south dakota medicaid program
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South Dakota Medicaid Program. April 23, 2013. What is Medicaid?. Medicaid is one of the largest healthcare insurers in South Dakota Federal-State partnership governed by Medicaid state plan- agreement with federal government on who is served and what services are covered - PowerPoint PPT PresentationTRANSCRIPT
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South Dakota Medicaid Program
April 23, 2013
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What is Medicaid?
• Medicaid is one of the largest healthcare insurers in South Dakota
• Federal-State partnership governed by Medicaid state plan- agreement with federal government on who is served and what services are covered
• Each state’s plan is different Makes comparisons between states difficult
• Different than Medicare - 100% federal coverage for older and some disabled adults
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Who Uses Medicaid Now?
• Medicaid covered 144,373 unduplicated individuals during FY12 • Nearly 1 of every 7 persons in any given month will have health
coverage through Medicaid or CHIP.
• 1 of every 3 persons under the age of 19 in South Dakota has health coverage through Medicaid or CHIP.
• 50 percent of the children born in South Dakota will be on Medicaid or CHIP during the first year of their life.
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Who Uses Medicaid Now?
Medicaid eligibility depends on: 1. Whether a person meets a specific eligibility category;
2. Resources; andExamples: bank accounts, bonds, stocks, certificates of
deposit, real property and other things of value that are owned
3. Income
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Who is covered by Medicaid?
• States required to cover some “mandatory” groups• Children under age 6 below 133% FPL• Children age 6-18 under 100% FPL• Pregnant women under 133% FPL• Elderly and disabled on SSI- also called Aged, Blind and Disabled• Parents below cash assistance eligibility levels- 49% FPL• 2013 FPL Chart:
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Who is covered by Medicaid?
• States have option to increase eligibility levels, with approval from CMS
• SD covers children through CHIP up to 200% FPL
• 69 percent are children and 31 percent are adults
• Adults who are not disabled or parents with very low incomes are not covered by Medicaid
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Who is covered by Medicaid?
21%
11%
2%
66%
Aged/Blind/Dis-abledLow Income Families
Pregnant Women
Children
31%
69%
AdultsChildren
SFY12 Actual Average Monthly Eligibles – 115,731
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Who is covered by Medicaid?
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What services are covered by Medicaid?
Medicaid Mandatory Services (examples)• Inpatient hospital services • Outpatient hospital services • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
services• Nursing facility services • Home health services • Physician services • Rural health clinic services • Federally qualified health center services • Laboratory and X-ray services • Nurse Midwife services • Certified Pediatric and Family Nurse Practitioner services • Transportation to medical care • Tobacco cessation counseling for pregnant women • All medically necessary care for eligibles under age 21
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What services are covered by Medicaid?
South Dakota Optional Services (examples)• Physician assistants • Psychologists and independent mental health practitioners • Intermediate Care Facilities for the Mentally Retarded (ICF/MR) • Podiatry • Prescription Drugs • Optometry • Chiropractic services • Durable medical equipment • Dental services • Physical, occupational, speech therapy, audiology • Prosthetic devices and eyeglasses • Hospice care, nursing services • Personal care services and home health aides
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Majority of expenses by provider type Provider SFY 2012 Expense
(Millions)% of Total
Hospital $168.6 23.14%
Nursing Homes/Assisted Living Providers $149.2 20.47%
Community Support Providers $108.9 14.94%
Physicians, Independent Practitioners and Clinics $91.3 12.53%
Indian Health Services $62.8 8.62%
South Dakota Developmental Center & HSC $32.7 4.49%
Pharmacies $27.0 3.71%
Substance Abuse, Mental Health and Other Community Support Providers
$22.5 3.09%
Psychiatric Residential Youth Care Providers $31.6 4.34%
Dentists $17.8 2.44%
Durable Medical Equipment Providers $10.2 1.40%
In-Home Service Providers for the Elderly and Skilled Home Health
$6.1 0.84%
Total for Majority of Expenses $728.70
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Recipient Cost Sharing
• Federal guidelines for imposing co-pays• Limits on emergency services, maximums for services
• Non-generic prescription drugs: $3.30 • Generic prescription drugs: $1.00 • Durable Medical Equipment: 5% • Non-emergency dental services: $3 co-pay, $1,000 annual
limit for adults • Inpatient Hospital: $50 per admission • Non-emergency outpatient hospital services, which
includes emergency room use for non-emergent care: 5% of billed charges, maximum of $50
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Third Party Liability and Premium Assistance
• When people have other insurance, Medicaid becomes a secondary payer• Cost avoid whenever possible, otherwise recover • Recovered more than $7.7 million in FY12
• When it is cost effective and the recipient is eligible for other insurance, Medicaid will pay the private insurance premiums, deductibles and co-pays
• FY12- 80 cases• Saved $8.9 million total- net
• $3.6 million general funds• Providers received $5.2 million more with private
insurance
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How is Medicaid funded?
• FMAP- Federal Medical Assistance Percentage• Determines how much the federal government pays for
Medicaid services Most administrative services are paid at 50% state
match• FMAP based on last three years of personal income,
compared to other states• When SD’s income goes up compared to other states, the
state pays more and the federal government pays less• Highest match rate for services is 50% • Every 1% change in FMAP equals about $7 million general
funds
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How is Medicaid funded?
• Services provided by Indian Health Services are reimbursed by Medicaid when the recipient is Medicaid eligible
• 100% federal funds when the service is provided directly by IHS• $63 million in FY12
• State pays the regular general fund match rate when IHS does not provide the service directly or through IHS contract funds
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How is Medicaid Funded?
• SFY14 blended FMAP is 54.20% federal/ 45.80% general The State will pay 45.80% of the cost of Medicaid services
SFY05 SFY06 SFY07 SFY08 SFY09 SFY10 SFY11 SFY12 SFY13 SFY14
34.0
6%
34.6
9%
36.5
4%
39.2
5%
32.9
6%
29.2
4%
30.6
0% 40.3
4%
43.0
7%
45.8
0%
65.9
4%
65.3
1%
63.4
6%
60.7
5%
67.0
4%
70.7
6%
69.4
0%
59.6
6%
56.9
3%
54.2
0%
State Share Federal Share
* Impacted by American Recovery and Reinvestment Act (ARRA)
* * *
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How is Medicaid Funded?
• Total Medicaid expenditures were $799.6 million in FY12• Medicaid budget is a large part of state government
spending• Medicaid part of budgets for several state agencies
• Department of Social Services-State Medicaid Agency• Department of Human Services• Department of Health• Department of Corrections• Department of Military and Veterans Affairs• Department of Education
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How is Medicaid Funded?
$3.6 billion Total Funds $1.1 billion General $2.5 billion Federal/Other
$799.6 million Total Funds $294.3 million General $505.3 million Federal/Other
Medicaid 22.2 % of Total State FY12 Expenditures 26.8% of Total FY12 State General Funds
Total FY12 State Expenditures
Total FY12 Medicaid Expenditures
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How is Medicaid Administered?
• Eligibility for Medicaid determined by DSS- Division of Economic Assistance Staff
• 63 offices throughout SD• Other aspects of Medicaid administered through DSS-
Division of Medical Services• Provider enrollment• State Plan management• Rate setting• Claims payment• Utilization review
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How is Medicaid Administered?
• Program Integrity• Fraud and Abuse Prevention and Detection
• Surveillance and Utilization Review Unit• Quality Improvement Organization• Recoveries and Fraud Investigations• Drug Utilization Review• Medicaid Integrity Contractors• Medicaid Fraud Control Unit• Federal Reviews- payment error rates
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Thank You!