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Medicaid and HIV: New Opportunities in a Changing Landscape PowerPoint Presentation
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Medicaid and HIV: New Opportunities in a Changing Landscape

Medicaid and HIV: New Opportunities in a Changing Landscape

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Medicaid and HIV: New Opportunities in a Changing Landscape

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  1. Cindy Mann, JDDirectorCenter for Medicaid and State OperationsCenters for Medicare & Medicaid ServicesInstitute of MedicineApril 16, 2010 Medicaid and HIV: New Opportunities in a Changing Landscape

  2. Medicaid: An Overview Medicaid serves 60 million people each year • 50 percent children, who account for less than 20 percent of the expenditures • Medicaid pays for nearly 50% of ALL births in the U.S. each year • 25 percent disabled and elderly, who account for nearly 70 percent of the cost • 40% of all Medicaid expenditures are for dual eligibles

  3. Medicaid Overview Before Reform: • Eligibility based on “categorical” and financial eligibility • Categories: children, parents, people with disabilities, pregnant women, elderly • Leaves a large gap

  4. Medicaid Overview • Major player in the health care system (15% of national health care expenditures in 2008) • Most people covered have lower incomes and are in poorer health than the general population • Expenditures highly skewed

  5. Source: FY MSIS 2008, FY MSIS 2007 for AZ, NC, ND, HI, UT, VT, WI

  6. Medicaid is Performing Well Medicaid covered an additional 3.3 million people from June 2008 – June 2009, as the economy worsened Studies show that enrollment is directly correlated with improved access to care Generally offers a package of benefits more geared to the needs of our beneficiaries than commercial products

  7. Also Facing Many Challenges • States pay share of the cost • State budget pressures • Rising health care costs • Generally high beneficiary satisfaction, but some access issues • Data needed to help guide the program is lacking

  8. Medicaid Expenditures by Population: 2009-2020 (in billions) Disabled & Elderly Families & Children Source: CMS Office of the Actuary, President’s FY 2011 Budget

  9. Medicaid and HIV Medicaid is the largest single source of care and coverage for people with HIV $8 billion in combined federal/state spending in FY 2009 Projected federal spending in FY 2011 $5.1 billion 4 in 10 HIV/AIDS patients receive services through Medicaid 70% of people with HIV who qualify for Medicaid are low-income AND disabled. Source: Kaiser Family Foundation, “HIV/AIDS Policy Fact Sheet,” February 2009; available at

  10. Federal Spending on HIV Care: FY 2008 $0.8 $2.2 $4.1 $4.5 Total $11.6 billion

  11. Medicaid and HIV Medicaid covers: Medically necessary and routine HIV testing/screening required for children through EPSDT/well-child care Testing for adults covered under mandatory lab benefit State option to cover testing as preventive benefit Prescription drugs June 24, 2009 letter to SMDs

  12. Medicaid and HIV 14 States offer home and community-based waiver services specifically designed for individuals with HIV 2 States (DC and Maine) have section 1115 waivers in place Ticket to Work demonstration Prescription drug costs have shifted to Medicare but remain critical

  13. Medicaid and HIV: Challenges Being HIV positive does not automatically qualify as a disability Provider participation/payment rates Need to do more to ensure/promote testing Prohibitions on payment for testing in prisons/other public institutions Many uninsured are income eligible for Medicaid or CHIP but are not enrolled

  14. Health Reform Is Here!!

  15. Coverage Guarantees Rely on ESI, Exchange, Medicaid/CHIP Medicaid/ CHIP Exchange ESI

  16. Source: Congressional Budget Office, 3/11/2010 Projected Changes in Insurance Coverage (2019) 24m 16m -4m -5m Total new coverage = 31 million

  17. Putting Medicaid into Reform: Eligibility Expansion • By January 2014, nonelderly individuals with incomes up to 133% of the FPL ($24,400 for a family of 3) will be eligible for Medicaid. • Simplified rules-- ends the “categorical gap” • Significant increase in federal support for Medicaid/CHIP

  18. Transition to a New Medicaid Program • Early option to receive FFP for covering low-income adults beginning April 1, 2010. • See • To avoid cost shifting and not lose coverage: • Medicaid eligibility MOE until 2014 • Medicaid and CHIP eligibility for children is maintained through 2019

  19. New Paradigm Reform is predicated on the principle that everyone who is eligible is enrolled; and that coverage is stable Necessary for coverage, cost containment and quality Essential to make a system out of different components Clear focus on prevention

  20. Putting Reform into Medicaid • Creating a high performing Medicaid Program • Eligible means enrolled • Access issues • Systems upgrades and Data/Performance measures • Payment and delivery systems reform • Continuing to make progress “(re)balancing” long term-care service and supports • Assuring program integrity

  21. (Some) Next Steps • Promoting testing • Identifying good models, eliminating barriers • Identifying and resolving access issues • Working with “early adopter” states • Establishing strong networks, outreach/enrollment mechanisms for 2014 eligibility changes