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Overview of Medicare, Medicaid and State Children’s Health Insurance Program for Citizens’ Health Care Working Group. William J. Scanlon Health Policy R&D National Health Policy Forum. Overview of Medicare, Medicaid and SCHIP. Eligibility Services Covered Financing. Eligibility.

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Overview of Medicare, Medicaid and State Children’s Health Insurance ProgramforCitizens’ Health Care Working Group

William J. Scanlon

Health Policy R&D

National Health Policy Forum

overview of medicare medicaid and schip
Overview of Medicare, Medicaid and SCHIP
  • Eligibility
  • Services Covered
  • Financing
  • Medicare
    • Open Ended Entitlement
    • Federal
      • Payroll Taxes
      • General Revenues
    • Beneficiary Premiums
  • Medicaid
    • Open Ended Entitlement
    • Federal and State General Revenues
    • Fixed Federal Appropriation
    • Federal and State General Revenues
    • Beneficiary Premiums
  • 41 million beneficiaries
  • $301 billion in 2004
    • 11.7% of Federal Budget
    • 2.6% of GDP (2003)
medicare program structure
“Original” or “Traditional” Medicare (also known as “Fee-for-Service” Medicare)

Medicare Advantage—Private plan options

Drug Benefit

Parts A and B

Medicare Program Structure

Part C

Part D

medicare benefits
Medicare Benefits

Medicare Covers Acute and Chronic Care

  • Part A
    • Inpatient hospital
    • Post-hospital skilled nursing facility (SNF) services
    • Home health
    • Hospice-care
  • Part B
    • Physician and laboratory services
    • Outpatient hospital
    • Therapy
    • Durable medical equipment and supplies
    • Home health (not-covered under Part A)
  • Part D
    • Drugs
medicare cost sharing
Medicare Cost-Sharing
  • Hospital Care
    • Days 1-60—Deductible ($912 in 2005)
    • Days 61-90—Per day coinsurance ($228 in 2005)
    • Days 91-150—Per day coinsurance ($456 in 2005) for 60 lifetime reserve days
  • SNF
    • Days 21-100—Per day coinsurance ($114 in 2005)
medicare cost sharing continued
Medicare Cost SharingContinued

Part B

  • Deductible: $110 in 2005
  • Coinsurance: 20% of Medicare approved amount
  • Exceptions
    • Mental health: 50% co-insurance
    • Hospital outpatient—Fixed amounts
    • Home health—none
  • Over-billing limit: 15 % above Medicare approved amount on unassigned claims
medicare cost sharing continued12
Medicare Cost SharingContinued

Beneficiary cost sharing on Medicare

covered services can be substantial

Beneficiaries in 1998 paying more than:

medicare supplementary coverage
Medicare Supplementary Coverage

Vast majority of beneficiaries in traditional Medicare have supplementary coverage

Supplementary Coverage in 2000

medicare advantage part c
Medicare Advantage—Part C
  • Offers choice to join private plan
  • Plan types include HMOs, PPOs, FFS, MSAs
  • Plans paid monthly per enrollee fee regardless of services used
  • Plan “savings” returned in extra benefits
medicare advantage part c15
Medicare Advantage—Part C

Plan and beneficiary participation have varied over time


Enrollees (millions)

medicare advantage part c16
Medicare Advantage—Part C
  • Medicare Modernization Act changed Part C
    • Increased payments to plans
    • Provided for financial competition among plans and share of savings to Medicare
    • Created regional PPOs to expand areas served
medicare advantage part c17
Medicare Advantage—Part C

PPO Regions for 2006

medicare drug benefit part d
Medicare Drug Benefit--Part D
  • Begins January 1, 2006
  • Separate enrollment and premium
  • Monthly premium expected to average $37 nationally
  • Benefit provided by competing private stand-alone drug plans or Medicare Advantage plans
  • Benefit
    • $250 deductible
    • Coinsurance
      • 25% from $250 to $2,250
      • 100% from $2,250 to $5,100
      • 5% on spending over $5,100
  • Subsidies for premium and cost sharing for low income persons
medicaid and schip

over 52 million beneficiaries

$ 309 billion in 2004

Federal share

$176 billion or .8% of federal budget

State share

$133 billion or 22%* of state budgets



~ 6 million beneficiaries

$6.1 billion in 2004

≈ 75 % Federal

≈ 25 % State

Medicaid and SCHIP

Program Roles

  • Primary health insurance—mostly families
  • Medicare supplement—dual eligible aged and disabled beneficiaries
  • Long-term care financer — beneficiaries with disabilities

Programs are state designed and administered subject to federal requirements

Result is 56 distinct Medicaid programs

medicaid mandatory and optional eligibility selected categories


6-18 years up to 100% FPL

0-5 years up to 133% FPL

Foster care

Pregnant women

Up to 133% FPL

SSI cash recipients


Children and Pregnant women

Up to 185% FPL

Elderly and Disabled

Up to 100%FPL

Medically Needy

MedicaidMandatory and Optional EligibilitySelected Categories
medicaid mandatory medicare supplementary insurance
Medicaid Mandatory Medicare Supplementary Insurance
  • Qualified Medicare Beneficiaries (QMBs)
    • Up to 100% FPL—Part B Premium and cost sharing
  • Specified Low-Income Medicare Beneficiaries (SLMBs)
    • 100-120% FPL---Part B Premium
  • Qualifying Individuals (QIs)
    • 120-135% FPL—Portion of Part B Premium
  • Qualified Disabled Working Individuals (QDWIs)
    • Up to 200% FPL---Part A Premium
medicaid mandatory and optional services selected types


Hospital inpatient and outpatient

Nursing Facility for persons 21 and over

Lab and X-ray

EPSDT for persons less than 21


Prescription Drugs

Dental services


Home and community-based services

MedicaidMandatory and Optional ServicesSelected Types
medicaid waivers
Medicaid Waivers
  • Program Waivers
    • Mandatory managed care enrollment (1915(b))
  • Section 1115 Demonstrations
    • Statewide experimentation with financing mechanisms, managed care, coverage expansions
    • HIFA—Health Insurance Flexibility and Accountability—tradeoff of more limited benefit packages and cost sharing for expanded coverage

Federal-State Partnership very different

  • Capped appropriation—not an entitlement

$39 billion for 10 years (reauthorization 2007)

  • State Flexibility
    • States can cap/close enrollment
      • 7 states froze enrollment at least temporarily between 2001 and 2004
      • 3 had freezes in effect at end of 2004
schip state flexibility continued
SCHIPState Flexibility (Continued)
  • Benefits
    • Medicaid Expansion
    • Distinct program with benefits similar to
      • BC/BS plan; state employees plan; largest Medicaid HMO; or actuarially equivalent
    • Combination
  • Cost sharing
    • Very limited for children in families ≤ 150%FPL
    • For others, premiums and co-payments allowed if

≤ 5% of income


5.7 Million

2.0 Million

3.9 Million

-0.1 Million

Changes in Health Insurance Coverage for Low-Income Children and Adults, 2000-2003Percentage Point Changes



Change in Population

Change in Uninsured

Note: Low-income is defined as less than <200% of poverty ($29,360 for a family of three)

SOURCE: Urban Institute for the Kaiser Commission on Medicaid and the Uninsured, 2004

medicaid as ltc financer
Medicaid as LTC Financer
  • Pays close to half of all LTC expenditures
  • Nursing homes

≈46 percent of revenues

≈1 million or 2/3 of residents partially or fully financed

  • Home and community services

≈48 percent of expenditures

≈850 thousand recipients


For more informationUnderstanding Medicare and Medicaid: Fundamentals and Issues for the New CongressBriefing Book — January 26,