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1 1 (April 20, 2023)

handle is hein.crs/goveljl0001 and id is 1 raw text is: Congressional Research Service informing Ih legisative d ba e sin e 1914 Medicaid Primer Updated April 20, 2023 Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as long-term services and supports (LTSS), to a diverse low- income population, including children, pregnant women, adults, individuals with disabilities, and people aged 65 and older. In FY2021, Medicaid covered health care services for an estimated 85 million individuals at an estimated cost of $748 billion. Participation in Medicaid is voluntary for states, though all states, the District of Columbia, and the territories choose to participate. The federal government requires states to cover certain mandatory populations and benefits but allows states to cover other optional populations and benefits. Due to this flexibility, there is substantial state variation in 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 federal rules. Eiigbi y Historically, Medicaid eligibility generally has been limited to low-income children, pregnant women, parents of dependent children, the elderly, and individuals with disabilities. However, the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) included the ACA Medicaid expansion, which expands Medicaid eligibility to non-elderly adults with income up to 133% of the federal poverty level (FPL) at state option. Figure 1 shows Medicaid enrollment for FY1970 through FY2021. Figure I. Medicaid Enrollment Enrollees, millions 100 60 40 I III FY71 FY FY01 FY11 FY21 Enrollments measured by average monthlyenrolment. Source: Medicaid and CHIP Payment and Access Commission (MACPAC), MACStats: Medicaid and CHIP Data Book, Exhibit 10, December 15, 2022. Note: Comparable actual Medicaid enrollment data is not available for FY2013-FY2021. The FY2021 increased enrollment is mainly due to the continuous coverage requirement for the Family First Coronavirus Response Act (P.L. I 16-127) federal medical assistance percentage (FMAP) increase. 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. Some eligibility groups are mandatory for states to cover under their Medicaid programs; others are optional. Individuals in need of Medicaid-covered LTSS must demonstrate the need for long-term care by meeting state- based eligibility criteria for services, and they also may be subject to a separate set of Medicaid financial eligibility rules in order to receive LTSS coverage. All Medicaid applicants must meet federal and state requirements regarding residency, immigration status, and documentation of U.S. citizenship. Benefits Medicaid coverage includes a variety of primary and acute- care services as well as LTSS. Not all Medicaid enrollees have coverage of the same set of services. Different eligibility classifications determine the covered services. For traditional Medicaid benefits, states are required to cover a wide array of mandatory services (e.g., inpatient hospital, physician, and nursing facility care). States may cover optional additional services, such as personal care services, prescription drugs, and physical therapy. Alternative Benefit Plan (ABP) coverage is generally 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 that might make ABPs more generous than private insurance (e.g., nonemergency transportation). Servic-Delivery Systems Medicaid enrollees generally receive benefits 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 program for each service provided to a Medicaid enrollee. Under managed care, Medicaid enrollees receive services through a managed care organization under contract with the state. States traditionally used FFS for Medicaid. However, since the 1990s, the share of Medicaid enrollees covered by managed care has increased. Almost 84% of Medicaid enrollees are covered by some form of managed care as of July 1, 2020, and most of them (72% of Medicaid enrollees) are covered with comprehensive risk-based managed care.

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