How is it like to be Sick in America? Medicaid/Medicare For Newbies.

You heard about Obamacare, Yes We Can! The campaign of Hope, Middle-Class Tax Reforms, and Trump’s appeal to stop the expansion of this Affordable Health Insurance For The Low-Income Childless Citizens of The United States of America. It’s all trending and buzzing on Twitter. Yet, the most fundamental question ought to be pondered first prior joining the conversation:

How is it like to be Sick in America?

Let’s explore.

First, What is Medicare?

The federal government grants Medicare coverage to people who are aged 65 and older, individuals of any age with End-Stage Renal Disease (ESRD) and certain individuals who are under the age of 65 with disabilities, such as people who are entitled for Social Security disability or Railroad Retirement Board benefits for 2-year duration waiting period.

What does each of the four parts of Medicare cover?

Part A — Hospital Insurance: covers inpatient hospital expenses, inpatient skilled nursing facilities services, hospice care, and certain home-health services that Medicare reviews on a case-basis.

Part B — Medical Insurance: covers outpatient care services, sturdy medical equipment, physician services, home health services and many other eligible preventive services.

Part C — Medical Advantage: A combination of Part A and Part B subsidized by Medicare-approved private insurance companies so to provide the services, in some cases, they may support prescription drug coverage or supplemental benefits.

Part D — Prescription Drug Benefit: covers prescription drug expenses subsidized by Medicare-approved private insurance companies. (Medicare.gov, n.d.)

How is Medicare financed or paid for?

Medicare is a national program that is operated by the Federal government. It is funded by Social Security Administration. Thus, it is primarily funded from three sources: general revenues (41%), payroll taxes (38%), and beneficiary premiums ( 13%). (Medicare.gov)

Who are the groups eligible for traditional Medicaid?

Eligibility relies on income, household, size and the State rules. Traditionally, Medicaid health coverages are eligible for pregnant women, children, parents of dependent children, people with disabilities, qualifying people over age 65.

Which level or levels of government finance Medicaid?

Medicaid is operated by State governments in a web of state-wide programs. The State governments do follow strictly the Federal government’s national rules, regulations, policies and guidelines regarding the administration of Medicaid. It is considered as jointly-funded by the federal government and the states.

What does the Federal Medical Assistance Percentage (FMAP) determine and what is it based on, and why does this basis make sense for the FMAP?

FMAP determine the percentage rates utilized in matching funds-rate for expenditures that are allotted annually to particular programs in the Medical and Social sphere across the nation. What is given to the States from FMAP, which is provided by the federal government, varies from State to State due to the difference in the criteria’s values, for instance, income per capita in California differs from Mississippi. This makes sense for FMAP since the different values in the criteria list from State to State determine which State needs most such expenditure funds and which can manage given other variables present. This gives the federal government a fair treatment to all states as possible. (Medicaid)

In many ways and in general terms, how did the Affordable Care Act (ACA) expand Medicaid coverage in States that chose to participate in Medicaid Expansion? How was this expansion paid for?

As of the Supreme Court ruling on ACA (June 2012) on the decision to effectively expand Medicaid for nearly all low-income Americans (childless or not) with income up to 138% of poverty across all states, this federal revenue became an option for the States. the federal government ought to pay 100% of Medicaid costs to the newly eligible from 2014 to 2016. Later, the federal government should gradually decrease to 90% by 2020 and remain thereafter. The estimated Medicaid expenditures in the States from 2015 to 2024 is the following: $2,522Billions in total with $971B from the State and $1,552B from the Federal Government, while the States who chose to expand will have $3,033B in Total, with $1,009B spent by the State and $2,024B by the Federal government. (Matthew Buettgens, 2015) The expansion is covered the federal government, the states are guaranteed to have an equivalent $1 in federal funds to every $1 spent on the Medicaid program. (The Henry J. Kaiser Family Foundation, 2014)

How many States are currently participating in Medicaid Expansion?

32 States including the District of Columbia have expanded Medicaid, 19 have not yet expanded (including Missouri). (FamiliesUSA, 2017)

What is the CHIP and who is covered under it?

CHIP stands for Children’s Health Insurance Program. This is considered as a low-cost health coverage to children from families that do not qualify for Medicaid. The child eligible for this coverage must be under 10 or be a primary caregiver with a child under 19, is a U.S citizen, legal alien, or permanent resident. (Benefits.gov, n.d.)

How is it financed or paid for?

Given that CHIP is a joint-partnership between the federal and state governments, CHIP abides the matching-fund rates under Medical — Federal Medical Assistance Percentage (FMAP) distribution. (Medicaid.gov, n.d.)

Private Individual and Group Health Insurance Markets

Which market — individual or group — were the state insurance exchanges under the ACA implemented to serve?

Under the ACA, Health Insurance Marketplaces are accessible for low-income persons and small employer groups that had previously a difficulty in affording coverage. (Taylor Burke, 2014)

Describe the Individual Mandate under the ACA, including what it helps to pay for, and who is eligible for it:

Individuals, regardless of their pre-existing health conditions, ought to acquire a health insurance or else risk paying a penalty of $796 per adult. This “individual mandate” requires the individual to assess if whether they are exempted from such penalty or not. For instance, if the individual is an undocumented immigrant, incarcerated, a member or a religion that opposes the health insurance policy, a member of an Indian tribe, the family’s income is below the threshold for a tax return, or even if the individual is eligible for a hardship exemption. The person can be exempted from penalty. Otherwise, the individual is required to purchase a private health insurance plan or enroll in Medicaid/CHIP/Medicare program with their specific eligibility in mind. (KFF.org, 2017)

What is the employer mandate, what employers does it affect, and what are the consequences of not complying with it?

The ACA requires all businesses with 50 or more full-time employees to provide the minimum affordable health insurance. Failure to comply shall lead to a penalty tax. The employer ought to show that it covered at least 95% of its employee roll. (SHRM.org, 2015)

What's Coming Up? Webinar 0n #mHealth MAY 26 2018, opt-in  here.