State and federal programs that provide assistance to individuals who need help with health care coverage are commonly referred to as medical assistance programs. Millions of people rely on these programs each and every day to cover costly medical expenses. The two most common medical assistance programs are Medicaid and Medicare.
It is understandable that these two national health insurance programs are often times mistakingly used interchangeably. They are both health care assistance programs and their spellings are very similar. Despite the similarities, there is a clear distinction between the two. That distinction lies in the target populations that they are designed to serve.
In broad terms, Medicare is a federal health care program that provides coverage to individuals who are 65 years or older. Medicare also provides coverage for individuals who are under 65 and have a qualifying disability. Medicaid, on the other hand, is a state and federal health care program that provides coverage for individuals who are low income.
Both of these programs are governed by the Centers for Medicare and Medicaid, or CMS, which is a federal agency under the umbrella of the United States Department of Health and Human Services. CMS administers the Medicare program and is the partner federal organization that states work with for Medicaid.
Individuals who are eligible for both can be covered by both programs at the same time to cover more costs and provide the most advantageous coverage.
Medicaid is the federal medical assistance program that aides low-income and disabled individuals. In fact, it is the largest source of funding for health services for low income individuals as it provides free health care to nearly 23% - nearly 71 million! - of Americans. Medicaid was created as part of the Social Security Amendments of 1965 which provided for federal funds to match state funding for individuals whose resources were to able to cover the cost of medical expenses.
Individual states manage their own Medicaid programs, therefore, the qualifying criteria for eligibility can vary greatly. Over 60% of Medicaid beneficiaries are enrolled in some sort of private managed care plan meaning that Medicaid is a prime example of a partnership that brings together the federal government, state governments, and private industry.
Medicaid, unlike Medicare, is a means-tested and needs-based programs. With Medicare, the primary determining eligibility require is age while Medicaid is focused on the individual’s available resources.
Medicaid saw a drastic expansion as a part of the Affordable Care Act (ACA). This resulted in an estimated 11 million more individuals qualifying that previously would not have. A United States Supreme Court ruling in 2012 clarified that states could not have their federal matching funds for Medicaid eliminated if they didn't expand under the ACA. Because of this, many states opted to not extend their coverage. In all 37 states chose to extend benefits.
Children are by far the largest group of enrollees in the Medicaid system. The program also helps nearly 60% of all nursing home residents and 37% of all childbirths in the United States.
Federal guidelines have provided an avenue for states to develop community-based services waivers (HCBS waivers) to better meet the long-term care goals of individuals who prefer to seek care in their own community or home as opposed to a hospital or institutional setting. The waivers must target a specific group and states are able to operate as many waivers as they wish.
The Medicaid website outlines the four criteria for the waivers under federal guidelines. The waiver programs must:
Some of the services of care that are often covered under these waivers include case management, home health aides, adult day health services, personal care, and respite care. While these are the most common, states are able to propose other types of care that they believe will help individuals which is a unique feature of the waiver program. Essentially, these HCBS programs give states the ability to tailor resources to more specialized groups.
An unfortunate reality that our society currently faces is the increasing frequency in which families are seeking managed care for their loved ones. It is a complicated and time intensive process and requires a fair amount of knowledge about how the health care system works. The federal government’s Medicaid website is a great resource for all topics related to Medicaid managed care.
It is absolutely understandable that managed care is sought out so frequently given the complex nature of medical assistance programs. In addition to caring for a loved one, the added stress of navigating government programs can take its toll. Managed care plans can be a great asset.
There are three types of Medicaid managed care plans: comprehensive risk-based plans, primary care case management, and limited-benefit plans.
The guidelines for Medicaid eligibility are complicated at best. In general, applicants must fall into one of the following categories to be eligible:
There’s a host of other criteria that factor into Medicaid eligibility. The CMS website is a great resource for understanding these factors.
Medicaid is a federal and state government partnership. Matched funding is provided by the federal government but the actual administration of the health plan and services is facilitated by individual states. Applications for Medicaid should be conducted through the various state Medicaid offices. One stipulation that is common to the various state programs is that potential enrollees must be residents they applying in and wish to received aide in.
An interesting feature of Medicaid is that children can be eligible for Medicaid even when their parent’s are not. Many times, a parent’s income is too high to qualify for Medicaid but too low to qualify for private insurance. In these instances, the Children’s Health Insurance Program, or CHIP, is available to help bridge that gap and provide the necessary insurance coverage for uninsured children up to the age of 19 years old.
The CHIP program doesn’t require enrollment during a traditional open enrollment program which allows for parents to enroll children in need any time of year.
As we discussed earlier, the world of Medicaid is layered and complicated. For those who are entering the world of medical assistance programs for the first time or for those who just want the best care they are able to get for themselves or a loved one, it can help to have a guide.
Medicaid case management is a service that helps Medicaid enrollees make the most of the opportunities afforded to them for medical, educational, and social services. Case managers are industry professionals who have a variety of tools and resources available to advocate on their client’s behalf with the hope of providing the services that are best suited to these individuals. Case managers have a good understanding of the community and local services that are available to their enrollees making them uniquely positioned to maximize the care of their client.
Case managers will work with clients to identify specific goals and needs and then develop a plan to achieve those goals.
One of the primary tools that Medicaid case managers use to ensure the highest qualify care for their clients is a comprehensive Medicaid case management software. PlanStreet is an industry tested case management system that can help Medicaid waiver providers address billing needs, scheduling of services, invoicing, and identifying and correcting organizational inefficiencies.
PlanStreet’s case management software’s strengths include:
PlanStreet excels in its ability to be flexible and adapt to new processes and regulations. The world of Medicare and Medicaid is not only a big one but it is one that experiences change frequently. The rules and regulations that govern the management of these programs are revisited and revised constantly in an effort to make them more efficient and accountable. Because of this, Medicaid case management services need to be prepared to adapt quickly. Planstreet’s medicaid program software is flexible and can be fitted to fit individualistic needs. Flexibility is a tremendous advantage with Medicaid programs specifically as there are 51 different sets of rules governing their implementation.
Another major advantage of using PlanStreet for your Medicaid case management is the ability to centralize work processes and information. Today’s offices are largely virtual so the ability to access the information you need anytime and any where you need it is a growing necessity. PlanStreet is a common work space where client data, documents, and schedules are at the finger tips of anyone in the organization.
Since their inception, Medicaid and Medicare have become essential threads in the fabric of the American health care system. A significant portion of the population depends on them for the most basic of services. Managed care is increasingly more common. As these programs grow in usage, they also become more and more complex. A good understanding of their operation is critical but so is having the right tools to help clients navigate the health care landscape. A flexible Medicaid case management software is indispensable and PlanStreet more than fits the bill.