Medicaid Managed Care - U.S. Senate Special Committee on Aging
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Medicaid Managed Care - U.S. Senate Special Committee on Aging

Medicaid Managed Care - U.S. Senate Special Committee on Aging Medicaid Managed Care - U.S. Senate Special Committee on Aging

aging.senate.gov
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268 If enrollment of eligible individuals does drop, one result may be that some of the poor may dela% seeking ong>Medicaidong> coverage until confronted with an acute episode, especially a costly inpatient stay. This situation is especially problematic if it means these individuals also defer preventive care because they lack coverage. ong>Medicaidong> managed-care plans could be affected as well if delayed enrollment into ong>Medicaidong> causes the mix of beneficiaries to be more expensive. States may base capitation rates on the lower utilization levels of the previous enrolled population. If so, plans drawing an average mix of enrollees would be more expensive than the healthier population on which capitation payments are based (United Hospital Fund 1996a; NHPF 1997). As noted above, there is already a gap between eligibility and enrollment. The Commission last year reiterated its longstanding call for monitoring access in the ong>Medicaidong> program (PPRC 1996). That recommendation called for the Department of Health and Human Services to monitor access and to report to the Congress on a yearly basis. As part of its recommendation, the Commission called for continued development of a uniform ong>Medicaidong> claims and encounter data system, a requirement that states participate in that system, and development and administration of a periodic access survey of ong>Medicaidong> beneficiaries and other low-income persons. The enactment of welfare reform heightens the urgency of monitoring access to health care and reemphasizes the need to determine whether there is an increase of eligible, but not enrolled, beneficiaries. Spending by Enrollment Group Patterns of service use and overall expenditures differ dramatically among the three major populations served by ong>Medicaidong> (Figure 20-1). Children and adults in families with dependent children accounted for 72 percent of ong>Medicaidong> beneficiaries in 1995, but only 33 percent of program payments. 4 By contrast, the elderly, only II percent of beneficiaries, accounted for 30 percent of total spending. Blind and disabled persons constituted 17 percent of beneficiaries and 38 percent of payments (Kaiser Commission 1996c; 1997a). Viewed another way, ong>Medicaidong> expenditures for each elderly beneficiary in 1995 were almost seven times those for each child and almost five times those for every adult in a low-income family (Figure 20-2). This difference is attributable largely, but not exclusively, to spending for long-term care for the elderly population; levels of acute spending are much more similar among these groups. Spending on blind and disabled beneficiaries is somewhat lower than that for elderly beneficiaries and includes a larger amount of acute care services than the other groups. ' This analysis excludes administrative expenses and payments to disproportionate share hospitals, which cannot be allocated by enrollment group. 417 Physician Payment Review Commission

269 Figure 20-1. ong>Medicaidong> Beneficiaries and Expenditures, by Enrollment Group, 1995 (percentage) Elderly 11.1% Blind & Elderty Disabled 29.7% 16.5% Low-Income Adults 23.1% Blind & Disabled 37.6% Low- | | Low-Income Income Adults Children 12.8% 49.3% Low-income Children 19.9% Beneficiaries Expenditures Total = 34.8 million people Total = $132.3 billion SOURCE: Kaiser Commission on the Future of ong>Medicaidong> 1997a. NOTE- Total expenditures exclude administrative expenses and disproportionate share hospital payments. Spending by Service ong>Medicaidong> requires all states to provide categorically needy beneficiaries a standard benefit package that includes inpatient and outpatient hospital services; physician services; laboratory and X-ray services; family planning; skilled nursing facility (SNF) services for adults; home health care for persons entitled to SNF services; rural health clinic services; nurse-midwife services; and early and periodic screening, diagnosis, and treatment (EPSDT) for children. The required benefit package for the medically needy is less comprehensive. States opting to cover the medically needy must, at a minimum, furnish ambulatory care for children and prenatal care and delivery services for pregnant women. Almost all states that have medically needy programs, however, provide the same services to both medically and categorically needy beneficiaries. States may also provide (and receive federal matching payments for) other services, including prescription drugs; dental care; eyeglasses; services provided by optometrists, podiatrists, and chiropractors; intermediate care facility (ICF) services; and ICF services for the mentally retarded (ICF/MR). States vary considerably in the optional services they offer. Virtually all cover prescription 1997 Annual Report to Congress/Chapter 20 418

269<br />

Figure 20-1. <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> Beneficiaries and Expenditures, by Enrollment Group, 1995<br />

(percentage)<br />

Elderly<br />

11.1%<br />

Blind & Elderty<br />

Disabled 29.7%<br />

16.5%<br />

Low-Income<br />

Adults<br />

23.1%<br />

Blind &<br />

Disabled<br />

37.6%<br />

Low- | | Low-Income<br />

Income Adults<br />

Children 12.8%<br />

49.3%<br />

Low-income<br />

Children<br />

19.9%<br />

Beneficiaries Expenditures<br />

Total = 34.8 milli<strong>on</strong> people Total = $132.3 billi<strong>on</strong><br />

SOURCE: Kaiser Commissi<strong>on</strong> <strong>on</strong> the Future of <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> 1997a.<br />

NOTE- Total expenditures exclude administrative expenses and disproporti<strong>on</strong>ate share hospital payments.<br />

Spending by Service<br />

<str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> requires all states to provide categorically needy beneficiaries a standard benefit package that<br />

includes inpatient and outpatient hospital services; physician services; laboratory and X-ray services;<br />

family planning; skilled nursing facility (SNF) services for adults; home health care for pers<strong>on</strong>s<br />

entitled to SNF services; rural health clinic services; nurse-midwife services; and early and periodic<br />

screening, diagnosis, and treatment (EPSDT) for children.<br />

The required benefit package for the medically needy is less comprehensive. States opting to cover the<br />

medically needy must, at a minimum, furnish ambulatory care for children and prenatal care and<br />

delivery services for pregnant women. Almost all states that have medically needy programs, however,<br />

provide the same services to both medically and categorically needy beneficiaries.<br />

States may also provide (and receive federal matching payments for) other services, including<br />

prescripti<strong>on</strong> drugs; dental care; eyeglasses; services provided by optometrists, podiatrists, and<br />

chiropractors; intermediate care facility (ICF) services; and ICF services for the mentally retarded<br />

(ICF/MR). States vary c<strong>on</strong>siderably in the opti<strong>on</strong>al services they offer. Virtually all cover prescripti<strong>on</strong><br />

1997 Annual Report to C<strong>on</strong>gress/Chapter 20 418

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