Missouri Medicaid Basics

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Missouri Medicaid Basics

Introduction

The Medicaid program, enacted through Title XIX of the federal Social Security Act in 1965 at the same time as Medicare, exists as the largest of the federal-state partnerships for low-income people. Nationally, Medicaid currently provides public health insurance coverage to approximately 60 million low-income Americans,including working families, seniors, and individuals with diverse physical and mental disabilities. The federal government offers matching funds to states to support the inancing of Medicaid.Each state administers its own Medicaid program. The federal Centers for Medicare and Medicaid Services (CMS) monitors state-run programs and establishes requirements for service delivery and quality, funding, and eligibility standards. State participation is voluntary, and all states have participated since 1982. Missouri’s participation in Medicaid (called MO HealthNet in Missouri) began in 1967.

Overview of MO HealthNet
The Missouri Department of Social Services (DSS), MO HealthNet Division administers the provision and payment of services for Missouri’s MO HealthNet program. The DSS Family Support Division (FSD) determines MO HealthNet eligibility for individuals and families. FSD ofices were previously located in each of Missouri’s 114 counties and the City of St. Louis; however, the state has begun to close some county-level FSD ofices and create regional ofices as a way to save on state administration costs.
MO HealthNet represents a signiicant portion of Missouri’s overall state budget. Approximately 28 percent of Missouri’s total budget will go to MO HealthNet in State Fiscal Year (SFY) 2011. However, about 51 percent of the state’s Medicaid funding comes from federal funds.
Increases in program costs can have a major impact on the overall iscal condition of the state.

Eligibility
In general, MO HealthNet covers low-income children; their parents, guardians, or caretakers; and aged, blind, or disabled individuals. However, certain income and resource criteria must be met as well. Income criteria are largely based on poverty guidelines established by the federal government.
Resource criteria (i.e., savings and other countable assets) largely apply only to aged, blind, and disabled people applying for MO HealthNet. Parents, Children, and Pregnant Women

In SFY 2010, MO HealthNet covered more than 530,000 low-income children and approximately 110,200 low-income adults in families with children. The majority of covered adults in families with children are women. Children represent the largest demographic group served by Missouri Medicaid, with 60 percent of all MO HealthNet enrollees being age 18 or younger. Pregnant women who meet certain income
criteria are also eligible for coverage during their pregnancy and postpartum.
Aged Approximately 77,500 Missourians age 65 and over were covered by MO HealthNet in SFY 2010. Eligible individuals must meet the income and resource requirements of the program. Missouri seniors can also “spend down” their incomes to qualify for MO HealthNet (see text box on pg. 3 for an explanation of spend down). In some cases, MO
HealthNet assists seniors in paying their Medicare premiums, copayments, and deductibles. Blind and DisabledAccording to Missouri DSS, an estimated 160,500 Missourians covered by MO HealthNet qualify for services due to a “physical or mental impairment, disease, or loss which keeps them from working in any job within their skill level for 12 months or longer.” People who are eligible for cash assistance through the federal Supplemental Security Income (SSI) program automatically qualify for MO HealthNet on the basis of disability. Other individuals who meet the SSI disability deinition are also eligible as long as their income does not exceed 85 percent of the federal poverty level (FPL) for disabled individuals and 100 percent of FPL for those who are blind. Additional people can qualify by spending down their incomes on medical expenses. Some people with a disability also receive MO HealthNet assistance to help pay their Medicare premiums, copayments, and deductibles.

What’s a Waiver?
States have lexibility when it comes to designing and running Medicaid and CHIP. However, federal law sets minimum standards for operating those programs. Sections 1115 and 1915 of the Social Security Act deine
peciic circumstances in which the federal government may, at a state’s request, “waive” certain provisions of these federal laws. The “waiver” is the agreement between the federal government and the state that exempts the state from the provisions of the federal law that were waived. The waiver includes special terms and conditions that deine the strict circumstances under which and for whom the state is exempt from the provisions of federal laws. Missouri currently has seven 1915(c) HCB waivers, two 1115 waivers, and a waiver to offer the Program of All-Inclusive Care for the Elderly (PACE)- a comprehensive service delivery system for the frail elderly. The 1115 waivers expanded coverage
to Missouri children up to 300 percent of FPL and expanded coverage to uninsured women  ages 18-55 years old who would otherwise lose their MO HealthNet eligibility 60 days after the birth of their child.
Health Reform and Medical Homes
In addition to expanding eligibility, the health reform legislation impacts Medicaid in numerous other ways.
Among its many provisions, the law encourages Medicaid programs
(through inancial incentives) to cover and remove cost-sharing requirements for preventive services and recommended immunizations.
Additionally, federal reform provides incentives to Medicaid beneiciaries to complete behavior modiication programs (e.g., smoking cessation classes, weight-loss programs) and requires Medicaid programs to cover tobacco cessation
services for pregnant women.The health reform law also provides
states the option to provide medical homes for enrollees with chronic conditions. Medical homes are composed of a team of health professionals and provide a comprehensive set of medical services, including care coordination. Care delivered by primary care physicians through the patient-centered medical
home (PCMH) model is consistently associated with better health outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, and improved patient

compliance with recommended care.MO HealthNet is actively working to take advantage of this opportunity in health reform. At the same time, the Missouri Foundation for Health (MFH) has launched a new PCMH initiative to promote partnerships among patients and their personal physicians. MFH has convened
interested stakeholders, including medical professionals, payers, patients, and MO HealthNet to explore the essential facets of developing a comprehensive PCMH model in Missouri. MFH also will work with medical providers throughout the state and provide technical assistance in transforming their practices into patient-centered medical homes.

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