States Follow Federal Guidelines But Have Some Autonomy

Although Medicaid funding is a federal-state partnership, states administer the programs and have some flexibility in determining who to cover, delivery models, and payment methods for physicians and hospitals. States may apply for a Section 1115 waiver to experiment with different implementation approaches as federal statutes require; however, the Secretary of the US Department of Health & Human Services (HHS) determines advanced program objectives.

Medicaid entitlement has two basic guarantees. First, all Americans who meet Medicaid eligibility requirements are guaranteed healthcare coverage. Second, states receive guarantees for federally matched funds without a cap for enrollees’ qualified services. Under current law, nearly all Medicaid federal funding is open-ended, but this may change for cost containment.

According to the Congressional Budget Office (CBO), the federal government pays anywhere from 54 percent to 79 percent of each state’s annual Medicaid outlays, with the states’ picking up the remainder. Beyond enrollment expansion due to COVID-19 for the fiscal year 2022, nearly one-third of states saw upward pressure on spending due to increasing costs for managed care and provider rate increases.

Medicaid Coverage Continues to Evolve

Medicaid began in 1965 and was a cash assistance program for qualifying individuals or families. In the following years, Congress expanded federal minimum requirements to provide more new coverage types, particularly for children, pregnant women, and people with disabilities. The broader health care coverage of the Affordable Care Act (ACA) in 2010 expanded Medicaid to non-elderly adults with qualifying low incomes and continues to meet changing needs.

A Broad Range of Health and Long-Term Care Services

In addition to the Medicaid federal law service requirements, many states provide optional services. These services include physical therapy, prescription drugs, eyeglasses, and dental care. Medicaid expansion for adults is part of the ACA’s ten “essential health benefits,” which include the following:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Pregnancy, maternity, and newborn care
• Mental health and substance abuse disorders
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventative and wellness services
• Pediatric services

Medicaid covers the cost of long-term care, including nursing homes and many community-based long-term services. Over half of all Medicaid long-term care spending is for home and community-based services (HCBS), enabling seniors and those with disabilities to live more independently. Emphasis is shifting away from institutional settings, although intermediate care facilities for adults with intellectual disabilities remain a priority.

Privately Managed Care Plans for Enrollees

More than two-thirds of Medicaid beneficiaries account for privately managed care plan enrollments contracting with states to provide comprehensive services. Other enrollees receive their care in a fee-for-service system.

Most states cover long-term services through risk-based managed care arrangements to contain costs. These managed care organizations (MCOs) are comprised of various entities, as some involve physicians while others combine physicians, hospitals, and other providers.

The blended approach of public and private partnerships to provide Medicaid care allows each participating group to function at their highest level, integrating efforts instead of trying to solve issues outside their expertise.

Medicaid beneficiaries have far better access to healthcare than the uninsured and seek medical care before health problems become severe and more costly. The satisfaction ratings of Medicaid recipients are comparable to those rates for individuals with private health insurance.

Conclusions

Despite experiencing low income, the rate of Medicaid enrollment is similar to those with private coverage. Medicaid covers preventative, rehabilitative, and acute health care in addition to costly long-term care for millions of Americans.

Medicaid services account for one-fifth of healthcare spending and receive a lot of attention regarding:

• Capacity expansion to address addictions, in particular, opioids
• Refining payment and delivery systems
• Lowering prescription drug costs
• Refining eligibility requirements
• Increasing community-based long-term care services

Medicaid funding is a major financial support for hospitals, doctors, nursing homes, and many other jobs in the healthcare sector. Federal matching funds guarantee an open-ended basis to provide flexibility in supporting each state’s population’s healthcare needs.

Medicaid is an extensive program and varies by state, making it difficult to know what is available to beneficiaries or potential enrollees. Attorneys specializing in Medicaid and disability can help you understand how to benefit from your state’s programs. They can guide your application process, ensuring you receive the necessary benefits. Reach out to speak to our office and speak with an elder law attorney about Medicaid planning.

We hope you found this article helpful. Contact our office at (740) 947-7277 and schedule a free consultation to discuss your legal matters. We look forward to the opportunity to work with you.

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Estimates are that more than 14 million Americans will be diagnosed with Alzheimer’s disease by the year 2050 and the financial cost to the United States will total more than 1.1 trillion dollars. Memory and medical care for those who have Alzheimer’s will also create challenges for their families starting with the most basic of questions about memory care, understanding what it is, and what it entails.

Currently, memory care for seniors with advanced Alzheimer’s is best provided in state-licensed assisted living residences or nursing homes with a secure unit designed specifically for memory patients. The unit may be a floor or separate building with security and other cueing devices to help prevent a patient from wandering. Memory care facilities offer programs that are designed to keep executive brain function active and engaged and also offer cognitive-behavioral therapies designed specifically for those with memory challenges. However, these facilities are expensive, and with the Alzheimer’s survival rate of 3 to 9 years post-diagnosis, many families are not able to pay the associated costs of memory care.

Because of these costs, many families become unpaid caregivers to their loved ones. In the earlier stages of the disease progression, it is a workable situation, but before long this selfless act and huge undertaking can take a toll on the caregiver leading to inadequate care for the patient. It is during this family caregiver stage that exploring the longer-term options for memory care becomes critical as there will come a time professional memory care will become necessary. There are several options to consider regarding paying for memory care which on average costs nearly 5 times more than seniors who do not require memory care.

Is your loved one a US Veteran? Research about the Aid & Attendance benefits available to them. Not a veteran? Then explore options for long-term care health insurance.  Another option is to learn how to spend down assets to qualify for Medicaid.  However, this must be done very carefully and with the understanding that even with Medicaid there are, and will continue to be, long waiting lists to get into memory care facilities. If you are fortunate enough to be able to private pay for memory care, it is still important to investigate options to identify the right facility for your loved one.

How will you know when professional memory care is needed? Some of the more common indicators are when someone who has Alzheimer’s forgets to take their medication or forgets the codes to alarms or neglects to lock doors. When a person living with dementia forgets their basic house chores or forgets to eat meals, shower, change clothes or groom themselves that is a sign that memory care may be in order. Finally, psychological changes occur such as consistent feelings of anger or confusion, withdrawal or depression, even personality changes such as mistrusting others are indicators that professional memory care is needed.

All people living with dementia should make plans with their family and attorney in the early stages of disease progression as to how they want to be handled medically in the advanced stages of Alzheimer’s. It is much better to have this discussion very early on as it can provide a sense of relief to the patient knowing things will proceed as documented.

In the absence of a cure for Alzheimer’s all seniors should proactively plan with their family and a trusted elder law attorney to create a plan in the event memory care becomes necessary. Contact our office at (740) 947-7277 and schedule a free consultation to discuss how we can help you with your planning.

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