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1 1 (November 30, 2020)

handle is hein.crs/govdcqu0001 and id is 1 raw text is: \ Q Medicaid Primer Medicaid is ajoint federal-stateprogramthat finances the delivery of primary and acute medical s ervices, as well as long-termservices and supports (LTSS), to a diverse low- income population, including children, pregnant women, adults, individuals with disabilities, and people aged65 and older. In FY2019, Medicaid provided health care services to an estimated 75 million individuals at an estimated cost of $627 billion, with the federal government paying about $405 billion of that amount. Participation in Medicaid is voluntary for states, though all states, theDistrict of Columbia, and the territories choose to participate. The federalgovernmentrequires states to cover certain mandatory populations and benefits but allows states to cover other optional populations and services. Due to this flexibility, there is substantial state variationin factors such as Medicaid eligibility, covered benefits, and provider payment rates. In addition, several waiver and demonstration authorities in statute allow states to operate their Medicaid programs outside of certain federalrules. Elgi bit y Historically, Medicaid eligibility generally has been limited to low-income children, pregnant women, parents of dependent children, the elderly, and individuals with dis abilities. However, the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) includedthe ACA Medicaid expansion, which expands Medicaid eligibility to non-elderly adults with income up to 133% of the federalpoverty level (FPL) at state option. Figure 1 shows historical and projected Medicaid enrollment for FY2000 throughFY2020. Figure I. Medicaid Enrollment liiFY'2}'C-Q.v)1 FY29It FY2Q2O Expansk n Adults NcEdr-Exp.^.scr 10 Source: Centers for Medicare & Medicaid Services (CMS), 2018 Actuarial Report on the Financial Outlook for Medicaid, 2020. H ereinafter CMS, 20l18Actuarial Report, 2020. Note: Projected en rollment was prepared prior to the Coronavirus Disease 20 19 (COVID- 19) pan demic. To be eligible for Medicaid, individuals must meet both categorical (e.g., elderly, children, or pregnant women) and financial(i.e., income and sometimes assets limits) criteria in addition to requirements regarding residency, immigration status, and U.S. citizenship. Some eligibility groups are mandatory, meaning all states with a Medicaid programmust cover them; others are optional. Medicaid coverage includes a variety of primary and acute- care services as well as LTSS. Not all Medicaid enrollees have access to the s ame set of services. Different eligibility classifications determine available benefits. For traditional Medicaid benefits, s tates are required to cover a wide array of mandatory services (e.g., inpatient hospital, physician, and nursing facility care). States may provide optional additional services, such as personal care services, prescription drugs, and physical therapy. Alternative Benefit Plan (ABP) coverage is required for enrollees in the ACA Medicaid expansion and optional for other Medicaid enrollees. Under ABPs, states have more flexibility to define which populations are served and what specific benefit packages enrollees will receive. In general, ABPs may cover fewer benefits than traditional Medicaid, but there are some requirements thatmight make ABPs more generous than private insurance (e.g., family planning services and nonemergency transportation). v Systems Medicaid enrollees generally receivebenefits via one of two service-delivery systems: fee-for-service (FFS) or managed care. Under FFS, health care providers are paid by the state Medicaid programfor each serviceprovided to a Medicaid enrollee. Under managedcare, Medicaid enrollees receive services through an organizationunder contract with the state. States traditionally used FFS for Medicaid. However, sincethe 1990s, the share of Medicaid enrollees coveredby managed care has increased. About 83% of Medicaid enrollees are coveredby some formof managed care as of July 1, 2018, and most ofthem(70% of Medicaid enrollees) are covered with comprehensive risk- based managed care. In general, premiums and enrollment fees are prohibited in Medicaid. However, premiums may be imposed on certain enrollees, such as individuals with incomes above 150% of FPL, certain working individuals with disabilities, and certain children with dis abilities. States can impose nominal co-payments, coinsurance, or deductibles on most Medicaid-covered benefits up to federal limits. The aggregate capon out-of-pocket costsharing is generally 5% of monthly or quarterly household income. Updated November 30,2020

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