Thursday 27 November 2014

Medicaid

The state-federal Medicaid program, known in Maine as MaineCare, was created as part of the Social Security Act of 1965. According to the Maine Department of Health and Human Services (DHHS), which administers the program here in Maine, Maine Medicaid “can make it possible for you to get the care that you need.”

The State directly pays health care providers, physicians, hospitals and pharmacies for services used by Medicaid beneficiaries.  This is similar to how a health insurance companies directly pays providers for services used by covered individuals.  Medicaid recipients can be charged very small copays (a couple dollars typically) for some health care services.  But, in Maine, Medicaid recipients are not required to pay these copays in order to receive the health care service.

Medicaid eligibility levels

Eligibility for Medicaid is based on income and, often, assets, with some income not counted toward the limit.  There are many 13 different categories of individuals eligible for Medicaid, each group with its own rules, income limits and, often, asset limits.  You can view a Medicaid application here and more details about the various Maine Medicaid programs here , courtesy of the Maine Equal Justice Project (MEJP), which advocates for low-income individuals.

To simplify, below is a table with the most common Medicaid programs and their income limits (meaning a family must generally earn less than the limit to qualify).

Size of Family Unit 100 Percent of Poverty 200 Percent of Poverty
  Medicaid Annual Income Limit for:
  Elderly, Adults with Disabilities, & Adults with no children and no disabilities Parents with children under 19 & Children under 19
  Income no more than
1 $10,830 $21,660
2 $14,570 $29,140
3   $36,620
4 $44,100
5 $51,580
6 $59,060
7 $66,540
8 $74,020

Many expenses are subtracted from the income limit including, according to MEJP:

  1. “The first $90/month of a family member’s earned income (from work). If both parents are working, they can each deduct the first $90 of earned income, for a total of $180.
  2. Child care expenses actually paid, up to $200/month (for children age 1 and younger) or $175/month per child (for children age two and older).
  3. Child support payments paid by a family member to someone outside the household.
  4. Up to $50/month for child support received by the household.”

Many assets are excluded from any Medicaid asset limits.  Again, from the Maine Equal Justice Project:

  • “The family’s home and surrounding lot
  • Basic items used in day-to-day living, such as furniture, tools and equipment
  • Two cars or trucks (the second vehicle must be necessary for employment, medical treatment, or essential daily activities, or it must have been modified for operation by a person with a disability or for the transportation of a person with a disability)
  • Property used to produce income such as boats, trucks, and machinery
  • Money in a savings account, CD, pension plan, or IRA: up to $8,000 for a single person, $12,000 for a family of two or more
  • Real estate that is up for sale
  • Loans that must be repaid
  • The cash value of life insurance the family has purchased
  • Up to $10,000 in a Family Development Account (FDA) that can be spent only for education, home repair or purchase, a car or truck needed for work or school, small business start up, health care, or to use for an emergency or other family need approved by DHHS”

Medicaid benefits

Here is a list of benefits to those on Maine Medicaid, again according the Maine Equal Justice Project:

Doctors’ Visits:

  • Well-child check-ups
  • Sick care
  • Specialist care, including surgery
  • Prenatal care

Dental Services: Full coverage for children (with limits for adults)

Hospital Care: In-patient, outpatient, and emergency room

Long-Term Care: Coverage for care in a nursing home, or other residential care. Services may also be provided in the home.

Services

  • Shots to prevent illness (immunizations)
  • Prescription drugs
  • Mental health services
  • Substance abuse services
  • Lab tests and x-rays
  • Medical equipment and supplies
  • Ambulance services
  • Chiropractic care
  • Family planning
  • School-based health centers
  • Interpreters
  • Transportation to medical and counseling appointments (see a list of transportation agencies)
  • Eye exams and eye glasses (with limits for adults)
  • Hearing tests (with limits for adults) and hearing aids (for children age 20 and younger)

Therapies

  • Speech therapy
  • Physical therapy
  • Occupational therapy

Early and Periodic Screening, Diagnosis and Treatment

Federal Medicaid law requires States to cover Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children and adolescents under age 21. EPSDT covers four separate screening services—medical, vision, hearing and dental—and includes immunizations, laboratory tests (including lead blood tests), and health education. Each type of screen must be furnished at pre-set, periodic intervals (periodic screens) and when a problem is suspected (interperiodic screens).

The treatment component of EPSDT must include any necessary health care, diagnostic services, treatment, and other measures, described in section 1396d(a) of the Medicaid Act, to “correct or ameliorate” physical and mental illnesses and conditions, whether or not such services are covered for adults in the state’s Medicaid program. EPSDT also includes outreach and informing to notify children and their families of EPSDT and the importance of preventative care, and to offer appointment scheduling and transportation assistance, if needed.

If a service that a child under age 21 needs is for some reason not available under MaineCare, or if the child requires more services than MaineCare may cover, then the child’s provider can file with the Office of MaineCare Services, a request for Prior Authorization for what is called “Optional Treatment- EPSDT Services.”

And More…

More details rules are available through the Maine Department of Health and Human Services.

Medicaid Time Limits

There are no time limits for how long a person can be on Maine Medicaid.  As an individual ages or their children reach age 19, those adults may no longer be eligible for Medicaid, given other factor such as income, assets and disability status.  DHHS does not publish information on how long individuals in Maine typically remain on Medicaid.

Medicaid Benefit Formula

Unlike other welfare programs, Medicaid has a strict income limit.  An individual is entitled to receive all Medicaid benefits if he or she is income eligible, with little cost sharing, and nothing if that individual earns $1 over the income limit.  Certain adults with disabilities can buy Medicaid coverage if they earn more than the income limit, but generally for all other groups it is an all or nothing arrangement.

Medicaid spending

Medicaid spending has increased by $1.2 billion or 137% in the twelve years from 1996 to 2008.  In 2008, Maine Medicaid budget is $2.1 billion.

Medicaid is funded almost with a combination of federal and state tax dollars.  Generally speaking, state tax dollars make up just over a third of total spending with the federal tax dollars paying the other two thirds. The federal share was increased during the past two years, as part of the federal Stimulus bill.

State Fiscal Year Total Medicaid Spending (state & federal)
1996 $881 million
2003 $1,712 million
2008 $2,091 million

Spending figures are taken from National Association of State Budget Officers’ annual reports for 1997, 2003, 2008

Medicaid Caseload

According to the Maine Legislature’s Office of Fiscal and Program Review and other sources, Medicaid enrollment in Maine has grown by 136,000 since 1998, an increase of 89%:

Year Total on Medicaid in Maine
1998 153,000
2001 180,671
2002 202,873
2003 237,298
2004 255,058
2005 264,298
2006 266,106
2007 274,756
2008 269,381
2009 276,320
2010 289,173

Additional Maine Medicaid enrollment data taken from 1998 enrollment.

The Maine Department of Health and Human Services reports 329,970 individuals eligible for Medicaid services, including some individuals eligible for only partial Medicaid coverage.