ACCESS II AND ACCESS III • Healthcare Connection • Risk Contracting • Assigned primary care provider (PCP).

  6. NC Sources of Medicaid Funds

  7. NC Medicaid Expenditure by Recipient Group

  8. Children’s Health Insurance Program (CHIP) • Purpose Expand health insurance coverage for children under 19 yrs of age with incomes up to 200% of federal poverty guidelines (2001) • $29,268 family of 3 • $35,304 family of 4 • $41,340 family of 5

  9. Children’s Health Insurance Program (CHIP) • Matched Federal and State funds • State Eligibility based upon agreement with one of the following plans Expand Medicaid program Create new children’s health insurance program Implement combination of Medicaid and new insurance program

  10. NC State Children’s Health Insurance Program • Cover families up to 200% of Federal Poverty Level (FPL) • Benefits package provided by NC Teacher’s and State Employees Comprehensive Major Medical Plan plus dental, vision, and hearing

  11. NC State Plan (cont) • Families above 150% pay co-payments $6 for prescription $5 for physician, clinic, dental, and optometry visits $5 for outpatient hospital visit $20 co-payment for unnecessary emergency room use

  12. NC State plan (cont) • Enrollment fee for those above 150% of FPL $50 per child per year $100 maximum for 2 or more children • Allow families whose income increases above 200% of FPL to buy into the program for 1 year at full cost

  13. Estimate of Children Eligible for Medicaid but Not Enrolled

  14. Problems Faced by Uninsured • Do not receive timely and appropriate health care • Do not receive routine physicals • Less likely to receive or complete childhood immunizations • More likely to be seen in ER with more serious illness • Less likely to get care for injuries

  15. Status of Poverty in US • US poverty continues to rise 11/7% in 2001 • Median household income continues to decline $43,000 in 2001

  16. Status of Poverty (cont) • Poverty rates continue to rise yearly 22.7% for African Americans 21.4% for Hispanics 10.2% for Asian-Pacific Islanders 7.4% to 7.8% for others

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