Ohio Medicaid March 13, 2019

Why We Care Ohio’s Medicaid Program is the: Largest health insurer in the state Largest payer of long-term care in the state Largest state program in Ohio Sixth largest Medicaid program in the nation

Historic Medicaid Spending

Why has Medicaid drawn everyone’s attention recently? Ohio Medicaid is the largest health insurer in the state, it covers more than one quarter of Ohio’s population. In FY 2018, the annual enrollment was about 3 million. To help put it into perspective, annual Medicaid enrollment is close to the entire population of Arkansa or Nevada. Medicaid is the largest payer of long-term care in the state. In particular for nursing home payments. About 60 to 70% of nursing home residents are supported primarily by Medicaid. In addition to payments for direct care services, Medicaid pays for room and board. Medicaid is also the largest state program in Ohio with more money spent on it than any other state program (combining state and federal dollars). Ohio’s Medicaid program is the sixth largest in the nation. It ranks after CA, NY, TX, PA, FL.

General Accounting Office’s Report on the Ohio Medicaid Program, 1978

FY 2018 GRF Expenditures by Category (State and Federal Funds)

FY 2018 GRF Expenditures by Category (State Funds Only)

Agenda Overview Eligibility Benefits Delivery Systems Budget

Medicaid Program Description Administration Medicaid vs. Medicare Overview Medicaid Program Description Administration Medicaid vs. Medicare

Medicaid Program Description Congress established Medicaid in 1965 Provides: Health care services to the poor Health care and long-term care services to the elderly and disabled Eligible individuals entitled to receive services Federal government sets guidelines; states administer their own Medicaid programs

Administration Ohio Department of Medicaid (ODM) is the single state agency administering Ohio Medicaid. ODM contracts with other state agencies Developmental Disabilities – provides institutional and community- based services to individuals with intellectual disabilities Aging – administers programs for older Ohioans Education – administers the Medicaid Schools Program Health – surveys and certifies Medicaid facilities (e.g. nursing homes) Job and Family Services – reimburses local administration and transportation Mental Health and Addiction Services – administers programs related to behavioral health State Board of Pharmacy – integration of its Rx reporting system into electronic medical records

Administration Local Administration County departments of job and family services County boards of developmental disabilities Area agencies on aging County behavioral health boards Schools

Medicaid vs. Medicare: What’s the Difference? State State, federal, local Kids, parents, adults, disabled and elderly Low-income Varies by state Primary, acute and long-term Administration Funding source(s) Population served Income limits Coverage Care Medicare Federal Elderly (65+) and some disabled No limits Standard across nation Primary and acute

Eligibility Requirements Eligible Populations

Eligibility Requirements Be a US citizen (or meet Medicaid citizenship requirements) and an Ohio resident Meet income requirements - different income limitations for different populations Asset Limitation Applies only to aged, blind, and disabled population $2,000 for an individual and $3,000 for a couple

Federal Poverty Level (FPL), 2019 Family Size 100% FPL 200% FPL 1 $12,490 $24,980 2 $16,910 $33,820 3 $21,330 $42,660 4 $25,750 $51,500 5 $30,170 $60,340

Eligibility Groups in Ohio Children, parents, pregnant women, and adults, as well as disabled and elderly individuals at different income levels are eligible for Ohio’s Medicaid program Three major groups receiving full benefits: Covered Families and Children (CFC) Aged, Blind, and Disabled (ABD) Affordable Care Act expansion adults (Group VIII)

Families, Children, and Adults 2019 Monthly Financial Eligibility Eligible Populations Parents/Caretaker Relatives Adults (age 19-64) Children with Insurance Pregnant Women Children without Insurance Income Limits (FPL) 90% 133% 156% 200% 206% Monthly Income Family of 1 Family of 3 $937 $1,600 $1,384 $2,364 $1,624 $2,773 $2,082 $3,555 $2,144 $3,662

Aged, Blind, or Disabled Individuals Aged, Blind, or Disabled Individuals 2019 Monthly Financial Eligibility Eligible Populations Aged, Blind, or Disabled Individuals Medicaid Buy-In for Workers with Disabilities (MBIWD) Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Qualified Individuals (QI-1) Income Limits SSI Benefit Rate 250% FPL 100% FPL 120% FPL 135% FPL Monthly Income Family of 1 Family of 2 $771 Individual, $1,157 Couple $2,602 Individual $1,041 $1,409 $1,249 $1,691 $1,405 $1,902

Medicaid Caseloads

Mandatory Benefits Optional Benefits

Mandatory Benefits Certified pediatric and family nurse practitioners EPSDT (Healthchek) Family planning services Federally qualified health center Freestanding birth center Home health Inpatient hospital Lab & x-ray Nursing facility care Nurse midwife Outpatient hospital Physician Rural health clinic Transportation to medical care Tobacco cessation counseling for pregnant women

Optional Benefits Ambulance & ambulette Chiropractic Community alcohol and drug addiction treatment Community behavioral mental health Dental Durable medical equipment and supplies Home & community-based service Hospice care Intermediate care facility Occupational therapy Physical therapy Podiatry Prescription drugs Private duty nursing Speech therapy Targeted case management Vision care

Fee for Service Managed Care Delivery Systems Fee for Service Managed Care

Delivery Systems Fee For Service (FFS) The state contracts directly with providers Enrollees can receive services from any provider that contracts with Ohio Medicaid State pays providers directly for services

Delivery Systems Managed Care Managed Care Organizations (MCOs) contract with providers Eligible enrollees must receive services from providers within their MCO’s provider network State pays a monthly capitated rate for each enrolled individual MCOs assume risk for each enrollee’s health care Most of Ohio’s Medicaid population is enrolled in a managed care plan – effective July 1, 2018 behavioral health services were integrated into managed care

Budget Spending Funding

Medicaid Spending & Enrollment Aged, Blind, & Disabled (ABD), Group VIII, and Covered Families & Children (CFC), FY 2018

Medicaid Spending by Payment Category (FY 2018) Hospital care and other services provided to Medicaid recipients enrolled onto a Managed Care plan are accounted for in the Managed Care category.

Federal Funding Federal Medical Assistance Percentages (FMAP) Percentage of Medicaid expenditures that the federal government reimburses FMAP varies by state and type of expenditure (services vs. administration) FMAP is based on the relative per capita income of each state Ohio’s federal fiscal year 2019 rate is 63.09%

State Sources of Funding General Revenue Fund Provider fees and assessments Hospitals Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) Managed Care Organizations Nursing Facilities Rebates from prescription drug purchases

Legislative Budget Office Health and Human Services Division Vern Riffe Center 77 South High Street, 15th Floor Columbus, Ohio 43215 Ivy Chen Principal Economist 644-7764 Ivy.chen@lsc.ohio.gov