This toolkit was compiled and written by Dinesh Kumar.
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Place your cursor over underlined terms to see definitions. You can also click on underlined terms to see definitions in the glossary at the end.
- Medicaid is a public health insurance program for low-income persons with acute care, chronic care and/or long-term care needs. It should not be confused with Medicare, which covers people age 65 and older, and certain people with disabilities.
- Medicaid is jointly financed by the states and the federal government, and is administered by the states within broad federal guidelines.
- An estimated 60 million people received Medicaid-financed services for at least part of 2006. 1 A smaller number (45.7 million) were covered by Medicaid at one point in time (June 30) that year. 2
- In Fiscal Year 2007, Medicaid enrollment experienced a 0.5 percent decrease, the first such decline since 1998. In explaining the reduction, Medicaid directors cited both lower unemployement and delays in processing applications due to new federal citizenship documentation requirements. 3
- In 2005, $305.5 billion in combined federal and state funds was spent for Medicaid, 4 and total spending for 2006 was an estimated $304.1 billion. 5
- In FY 2006, Medicaid made up an estimated 22.2 percent of total state spending and 18.1 percent of state general fund expenditures. 6
- Reversing a six-year trend, Medicaid is not expected to be the fasting growing category of state general fund spending in FY 2007. Instead, K-12 education is projected to take the top spot. 7
- Medicaid is the largest insurer of low-income children, low-income pregnant women and newborns, low-income people with disabilities, and those requiring long-term care. 8
- Medicaid is a critical source of financing for the nation's health care safety net, including community health centers, public clinics, and other providers that serve low-income people. 9
Medicaid is a public health insurance program covering certain low-income people with acute care, chronic care and long-term care needs. The country's main source of public health coverage for these populations, Medicaid constitutes the third cornerstone of American health insurance, along with Medicare and private insurance.
About half of Medicaid enrollees are children. But 70 percent of Medicaid expenditures go for the care of elderly and disabled adults.10 This is because elderly and disabled persons use more acute and long-term care services.
A little more than a third of Medicaid spending is for long-term care. The program finances most of the institutional long-term care services for those living in nursing homes.
Unlike Medicare (for senior citizens and people with disabilities, of all incomes), Medicaid is administered at the state rather than the federal level. However, the federal government shares in funding for the program with the states, paying 50 percent or more of the total cost of the program in each state, with the exact percentage based on the average per capita income of a state compared to the national average. The formula is designed to pay a higher percentage to states with a lower per capita income. 11
Current debates about Medicaid revolve around the rising costs of the program and its role, given the current erosion of employer-based coverage. Medicaid costs are straining both state governments and the federal government. Many states have tried to contain these costs by cutting back on Medicaid eligibility, by making it less convenient to enroll, by setting or maintaining provider reimbursements at below-market levels, or a combination of these methods.12 , 13
On the other hand, some states have taken steps to expand their Medicaid programs, picking up the pace as some employers scale back their coverage. Ironically, some employees drop employer-sponsored coverage when states make it easier for people to enroll in public programs such as Medicaid - a phenomenon called "crowd-out."14 (To learn more about "crowd-out," see the Alliance's toolkit on children's coverage.)
States often request federal permission to deviate from some aspect of federal Medicaid law. This permission is called a "waiver." There are two main types of waivers, each authorized under a section of the
Social Security statute: 1115 waivers, which are statewide, and 1915(c) waivers. Both are time-limited and can be renewed. For example, Vermont's Medicaid 1115 waiver issued in 2005 allows the state to use federal Medicaid funds to help finance non-Medicaid state health initiatives - such as tobacco cessation programs and the state medical school - in exchange for a cap on Medicaid funds flowing into the state. 15 Home and community-based waivers under section 1915(c) have often been used to allow states to offer a more comprehensive package of services than they otherwise could to individuals needing substantial assistance to live in the community, rather than in a nursing home. 16
Some low-income individuals, called "dual eligibles," receive benefits from both Medicaid and Medicare. Some of these individuals get the full range of Medicaid and Medicare benefits; others get help from Medicaid to pay out-of-pocket expenses not covered by Medicare.
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Basics: Statistics, Eligibility, Costs
- "Medicaid-at-a-Glance 2005: A Medicaid Information Source"
Centers for Medicare and Medicaid Services
Though somewhat dated, this is the official overview of the Medicaid program from the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS). The document defines Medicaid eligibility (differentiating between the "categorically needy" and the "medical needy"), points out some of the differences in the way various states run their respective programs (for example, by using Medicaid eligibility waivers or by covering TB or breast cancer), and also discusses the State Children's Health Insurance Program (SCHIP).
- "The Medicaid Program at a Glance"
Kaiser Commission on Medicaid and the Uninsured, March 2007
This is an easy-to-use two-page summary of the Medicaid program prepared by the Kaiser Commission on Medicaid and the Uninsured. It gives a brief history, defines eligibility levels, and gives recent figures on enrollment and cost, with future projections. ( 2 pages) For a much more comprehensive overview of Medicaid from the Kaiser Commission, see "Medicaid: A Primer," March 2007, www.kff.org/medicaid/upload/Medicaid-A-Primer-pdf.pdf (33 pages)
- "Medicaid Benefits: Online Database"
Kaiser Commission on Medicaid and the Uninsured
The Kaiser Commission also maintains a database describing which states' Medicaid programs cover which acute and long-term care services, how copayment levels differ, and how these data have changed over time. Kaiser explains the database and Medicaid benefits in general here: www.kff.org/medicaid/benefits/about_mb.jsp#gn
- "The Fiscal Survey of States"
National Association of State Budget Officers, June 2007
During 2006, states continued their revenue recovery from the fiscal downturn of the early 2000's. Total state spending in fiscal year 2006 was estimated at more than $1.3 trillion, including both operating and capital expenditures. Medicaid led all categories within total state spending at a projected 22.2 percent. Within state general fund spending, Medicaid was the second largest category at 18.1 percent, behind elementary and secondary education. For FY 2008, governors are recommending an aggregate increase of 7.0 percent in state funds for Medicaid. This report includes state-by-state Medicaid spending growth rates (actual for FY 2006, estimated for FY 2007 and recommended for FY 2008). A similar report for FY 2006 and FY 2007 is available for purchase from the National Conference of State Legislatures. (66 pages) Executive summary available at www.ncsl.org/programs/fiscal/sba06sum.htm)
- "New Survey Indicates Medicaid Enrollment Declines for the First Time in Nearly a Decade"
Kaiser Commission on Medicaid and the Uninsured, October 10, 2007
Press release: www.kff.org/medicaid/kcmu101007nr.cfm
Executive summary: www.kff.org/medicaid/upload/7699_ES.pdf
According to a survey of state Medicaid directors for all 50 states and the District of Columbia, enrollment in Medicaid during fiscal year 2007 declined for the first time since 1998. The 0.5 percent decrease was attributed to two factors by the state Medicaid directors: a strong economy with lower rates of unemployment, and the requirement for new and renewing enrollees to produce evidence of U.S. citizenship. That requirement was part of the Deficit Reduction Act of 2005 and has been in place since July 2006.
Federal and State Medicaid Financing
- "Federal Matching Rate (FMAP) for Medicaid and Multiplier"
Kaiser Family Foundation's State Health Facts
The federal government reimburses each state government a certain percentage of what the state spends on its Medicaid program. You will see this referred to as the FMAP, which stands for Federal Medical Assistance Percentages. This site from the Kaiser Family Foundation provides an interactive table that compares the federal matching rates for every state for FY 2004 to FY 2007.
- "The Medicaid Matching Formula: Responding to States in Times of Need"
AARP Public Policy Institute, March 2007
This fact sheet provides a more detailed explanation of the Federal Matching Assistance Percentage (FMAP), with a special emphasis on "countercyclical FMAP" - the phenomenon in which federal matching is less favorable to states during economic downturns, rather than more favorable, as one might expect, since the need for Medicaid coverage grows during downturns. The data used to calculate FMAP are usually from an earlier period - in which a state's economy was better or worse than at present - and this lag creates problems in finding the most equitable FMAP value at a given time. (2 pages)
- "FY 2004 Budget of the United States Government"
U.S. Office of Management and Budget, 2003
In 2003, President Bush proposed changing Medicaid from an eligibility program to a block grant program, in which the federal government would provide a fixed amount of funding to states. The aim was to give states an incentive to contain costs. (Several candidates for the Republican presidential nomination in 2008 have proposed similar plans.) The FY 2004 budget refers to these block grants as federal "allotments" to states and describes how the new program would change Medicaid funding. Scroll down in the budget document for the subhead "Medicaid and SCHIP Modernization," where the block grant (allotment) idea is described.
- "Making Medicaid a Block Grant Program: An Analysis of the Implications of Past Proposals"
Jeanne M. Lambrew, The Milbank Quarterly, Vol. 83, No. 1, 2005
Full text: http://aucd.org/docs/policy/medicaid/lambrew_medicaid_012605.pdf
In this article written in response to President Bush's 2003 proposal to make Medicaid a block grant, the author evaluates how Medicaid would be affected if it were to become a block grant program, and how the Bush plan compares with block grant proposals from the past.
- "Medicaid State Waiver Program Demonstration Projects - General Information"
Centers for Medicare and Medicaid Services
The official CMS overview of the major Medicaid waiver program, which allows states to apply through Section 1115 of the Social Security Act to modify their respective Medicaid programs to differ from the core requirements laid out by the federal government, often aimed at expanding coverage. The 1115 waiver is an important provision that gives the Medicaid program a unique flexibility, but is also a point of intense debate. For a list of all waivers applied for by states, as well as the status of the application, see this CMS database: www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp
- "An Early Look at Ten State HIFA Medicaid Waivers"
Teresa A. Coughlin and others, Health Affairs, April 25, 2006
Health Insurance Flexibility and Accountability (HIFA) is a major Medicaid initiative of the Bush administration, encouraging states to subsidize private insurance coverage with public funds. The authors look at 10 states that have applied for waivers under the program and found that states have adopted varied program designs, reflecting their particular goals and circumstances. An estimated 300,000 people were covered under HIFA by December 2005; the states had projected some 820,000 would enroll. For general information on HIFA, see this site from the National Conference of State Legislatures: www.ncsl.org/programs/health/hifa.htm
- "New Directions for Medicaid Section 1115 Waivers: Policy Implications of Recent Waiver Activity"
Samantha Artiga and Cindy Mann, Georgetown Health Policy Institute (commissioned by Kaiser Commission on Medicaid and the Uninsured), March 2005
This is an older article that explains what 1115 waivers are, the tension between states and the federal government in implementing them, early evaluations on HIFA, and how the waiver system increases the complexity of the Medicaid program. (23 pages)
Reforms and Barriers to Enrollment - Federal Level
- "The President's Budget: Improving Medicaid and SCHIP"
Nina Owcharenko, Heritage Foundation, February 7, 2007
President Bush's fiscal year 2008 budget for Medicaid and the State Children's Health Insurance Program (SCHIP) builds on the Medicaid reforms in the Deficit Reduction Act of 2005 and recommends the reauthorization of SCHIP. The president's budget presents Congress with his ideas for reforming and improving both SCHIP and Medicaid.
- "Deficit Reduction Act of 2005: Implications for Medicaid"
Kaiser Commission on Medicaid and the Uninsured, February 2006
In February 2006, President Bush signed the Deficit Reduction Act (DRA). Among other cost-saving measures, the act proposed to reduce federal spending for Medicaid by $4.8 billion over the next five years and by $26.1 billion over the next ten years. This fact sheet from the Kaiser Commission outlines the ways in which Medicaid beneficiaries (who are typically low-income) would be affected by this new legislation. (6 pages)
- "Survey Indicates the Deficit Reduction Act Jeopardizes Medicaid Coverage for 3 to 5 Million U.S. Citizens"
Leighton Ku and others, Center on Budget and Policy Priorities, January 26, 2006
One of the mandates of the February 2006 Deficit Reduction Act required all Medicaid beneficiaries to provide proof of U.S. citizenship. A nationwide survey was commissioned, on the basis of which the authors of this paper estimated that 3 to 5 million beneficiaries would be at risk of losing Medicaid under the new rule. For a more recent study on how the documentation requirement affects Hispanics and Non-Hispanics differently, see this paper by Donna Cohen Ross, also from the Center on Budget and Policy Priorities: www.cbpp.org/7-10-07health.htm
Reforms and Barriers to Enrollment - State Level
- "Post-Katrina Health Care: Continuing Concerns and Immediate Needs in the New Orleans Region" (LOUISIANA)
Leslie V. Norwalk, U.S. Department of Health and Human Services, March 13, 2007
This testimony by the former CMS acting administrator outlines the steps the Department of Health and Human Services, including the Centers for Medicare and Medicaid Services, have taken to help New Orleans residents get health care in the wake of Hurricane Katrina. It focuses on the CMS establishment of a special Medicaid 1115 demonstration waiver program to help ensure continuity of healthcare services for the victims of Hurricane Katrina, allowing States to apply to be part of a unique cooperative demonstration. The 1115 demonstration program provided Medicaid coverage to affected individuals and evacuees from areas declared by FEMA as designated counties / parishes in Louisiana, Mississippi and Alabama.
- "For Medicaid Clients, New Hurdles Loom" (NEW YORK)
Richard Pérez-Peña, New York Times, Nov. 21, 2005
For many years, New York had a waiver to bypass the federal stipulation prohibiting "facilitated enrollment," in which states assist poor populations to enroll in Medicaid by teaching them about the paperwork, providing forms, etc. In 2005 and again in 2007, the federal government threatened to rescind this waiver when New York wanted to expand Medicaid coverage. This article from 2005 explains facilitated enrollment and the tensions involved in it.
- "Uncertain Access to Needed Drugs: Florida's Medicaid Reform Creates Challenges for Patients" (FLORIDA)
Georgetown Health Policy Institute, July 2007
The Georgetown Health Policy Institute has been tracking the effectiveness of pilot Medicaid programs that have been conducted in Florida's Broward and Duval counties since September 2006. Under this cost-cutting measure, acute care services were changed from a "defined benefit" (in which all Medicaid beneficiaries were covered for a range of services) to a "defined contribution" (in which beneficiaries are given a credit to enroll, and health plans are free to restrict certain services). In this issue brief, the authors find that access to needed drugs is a major barrier to adequate care experienced by disabled patients in the pilot program. (4 pages) For previous institute reports on the Florida pilot program, see http://hpi.georgetown.edu/floridamedicaid
Medicaid & Children's Health
- "Dynamics in Medicaid and SCHIP Eligibility Among Children in SCHIP's Early Years: Implications for Reauthorization"
Anna S. Sommers and others, Health Affairs, August 24, 2007
This article explores the differences in eligibility for Medicaid and eligibility for the State Children's Health Insurance Program (SCHIP) since the enactment of SCHIP in 1998. Between 1996 and 2000, two-thirds of uninsured U.S. children were income-eligible for Medicaid or SCHIP.
- "Covering Kids & Families Case Study in Michigan: Exploring Medicaid and SCHIP Enrollment Trends and their Links to Policy and Practice"
Eileen Ellis and others, Mathematica Policy Research (commissioned by Robert Wood Johnson Foundation), May 2007
This case study, one of 10 state-based case studies conducted by Mathematica Policy Research, Inc., looks at enrollment trends in Michigan for children in Medicaid and in the Medicaid expansion portion of SCHIP from 1999 through late 2003. It also examines the activities of the Covering Kids and Families (CKF) project and its interaction with state agency policy through early 2006, when the Michigan CKF grant ended. (Note: The Covering Kids and Families website is merging with the Cover the Uninsured site - www.covertheuninsured.org. Both are sponsored by the Robert Wood Johnson Foundation.)
Medicare/Medicaid Dual Eligibility
- "Perspectives on Medicare Part D and Dual Eligibility: Key Informants' Views from Three States"
Kaiser Commission on Medicaid and the Uninsured, May 2007
"Dual eligibles" are people who receive health coverage through both Medicare and Medicaid. The 2006 start-up of the Medicare Part D prescription drug benefit meant that dual eligibles' Medicaid prescription drug coverage was replaced by Medicare Part D coverage. This 50-page report takes an early look at how dual eligibles from three states have been affected by the change in prescription drug coverage. (50 pages)
- "Medicaid Advantage: A Medical Home for Dual-Eligible Beneficiaries"
Grace-Marie Turner and Robert B. Helms, Galen Institute, March 30, 2007
Full article: www.galen.org/fileuploads/MedicaidAdvantage.pdf
Ms. Turner and Dr. Helms propose the creation of a new Medicaid Advantage program that would integrate acute and long-term care benefits for seniors who are eligible for both Medicare and Medicaid into a single program, managed by the states, to provide a medical home and better coordinated care for these beneficiaries. (13 pages)
- "Accomplishments and Lessons from the State Solutions Initiative to Increase Enrollment in the Medicare Savings Program"
Laura L. Summer, Georgetown University Health Policy Initiative, May 2006
Commissioned by the State Solutions Initiative
The State Solutions Initiative is a Robert Wood Johnson funded effort to increase enrollment in Medicare Savings Programs (MSPs). Congress established MSPs in 1988 to provide low and moderate income Medicare beneficiaries who do not qualify for a full Medicare benefits package. MSPs are administered by individual states and are financed by Medicaid, so MSP recipients are often referred to as "dual eligible." (36 pages) For more documents on MSPs, see www.statesolutions.rutgers.edu.
- "Maximizing MSP Enrollment with Part D: Co-location of SHIP Volunteers within Social Security Administration Offices"
Medicare Rights Center, May 2006
Commissioned by the State Solutions Initiative
Historically, the Medicare Savings Programs (MSPs) have been under-enrolled. The inception of the Medicare Part D prescription drug benefit represents an opportunity to reach out to low-income Medicare beneficiaries who could be enrolled in MSPs to share in the cost of Part D premiums and copays. (6 pages)
Medicaid & Managed Care
- "Quality of Care in Medicaid Managed Care and Commercial Health Plans"
Bruce E. Landon and others, JAMA, October 2007
Free abstract at: http://jama.ama-assn.org/cgi/content/abstract/298/14/1674
Enrollment in managed care programs among the Medicaid population is increasing while that of the commercial insurance population is decreasing. The authors compared the quality of care between Medicaid and commercial insurance recipients across three types of managed care programs: Medicaid-only plans, commercial-only plans, and Medicaid/commercial plans. They found that Medicaid managed care enrollees receive lower-quality care than that received by commercial managed care enrollees. There were no differences in quality of care for the Medicaid population between Medicaid-only plans and commercial plans that also served the Medicaid population.
- "Policies and Practices that Lead to Short Tenures in Medicaid Managed Care"
Gerry Fairbrother and others, Center for Health Care Strategies, Inc., July 2004
Short durations of Medicaid coverage have long been recognized as problems for both adults and children, as has the related problem of "churning," a situation in which a person qualifies for a program, then is dis-enrolled, and later qualifies again This paper explores reasons for differences in coverage durations in Medicaid and in health plans. The paper offers recommendations for addressing the issues of turnover and short durations in Medicaid managed care, including options for measuring performance and monitoring quality.
- "Medicaid and Managed Care: A Lasting Relationship?"
Robert E. Hurley and Steven A. Somers, Health Affairs, February 2003
Medicaid made a major commitment to managed care in the 1990s. Following some years of turbulence, the Medicaid managed care program has matured and is in a relatively favorable state, in contrast to turmoil in both the commercial and Medicare sectors. The authors acknowledge continuing changes in the managed care marketplace and financial distress in state budgets present new challenges to the strength of Medicaid managed care, but that the future of the program can be strong.
Medicaid & Long-Term Care
- "Financing Long-Term Care: Lessons from Abroad"
Howard Gleckman, Center for Retirement Research at Boston College, June 2007
Howard Gleckman, a Kaiser Family Foundation Media Fellow on leave from Business Week, compares the current U.S. system of financing long-term care (in which half is paid by Medicaid, about 20 percent by Medicare, and the rest out-of-pocket) with that of several other countries, including the United Kingdom, Japan, Germany, and France. He notes that these countries, like the U.S., face a rapidly increasing elderly population, and each has gone about tackling the problem of financing long-term care for these populations in a different way. (10 pages)
- "Medicaid's Long-Term Care Beneficiaries: An Analysis of Spending Patterns"
Anna Sommers and others, Kaiser Commission on Medicaid and the Uninsured, Feb. 8, 2007.
Those who use long-term care services are among the most disabled and chronically ill of the Medicaid population. Long-term care users account for 7 percent of the overall Medicaid population but use up 52 percent of total Medicaid spending. Only 15 percent of Medicaid enrollees classified as disabled use long-term care services, but over half of disabled Medicaid spending (58 percent) is directed towards long-term care users. For a two-page brief on Medicaid long-term care financing prepared by Sommers and others for the Georgetown Health Policy Institute (Feb. 2007), see http://ltc.georgetown.edu/pdfs/medicare0207.pdf
- "The Future of Long Term Care and Medicaid"
Dennis Smith, Center for Medicaid and State Operations, June 2006
This testimony by the director of the CMSO, a division of the Centers for Medicare and Medicaid Services, outlines the long-term care reforms that were contained in the Deficit Reduction Act of 2005, and how those reforms will change the Medicaid long-term care landscape.
- "Medicaid Managed Long-Term Care"
Paul Saucier, AARP, November 2005
This issue brief gives a quick background of Medicaid managed long-term care - why it was instituted, how it works, how many people are enrolled, etc. It then outlines the risks and benefits of Medicaid managed long-term care to the consumer, as well as the ways in which it has grown in recent years in several states.
- "The Looming Problem of Long-Term Care and Medicaid Spending"
Kirk A. Johnson, Heritage Foundation, October 2005
Dr. Johnson states that "staying the course is unsustainable" when it comes to increased Medicaid spending for long-term care. He argues that individuals should be given more incentive to seek long-term care insurance on the private market.
- "Long-Term Care and Medicaid: Better Quality and Sustainability By Giving More Control to People with a Disability"
Testimony of Mark McClellan before House Committee on Energy and Commerce, April 27, 2005
This testimony by the former head of the Centers for Medicare and Medicaid Services before the House Energy and Commerce Committee lays out the reasons for having a long-term program in Medicaid, the ways in which the cost of maintaining the program have risen in recent years, and several proposals for how to reform the Medicaid program to address these rising costs.
- "Does Medicaid Crowd Out Private Long-Term Care Insurance?"
American Enterprise Institute, February 17, 2005
This event sponsored by AEI asked whether Medicaid was exacerbating its cost pressure problem by discouraging people from buying private long-term care insurance. This event page has links to several documents analyzing the question, including one by panelists Jeffrey Brown and Amy Finkelstein arguing that a substantial amount of private long-term care insurance crowd-out takes place because of the Medicaid program.
Medicaid & Disparities in Care
- "Separate and Unequal: Racial Segregation and Disparities in Quality Across U.S. Nursing Homes"
David Barton Smith and others, Health Affairs, September/October 2007
Free abstract at: http://content.healthaffairs.org/cgi/content/abstract/26/5/1448
The authors describe the racial segregation in U.S. nursing homes and its relationship to racial disparities in the quality of care. Nursing homes remain relatively segregated, roughly mirroring the residential segregation within metropolitan areas. As a result, blacks are much more likely than whites to be located in nursing homes that have serious deficiencies, lower staffing ratios, and greater financial vulnerability. Among the authors' policy recommendations in reducing disparity are disproportionate-share pay adjustments to nursing homes with a higher proportion of Medicaid residents, and an equalization of Medicaid and private-pay payments.
- "Reducing Racial and Ethnic Disparities: A Quality Improvement Initiative in Medicaid Managed Care"
Center for Health Care Strategies, Jan. 2007
Full text: www.chcs.org/usr_doc/Racial_&_Ethnic_Health_Disparities.pdf
Funded by the Robert Wood Johnson Foundation and the Commonwealth Fund, this 50-page toolkit outlines current racial and ethnic disparities in quality of care among managed care Medicaid beneficiaries, as well as some suggestions on how to go about addressing the problem. (48 pages)
- Nationwide, losses in the numbers of people covered by private insurance have not been made up by gains in coverage under public programs, including Medicaid. What's happening in your state? Is the situation better or worse for children compared to adults?
- How much does your state project Medicaid spending will be next year? In five years, and in 10 years? How is that affecting state budget planning? What are the leading ideas for controlling costs without sacrificing coverage?
- How does your state compare to its neighboring states or to the U.S. as a whole in Medicaid coverage and spending? Using the custom data sheets (available at www.statehealthfacts.org/medicaid.jsp ), what are the significant differences in eligibility, benefits, and spending between your state and others? What are the underlying reasons?
- What changes has your state made in eligibility or benefits recently? How have these changes affected access for beneficiaries? How have they affected those health care providers (such as public hospitals, community health centers, or nursing homes) that serve a large number of Medicaid beneficiaries?
- How much per beneficiary does it cost to provide health services to certain categories of Medicaid care recipients vs. others? Do recent or proposed cuts in the program target services for certain groups of beneficiaries, and if so, is this related to their per beneficiary cost?
- New cost-sharing requirements may save states money if they deter people from enrolling and induce beneficiaries to seek fewer services. Is this occurring in your state?
- How are the Deficit Reduction Act citizenship documentation requirements being implemented in your state? Are there elderly people or nursing home residents without papers? What have they used for records until now?
- How many people in your state are classified as Medicare-Medicaid "dual eligibles"? What are the costs of treating these dual eligibles in your state?
- Is your state experiencing Medicaid "crowd-out" - people switching from private coverage to Medicaid?
Drawn from the Alliance for Health Reform's Find-an-Expert Service for reporters. Descriptions in quotes are written by the experts themselves. Credentialed reporters can see full profiles for these and other experts,
including after-hours contact numbers, by going to
- LISA ALECXIH
Vice President, The Lewin Group
Falls Church VA 22042
"My research and consulting focuses on the elderly and individuals with disabilities, including their acess to, use and financing of both acute and long-term care services as well as the service systems. I have examined many of the more innovative approaches to service access, delivery and financing."
- JOAN ALKER
Senior Researcher, Center for Children and Families, Georgetown University
Washington DC 20057-1485
"My primary focus is on federal and state public policy as it relates to the health care needs of low-income families (i.e. Medicaid, SCHIP). Special interest in state Medicaid waivers, especially Florida."
- JOSEPH ANTOS
Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute
Washington DC 20036
"Areas of expertise include Medicare (including Part D), Medicaid, and other federal health programs; private health insurance (including consumer-driven health care); price/spending trends; health policy and the budget. Former senior official at CBO, CMS, and OMB."
- KATHERINE BAICKER
Professor of Health Economics, Harvard School of Public Health
Boston MA 02115
"My research focuses on public health insurance programs and disparities in health care and outcomes. From 2005-2007, I served as a Member of the President's Council of Economic Advisers."
- RICHARD BRINGEWATT
President, National Health Policy Group
Washington, DC 20004
"Mr. Bringewatt is a nationally recognized leader on health systems transformation for people with complex chronic conditions. Currently, Mr. Bringewatt is Co-founder and President of the National Health Policy Group (NHPG) and Co-founder and Chair of the National Alliance for Specialty Healthcare Programs (SHP Alliance), a national leadership group of healthcare plans and programs specializing in care of persons with serious and disabling chronic conditions. Prior to establishing the National Health Policy Group, Mr. Bringewatt was co-founder and President and CEO of the National Chronic Care Consortium (NCCC). Mr. Bringewatt evolved the NCCC from a national demonstration to a national leadership association involving many of the premier health plans and integrated health and long-term care delivery systems in the United States. The NCCC was widely known for its real-world, high-quality solutions for improving health policy and practice using systems integration and planned change technologies."
- MICHAEL CANNON
Director of Health Policy Studies, Cato Institute
Washington DC 20001
"Expanding patient and provider freedom. Using market mechanisms to improve quality, reduce cost, generate information for patients, and drive IT innovation. Encouraging regulatory competition among governments, incl. devolving power over health care to states."
- DAVID COLBY
Vice President, Research and Evaluation
Robert Wood Johnson Foundation
Dr. Colby "leads a team dedicated to improving the nation's ability to understand key health and health care issues so that informed decisions can be made concerning the way Americans maintain health and obtain health care."
- KAREN DAVENPORT
Director of Health Policy, Center for American Progress
Washington DC 20005
"As Director of Health Policy at CAP, I focus on issues related to health care reform and the uninsured. Reforming our nation's health care system to provide affordable coverage to all Americans is one of CAP's top priorities, which we pursue through political advocacy (under the umbrella of the CAP Action Fund) as well as research and analysis. I also draw on my Congressional, Executive Branch and philanthropic experience when CAP develops work on Medicaid, SCHIP, Medicare, health disparities and other policy issues."
- KAREN DAVIS
President, The Commonwealth Fund
New York NY 10021
"My primary interests are the uninsured, Medicare, Medicaid, health policy, quality and organization of health services, international health, minority health, and women's health. My training is in economics with experience in government health policy, academia, and currently private foundation sponsoring independent research on health and social issues."
- NANCY-ANN DEPARLE
Adjunct Professor of Health Care Systems, The Wharton School, University of Pennsylvania
Washington DC 20015
"I was a senior health policy official in the Clinton Administration from 1993-2000. From 1997-2000 I ran the Health Care Financing Administration (HCFA, now CMS), which administers Medicare, Medicaid, and the State Children's Health Insurance (S-CHIP) program. Currently, I teach health policy at the Wharton School, serve on the Medicare Payment Advisory Commission (MedPAC), and am a senior advisor to JPMorgan Partners, a private equity firm."
- ALLEN DOBSON
Sr. VP Director of Health Care Finance, The Lewin Group
Falls Church VA 22042
"Former Director of research for Medicare. Interests: health care finance, Payment systems, Insurance, advance tax credit for health care coverage, costing, Medicare and Medicaid, Long term Care and hospitals."
- JIM DUFFETT
Executive Director, Illinois Campaign for Better Health Care
Champaign IL 61820
"I have been conducting local and statewide grassroots health care organizing for the past 25 years. Illinois is one of a handful of states that is moving towards implementing affordable, accessible and quality health care for all of its residents."
- JUDY FEDER
Professor and Dean of Public Policy, Georgetown University
Washington, DC 20007
"Long-time health policymaker and researcher; experience in health reform and other congressional initiatives. research on health and long-term care financing."
- DEBORAH FREUND
Distinguished Professor, Syracuse University
Syracuse NY 13244-1020
"I study Medicaid, conduct outcomes research and started pharmacoeconomics. My research has directly lead to new policies in the United States and abroad."
- ROBERT FRIEDLAND
Director, Center on an Aging Society
Washington DC 20057
"I am interested in the relationships between financing and the delivery of health and long-term care. I follow changes in health coverage, health care costs, health care budgets, Medicaid, Medicare, and employment based health insurance. I am also quite interested in structural issues in health care; such as coordinating care for chronic and disabling conditions, caregiving, and health literacy."
- PATRICIA GABOW
CEO and Medical Director, Denver Health
Denver CO 80204
"Dr. Gabow is well-known as a leader in management of a safety net system that is the largest Colorado provider of care to uninsured and Medicaid patients; policy; system redesign. Top 25 women in healthcare, top 100 people in health care."
- MARSHA GOLD
Senior Fellow, Mathematica Policy Research
Washington DC 20024
"My primary interests are in managed care, including the organization and financing of care under Medicare, Medicaid and private insurance."
- VAL J. HALAMANDARIS
President, The National Association for Homecare and Hospice
Washington DC 20878
"President of the National Association for Homecare and Hospice (NAHC) for twenty years. Served as Counsel to committees of the US Senate and U.S. Congress for twenty years. Joined staff of the U.S. Senate Special Committee on Aging chaired at that time by Senator Frank Church(1969). In 1978I joined the staff of the U.S. House Select Committee on Aging as Special Counsel. Researched and authored 25 major Congressional Reports. Selected as a contributing editor for aging issues for the new Encyclopedia of Congress in 1977. Areas of expertise: Fraud and abuse of the Elderly, Long Term Care, Medicare, Medicaid, Health coverage, Health Legislation, Disabilities, Chronic Care."
- MICHAEL HASH
Principal, Health Policy Alternatives, Inc.
Washington DC 20001
"I have worked on health policy issues -- mainly Medicare & Medicaid -- for nearly 30 years in Washington. Work experience includes the American Hospital Association, the House Commerce Committee, my current employer (HPA), and CMS (HCFA) where I served as deputy administrator in the Clinton Administration."
- ROBERT HELMS
Resident Scholar, Health Policy Studies, American Enterprise Institute
Washington DC 20036
"I am an economist who has worked in the health policy area in Washington for about 30 years, including 8 years at HHS/ASPE during the Reagan years. I have written on the tax treatment of health insurance, private health insurance, tax credits for expanding coverage, Medicare and Medicaid reform, and the economics of the pharmaceutical industry."
- JACK HOADLEY
Research Professor, Georgetown University Health Policy Institute
Washington DC 20057
"Jack Hoadley conducts research projects on health financing topics, including Medicare and Medicaid, with a particular focus on prescription drug issues. Recent projects include the use of formularies in Medicare Part D, how beneficiaries made choices about Part D, the use of evidence-based medicine to manage pharmacy costs for Medicaid, and an evaluation of Florida's Medicaid reform."
- JOHN HOLAHAN
Director, Health Policy Center, The Urban Institute
Washington DC 20037
"My principal areas of interest are Medicaid policy, the uninsured and the uninsured."
- EDWARD F. HOWARD
Exec V-P, Alliance for Health Reform
Washington DC 20005
"Has run the nonpartisan Alliance for Health Reform since its founding in 1991, where he has arranged hundreds of policy briefings for Congressional staff and media in Washington and around the country."
- CHRIS JENNINGS
President, Jennings Policy Strategies, Inc.
Washington DC 20001
"Former senior health care advisor to President Clinton for eight years and ten year veteran of Senate Aging/Finance Committee. Expertise in insurance coverage, cost containment, Medicare, Medicaid, CHIP, long term care and overall politics of health care."
- RICHARD KAPLAN
Professor of Law, University of Illinois
Champaign IL 61820-6909
"My areas of specialization are Elder Law (advance directives, Medicare, long-term care financing) and federal income taxation, including employer-based health insurance."
- GENEVIEVE KENNEY
Principal Research Associate, The Urban Institute
Washington DC 20037
"My primary research interests include Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance coverage and access issues among low-income children and families."
- LEIGHTON KU
Senior Fellow, Center on Budget and Policy Priorities
Washington DC 20010
"My main areas of interest are health insurance coverage and how we pay for it; this particularly includes Medicaid and SCHIP. My organization is engaged in timely research and advocacy at both federal and state levels."
- JOANN LAMPHERE
National Coordinator, Health and LTC Team, AARP
Washington DC 20049
- ENRIQUE MARTINEZ-VIDAL
Director, State Coverage Initiatives, AcademyHealth
Washington DC 20006
"The State Coverage Initiatives program works with states to plan, execute and maintain health insurance expansions. Areas of Expertise: State Coverage Programs; Health Insurance Markets; Medicaid/SCHIP; Quality/Cost Containment Efforts at the State Level."
- TRUDI MATTHEWS
Associate Director for Health Policy, The Council of State Governments
Lexington KY 40578
"I work for a 70-year old national, nonpartisan organization of state officials in all three branches of government, including governors, state legislators, and executive branch appointees. It is my job to monitor health policy developments, trends and innovations and know what they mean for states."
- LAWRENCE MCANDREWS
President & CEO, National Association of Children's Hospitals
Alexandria VA 22314
"Mr. McAndrews is an expert in children's health care and federal policy issues that affect children's health and children's hospitals' ability to serve all children. These issues include Medicaid, quality measurement and improvement in pediatrics, graduate medical education and pediatric research funding. Mr. McAndrews is also an expert in the (children's) hospital industry and can provide commentary on health care trends as they impact children's hospitals."
- MARK McCLELLAN
Senior Fellow, The Brookings Institution
Washington DC 20036
"Dr. Mark B. McClellan is the former administrator for the Centers for Medicare and Medicaid Services (CMS) and the former commissioner of the Food and Drug Administration (FDA) in the U.S. Department of Health and Human Services. In October 2006, Dr. McClellan joined the AEI-Brookings Joint Center for Regulatory Studies as a visiting senior fellow. At AEI and Brookings, Dr. McClellan works on developing and implementing ideas to drive improvements in high-quality, innovative, affordable health care. Dr. McClellan is also an associate professor of economics and associate professor of medicine at Stanford University, from which he was on leave during his government service."
- BRENDAN McTAGGART
Communications Director, National Health Law Program
Washington DC 20005
"I am the communications director for the National Health Law Program, which employs some of the nation's foremost experts on Medicaid law. Areas of focus include children's health, immigrant access to health care, reproductive health, and racial disparities in health care. I am not an expert on health care law myself but can direct you to the appropriate staff attorney."
- MARK MERLIS
Health policy consultant
New Hope PA 18938
"I provide policy and data analysis to the federal government and private foundations on a wide range of subjects, including Medicare and Medicaid, private health insurance reform, long-term care financing, and international comparison of healthcare systems."
- TOM MILLER
Resident Fellow, American Enterprise Institute
Washington DC 20036
"Areas of research include consumer-driven health care, health insurance regulation, information transparency, value purchasing, tax treatment of health care, Medicare reform, genetic information, Medicaid, health care cost factors, uninsured."
- ALICIA MITCHELL
Vice President, Media Relations, American Hospital Association
Washington DC 20004
"The American Hospital Association is the umbrella group for the nation's hospitals. The AHA has experts working on issues, including access and coverage for the uninsured, Medicare and Medicaid, medical liability reform, quality and patient safety, regulatory reform and relief, health care costs, bioterrorism and disaster readiness, among others."
- JUDITH MOORE
Senior Fellow, National Health Policy Forum
Washington DC 20037
"Principle expertise and interest in public programs and health insurance for low income people, particularly the Federal-state Medicaid program and the State Children's Health Insurance Program (SCHIP). Knowledge of Medicaid enrollment, eligibility, benefits, state and federal program administration, recent policy changes, and policy history of the programs."
- MICHAEL O'GRADY
Senior Fellow, NORC at the University of Chicago
washington DC 20036
"Former Assistant Secretary for Planning and Evaluation at HHS, former senior health economist Senate Finance Committee and Joint Economic Committee. Expertise is Medicare, Medicaid, long-term care and the uninsured, especially issues related to the aging of the baby boom and its impact on the long-term financial viability of programs like Medicare and Medicaid."
- EDWIN PARK
Senior Health Policy Analyst, Center on Budget & Policy Priorities
Washington DC 20002
"Medicaid, SCHIP, Medicare, and tax issues related to health care Previously, health care policy advisor for the National Economic Council at the White House and Medicaid health professional staff member for the Senate Finance Committee (minority staff, Senator Daniel Patrick Moynihan). Also, an associate practicing health law for the law firm of Hogan & Hartson. Graduated from Harvard Law School and Princeton University."
- KIP PIPER
President, Health Results Group LLC
Washington DC 20006
"Healthcare strategist. Expert in Medicare, Medicaid, and pharmaceutical industry. Consultant, speaker, and blogger. Topics include Medicare Part D drug benefit, Medicaid reform, consumer-driven health care, prescription drug benefits, pharma / biotechnology industry, health financing, and managed care. Experience includes consultant to Fortune 100 companies, states, and foundations; senior advisor to CMS administrator; state Medicaid director; state health commissioner; and Medicare expert at White House budget office. On web at kippiper.com. Blog at piperreport.com."
- RON POLLACK
Executive Director, Families USA
Washington, D.C. DC 20005
"Families USA is the national organization for health care consumers. As executive director of Families USA, health care expertise includes health coverage for the uninsured, prescription drugs costs and affordability, Medicare and Medicaid, patients' rights legislation, and health care ombudsman issues."
- MICHAEL POLLARD
Consultant, Federal Policy & Regulation, Medco Health Solutions, Inc.
Washington DC 20004
"I am an experienced health lawyer with knowledge of federal health programs (e.g.,Medicare, Medicaid), prescription drug management, fraud and abuse and anti-kickback laws, electronic prescribing, HIPAA, confidentiality of medical records, and antitrust enforcement."
- MARTHA ROHERTY
Director, National Association of State Medicaid Directors
Washington DC 20002
202-682-0100 ext. 299
"Martha Roherty is the Director of the National Association of State Medicaid Directors and the Center for Workers with Disabilities. The National Association of State Medicaid Directors (NASMD) is a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories). Since 1979, NASMD has been affiliated with the American Public Human Services Association (APHSA). The primary purposes of NASMD are: to serve as a focal point of communication between the states and the federal government, and to provide an information network among the states on issues pertinent to the Medicaid program."
- SARA ROSENBAUM
Chair, Department of Health Policy, George Washington University
Washington DC 20006
Sara Rosenbaum is Hirsh Professor and founding chair of the Department of Health Policy at the George Washington University School of Public Health and Health Services. She has devoted her career to issues of health law and policy affecting low income, minority, and medically underserved populations, and the health care safety net. Between 1993 and 1994, she worked for President Clinton, directing the legislative drafting of the Health Security Act and developing the Vaccines for Children program. She has written more than 250 articles and studies focusing on all phases of health law, as well as health care for medically underserved populations, and is coauthor of Law and the American Health Care System (Foundation Press, NY).
- DIANE ROWLAND
Executive Director, Kaiser Commission on Medicaid and the Uninsured
Washington DC 20005
"My primary interests are Medicare and Medicaid policy, health coverage and the uninsured, coverage and access to care for the low-income population, and health care reform. As executive director of the Kaiser Commission on Medicaid and the Uninsured, much of my work examines coverage for the low-income and uninsured populations."
- MATT SALO
Director of Health Legislation, National Governors Association
Washington DC 20001
"I have been the director of health legislation for the National Governors Association since January 1999. Prior to that I spent 5 years working for the National Association of State Medicaid Directors."
- JOHN SHEILS
Vice President, The Lewin Group
Falls Church VA 22042
"Sheils specializes in financial analyses of programs to expand insurance coverage including the impact on providers, consumers employers and governments. He has analyzed a broad range of proposals including tax credits, single-payer, Medicaid/SCHIP expansions, individual mandates and employer pay-or-play proposals."
- JUDITH SOLOMON
Senior Fellow, Center on Budget and Policy Priorities
Washington DC 20002
"My expertise is in the area of the provision of services to children and families in Medicaid and SCHIP (HUSKY in Connecticut)as well as eligibility for these programs. This includes knowledge of state and federal statutory and regulatory requirements governing eligibility and the provision of services."
- STEPHEN A. SOMERS
President, Center for Health Care Strategies
Hamilton NJ 08619
"My primary interests include identifying opportunities to: improve the quality and cost-effectiveness of Medicaid programs, particularly for those beneficiaries with the highest-risk and highest-cost needs; make long-term care more affordable; reduce health care disparities; leverage Medicaid's position as a leading health purchaser to support regional quality improvement efforts; and demonstrate the "business case" to support investments in health care quality."
- MICHAEL TANNER
Director, Health & Welfare Studies, Cato Institute
Washington DC 20001
"As director of Cato's health and welfare studies, Michael Tanner oversees Cato's research on new, market-based approaches to health care reform and social welfare programs. He is the author or coauthor of several books, including Healthy Competition: What's Holding Back Health Care and How to Free It. His writings have appeared in nearly every major American newspaper, including the New York Times, Washington Post, Los Angeles Times, Wall Street Journal, and USA Today. A prolific writer and frequent guest lecturer, Tanner appears regularly on network and cable news programs."
- ALAN WEIL
Executive Director, National Academy for State Health Policy
Washington DC 20036
"My research focuses on Medicaid, the uninsured and state/federal issues. I also have experience as a state Medicaid administrator."
- TIM WESTMORELAND
Visiting Professor of Law, Research Professor of Public Policy, Georgetown University
Washington DC 20007
"I have been health staff for the U.S. House on and off for the last 25 years. I was also the director of the Medicaid program."
- JOSHUA WIENER
Senior Fellow, RTI International
Washington, DC 20005
"I am an expert in long-term care, Medicaid, state health policy, and health care for the elderly and people with disabilities."
- PETERS WILLSON
Vice President, Public Policy, National Association of Children's Hospitals
Alexandria VA 22314
"My areas of expertise include Medicaid policy - its impact on children and safety net providers, specifically children's hospitals; and graduate medical education in children's hospitals."
- JUDITH WOOLDRIDGE
Senior Vice President, Mathematica Policy Research
Princeton NJ 08543-2393
"My current area of study is Medicaid and SCHIP health insurance coverage policy and the use of managed care in these programs, especially for vulnerable populations. I have a long term interest in diabetes secondary prevention among Medicare beneficiaries."
- JENNIFER YOUNG
Principal, Tarplin, Downs & Young
Washington DC 20005
"During the Bush Administration. I served as the Assistant Secretary for Legislation at the Department of Health and Human Services and as Senior Counselor to Secretary Leavitt. Previously, I have worked for the Ways and Means Committee, the Finance Committee and the National Governors' Association. I am well versed in Administration and Congressional health care priorities, particularly related to entitlement programs."
- STEPHEN ZUCKERMAN
Principal Research Associate, The Urban Institute
Washington DC 20015
"I have expertise on Medicaid and state health policy, managed care, access and use among low-income groups, the health care safety net, physician and hospital payment. In addition, I have developed a modified approach to survey measurement of the uninsured that was adopted by the Current Population Survey"
Glossary on the Uninsured
ADVANCEABLE TAX CREDIT - A subsidy to help pay for health insurance that is available when the insurance premium is due, without having to wait until a year-end tax return is filed. Also see "tax credit."
ACTIVITIES OF DAILY LIVING (ADL) - An index or scale which measures a patient's degree of independence in bathing, dressing, using the toilet, eating and transferring (moving from a bed to a chair, for example). Used to determine need for long-term care and eligibility for payments for care by insurers.
ACUTE CARE - Medical services provided to treat an illness or injury, usually for a short time. Contrast with "chronic care."
BLOCK GRANT - A lump sum of money given to a state or local government to be spent for certain purposes. Normally, it is based on a formula, the objectives are broadly defined and the grant's source places relatively few limits on the money's use.
CAPITATION - Method of payment for health services in which a health care provider is paid a fixed amount for each person on the provider's patient roster, regardless of the actual number or nature of services provided to each person.
CARVE-OUTS - A payer strategy in which an HMO or insurance company isolates ("carves out") a benefit and hires another organization to provide this service. Common carve-outs include behavioral health and prescription drugs. The technique is intended to allow the insurer to better control its costs.
CASE MANAGEMENT - A process where a health plan identifies covered persons with specific health care needs, then devises and carries out for them a plan to achieve the best patient outcome in the most cost-effective manner.
CASH AND COUNSELING - A Medicaid long-term care waiver demonstration program that allows certain Medicaid beneficiaries to purchase their own personal care and related services. Medicaid provides a monthly allowance, the amount of which is determined after assessing the beneficiary's need for community-based long-term care services. Starting in 2007, states may implement similar capped programs covering costs of self-directed personal care services without a waiver.
CATEGORICAL ELIGIBILITY - Medicaid's eligibility pathway for individuals who can be covered. The program's 25+ categories can be organized into five broad groups - children, pregnant women, adults in families with dependent children, individuals with disabilities and the elderly. Certain individuals, notably single adults without children, cannot qualify for Medicaid, even if their incomes are low enough to meet financial eligibility standards.
CHRONIC CARE - Medical services provided to those a chronic condition, one that is not expected to improve, that lasts a year or longer or recurs, and may result in long-term care needs. Chronic illnesses include Alzheimer's disease, arthritis, diabetes, epilepsy and some mental illnesses. Contrast with "acute care."
CHURNING - The cycle involving a person's enrollment in a health insurance program (such as Medicaid or employer-sponsored coverage), then losing eligibility, the regaining it and re-enrolling.
COINSURANCE - A portion of the bill for a medical service, that is not covered by the patient's health insurance policy and therefore must be paid out of pocket by the patient. Coinsurance refers to a percentage, e.g., 10 percent of the total charge up to a specified maximum. Contrast with "copayment."
COMMUNITY HEALTH CENTER (CHC) - Organization providing comprehensive primary care to medically underserved populations, regardless of their ability to pay. These public and non-profit entities receive federal funding under Section 330 of the Public Health Service Act, as amended.
COPAYMENT - A flat dollar amount that a patient must pay out of pocket for a medical service, e.g. $5 per office visit.
COST SHIFTING - The practice by which a seller of a health service, such as a hospital, increases charges for some payers to offset losses due to uncompensated or indigent care or lower payments from other payers.
CROSS-SUBSIDY - The concept of certain purchasers paying more for medical services than they otherwise would so that others can pay less (or nothing at all), or another activity can be funded. In the U.S. health system, this mechanism has been used to pay for medical services for the poor and uninsured, medical education and research.
CROWD-OUT - A phenomenon whereby expansions of public programs designed to extend coverage to the uninsured encourage some employers to drop coverage, or cause some employees to enroll themselves and/or family members in public coverage programs rather than employer-sponsored coverage.
DEDUCTIBLE - A fixed amount, usually expressed in dollars in the form of an annual fee, that the beneficiary of a health insurance plan must pay directly to the health care provider before a health insurance plan begins to pay for any costs associated with the insured medical service.
DEFICIT REDUCTION ACT OF 2005 (DRA) - The DRA made significant changes to the Medicaid program - for example, allowing states to increase premiums and cost-sharing for families and to base benefits on private plans. The law also tightened long-term care asset transfers and capped the amount of home equity that can be disregarded in measuring eligibility at $500,000. A DRA provision in effect since July 1, 2006 requires Medicaid beneficiaries to show proof of citizenship upon applying for or renewing their benefits. For more information, see www.kff.org/medicaid/7465.cfm.
DEFINED BENEFIT - A health insurance model used by an employer or government program where specified health services covered under the plan are standardized and guaranteed. The cost of providing the standard benefits may fluctuate. One example of a defined benefit plan is Medicare. Contrast with "defined contribution."
DEFINED CONTRIBUTION - A health benefit model used by employers or government programs where health services covered may fluctuate based on choice of plan, but the employer or government contributes a set amount (percentage or dollar amount) towards the purchase of the selected health plan. A defined contribution plan limits the financial liability of employers or the government, because the contribution is defined, or fixed. An example of a defined contribution plan is the State Children's Health Insurance Program. Contrast with "defined benefit."
DISPROPORTIONATE SHARE HOSPITAL (DSH) ADJUSTMENT - An increased payment under Medicare's prospective payment system or under Medicaid for hospitals that serve a relatively large number of low-income uninsured patients.
DUAL ELIGIBLE - A Medicare beneficiary who also receives either a full range of Medicaid benefits offered in his or her state, or help through Medicaid with Medicare out-of-pocket expenses. For more information, see www.cms.hhs.gov/DualEligible. Also see "qualified Medicare beneficiary" and "specified low-income Medicare beneficiary."
FEDERAL MEDICAL ASSISTANCE PERCENTAGE (FMAP) - Percentage used to determine the amount of federal matching funds for state Medicaid expenditures. By law, FMAP cannot be less than 50 percent or exceed 80 percent. Slightly higher Enhanced Federal Medical Assistance Percentages are used to determine matching payments for the State Children's Health Insurance Program (SCHIP). These payments cannot exceed 85 percent of the state's total SCHIP expenditures. For more information, see http://aspe.hhs.gov/health/fmap07.htm.
FEDERAL POVERTY GUIDELINES - Income amounts set each February by the U.S. Department of Health and Human Services used to determine an individual's or family's eligibility for various public programs, including Medicaid and the State Children's Health Insurance Program. Sometimes called Federal Poverty Level/Line (FPL). (The poverty guidelines are different from the U.S. Census Bureau's "poverty thresholds," which are used for Census statistical purposes.) For the 2007 poverty guidelines, see http://aspe.hhs.gov/poverty/07poverty.shtml
HEALTH INSURANCE FLEXIBILITY AND ACCOUNTABILITY (HIFA) DEMONSTRATION INITIATIVE - A Bush Administration initiative to encourage states to apply for certain Medicaid Section 1115 and SCHIP waivers. HIFA waivers make it possible for states to offer private health insurance coverage or employer-sponsored coverage, with subsidies, as an alternative to enrolling beneficiaries in traditional Medicaid or SCHIP. For more information, see www.cms.hhs.gov/HIFA
HEALTH OPPORTUNITY ACCOUNT (HOA) - A type of health savings account for Medicaid beneficiaries created by the Deficit Reduction Act of 2005 . States may deposit annual sums of up to $2,500 per adult and $1,000 per child into the account, to be used to pay for medical expenses not covered by the high deductible health plan with which the account is coupled. Beginning January 1, 2007, as many as 10 states could initiate HOA demonstration projects. Compare to "Health Savings Account" and "Health Reimbursement Arrangement."
HEALTH REIMBURSEMENT ARRANGEMENT (HRA) - A type of health insurance plan also known as "health reimbursement account" or "personal care account," HRAs are tax-preferred accounts with funds established by employers to reimburse employees for qualified medical expenses; often HRAs are paired with a high-deductible health plan. An HRA may be used by an employee to pay for medical coverage until funds are exhausted. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year, but do not follow the employee once he or she changes jobs. Compare to "health savings account."
HEALTH SAVINGS ACCOUNT (HSA) - A type of health insurance plan similar to a Health Reimbursement Account, but which is owned by workers. An HSA is a tax-preferred savings account and is paired with a high-deductible health plan. Any employer can offer an HSA (or a self-employed individual can set one up on his or her own), and both employers and employees can contribute to it. The worker must pay for all services until the amount of the deductible is reached (in 2007, a minimum of $1,100 for an individual and $2,200 for family coverage). The worker can withdraw money from the HSA to pay for medical services under the deductible. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year. Unlike HRAs, HSAs follow an employee when he or she changes jobs. Also see "health reimbursement arrangement."
HOME AND COMMUNITY-BASED SERVICES (HCBS) - State-designed HCBS encompass case management, adult day care, home health aide assistance, personal care, assisted living services and respite care. Section 1915(c) of the Social Security Act permits the HHS Secretary to approve Medicaid waivers that allow for long-term care services to be delivered in community instead of institutional settings. The Deficit Reduction Act also created a new capped HCBS option that allows states to offer these services without having to obtain administrative waiver approval. See "Medicaid Section 1915 Waiver."
HOME HEALTH CARE - Health services rendered in the home, including skilled nursing care, speech therapy, physical therapy, occupational therapy, rehabilitation therapy and social services. Medicare covers some home health care services if the beneficiary is homebound but does not require more than 35 hours of services per week. Medicaid pays for home health care services in 12 states.
HOME HEALTH AGENCY (HHA) - Health care provider organization that renders skilled nursing and health care services in the home. See "home health care."
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs) - Activities relating to independent living, which include preparing meals, keeping a budget, purchasing groceries, performing housework and using a telephone. IADLs refer to skills beyond basic self care, or "activities of daily living."
INTERGOVERNMENTAL TRANSFER (IGT) - Transfer of funds among or between different levels of government, including state-owned or operated facilities and local governments. The term is most often used in Medicaid, where transfers of non-federal public funds to the state Medicaid agency are used to draw down federal matching funds. States also use IGTs to draw down federal "disproportionate share hospital adjustment" and "upper payment limit" funds.
LONG-TERM CARE (LTC) - Ongoing health and social services provided for individuals who need continuing assistance with activities of daily living and/or instrumental activities of daily living. Services can be provided in an institution, the home or the community, and include informal services provided by family and friends as well as formal services provided by professionals or agencies. Medicaid is the primary payer of LTC services in nursing homes.
MANAGED CARE - Care provided by a health care organization, such as a health maintenance organization (HMO) or preferred provider organization (PPO), that contracts to provide medical services to a group of enrollees in exchange for capitated monthly premiums. Payments to physicians and other practitioners in HMOs are often lower than fee-for-service payments.
MEANS-TESTING - Determining eligibility for government benefits based on an individual's lack of means, as measured by income and/or assets. Under Medicaid, means-testing differs for different eligibility groups (see "categorical eligibility").
MEDICAID - Public health insurance program that provides coverage for an estimated 60 million low-income persons for acute and long-term care. It is financed jointly by state and federal funds (the federal government pays at least 50 percent of the total cost in each state), and is administered by states within broad federal guidelines. Contrast with "Medicare."
MEDICAID SECTION 1115 WAIVER - Under Section 1115(a) of the Social Security Act, the secretary of Health and Human Services may waive most provisions of Medicaid law for demonstrations "likely to assist in promoting the objectives" of the program. Under long-standing policy, these waivers must be cost-neutral. Demonstration waivers may be granted for research purposes, to test a program improvement, or investigate a new way of delivering services.
MEDICAID 1915 (b) AND (c) WAIVER - Under Section 1915(b) of the Social Security Act, the secretary of Health and Human Services may waive any provision of Medicaid law that prevent states from limiting beneficiaries' ability to choose providers. Section 1915(b) waivers are often sought by states that hope to control costs through managed care. Under Section 1915(c), the Secretary can allow states to obtain matching funds for long-term care services provided to Medicaid beneficiaries in home and community-based settings. Waivers are effective for two years.
MEDICALLY NEEDY - A Medicaid category for income eligibility in which states can choose to cover individuals and families who quality for coverage because of high medical expenses, usually for hospital or nursing home care. To qualify, individuals must be categorically eligible and their monthly incomes minus accumulated medical bills must be below state income limits for the Medicaid program. This allows Medicaid coverage for people who have extensive health care needs but too much income to be eligible for Medicaid. Also see "spend-down."
MEDICARE - Federal health insurance program for virtually all persons age 65 and older, and permanently disabled persons under age 65, who qualify by receiving Social Security Disability Insurance. Contrast with "Medicaid."
MEDICARE SAVINGS PROGRAM - A series of Medicaid-financed provisions enacted by Congress beginning in 1988 to assist Medicare beneficiaries who do not qualify for a full Medicare benefits package. People enrolled in MSPs are often referred to as "dual eligibles" because they are usually eligible for both Medicare and Medicaid.
PREMIUM ASSISTANCE - The use of federal funds available through public health coverage programs -- especially Medicaid and the State Children's Health Insurance Program -- to purchase or help purchase private insurance.
PRIMARY CARE CASE MANAGEMENT, INITIATIVE, OR CLINICIAN - (PCCM/PCI/PCC) - A Medicaid managed care program in which an eligible individual may use services only with authorization from his or her assigned primary care provider. That provider is responsible for locating, coordinating, and monitoring all primary and other medical services for enrollees. Those services are usually paid on a fee-for-service basis.
QUALIFIED MEDICARE BENEFICIARY (QMB) - A person who is eligible for Medicare, has an income below 100 percent of the federal poverty level and has limited assets, is eligible to receive cost-sharing assistance if enrolled in the Qualified Medicare Beneficiary program. Under the QMB program, state Medicaid agencies are required to pay the cost of Medicare Part A and B premiums, deductibles, and coinsurance. For more information, see www.cms.hhs.gov/DualEligible. Compare to "specified low-income Medicare beneficiary."
SAFETY NET PROVIDERS - Providers that have a primary focus of servicing low-income and uninsured people. They include community and migrant health centers and public hospitals.
SECTION 1115 WAIVER - See "Medicaid Section 1115 Waiver"
SECTION 1915 (a) AND (b) WAIVER - See "Medicaid 1915 (a) and (b) Waiver"
SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (SLMB) - A person who is eligible for Medicare, has an income of between 100 to 120 percent of the federal poverty level and has limited assets, is eligible to receive cost-sharing assistance if enrolled in the Specified Low-Income Medicare Beneficiary program. Under the SLMB program, state Medicaid agencies are required to pay the beneficiary's Part B premiums, but not deductibles or copayments. Also see "qualified Medicare beneficiary." For more information, see www.cms.hhs.gov/DualEligible.
SPEND-DOWN - Process by which individuals in many states can qualify for Medicaid because high medical expenses, usually hospital or nursing home care, reduce their monthly income to below state income limits for the Medicaid program. The amount that each individual must "spend down" is determined at the time eligibility is determined. Also see "medically needy."
STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP) - A program enacted by Congress in 1997 that provides federal matching funds for states to spend on health coverage for uninsured kids. The program is designed to reach uninsured children whose families earn too much money to qualify for Medicaid but not enough to afford private coverage.
SUPPLEMENTAL SECURITY INCOME (SSI) - A federal income support program for low-income disabled, aged and blind individuals. Eligibility for SSI monthly cash payments does not depend on previous employment or contributions to a trust fund. Eligibility for SSI usually confers eligibility for Medicaid.
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) - The block grant program that, in 1996, replaced categorical welfare assistance such as Aid to Families with Dependent Children. Under TANF, time limits are set for cash benefits, and recipients are expected to accept work or be enrolled in training programs. TANF was reauthorized in 2005 as part of the Deficit Reduction Act with $16.4 billion in annual funding through FY 2010. For more information, see www.acf.hhs.gov/programs/ofa/.
TRANSITIONAL MEDICAL ASSISTANCE (TMA) - Medicaid coverage for up to one year for families leaving welfare to become self-supporting through work. During this transition period, states are required to continue Medicaid benefits even if earnings increase. For more information, see http://opencrs.cdt.org/document/RL31698/.
UPPER PAYMENT LIMIT (UPL) - Federal regulatory payment limit governing what states can pay eligible public facilities for Medicaid services. The UPL is usually the rate Medicare would pay for the same service. In some cases, states request federal matching funds in amounts that exceed the state's standard Medicaid reimbursement rate, and use the new revenues generated for other goods or services. Also see "Intergovernmental Transfer."
1 Congressional Budget Office, "Statement of Donald B. Marron, Acting Director: Medicaid Spending Growth and Options for Controlling Costs," Testimony before the Special Committee on Aging, U.S. Senate, July 13, 2006. http://www.cbo.gov/ftpdocs/73xx/doc7387/07-13-Medicaid.pdf
2 Centers for Medicare and Medicaid Services, "2006 Medicaid Managed Care Enrollment Report," June 30, 2006. http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/Downloads/mmcer06.pdf
3 Kaiser Commission on Medicaid and the Uninsured, "New Survey Indicates Medicaid Enrollment Declines for the First Time in Nearly a Decade," Oct. 10, 2007. http://www.kff.org/medicaid/kcmu101007nr.cfm
4 Kaiser Commission on Medicaid and the Uninsured, "The Medicaid Program At a Glance," March 2007. http://www.kff.org/medicaid/upload/7235-02.pdf
5 Kaiser Family Foundation State Health Facts, "Total Medicaid Spending FY 2006," http://www.statehealthfacts.org/comparetable.jsp?cat=4&ind=177. This page also included individual spending for each state in 2006.
6 National Association of State Budget Officers, "The Fiscal Survey of States," June 2007. www.nasbo.org/Publications/PDFs/Fiscal%20Survey%20of%20the%20States%20June%202007.pdf
7 National Conference of State Legislatures (2007). "State Budget Actions FY 2006 and FY 2007." http://www.ncsl.org/programs/fiscal/sba06sum.htm
8 Kaiser Commission on Medicaid and the Uninsured, "Medicaid: A Primer," March 2007. http://www.kff.org/medicaid/upload/7334%20Medicaid%20Primer_Final%20for%20posting-3.pdf
9 Rowland, Diane (2005) "Medicaid - Implications for the Health Safety Net," New England Journal of Medicine 353(14): 1439-1441. http://content.nejm.org/cgi/content/short/353/14/1439
10 Kaiser Commission of Medicaid and the Uninsured, "The Medicaid Program at a Glance." March 2007. (www.kff.org/medicaid/7334-02.cfm)
11 AARP, "The Medicaid Matching Formula: Responding to States in Times of Need," March 2007. http://assets.aarp.org/rgcenter/health/fs134_medicaid.pdf
12 Kaiser Commission on Medicaid and the Uninsured, "State Fiscal Conditions and Medicaid," October 2006, p. 2. http://www.kff.org/medicaid/upload/7580.pdf
13 Robert Pear, "Planned Medicaid Cuts Cause Rift with States," New York Times, Aug. 13, 2006.
14 David M. Cutler and Jonathan Gruber, "Does Public Insurance Crowd Out Private Insurance" National Bureau of Economic Research Working Paper No. 5082, April 1995, http://www.nber.org/papers/w5082.v5.pdf, cited in Andrew M. Grossman and Greg D'Angelo, "SCHIP and 'Crowd-Out': How Public Program Expansion Reduces Private Coverage." Heritage Foundation, June 21, 2007. http://www.heritage.org/Research/HealthCare/wm1518.cfm
15 Kaiser Commission on Medicaid and the Uninsured, "Vermont's Global Commitment Waiver: Implications for the Medicaid Program." May 2, 2006. http://www.kff.org/medicaid/7493.cfm
16 Centers for Medicare and Medicaid Services, "Medicaid State Waiver Program Demonstration Projects - General Information," http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/