1. Ohio Medicaid
March 13, 2019

2. 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

3. Historic Medicaid Spending

4. 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.

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

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

7. FY 2018 GRF Expenditures by Category (State Funds Only)

8. Agenda
Overview
Eligibility
Benefits
Delivery Systems
Budget

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

10. 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

11. 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

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

13. 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

14. Eligibility Requirements Eligible Populations

15. 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

16. 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

17. 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)

18. 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

19. 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

20. Medicaid Caseloads

21. Mandatory Benefits Optional Benefits

22. 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

23. 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

24. Fee for Service Managed Care
Delivery Systems
Fee for Service
Managed Care

25. 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

26. 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

27. Budget
Spending
Funding

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

29. 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.

30. 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%

31. 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

32. Legislative Budget Office Health and Human Services Division
Vern Riffe Center 77 South High Street, 15th Floor Columbus, Ohio 43215
Ivy Chen
Principal Economist