What does it mean for Patients?

Currently, national guidelines require Medicaid to cover children under the age of 6, and pregnant women with an income at or below 133% of the federal poverty level (FPL), and excludes individuals under the age of 65 with no dependent children from coverage. (H.R 3590, 2010) The expansion of Medicaid broadens that coverage to include all individuals and families with an income at or below 133% of the FPL ($14,483.70) for an individual, and $29,725.50 for a family of 4). Additionally, applicants will no longer be required to complete an asset or resource test. Legislation also maintains eligibility limits (e.g., Medicaid limits as of March 23, 2010) through 2014 for adults and 2019 for children and provides states with the option for covering patients above 133% of the FPL.^3,4

For individuals and families with an income ranging from 133% to 400% of the FPL, the expansion of insurance coverage will be in the form of state based health insurance exchanges where certain qualified patients will be eligible for premium or cost sharing assistance for private insurance. National guidelines will also govern a standard profile of benefits that will include among other things access to prescription drugs. The uniform coverage for Medicaid will also mirror the basic coverage package available to those purchasing coverage through the exchange. In an effort to empower patients, Enrollment information will be accessible on-line. States will be required to create a website for patients by January 1, 2014 where they can apply or renew Medicaid/CHIP or the State run insurance exchange.

How will this affect healthcare providers?

With the expansion of Medicaid enrollees many physicians may be concerned with an increased patient population enrolled in a program that may have lower rates of reimbursement. On average, current provider payment rates for Medicaid patients are lower than Medicare, and those rates can vary from state to state. Providers should stay abreast of updates and announcement from their state Medicaid providers and CMS. More details on the implementation of Medicaid reform will continue to roll out in the coming months and years.

References:

¹ H.R. 3590, The Patient Protection and Affordable Care Act, Passed March 23, 2010, 111th Congress, 2nd session, available at. http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf Sec. 2001

² Coverage for Consumers, Savings for States: Options for Modernizing Medicaid. United Health Center for Health Reform and Modernization. April 2010, available at http://www.unitedhealthgroup.com/hrm/UNH_WorkingPaper3.pdf.

³Medicaid and Children's Health Insurance Program Provisions In The New Health Reform Law. The Henry J. Kaiser Family Foundation. April, 7, 2010. http://www.kff.org/healthreform/upload/7952-03.pdf.

⁴ Federal Register. Department of Health & Human Services. "Annual Update of the HHS Poverty Guidelines" Vol 16, No 13, January 20, 2011