medicaid overview

Medicaid is a federal and state entitlement program that provides medical benefits to low-income individuals who have no or inadequate health insurance coverage. Medicaid guarantees coverage for basic health services based upon income and/or resources. Created as Title XIX of the Social Security Act in 1965, Medicaid is administered at the federal level by the Centers of Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS). CMS establishes and monitors certain requirements concerning funding, eligibility standards and quality and scope of medical services. States have the flexibility to determine some aspects of their own programs, such as setting reimbursement rates, the eligibility requirements, and benefits offered within certain federal parameters.

Medicaid serves as the nation’s primary source of health insurance coverage for the poor. During the past decade, federal and state eligibility policy changes to promote Medicaid coverage of low-income pregnant women, children, the disabled, and the elderly have resulted in greater coverage of these groups within the low-income population.

In exchange for federal financial participation (FFP), states agree to cover certain groups of individuals (referred to as “mandatory groups”) and offer a minimum set of services (referred to as “mandatory benefits”). States also can receive federal matching payments to cover “optional” groups of individuals and provide additional “optional” services.

The terms on which federal Medicaid matching funds are available to states include five broad requirements related to eligibility: categorical, income, resources, immigration status and residency. In order to be eligible for Medicaid, an individual must meet all of these applicable requirements. The availability of federal matching funds for particular categories of individuals, however, does not necessarily mean that a state will cover these individuals since the state must still contribute its own matching funds toward the cost of coverage.

Each state sets an income limit within federal guidelines for Medicaid eligibility groups and determines what income counts towards that limit. Part of financial qualification for Medicaid is based upon the family size and relation of monthly income to the Federal Poverty Guidelines (FPG). According to Oklahoma State Statutes Title 63 Sec. 5009, the Oklahoma Health Care Authority (OHCA) shall contract with the Oklahoma Department of Human Services (OKDHS) for the determination of Medicaid eligibility. This means that all applications for Oklahoma Medicaid enrollment are processed and approved or denied by OKDHS. Applications and renewals are reviewed by each county of residence OKDHS office for financial and/or medical requirements. After eligibility has been certified or extended, the records are sent to OHCA to coordinate medical services and process payments for those services.

Medicaid Eligibility

As required by state law, Oklahoma’s eligibility is determined at each of the county OKDHS offices. The following table lists the family income guidelines for children under 19 and pregnant women who may be eligible for Medical Benefits.

Family Size	Monthly Income
1	$1,476
2	$1,978
3	$2,461
4	$2,984
5	$3,486
6	$3,989
7	$4,491
8	$4,994

For family units with more than eight members, add $3,180 for each additional member. The above table is based on family monthly incomes that are equal to or less than 185% of the current Federal Poverty Guidelines. FPG are revised on an annual base by the federal government. The FPG are published around April of each year.

The federal and state governments share Medicaid costs. For program administration costs, the federal government contributes 50 percent for each state. For medical services provided under the program, the federal matching rate varies between states. Each year the federal matching rate known as the “federal medical assistance percentage” (FMAP) is adjusted. States having lower per capita income receive a higher federal match. As an entitlement program for individuals who meet eligibility criteria, Medicaid’s federal funding is open-ended. The minimum federal match regardless of per capita income is 50 percent. The federal match for Oklahoma, effective October 1, 2005, is 67.91 percent.

Medicaid is the largest source of federal financial assistance in Oklahoma. Medicaid accounted for an estimated 40 percent of all federal funds flowing into Oklahoma. Federal payments for Medicaid exceeded those for highways, education, housing, Temporary Assistance to Needy Families (TANF), food stamps, and child nutrition programs. Federal Medicaid dollars received for SFY 2004 totaled almost 1.9 billion dollars. Since 1997 the Medicaid expenditures for Oklahoma has increased from 1.2 billion dollars per year to 2.7 billion dollars in 2004. Medicaid is big business in Oklahoma.

Title XIX of the Social Security Act requires that in order to receive federal matching funds, certain basic services must be offered to the categorically needy population in any state program. States may also receive federal funding if they elect to provide other optional services. Within broad federal guidelines, states determine the amount and duration of services offered under their Medicaid programs. The amount, duration and scope of each service must be sufficient to reasonably achieve its purpose. States may place appropriate limits on a Medicaid service based on such criteria as medical necessity or utilization control.

With certain exceptions, a state’s Medicaid plan must allow beneficiaries freedom of choice among health care providers participating in Medicaid. In general, states are required to provide comparable services to all categorically needy eligible persons.

Medicaid Services

Federally Mandated Services:

Early Periodic Screening, Diagnosis and Treatment (EPSDT) (Under age 21)
Family planning services and supplies
Inpatient Hospital
Laboratory and X-ray
Emergency transportation
Nurse midwife
Nurse practitioner
Nursing facility/ home health (age 21 and above)
Outpatient hospital
Physician
Rural health clinic and federally qualified health center
Non-emergency transportation

Optional Covered Services:

Case Management                                              Chiropractor
Clinic                                                                 Dental
Diagnostic services                                             Emergency hospital
Inpatient hospital (age 65 plus) (institutions for mental disease)
Inpatient psychiatric (under 21)                           ICF/MR
Nurse anesthetist                                               Nursing facility (under 21)
Occupational therapy                                          Optometrist
Personal care                                                     Physical Therapy
Podiatrist                                                           Prescribed drugs
Preventive services                                             Private duty nursing
Prosthetic devices                                               Psychologist
Rehabilitative                                                     Respiratory care
Screening services                                             Speech/hearing/language disorders
TB related