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everyone who is eligible for the program is legally entitled to receive benefits; government can't refuse services, can't limit access, no spending limits
a set sum of money for a program for a period of time -- no additional money, so program change benefits, access to save money
What is medicaid?
federal-state's public health insurance program
How does medicaid impact a state's budget?
As health care cost increases, they have less money for other things
How does medicaid reduce costs?
- Freeze or reduce reimbursement rates
- Eliminating optional benefits
- Tighten eligibility
- Drop optional groups
- Increase co-payments
- Limit prescription drugs
- Seek deeper discounts and rebates
How do feds work with states to make determination?
- Mandatory population: must be covered
- Optional population: may be covered
- Mandatory benefits: must be gven
- Optional benefits: may be offered
How do medicaid waivers work?
They allow states to experiment with coverage and benefits
Why is it important that states mkae the local medicaid rules?
They determine what htey will give, how they will give it, they monitor and police themselves but they use both State and Federal monies
How do states make the local medicaid rules?
- they establish their own eligibility criteria
- determine the type, amount, duration, and scope of services
- sets rates of payment for services
- administer program
Who must state medicaid cover?
Children and pregnant women with family income below the 133% Federal poverty limit and chldren under 19 years old who fall below the poverty level
What are the main things that state medicaid must cover?
- categorical: individuals must fit int he category
- income: must not earn more than income lmits
- resources: individual/family must not have nonwage assets that exceed limits
- residency: must be US resdent and state resident
- immigration status: 5 year residency in the country
- In 2014, movement of individuals who are non-medicare eligible under 65, under 133% poverty income will be available for medicaid
- Children 6-19 who fall under 133% FPL, and increase of 100%
- No longer required to cover undocumented immigrants who lived in US less than 5 years
Health Policy Issues
- Medicaid cost $366 billion in 2009
- Undesirable clientele
- Children are cheaper and popular -- older are expensive but vote
- Feds pay 57% average, state pays rest
- FMAP formula for each States per capita income for reimbursement
What are some optional choices included in medicaid?
Occupational tx, speech tx, physical tx, transportation, dental, chiropractic, optometrist, long-term care, drugs and prosthetic devices
Setting rates that are sufficient to ensure equal access as compared to general public; it is lower than medicare and less physicians are willing to do it
Monthly capitation rates and accept risk
CHIP: Children's Health Insurance Program
Provides health insurance to low income children whose family income is about eligibility set by the state; the state has the option to joiin
CHIPRA: Children's Health Insurance Program Reauthorization Act
Extended CHIP program through 2013
- Cover children up to 300% FPL
- States must cover age 6-19
- inpatient/outpatient hospital
- physician services
- well baby - well child
- and now dental
- additonally: drug coverage, mental health, vision, hearing, services to children
What is medicare?
A federally funded program for elderly and some persons with disability
Eligibility for medicare
- At least 65 year minimum and eligible for social security and paid into it for 10 years
- totally and permanently disabled and received social security and paid into it for 2 years
- end stage renal disease or amyotrophic lateral sclerosis
- Hosptal insurance (Part A)
- Supplemental Medical Insurance (Part B)
- Medicare Advantage (Part C)
- Prescription Drug Program (Part D)
Individuals have no legal right to healthcare services
Healthcare providrs have no general, legal duty to provide care
What do the individual rights mean?
Just because you get licensed does not mean you have to practice
"Spells of Illness"
law of patient-physician relationship exists for a specific period of time and must be establish (renewed)
What are the two duties of the EMTALA?
- Requires hospitals to provide appropriate screening exmanation to everyone who seeks ER services
- Hospitals must stabilize any condition in a medically appropriate fashon
Affordable Care Act
- Ban exclusion and discrimination based on health status or pre-existing health conditions
- No life expenditure caps
- No dropping of insurance once approved unless applicant fraud
- Band extra fees for emergencies out of your network
- Health exchanges for small businesses
- Right for you to make own informed decision abotu scope and course of your own care
- Right to refuse treatment
- Duty to reasonable disclosure of choice about dangers (potential and inherent)
- Need to ensure patient "self decision" by giving "intelligent choice" with enough "material to the decision"
What are the three requiremed information for an informed decision?
- Proposed treatments risk
- Alternative available
- Likely outcome of no treatment
- Personal right to have "informational privacy" (limit access and use of info)
- Freedom from government interference in making basic personal decisions and invidiual autonomy (abortion is an example)
- Government's authority to require individual conformity to standards of conduct
- (security, professional licensing, public welfare)
- Issues include: smoking, disease outbreaks
- Interpretation fo constitution does not require government to provide any services, public health or otherwise
- Empowers government to act but not mandated