By skyforbes 
Coronavirus to increase the number of Medicaid recipients
By Abbas Mooraj, Managing Director, Health and Life Sciences, Cloudera
This article is part of a continuing series around the challenges being faced within healthcare as a result of the COVID-19 pandemic. I have written about how healthcare organizations are responding, resources for the healthcare supply chain, what’s happening within telemedicine, behavioral health, remote monitoring, home health, and other players, and how technology companies are stepping in to help during the pandemic.
This article will be about the impact COVID-19 is having on Medicaid. It’s a big topic, and because of that, I plan to split it into two parts. For this piece, I will focus on the many moving parts that affect Medicaid recipients, including a definition of Medicaid, how many people are covered, what types of Medicaid programs exist, eligibility and coverage guidelines, and what essential services must be offered. Most importantly, I’ll talk about how COVID-19 affects Medicaid and its members.
I believe it’s important as we work through ongoing COVID-19 challenges to determine the best way to care for this growing part of our population. We need to be prepared and ready for possible influxes of patients, not only from a treatment perspective but from a financial one.
My second article will offer more details around what this means to providers and health plans, and specifically what private Medicaid plans are doing differently to care for COVID-19 patients, how Social Determinants of Care play a role in COVID-19, and the impact on individual health insurance plans. I’ll also take a look at the role data can play to help healthcare organizations manage the expanding number of Medicaid recipients.
Medicaid defined
Medicaid, the national safety net of healthcare insurance in the US, was signed into law in 1965 alongside Medicare. It pays the medical costs for individuals with limited incomes, including seniors and people with disabilities. More than 1 in 5 people are “dual eligibles,” or people who qualify for both Medicare and Medicaid. Overall, Medicaid covers 1 in 5 Americans, serving a diverse population of 75 million people, of which 40% self-identify as white; 21% as Black, and 25% as Hispanic.
Estimates indicate that the total number of recipients could leap to between 82 million and 94 million due to COVID-19’s impact on the job market and the number of people who are currently unemployed. With a total population of close to 330 million people in the US, that means the number of people on Medicaid could rise to nearly a third of our population.
Looking at the numbers today, there are 12 states with more than 24% of their population covered by Medicaid or CHIP plans, with the state having the highest percentage of enrollees — New Mexico — at 34%. In California, 26% of a population of 38.7 million people, or nearly 9.9 million individuals, are covered by Medicaid or CHIP plans. As of late last year, 64% of Medicaid enrollees worked, so think about how the number will grow now that people have lost their jobs due to COVID-19.
Healthcare providers and health plans, and in fact all of us, need to be prepared.
Eligibility guidelines
Medicaid is administered by each state and shares the cost of care with the federal government. In some states, Medicaid may be recognized under a different name, such as MediCal in California, MassHealth in Massachusetts, and TennCare in Tennessee, for example. Each state applies different eligibility rules.
Generally speaking, these are the eligibility guidelines:
- Monthly income is under state-set levels
- Individual’s savings and resources are under state-set levels
- Individuals must reside in the state
- Individuals must be US citizens, legal residents, or green card holders
In terms of payments, if an individual is eligible for Medicaid, they should pay little or nothing for their medical care. For dual eligibles, Medicaid also pays for certain items excluded by Medicare:
- Out-of-pocket expenses
- Extended stays in skilled nursing facilities and other services
- Certain items such as eyeglasses and hearing aids
- Long-term care in a nursing home
- Prescription drugs (free or low-cost through Part D’s Extra Help program)
Since the onset of COVID-19, many new applications for Medicaid are streaming through state and local agencies, and with limited or no hours due to social distancing guidelines in agency offices, and in some instances staff lacking the equipment to work from home, the processing time to determine eligibility is taking longer than usual. However, once approved, the coverage becomes retroactive to the date individuals request coverage.
Types of Medicaid plans and benefits
While eligibility is for the most part determined by income, there are a few options for individuals seeking coverage, including public Medicaid, private or non-profit managed Medicaid (also called Managed Care Organizations or MCOs), and state Children’s Health Insurance Programs (CHIP). As of 2017 (the last year stats were available), 69% of Medicaid enrollees received care through MCOs. Let’s take a closer look to see who pays for the costs of care.
Public Medicaid is paid for from federal and state government funds, and in some instances eligible individuals may be asked to cover a portion of their insurance. States administer the plans, determine what is covered, and set eligibility guidelines based on income, family size, disabilities, pregnancy, and immigration status. For individuals on public Medicaid plans, out-of-pocket costs are typically lower.
Private Medicaid, or managed Medicaid plans, are those administered by non-government organizations. There are many private plans in the US, and cost and services covered vary quite a bit by region, insurance company, and plan type. Some plans reimburse members for health care costs after care is received or may require recipients to go to participating providers, who bill the private Medicaid plans directly for services. Plans may cover all costs or require a copayment for services, and recipients also pay premiums if they meet qualification guidelines. The number of Medicaid recipients who received coverage from a private plan increased from 60% in 1999 to more than 80% in 2012.
The Children’s Health Insurance Program (CHIP), funded jointly by states and the federal government, provides low-cost coverage to children whose families earn too much money to qualify for Medicaid. CHIP is administered by states, and covers pregnant women as well as children.
Medicaid Expansion plans are offered by 35 of the 50 states, and eligibility is determined by household income that is below 138% of the federal poverty level, with levels that vary by number of people in a household. For example, in a one-person household, 138% of the federal poverty level is someone who earns $15,417 per year, or $26,347 for a family of three. Medicaid Expansion is part of the Affordable Care Act and is meant to offer coverage to individuals who may not otherwise qualify for Medicaid, including low-income parents, low-income adults without children, and many low-income individuals with chronic mental illness or disabilities who struggle to maintain good paying jobs but don’t meet disability standards for Medicaid.
Benefits
While states design Medicaid programs, they must provide a minimum amount of coverage for medically necessary services:
- Hospital or nursing home care (coverage varies by state)
- Emergency and preventive services
- Doctor visits
- Lab visits
- X-ray services
- Prescription medications (recipients may have to pay specified amounts in some states, which also determine which medications they will cover)
- Screening and diagnostic treatment for children, including immunizations
- Recommended vaccines covered for children (some are covered for adults)
States may choose to not offer coverage for the following:
- Institutionalization for the mentally challenged
- Dental care
- Vision care
One study suggests that while arguments point to better care and better health for recipients in private Medicaid plans, the cost of care is generally higher than public Medicaid and CHIPs. However, a recent study from the Lewan Group reports that Medicaid managed care plans improve beneficiaries’ access to services, earn high enrollee satisfaction ratings, and generally improve care and save money.
In addition to the overview of services covered for Medicaid plans listed above, the Affordable Care Act outlines these 10 categories of essential services health insurance plans must cover:
- Ambulatory/outpatient care
- Emergency services
- Hospitalization
- Pregnancy, maternity, and newborn care
- Mental health care and substance abuse services
- Prescription drugs
- Rehab and habilitative services and devices
- Lab service
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision, but adult services are optional
A word of caution, though, because it’s not guaranteed that health insurance policies will cover every single essential service. For example, brand-name prescriptions may not be covered so Medicaid recipients would then be forced to choose the generic version if there is one, or pay out of pocket for the entire prescription.
With the onset of COVID-19, the Families First Coronavirus Response Act has mandated that Medicaid and most private plans cover testing costs for the coronavirus. And while testing is free, individuals could still end up owing thousands of dollars in out-of-pocket fees if the doctor determines the visit does not justify a test, is out-of-network, or if the trip requires treatment for a non-COVID-19 illness. Also, recommended vaccinations are covered as outlined by individual states for children and in Medicaid Expansion states for adults as well. The same guidelines apply for inpatient services, emergency transportation, stays in nursing facilities, and telehealth services. The question that is beginning to be asked is whether services such as telehealth and treatments for things that were more traditionally handled in an in-person setting, such as addiction services, will continue to be treated via telehealth once we’ve moved past the pandemic. Already, Congress and the Centers for Medicare and Medicaid Services (CMS) are being inundated with requests to make permanent the expanded telemedicine guidelines enacted during the pandemic, so perhaps the genie has been permanently released from the bottle.
Conclusion
As the pandemic continues, we all need to be prepared for a possible influx of Medicaid patients, and I again encourage healthcare organizations to ask themselves these questions:
- Do I have a clear understanding of how many additional people have been added to Medicaid plans in my state?
- Do I have the appropriate billing and financial controls in place to handle these patients?
- Do I have a plan in place that accounts for social determinants of health (SDOH) for Medicaid recipients?
- Have I considered social risk adjustments for dual-eligible recipients?
- How do I encourage these recipients to take necessary precautions against COVID-19?
- Is it more likely that these patients will have underlying health conditions that currently aren’t being managed that may cause them to become more acutely ill if they get COVID-19?
As we begin to re-emerge after months of stay at home orders closed many non-essential businesses or allowed curb-side only service, please continue to practice caution in your daily lives. As we all know, COVID-19 is not going away, so please be safe out there.
Stay tuned for my second article that will offer more details around what all this means to healthcare providers and health plans. I’ll also take a look at the role data can play to help healthcare organizations manage the expanding number of Medicaid recipients.