Medicaid Eligibility

1
Medicaid Eligibility

• Low-income by federal poverty level (FPL)
• 17,960 for family of 1 (2003)
• Us citizen or lawful immigrant
• Pregnant Women and newborn
• Children 18 years and younger (some states cover
  up to 21 yrs of age)
• Aged, Blind, and/or Disabled

2
NC Financial Eligibility(April 1, 2003)
Family Size Annual Income Monthly Income
1 17,960  1497 
2 24,240  2020 
3 30,520  2544 
4 36,800  3067 
5 43,080  3590 
6 49,368  4114 
7 55,644  4637 
8 61,920  5160 
3
Limitations on Services

• 24 visits per yr. to practitioner, clinics,
  outpatient departments
• Limit of 6 prescriptions per month
• Exceptions
• Preventive care for pregnant women
• People with life threatening conditions
• Some services require a co-pay

4
NC Medicaid Co-payment Amounts
Service Co-payment Amount
Chiropractor visit 1.00
Dental visit 3.00
Optical service 2.00
Optometrist visit 2.00
Outpatient visit 3.00
Physician visit 3.00
Podiatrist visit 1.00
Prescription drug 1.00
5
Medicaid Recipients and Managed Care

• Carolina Access
• ACCESS II AND ACCESS III
• Healthcare Connection
• Risk Contracting
• Assigned primary care provider (PCP).

6
NC Sources of Medicaid Funds
2000 Percent 2001 Percent
Federal 3,405,578,752 58.83 4,095,353,070 57.96
State 1,429,745,564 24.70 1,520,067,658 21.51
Other State 661,374,876 11.42 1,061,305,314 15.02
County 213,520,774 3.69 299,426,810 4.24
Admin-Other DHHS 78,913,119 1.36 86,258,048 1.22
Admin-non DHHS Not available 2,943,719 .04
Total 5,789,133,085 100 7,065,354,618 100
7
NC Medicaid Expenditure by Recipient Group
Eligibile Group Total Dollars Percent Dollars Total Recipients Percent Recipients
Elderly 1,696,633,962 31.0 195,307 14.9
Disabled 2,297,193,767 42.0 215,799 16.5
Families Children 1,456,832,820 26.6 888,705 67,9
Aliens Refugees 35,911,592 .7 9,944 .8
8
Childrens Health Insurance Program (CHIP)

• Purpose
• Expand health insurance coverage for children
  under 19 yrs of age with incomes up to 200 of
  federal poverty guidelines (2001)
• 29,268 family of 3
• 35,304 family of 4
• 41,340 family of 5

9
Childrens Health Insurance Program (CHIP)

• Matched Federal and State funds
• State Eligibility based upon agreement with one
  of the following plans
• Expand Medicaid program
• Create new childrens health insurance program
• Implement combination of Medicaid and new
  insurance program

10
NC State Childrens Health Insurance Program

• Cover families up to 200 of Federal Poverty
  Level (FPL)
• Benefits package provided by NC Teachers and
  State Employees Comprehensive Major Medical Plan
  plus dental, vision, and hearing

11
NC State Plan (cont)

• Families above 150 pay co-payments
• 6 for prescription
• 5 for physician, clinic, dental, and
  optometry visits
• 5 for outpatient hospital visit
• 20 co-payment for unnecessary emergency
  room use

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NC State plan (cont)

• Enrollment fee for those above 150 of FPL
• 50 per child per year
• 100 maximum for 2 or more children
• Allow families whose income increases above
  200 of FPL to buy into the program for 1 year at
  full cost

13
Estimate of Children Eligible for Medicaid but
Not Enrolled
County Uncovered Child Medicaid Eligibles
Alamance 788
Durham 1,292
Forsyth 1,703
Guilford 2,863
Mecklenburg 3,761
Orange 488
Randolph 1,116
Rockingham 722
Wake 2,909
14
Problems Faced by Uninsured

• Do not receive timely and appropriate health care
• Do not receive routine physicals
• Less likely to receive or complete childhood
  immunizations
• More likely to be seen in ER with more serious
  illness
• Less likely to get care for injuries

15
Status of Poverty in US

• US poverty continues to rise
• 11/7 in 2001
• Median household income continues to decline
• 43,000 in 2001

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Status of Poverty (cont)

• Poverty rates continue to rise yearly
• 22.7 for African Americans
• 21.4 for Hispanics
• 10.2 for Asian-Pacific Islanders
• 7.4 to 7.8 for others