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How Does Medicaid Work
Medicaid funds come from both the federal government and the state, with each state operating its own Medicaid program . These guidelines are relatively vague and states have a large degree of freedom when it comes to designing and implementing their Medicaid programs. Because of this, Medicaid eligibility and benefits can, and often do, vary widely from state to state.
Medicaid is oftentimes confused with Medicare, the federal government health insurance program for individuals over 65, as well as some individuals with disabilities. To be fair, there is some overlap between the two nearly 10 million low-income seniors and people with disabilitiessometimes referred to as dual eligiblesare enrolled in both Medicare and Medicaid. This can make discourse around the two programs a bit unclear at times.
Medicaid is a counter-cyclical program meaning its enrollment expands to meet rising needs during an economic downturn, when people lose their jobs and job-based health coverage. For example, during the Great Recession of 2007-2009, more than 10 million peopleroughly half of them childrenenrolled in Medicaid. As of May 2021, 75.9 Million people are covered by Medicaid due to the ongoing COVID-19 pandemic.
States have guaranteed federal financial support for part of the cost of their Medicaid programs, but in order to receive federal funding, states must cover certain mandatory populations including:
Kids On Medicaid Parents Not
To examine the role state and local policy play in issues related to income inequality such as health care, the Tribune collaborated with news outlets in Georgia, New York and Washington state.
New York and Washington state both expanded Medicaid, and their rates of uninsured citizens 6 percent and 7 percent, respectively have fallen below the 2016 national average of 9 percent, according to Kaiser Family Foundation. Texas and Georgia, both non-expansion states, had uninsured rates exceeding the national average, by 6 and 3 percent respectively, in 2016.
Advocates and experts say if the state were to expand Medicaid, the coverage gap would disappear and more than a million uninsured Texans would obtain health coverage. Like Walker, many of them are the parents of children who qualify for Medicaid or the Childrens Health Insurance Program based on their parents income, said Anne Dunkelberg, program director for the health and wellness team at the left-leaning Center for Public Policy Priorities.
Many have incorrectly believed that the parents of our kids on Medicaid get Medicaid too. They dont, Dunkelberg said. We have about 3.2 million children on Medicaid on any given day, and only about 150,000 parents.
Walker said her opinion on health care has been influenced by her personal experiences trying to make ends meet and trying to stay healthy.
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Is Targeted Case Management And Mental Health Rehabilitative Services Covered Under Managed Care In The Future
Yes, targeted case management for individuals with mental illness and mental health rehabilitative services is available through managed care. Mental health targeted case management and mental health rehabilitative services are available to Medicaid recipients who are assessed and determined to have a severe and persistent mental illness such as schizophrenia, major depression, bipolar disorder and children and adolescents ages 3 through 17 years with a diagnosis of a mental illness who exhibit a serious emotional disturbance. Legislative direction was given to HHSC to make these services available in Medicaid managed care to provide better coordination of care by integrating physical and behavioral health care for these Medicaid recipients.
The Human Toll Of The Medicaid Coverage Gap
Of course, theres more to Medicaid expansion than just money. Harold Pollack very clearly explains the human toll of the Medicaid coverage gap: Based on the 3,846,000 people who were expected to be in the coverage gap in January 2015, we can expect 4,633 of them to die in any given year because they dont have health insurance.
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Medicaid Estate Recovery Program Statute Of Limitations
Not every state has a statute of limitations. In those that do, the statute of limitations caps the amount of time Medicaid offices have to seek reimbursement from a recipients estate after their death. The statute of limitations for MERP, in states that have one, is usually one year. After one year following the death of a Medicaid recipient, in other words, the state cannot seek to recover costs from their estate due to the statute of limitations.
How The State Takes A Home
Medicaid can put a lien on a recipients home, but not every state will do this. A lien prevents the sale until debts are paid. This means a Medicaid recipient cant transfer ownership of a home before death to prevent it from being used to pay back state Medicaid.
A lien will be filed by the state after the recipient moves out, if they are not expected to ever move back in. The lien gets lifted if the recipient moves home or if the home is sold to pay back Medicaid.
Medicaid cannot put a lien on a home if any of the following still live there: The recipients spouse Recipients child who is under 21 Recipients child who is disabled or blind Recipients sibling with partial ownership
The process of selling a home and collecting debts via MERP will often be contracted to an agency outside Medicaid, like a Health Management Service . The home is put up for sale with a MERP claim on it. Once a buyer is found, the MERP claim must be addressed before the sale can close.
State Variances on How MERP Takes Homes
How a state seeks reimbursement through the Medicaid Estate Recovery Program can vary quite a bit depending on the state. Some states wont use MERP if the home is valued below a certain amount. Texas, for example, does not try to be reimbursed from a recipient whose estate is valued below $10,000.
Some states waive the MERP process if the cost of Medicaid Long Term Care for the deceased recipient was less than a certain amount .
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How Much Does Medicaid Cost In Texas
There are a variety of Medicaid programs in Texas from traditional Medicaid to a Medicaid Buy-in program. Like any health program, Medicaid is subject to copay and deductibles. But the Medicaid Buy-in program operates more like traditional insurance for the working disabled. The monthly premium depends on a variety of factors including income. There is no way to know the exact premium you will have to pay without first applying.
Apply For Medicaid In Texas
Eligibility: The aged, blind, and disabled. Also, parents with dependent children are eligible with household incomes up to 15% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 201% of FPL, and pregnant women are eligible with household incomes up to 198% of FPL.
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Texas Medicaid Application And Qualifications
It is easy to confuse Medicaid with Medicare. The two programs are not without their similarities. One key difference is that Medicare is a federal program, whereas Medicaid is a state program with rules that vary depending on where you are. The other major difference is that Medicare is based largely on age and disability, while Medicaid is based largely on income.
Depending on your circumstances, you can be on both at the same time. Circumstances is the key word. Medicare tends to be long-term, if not permanent. Medicaid is often a shorter-term solution. There are other programs that are generally associated with Medicaid such as financial and grocery assistance. It is possible that if you have qualified for these other forms of assistance, Medicaid will be included.
Medicaid Estate Recovery Programs Explained
The Medicaid Estate Recovery Program is required by law in every state. This means someone receiving Medicaid Long Term Care usually must repay the program after death. The services one receives from Medicaid while still alive include all the expenses of living in a nursing home getting help with activities of daily living in ones own home via waivers or Aged, Blind and Disabled Medicaid services prescription drugs and much more. These services can be expensive, and MERP is designed to allow the state to recoup those costs, though the details will differ depending on the recipients state of residence.
Usually when someone has been on Medicaid up until the end of their life, the home is the last remaining thing of value after death. This is not always the case, however. Less often, Medicaid will recover other parts of the estate after death, including:
Cash Remaining funds in Qualified Income Trusts Remaining funds in irrevocable funeral trusts Items of value including vehicles
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Can The Home Be Exempt From A Medicaid Estate Recovery Program
Without Medicaid planning strategies, the home is not exempt from MERP after death. This can be somewhat confusing when one considers that when the recipient was alive the home was exempt from Medicaids asset limit. So: The home is exempt when determining assets at the time of applying for Medicaid benefits, but it is not exempt when the state comes to collect reimbursement after death.
For details on how to protect the home from Medicaid, including asset protection trusts and Ladybird Deeds, .
How Often Is The Medicaid Estate Recovery Program Used To Recoup Costs
Every state has a Medicaid Estate Recovery Program and will use it to be reimbursed for Medicaid Long Term Care costs unless certain exceptions apply.
These are the reasons a state Medicaid office will choose not to use MERP to recover costs of Long Term Care: The recipients spouse is still alive The statute of limitations has expired The deceased has a child under 21 The deceased has a blind or disabled child The sibling exemption applies: This means the sibling has an equal interest in the deceaseds home, but the sibling must have lived there for more than a year before the recipient moved into a nursing home The recipients adult child lived in the home for at least two years, serving as caregiver, before the recipient moved into a nursing home
All states have an Undue Hardship Exemption, which means they will not use MERP to recover Medicaid costs if it will result in a problem like homelessness or an inability to live comfortably for the surviving family members. If relatives run a business out of the deceaseds home, for instance, it might be exempt from MERP due to undue hardship, but the definitions and exceptions are not uniform, meaning undue hardship will differ depending on the state.
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How Will Hhsc Provide Consumer Direction In A Managed Care Model
Medicaid managed care includes consumer-directed services that allow individuals who receive certain services to hire and manage the people who provide their services. The following services are available for self-direction:
- Personal assistance services
- Professional therapies
- Supported employment
- Employment assistance
- Cognitive rehabilitation therapy
Consumer-directed services will continue to be an option in the STAR+PLUS model as it is in traditional Medicaid. In addition, the STAR+PLUS health plans are required to submit quarterly consumer directed services utilization reports to HHSC for review.
Extending Postpartum Medicaid Coverage As Texas Proposes Would Fail Pregnant People
Director of Health Care Reform and Senior Fellow
On July 6, 2022, TCF director of health care reform and senior fellow Jamila Taylor submitted the following public comment to the U.S. Department of Health and Human Services in response to a Section 1115 demonstration application by the state of Texas. In her comment, Dr. Taylor highlights how the proposed extension falls short of what the evidence shows pregnant people need and describes how its attempt to restrict eligibility for this extension of coverage is a weaponization of the Medicaid program against pregnant people after the overturning of the federal right to abortion established by Roe v. Wade.
I am pleased to provide comments to the U.S. Department of Health and Human Services request for public input on this 1115 demonstration waiver request. 1
While I support the goal of extending postpartum Medicaid coverage in Texas, I strongly oppose this waiver. The proposed extension falls short of the state plan amendment option for a full year extension provided by the American Rescue Plan Act, and attempts to restrict eligibility for this extension based on pregnancy outcomes are extremely concerning and counter to the goals of the Medicaid program. The proposed extension also drastically undermines broader efforts to advance maternal health equity.
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Expansion Of Medicaid Managed Care
Most people in Texas who have Medicaid get their services through managed care. In this system the member picks a health plan and gets Medicaid services through that health plan’s network of providers. Most health plans offer Medicaid members extra services not available through traditional Medicaid.
Right now, there are three Medicaid managed care programs in Texas: STAR, STAR+PLUS, and STAR Health. The 2013 Texas Legislature approved several expansions of Medicaid managed care and directed HHSC to develop a performance-based payment system that rewards outcomes and enhances efficiencies. Managed care expansion plans include:
Work Requirements For States That Have Not Expanded Medicaid:
Several states that have not expanded Medicaid have sought federal permission to impose Medicaid work requirements, despite the fact that their Medicaid populations are comprised almost entirely of those who are disabled, elderly, or pregnant, as well as children.
The Trump Administration has begun granting work requirements in some of these states, although CMS Administrator, Seema Verma clarified in May 2018 that these states would have to clearly demonstrate how they plan to avoid situations in which people lose access to Medicaid as a result of the work requirement, and yet also do not have access to premium subsidies in the exchange.
Non-expansion states with approved work requirement waivers that have since been withdrawn by HHS
Two non-expansion states have been granted federal approval to implement Medicaid work requirements for their existing Medicaid populations:
Non-expansion states seeking federal permission to impose a Medicaid work requirement:
Note that these states waiver proposals were all pending when the Biden administration took office, and none have been approved. The Biden administration has noted that work requirements are not in line with the overall mission of Medicaid .
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How Do I Enroll In Medicaid In Texas
If you believe you may be eligible to enroll in Medicaid in Texas:
- You can enroll through HealthCare.gov, either online or by phone at 1-800-318-2596.
- You can enroll through the Medicaid website maintained by the Texas Health and Human Services Commission.
- You can also download and print a paper application, or request that one be mailed to you, by using this page on the Texas Medicaid website.
The Gaps Origins In Texas
Texas has one of the most restrictive Medicaid systems in the country, said Tiffany Hogue, policy director for the Texas Organizing Project, a state nonprofit that advocates for low-income and working families.
In Texas, adults who have children can receive Medicaid, but cant make more than about 18 percent of the federal poverty level. According to Texas Health and Human Services Commission, a family of four can only make up to about $285 per month for parents to qualify for Medicaid. Adults without children cant qualify for Medicaid unless they are disabled or pregnant and meet specific income thresholds.
In other non-expansion states like Georgia and Oklahoma, adults with children can make up to 36 percent and 45 percent of the federal poverty level and qualify for Medicaid.
The parents that you do have in that tiny slice , they are desperately poor, Dunkelberg said. Theyre like people living with their parents or in a homeless shelter. Three hundred dollars a month, you cant live on that.
Alisha Brummett, a 43-year-old mother of five from Katy, said before her husband found a job as a middle school choir teacher, the couple lived for about two years in the coverage gap. While her husband was attending school full time and working a part-time job, the family earned about $12,000 a year, Brummett said.
For her, living in the gap meant looking for alternatives to traditional health care.
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Executive Commissioner’s Commitment To Improving Member And Provider Experience In Medicaid Managed Care
Executive Commissioner Chris Traylor held stakeholder meetings in 2015 to gather input on ways to improve the managed care landscape, from both the member and provider perspective. According to Executive Commissioner Traylor, the purpose was to improve provider experience in managed care and ultimately to ensure the 4.5 million people relying on the Medicaid and Children’s Health Insurance Program programs have appropriate access to services to enable them to live strong, productive lives. He also shared thoughts that it is important as Texas evolves from fee-for-service to managed care, to project future needs to create the best system possible.
HHSC responses were shared directly with stakeholder groups in February 2016, updates were posted to the website on April 11, 2016, and July 22, 2016, and biannual updates on items in progress or under discussion will continue to be shared on the website. Items that are closed as of the last update will be provided in a separate file as there will be no further update. Items were closed either as complete, no action to be taken, or other . In each update, changes to previous responses are noted with red strikethrough for language that is being removed in order to provide an update, and new language is provided in red.
Questions about this project can sent to .