Medi-Cal FACTS AND FIGURES A Look at California’s Medicaid Program January 2004 Medi-Cal 101 CONTENTS Introduction Introduction Overview Medi-Cal (Medicaid) is the main source of health care insurance for Eligibility more than six million people, or one in six Californians. It draws nearly Enrollment Benefits $17 billion in federal funds into the state’s health care system and Service Delivery accounts for 15 percent of General Fund spending. Medi-Cal is a Expenditures complex program that pays providers for essential acute and long-term Beneficiary Experiences care services delivered to a wide range of beneficiaries. Although many Importance of Medi-Cal people associate Medi-Cal with welfare, more than half of funds pay for Medi-Cal and Other States medical and long-term care for the elderly and adults with disabilities. Medi-Cal and the State Budget Medi-Cal also provides essential support to California’s safety net providers. Because it is the single largest source of coverage in the state, a thorough grasp of Medi-Cal is essential to understanding how health care is financed and delivered in California. NAVIGATION This document highlights the most important aspects of Medi-Cal. The topics covered are listed in the contents sidebar on each page. This list serves as an interactive tool for navigating through the file. Click on the category you’d like to learn about and you’re there! © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 1 Medi-Cal 101 CONTENTS Description Introduction Overview >> Description ● California’s Medicaid program. >> Importance of Medi-Cal >> Comparison to Medicare >> Legislative History ● A publicly funded health care program that: >> Governing Agencies ● Covers 6.4 million low-income children, parents, blind, >> Budget Funding Sources >> Beneficiaries and Cost disabled, and elderly as of June 2003. Eligibility ● Pays for acute care and long-term care services. Enrollment ● Charges no premiums for most low-income beneficiaries; Benefits some pay a share of the cost. Service Delivery Expenditures ● Jointly funded with federal and state dollars. Beneficiary Experiences ● Is administered by state Department of Health Services Importance of Medi-Cal and county human services offices. Medi-Cal and Other States Medi-Cal and the State Budget © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 2 Medi-Cal 101 CONTENTS Importance of Medi-Cal Introduction Overview >> Description ● Provides health insurance coverage and long-term care >> Importance of Medi-Cal assistance to one in six Californians under age 65. >> Comparison to Medicare >> Legislative History ● Insures nearly one in four of California’s children. >> Governing Agencies >> Budget Funding Sources ● Covers the majority of persons living with AIDS. >> Beneficiaries and Cost Eligibility ● Fills in gaps in Medicare coverage for low-income Enrollment elderly and persons with disabilities. Benefits Service Delivery ● Paid for 42 percent of all births in the state in 2000. Expenditures ● Pays for two-thirds of all nursing home days. Beneficiary Experiences ● Is the largest source of public funding for mental Importance of Medi-Cal health care. Medi-Cal and Other States Medi-Cal and the State Budget ● Brought nearly $17 billion in federal revenues to California in FY 2003, which was paid to health plans and health care providers. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 3 Medi-Cal 101 CONTENTS Comparison to Medicare Introduction Overview >> Description >> Importance of Medi-Cal Category Medi-Cal Medicare >> Comparison to Medicare >> Legislative History Population Low-income families and Persons 65 years and older or >> Governing Agencies >> Budget Funding Sources children, persons with permanently disabled >> Beneficiaries and Cost disabilities, and seniors (65+) Eligibility Services Covered Acute and long-term care Most acute care except Enrollment (no premiums or co-payments outpatient prescription drugs Benefits for lowest income beneficiaries) (beneficiaries pay premiums Service Delivery and deductibles) Expenditures Beneficiary Experiences Funded by Federal and California Federal government and Importance of Medi-Cal governments beneficiaries Medi-Cal and Other States Administered by California with oversight by Federal government through Medi-Cal and the State Budget Centers for Medicare and CMS Medicaid Services (CMS) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 4 Medi-Cal 101 CONTENTS Legislative History Introduction Overview >> Description Selected Milestones >> Importance of Medi-Cal FEDERAL >> Comparison to Medicare >> Legislative History Passed Medicaid law. >> Governing Agencies Expanded coverage of long-term care services. >> Budget Funding Sources Created Disproportionate Share Hospital (DSH) program. >> Beneficiaries and Cost Expanded coverage for certain low-income families. Eligibility Further expanded coverage for pregnant women Enrollment and children. Established State Children’s Health Benefits Insurance Program and limited Service Delivery DSH payments. Expenditures 1965 1970 1980 1988 1990 1997 Beneficiary Experiences 1966 1973 1993 1994 1998 2000 Importance of Medi-Cal CALIFORNIA Medi-Cal and Other States Created Medi-Cal. Medi-Cal and the State Budget Established first Medi-Cal managed care plans. Passed legislation to shift many Medi-Cal beneficiaries into managed care plans. Began consolidation of mental health services at county level. Created Healthy Families program for children. Extended Medi-Cal to families with incomes up to 100% of FPL. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 5 Medi-Cal 101 CONTENTS Governing Agencies Introduction Overview >> Description >> Importance of Medi-Cal Federal Centers for Medicare California Department of >> Comparison to Medicare >> Legislative History and Medicaid Services (CMS) Health Services (DHS) >> Governing Agencies ● Provide regulatory oversight ● Administers Medi-Cal >> Budget Funding Sources >> Beneficiaries and Cost ● Review and monitor ● Contracts for managed care, waivers to program rules dental care, enrollment Eligibility services, and data Enrollment management Benefits Service Delivery Expenditures Beneficiary Experiences Importance of Medi-Cal Medi-Cal and Other States Medi-Cal and the State Budget County Health and Social Services Departments ● Conduct eligibility ● Implement state policy changes determination ● Outstation eligibility workers ● Oversee enrollment in community sites and recertification © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 6 Medi-Cal 101 CONTENTS Budget Funding Sources Introduction Overview State FY 2003–2004 >> Description >> Importance of Medi-Cal >> Comparison to Medicare Special Funds and Reimbursements >> Legislative History Total: $1.6 billion Total Budget >> Governing Agencies $28.7 billion Disportionate Share >> Budget Funding Sources Hospital (DSH) $900 million >> Beneficiaries and Cost Federal Eligibility Matching Funds Enrollment $16.6 billion Benefits Service Delivery Expenditures Beneficiary Experiences Importance of Medi-Cal Medi-Cal and Other States Medi-Cal and the State Budget State General Fund $10.5 billion Source: Legislative Analysts’ Office, 2003. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 7 Medi-Cal 101 CONTENTS Beneficiaries and Cost Introduction Overview >> Description >> Importance of Medi-Cal >> Comparison to Medicare Seniors and people with disabilities account for only 23 >> Legislative History >> Governing Agencies percent of beneficiaries, but 57 percent of expenditures. >> Budget Funding Sources >> Beneficiaries and Cost Eligibility 5.8 million $24.3 billion Enrollment 9% Elderly Benefits 12% DSH Service Delivery 14% Blind & Disabled Expenditures 20% Elderly Beneficiary Experiences 25% Adult Importance of Medi-Cal Parents 37% Blind & Disabled Medi-Cal and Other States Medi-Cal and the State Budget 52% Children 14% Adult Parents 17% Children Beneficiaries Expenditures Source: Department of Health Services, 2003 (2001 Data). © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 8 Medi-Cal 101 CONTENTS Eligibility Factors Introduction Overview Eligibility ● Eligibility for Other Public Assistance Programs (See page 10.) >> Eligibility Factors ● Deprivation* >> Profile of Eligible Groups >> Income Limits ● Institutional Status >> Mandatory Categories >> Optional Categories ● Family Income Enrollment Benefits ● Family Assets Service Delivery ● Not considered for certain pregnant women and children who are under certain levels of federal poverty. Expenditures ● The home is usually not considered. Beneficiary Experiences ● Countable personal property includes but is not limited to savings, checking, Importance of Medi-Cal stocks, bonds, and certain life insurance policies and annuities. Medi-Cal and Other States ● For most beneficiaries, the upper limit starts at $2,000 for one person and Medi-Cal and the State Budget increases with family size. ● U.S. Citizenship ● Some legal immigrants are eligible. ● Undocumented aliens and certain other immigrants are eligible only for emergency and pregnancy-related services and some nursing home care. ● California Residency (documented) *Deprivation exists when a parent is absent from the home, or is incapacitated, disabled, deceased, employed less than 100 hours per month, or has earnings that are below 100 percent of the Federal Poverty Level. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 9 Medi-Cal 101 CONTENTS Profile of Eligible Groups* Introduction Overview Eligibility ● Recipients of Other Public Assistance Programs >> Eligibility Factors ● Low-income families participating in such programs as >> Profile of Eligible Groups >> Income Limits CalWORKS or those that can show deprivation >> Mandatory Categories ● Seniors and persons with disabilities through participation >> Optional Categories in the Supplemental Security Income (SSI) program Enrollment Benefits ● Pregnant Women and Children Service Delivery ● Based on their income levels and family size according to Expenditures the Federal Poverty Level (FPL) (See note on page 11.) Beneficiary Experiences Importance of Medi-Cal ● Other Medical Conditions or Life Situations Medi-Cal and Other States ● Individuals transitioning off of public assistance programs Medi-Cal and the State Budget ● Refugees ● Persons receiving treatment for Tuberculosis or End Stage Renal Disease *Not a comprehensive list. Multiple criteria have contributed to the creation of more than 100 eligibility categories or aid codes for beneficiaries. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 10 Medi-Cal 101 CONTENTS Income Limits* Introduction Overview Federal Poverty Level Eligibility >> Eligibility Factors >> Profile of Eligible Groups 250% >> Income Limits Healthy Families >> Mandatory Categories Medi-Cal Optional >> Optional Categories Medi-Cal Mandatory Enrollment 200% Benefits Service Delivery Expenditures 150% Beneficiary Experiences Importance of Medi-Cal Medi-Cal and Other States 100% Medi-Cal and the State Budget 50% 0% Children Children Children Pregnant Parents of Elderly Disabled < 1 Year 1–5 Years 6–19 Years Women Children < 19 *As of April 2003, 100 percent of FPL for a family of three is $15,260. Excludes Medi-Cal spend-down and share-of-cost Medi-Cal. Source: Department of Health Services, 2003. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 11 Medi-Cal 101 CONTENTS Mandatory Eligibility Categories Introduction Overview Required by Federal Law Eligibility >> Eligibility Factors >> Profile of Eligible Groups Medicare Beneficiaries Total Beneficiaries >> Income Limits (39,851) 5.5 million >> Mandatory Categories Pregnant Women and Children >> Optional Categories • Children < 6 Years Family Income < 133% FPL Enrollment (109,842) Benefits • Children 6 to 19 Years Family Income < 100% FPL Service Delivery (110,435) Expenditures • Pregnant Women Beneficiary Experiences Incomes < 133% FPL (12,000) Importance of Medi-Cal Medi-Cal and Other States Medi-Cal and the State Budget Elderly and Disabled (SSI Beneficiaries) (1,145,415) AFDC-related CalWORKS Recipients Parents and children (1,354,342) with incomes below AFDC threshold in July 1996 (1,761,342) *Not included in the distribution above were 46 working disabled people. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 12 Medi-Cal 101 CONTENTS Optional Eligibility Categories Introduction Overview Allowed by California Eligibility >> Eligibility Factors >> Profile of Eligible Groups Total Beneficiaries >> Income Limits Other Elderly and Disabled 970,000 >> Mandatory Categories • Incomes 74%–100% FPL >> Optional Categories (63,982) Families • Under Home and Community- • Children < 19 Years Enrollment based Services (HCBS) Waiver Family Incomes Benefits (2,517) > Required FPL • Working Disabled Persons (56,254) Service Delivery (639) • Parents Expenditures Incomes > Nursing Home Required Beneficiary Experiences Residents FPL Importance of Medi-Cal Incomes up to Medi-Cal and Other States 300% SSI (69,452) Medi-Cal and the State Budget Pregnant Women Incomes > 133% FPL (78,216) Medically Indigent (91,596) Medically Needy (606,795) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 13 Medi-Cal 101 CONTENTS Individual Application Process Introduction Overview Eligibility ● For those receiving Supplemental Security Income (SSI) Enrollment or CalWORKs, Medi-Cal coverage is automatic. >> Individual Application Process >> Child Application Process ● Other individuals may apply for Medi-Cal at their local >> Recent Enrollment Process Changes county social services office or at hospitals and clinics >> Beneficiary Profile where county eligibility workers are located. >> Enrollment After One Year Benefits ● Doctors can request immediate temporary coverage for Service Delivery pregnant women and children while they apply for Expenditures the program. Beneficiary Experiences Importance of Medi-Cal ● Pregnant women, children, and adults may also apply Medi-Cal and Other States for Medi-Cal using a mail-in application. (See page 15.) Medi-Cal and the State Budget ● Applicants can now submit Medi-Cal applications electronically using Health-e-App, an Internet-based system, with the help of certified application assisters. (See page 15.) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 14 Medi-Cal 101 CONTENTS Child Application Process Introduction Overview Eligibility Enrollment 2. Internet >> Individual Application Process Health-e-App >> Child Application Process >> Recent Enrollment Process 1. Mail-in Application Changes May receive help from >> Beneficiary Profile certified application assister 3. In-person >> Enrollment After One Year Interview Benefits Service Delivery Expenditures Beneficiary Experiences SINGLE POINT COUNTY SOCIAL SERVICES OF ENTRY Importance of Medi-Cal Healthy Families IN SACRAMENTO Medi-Cal Family notified Family notified within Medi-Cal and Other States within 10 days of receipt 45 days of receipt Medi-Cal and the State Budget APP APP D IS LICA D IS LICA CHIL LED DEN TION CHIL LED DEN TION OL IED OL IED ENR ENR © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 15 Medi-Cal 101 CONTENTS Recent Enrollment Process Changes Introduction Overview Eligibility Enrollment Implemented mail-in application for >> Individual Application Process pregnant women and children Eliminated assets test for children >> Child Application Process Created joint Medi-Cal and Healthy Instituted 12-months continuous >> Recent Enrollment Process Families application eligibility for children Changes Reduced documentation >> Beneficiary Profile requirements (SB87) Adopted semi-annual status >> Enrollment After One Year reports for adults Benefits Service Delivery 1998 2000 2003 Expenditures 1999 2001 Beneficiary Experiences Importance of Medi-Cal Eliminated face-to-face application Medi-Cal and Other States for children/families Medi-Cal and the State Budget Implemented Health-e-App Eliminated quarterly status reports for families Source: The Lewin Group, 2003 © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 16 Medi-Cal 101 CONTENTS Beneficiary Profile Introduction Overview Eligibility Enrollment Children comprise more than half the beneficiaries >> Individual Application Process >> Child Application Process while Latinos represent the largest ethnic group. >> Recent Enrollment Process Changes >> Beneficiary Profile >> Enrollment After One Year Age/Disability Ethnicity Benefits Service Delivery Asian/Pacific Islander Expenditures Elderly (8%) Beneficiary Experiences (10%) Latino Not Available (38%) Importance of Medi-Cal (10%) Blind and Medi-Cal and Other States Disabled Medi-Cal and the State Budget (17%) African American Adults (14%) (21%) Caucasian Children (30%) (52%) Source: Department of Health Services, 2003 (2002 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 17 Medi-Cal 101 CONTENTS Enrollment After One Year Introduction Overview Eligibility ● More than 75 percent Enrollment All Categories 77% >> Individual Application Process of all beneficiaries >> Child Application Process remain enrolled after >> Recent Enrollment Process Changes Share of Cost 13% one year. >> Beneficiary Profile >> Enrollment After One Year ● Individuals who are Benefits Other Families 39% required to pay a Service Delivery share of their costs Expenditures Aged, Blind, 68% Disabled Beneficiary Experiences are much less likely Importance of Medi-Cal to retain coverage. Long-term Care 72% Medi-Cal and Other States ● Nearly all disabled Medi-Cal and the State Budget persons who qualify Cash Assistance 80% for Medi-Cal through SSI/SSP stay covered SSI/SSP 91% after 12 months. Source: DHS Annual Managed Care Statistical Reports, 2002. (1998 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 18 Medi-Cal 101 CONTENTS Medi-Cal Benefits Introduction Overview Eligibility All states are federally required to provide certain benefits. California offers Enrollment a number of additional benefits. The following are partial lists of both. Benefits >> Medi-Cal Benefits >> Medicare Beneficiary Coverage Required Services Optional Services Service Delivery ● In/outpatient hospital ● Prescription drugs Expenditures ● Physician visits ● Vision services and eyeglasses Beneficiary Experiences ● Lab tests and x-rays ● Dental care and dentures Importance of Medi-Cal ● Early and Periodic Screening, ● Physical therapy Medi-Cal and Other States Diagnosis and Treatment ● TB-related Medi-Cal and the State Budget (EPSDT) for children under 21 ● Provided by Intermediate Care Facilities ● Family planning and supplies for Mentally Retarded (ICF/MR) ● Clinic in Federally Qualified ● Inpatient/nursing for adults over 65 Health Centers (FQHC) ● Inpatient psychiatric for children under 21 ● Certified midwife ● Rehabilitation for mental health and ● Certified nurse practitioner substance abuse ● Nursing home care for adults ● Personal and home health care over 21 ● Hospice Source: Department of Health Services, 2003 © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 19 Medi-Cal 101 CONTENTS Medicare Beneficiary Coverage Introduction Overview Eligibility Coverage Eligibility Category (FPL) Covered Services Entitlement Enrollment Benefits Dual Eligibles Up to 100% ● Additional benefits such Yes, up to >> Medi-Cal Benefits as prescription drugs 74% FPL (SSI >> Medicare Beneficiary Coverage and long-term care. eligibility level) Service Delivery ● Medicare Part B Expenditures premium Beneficiary Experiences ● Cost-sharing Importance of Medi-Cal Qualified Medicare Up to 100% ● Medicare Parts A Yes Medi-Cal and Other States Beneficiary and B premiums Medi-Cal and the State Budget ● Cost-sharing Specified Low-income 101–120% ● Medicaid Part B Yes Beneficiary (SLMB) premium Qualifying Individuals: QI1 121–135% ● Medicare Part B No premium QI2* 136 –175% ● Portion of Medicare No Part B premium *Enrollment is closed as of December 2002. Source: Kaiser Commission on Medicaid and Uninsured, 2003. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 20 Medi-Cal 101 CONTENTS Delivery Systems Introduction Overview Eligibility Area Fee-for-Service Managed Care Enrollment Availability All 58 counties 25 large counties Benefits Service Delivery Market Share 55% of all beneficiaries 45% of all beneficiaries >> Delivery Systems >> Managed Care Models by County Population ● Most elderly and disabled Mandatory Enrollment >> Managed Care Enrollment ● Children Trends In counties without >> Physician Participation ● Pregnant women Managed Care Expenditures ● Non-disabled parents ● Children Beneficiary Experiences ● Pregnant women Voluntary Enrollment Importance of Medi-Cal ● Non-disabled parents ● Most elderly and disabled Medi-Cal and Other States Medi-Cal and the State Budget Expenditures* 74% 16% Exclusions N/A ● Mental health ● Dental ● Long-term care ● California Children Services (CCS) for the seriously ill and disabled *Do not include services delivered in Disproportionate Share Hospitals (DSH). © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 21 Medi-Cal 101 CONTENTS Managed Care Models by County Introduction Overview Del Eligibility Norte County Organized Health Siskiyou Modoc Enrollment System (COHS) Benefits Shasta ● 550,000 beneficiaries Humboldt Trinity Lassen Service Delivery in 8 counties Tehama Plumas >> Delivery Systems ● 5 county organized Glenn Butte >> Managed Care Models Sierra by County health plans Mendocino Lake Colusa Yuba Nevada Placer >> Managed Care Enrollment Sutter ● Implemented in 1983 Yolo El Dorado Trends Napa Sacramento Alpine Sonoma Amador >> Physician Participation Solano Calaveras Marin San Geographic Managed Care Contra Costa Joaquin Tuolumne Mono Expenditures (GMC) San Francisco San Mateo Alameda Stanislaus Mariposa Beneficiary Experiences Santa Merced Madera Clara ● 340,000 beneficiaries in Santa Cruz San Importance of Medi-Cal Inyo 2 counties Benito Fresno Medi-Cal and Other States Tulare ● 9 commercial health plans Monterey Kings Medi-Cal and the State Budget ● Implemented in 1993 San Luis Obispo Kern San Bernardino Two-plan Santa Barbara Ventura Los Angeles ● 2.41 million beneficiaries in 12 counties Riverside ● 8 local initiatives and 3 commercial health plans Orange ● Implemented in 1993 San Diego Imperial Source: Department of Health Services, May 2003 Enrollment by Plan Type. Excludes special plans. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 22 Medi-Cal 101 CONTENTS Managed Care Enrollment Trends Introduction Overview Eligibility The two-plan model experienced dramatic enrollment Enrollment Benefits growth between 1996 and 2002. Service Delivery >> Delivery Systems >> Managed Care Models millions by County >> Managed Care Enrollment 3.5 Trends GMC Other COHS Two-Plan >> Physician Participation 3.0 Expenditures Beneficiary Experiences 2.5 Importance of Medi-Cal Medi-Cal and Other States 2.0 Medi-Cal and the State Budget 1.5 1.0 0.5 0 1996 1997 1998 1999 2000 2001 2002 Source: DHS Annual Managed Care Statistical Reports. (1996–2002 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 23 Medi-Cal 101 CONTENTS Physician Participation Introduction Overview Eligibility Enrollment 70 There are only Per 100,000 People Benefits Medi-Cal Overall Service Delivery 46 primary care >> Delivery Systems >> Managed Care Models providers for by County 46 >> Managed Care Enrollment Trends every 100,000 >> Physician Participation Expenditures beneficiaries, Beneficiary Experiences well below Importance of Medi-Cal Medi-Cal and Other States the federal 15 15 Medi-Cal and the State Budget 12 minimum 10 4 5 standard of Primary Ob-Gyn Medical Surgical 60 to 80. Care Specialist Specialist © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 24 Medi-Cal 101 CONTENTS Expenditure Distribution Introduction Overview Eligibility Enrollment Total Benefits Mental Health (3%) $24.3 billion Service Delivery Dental (4%) Expenditures Physicians (4%) >> Expenditure Distribution Hospitals* >> Enrollment and Expenditure Administration (29%) Trends (6%) >> Average Annual Cost Per Beneficiary >> Average Annual Cost Trends Pharmacy* >> Expenditure Trends by Service (9%) Beneficiary Experiences Importance of Medi-Cal Medi-Cal and Other States LTC Facilities* (12%) Medi-Cal and the State Budget Health Plans (16%) Other Services* (17%) *Fee-for-service payments only. Excludes DSH. Source: Department of Health Services, 2002. (2001 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 25 Medi-Cal 101 CONTENTS Enrollment and Expenditure Trends Introduction Overview Eligibility Over the past decade, Medi-Cal expenditures increased by more than Enrollment 60 percent due to enrollment growth and rising costs per beneficiary. Benefits Service Delivery Expenditures >> Expenditure Distribution Beneficiaries Expenditures >> Enrollment and Expenditure (millions) (billions) Trends 7 $35 >> Average Annual Cost Per Beneficiary 6 $30 >> Average Annual Cost Trends >> Expenditure Trends by Service 5 $25 Beneficiary Experiences Importance of Medi-Cal 4 $20 Medi-Cal and Other States 3 $15 Medi-Cal and the State Budget 2 $10 1 $5 0 $0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 (est.) Source: California Department of Health Services. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 26 Medi-Cal 101 CONTENTS Average Annual Cost Per Beneficiary Introduction Overview Eligibility $9,107 Enrollment Due to intensive Long-term Care Benefits $8,225 use of both acute Acute Care Service Delivery Expenditures and long-term >> Expenditure Distribution >> Enrollment and Expenditure Trends care services, >> Average Annual Cost Per Beneficiary expenditures >> Average Annual Cost Trends >> Expenditure Trends by Service are seven times Beneficiary Experiences Importance of Medi-Cal greater for the Medi-Cal and Other States Medi-Cal and the State Budget elderly and $1,914 $1,229 disabled than for children. Children Adults Elderly Disabled Source: Based on analysis of 20 percent sample of Medi-Cal fee-for-service claims (2001 Data). © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 27 Medi-Cal 101 CONTENTS Average Annual Cost Trends Introduction Overview Eligibility Enrollment The cost per person for children and adults with Benefits disabilities increased the most rapidly. Service Delivery Expenditures >> Expenditure Distribution >> Enrollment and Expenditure Trends Average Annual 10% >> Average Annual Cost Spending Growth Per Beneficiary >> Average Annual Cost Trends >> Expenditure Trends by Service 7% Beneficiary Experiences Importance of Medi-Cal 5% Medi-Cal and Other States Medi-Cal and the State Budget 3% 2% Children Adults Children with Adults with Aged TANF* TANF* Disabilities Disabilities *Temporary Assistance for Needy Families. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 28 Medi-Cal 101 CONTENTS Expenditure Trends by Service Introduction Overview Eligibility Enrollment Rising drug costs have fueled recent growth in spending. Benefits Service Delivery Expenditures >> Expenditure Distribution Medi-Cal FFS Spending per Person Average >> Enrollment and Expenditure Adults with Disabilities Compound Trends Growth Rate $9,183 >> Average Annual Cost Outpatient Hospital 0.2% Per Beneficiary 6.6% >> Average Annual Cost Trends Physician >> Expenditure Trends by Service Other 7.9% Beneficiary Experiences $6,213 Long-term Care 8.0% Importance of Medi-Cal Medi-Cal and Other States Pharmacy 19.9% Medi-Cal and the State Budget Mental Health 0.1% Inpatient Hospital 1.6% 1995 2001 © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 29 Medi-Cal 101 CONTENTS Overall Program Experience Introduction Overview Eligibility “Overall, how satisfied are you with Medi-Cal?” Enrollment ● 87 percent of Benefits Medi-Cal Very Dissatisfied Service Delivery beneficiaries (3%) Expenditures report that they Don’t Know Beneficiary Experiences are satisfied with (4%) >> Overall Program the program >> Enrollment Process >> Locating a Doctor ● Satisfaction levels >> Quality of Care Somewhat >> Access to Care are comparable Dissatisfied (6%) Importance of Medi-Cal to employer- Medi-Cal and Other States sponsored Medi-Cal and the State Budget coverage ● “Medi-Cal is Satisfied worth the hassle (40%) because of what you get Very Satisfied in return.” (47%) Source: Medi-Cal Policy Institute, Medi-Cal Beneficiary Survey, 1999. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 30 Medi-Cal 101 CONTENTS Enrollment Process Experience Introduction Overview Eligibility “Signing up for Medi-Cal requires Enrollment Barriers to Enrollment too much paperwork.” Benefits ● Complexity of Service Delivery application process Don’t Know (2%) Expenditures ● Difficulty obtaining Beneficiary Experiences required documentation Disagree >> Overall Program such as income Strongly >> Enrollment Process (7%) verification >> Locating a Doctor >> Quality of Care ● Lack of knowledge about Disagree >> Access to Care the program Somewhat (13%) Importance of Medi-Cal ● Stigma associated with Medi-Cal and Other States Medi-Cal because of its Medi-Cal and the State Budget historic links to welfare ● Fear that enrollment in Agree Medi-Cal will adversely Somewhat (26%) effect future opportunities for citizenship for immigrant families Agree Strongly (52%) Source: Medi-Cal Policy Institute, Medi-Cal Beneficiary Survey, 1999. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 31 Medi-Cal 101 CONTENTS Experience Locating a Doctor Introduction Overview Eligibility “Finding a doctor nearby is…” Enrollment ● More than half Benefits of beneficiaries Very Easy (16%) Service Delivery reported some Expenditures Don’t Know difficulty in (2%) Beneficiary Experiences >> Overall Program finding a doctor. >> Enrollment Process >> Locating a Doctor ● “Medi-Cal is good Somewhat >> Quality of Care until you actually Difficult >> Access to Care (30%) Importance of Medi-Cal go and try to find Medi-Cal and Other States a doctor. That’s Medi-Cal and the State Budget the hardest part.” ● State and Very Difficult counties provide (26%) limited help in this area. Somewhat Easy (26%) Source: Medi-Cal Policy Institute, Medi-Cal Beneficiary Survey, 1999. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 32 Medi-Cal 101 CONTENTS Quality of Care Experience Introduction Overview Eligibility “Medi-Cal provides high quality services.” Enrollment ● Eight in ten Medi-Cal Benefits beneficiaries report Don’t Know Service Delivery that it provides high (2%) Expenditures quality services. Disagree Strongly Beneficiary Experiences (6%) >> Overall Program ● This result is >> Enrollment Process Disagree >> Locating a Doctor comparable to that Somewhat >> Quality of Care for commercial (12%) >> Access to Care health plans. Importance of Medi-Cal Medi-Cal and Other States ● However, nearly Medi-Cal and the State Budget all beneficiaries (92 percent) believe Agree Strongly that it is important (39%) to improve the Agree Somewhat quality of services. (41%) Source: Medi-Cal Policy Institute, Medi-Cal Beneficiary Survey, 1999. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 33 Medi-Cal 101 CONTENTS Access to Care Experience Introduction Overview Eligibility Use Rates for Primary Care Services Enrollment Children and women Medi-Cal Employer Coverage Uninsured Benefits enrolled in Medi-Cal Service Delivery 76% Expenditures 74% report use rates 72% 69% Beneficiary Experiences >> Overall Program for primary care 63% 62% >> Enrollment Process >> Locating a Doctor services that are >> Quality of Care >> Access to Care comparable to those 44% 44% 41% Importance of Medi-Cal for people enrolled Medi-Cal and Other States Medi-Cal and the State Budget in employer coverage and much greater than the uninsured. Any Doctor Visit Any Dental Visit Any Pap Smear (Children) (Children) (Women) Percent who report. Source: Urban Institute, 2001. (1999 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 34 Medi-Cal 101 CONTENTS Low-Income Californians Introduction Overview Eligibility Enrollment Medi-Cal acts as a vital safety net for residents of limited means. Benefits Service Delivery Expenditures Among Other Services, Medi-Cal: Beneficiary Experiences ● Provides health coverage for many poor children and Importance of Medi-Cal >> Low-Income Californians some poor adults. >> California’s Children >> Non-Elderly Population ● 55 percent of California’s children with family >> Adults with Disabilities incomes below 100 percent of FPL >> California’s Health System >> Community Health Centers ● 20 percent of all people with family incomes >> Public Hospitals below 100 percent of FPL Medi-Cal and Other States ● Pays for 42 percent of all births in the state. Medi-Cal and the State Budget ● Covers the majority of persons living with AIDS. ● Fills in Medicare coverage gaps for low-income elderly. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 35 Medi-Cal 101 CONTENTS Children’s Coverage Introduction Overview Eligibility Enrollment ● Nearly one in four Total: 10 million Benefits of California’s Private/Other Service Delivery children are insured (6%) Expenditures Beneficiary Experiences by Medi-Cal and Uninsured Importance of Medi-Cal Healthy Families (10%) >> Low-Income Californians >> California’s Children >> Non-Elderly Population ● Among the one >> Adults with Disabilities million uninsured >> California’s Health System >> Community Health Centers children in the >> Public Hospitals Medi-Cal and Other States state, two-thirds Medi-Cal/ Healthy Families Medi-Cal and the State Budget are eligible for (22%) Medi-Cal or Employer Healthy Families (62%) Source: California Health Interview Survey. (2001 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 36 Medi-Cal 101 CONTENTS Non-Elderly Coverage Introduction Overview Eligibility Enrollment ● One in six Total: 29.6 million Benefits individuals under Private/Other Service Delivery age 65 is covered (7%) Expenditures by Medi-Cal Beneficiary Experiences ● Two-thirds Importance of Medi-Cal Uninsured >> Low-Income Californians receive coverage (15%) >> California’s Children through their >> Non-Elderly Population >> Adults with Disabilities employer >> California’s Health System >> Community Health Centers ● Among the state’s >> Public Hospitals 4.6 million Medi-Cal and Other States uninsured, Medi-Cal Medi-Cal and the State Budget 25 percent may (16%) be eligible for Medi-Cal or Healthy Families Employer (62%) Source: California Health Interview Survey. (2001 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 37 Medi-Cal 101 CONTENTS Adults with Disabilities Coverage Introduction Overview Eligibility Average Annual Spending Per Beneficiary* ● Medi-Cal covers Enrollment with Disabilities without Disabilities Benefits 750,000 people $2,430 Service Delivery with disabilities $2,303 Expenditures ● Types of disability Beneficiary Experiences include: Importance of Medi-Cal >> Low-Income Californians ● Physical >> California’s Children ● Developmental >> Non-Elderly Population ● Mental >> Adults with Disabilities $1,313 >> California’s Health System ● Other conditions >> Community Health Centers such as HIV/AIDS >> Public Hospitals Medi-Cal and Other States ● On average, people $714 Medi-Cal and the State Budget with disabilities $575 consume seven times the health $193 $175 care resources used $13 by other categories Physician Inpatient Pharmacy Long-Term Services Hospital Care *Fee-for-service expenditures only. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 38 Medi-Cal 101 CONTENTS Role in Health System Introduction Overview Eligibility ● Medi-Cal pays: Enrollment ● $1 out of every $6 spent on health care in California Benefits ● 64 percent of all nursing home days Service Delivery Expenditures ● Largest source of public funding for mental health services Beneficiary Experiences Importance of Medi-Cal ● Enrolls one-quarter of community health center and >> Low-Income Californians >> California’s Children public hospital patients >> Non-Elderly Population >> Adults with Disabilities >> California’s Health System ● Accounts for two-thirds of revenues at California’s >> Community Health Centers public hospitals >> Public Hospitals Medi-Cal and Other States Medi-Cal and the State Budget © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 39 Medi-Cal 101 CONTENTS Community Health Centers Introduction Overview Eligibility Enrollment Medi-Cal accounts for one-quarter of patients and 42 percent Benefits of revenues at community health centers in California. Service Delivery Expenditures Beneficiary Experiences Importance of Medi-Cal 2.8 million $538 million >> Low-Income Californians Medicare 5% 6% >> California’s Children Private 7% 7% >> Non-Elderly Population >> Adults with Disabilities >> California’s Health System >> Community Health Centers 45% >> Public Hospitals Uninsured 61% Medi-Cal and Other States Medi-Cal and the State Budget 42% Medi-Cal 26% Patients Revenues Percentages may not total 100 percent due to rounding. Source: Office of Statewide Health Planning and Development, 2002. (2001 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 40 Medi-Cal 101 CONTENTS Public Hospitals Introduction Overview Eligibility Enrollment ● Medi-Cal accounts for Total Revenue $5 billion Benefits 64 percent of net Service Delivery revenues at public Private Insurance (5%) Expenditures hospitals Beneficiary Experiences ● Public and some Medicare Importance of Medi-Cal non-profit hospitals (7%) >> Low-Income Californians receive supplemental >> California’s Children >> Non-Elderly Population payments (DSH and >> Adults with Disabilities SB 855) to reimburse >> California’s Health System them for treating >> Community Health Centers >> Public Hospitals Medi-Cal patients Medi-Cal and Other States and the uninsured Other Medi-Cal and the State Budget ● Federal supplemental Sources (24%) payments to California hospitals have declined from $1.1 billion in 1998 Medi-Cal to $900 million in 2002 (64%) Source: Office of Statewide Health Planning and Development, 2002. (2001 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 41 Medi-Cal 101 CONTENTS Enrollment in Other States Introduction Overview Eligibility Enrollment California ranks second among the ten largest states. Benefits Service Delivery Expenditures Non-elderly Population Covered by Medicaid Beneficiary Experiences New York 15% Importance of Medi-Cal Medi-Cal and Other States California 14% >> Enrollment Comparison Florida 11% >> Low-Income Child Coverage >> Spending Comparison Michigan 11% >> Physician Payment Rates Georgia 10% >> Major Optional Benefits Covered >> Overall Generosity Pennsylvania 10% Medi-Cal and the State Budget Texas 10% Illinois 9% Ohio 9% New Jersey 8% U.S. Average 11% Source: Kaiser State Health Facts. (2000–2001 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 42 Medi-Cal 101 CONTENTS Low-Income* Child Coverage Introduction Overview Eligibility Enrollment Medi-Cal and Healthy Families cover a greater percentage of Benefits low-income children than the U.S. average, but 25 percent Service Delivery are uninsured. Expenditures Beneficiary Experiences Importance of Medi-Cal Medi-Cal and Other States 7% 11% >> Enrollment Comparison 16% 16% 25% 26% 37% 22% Uninsured >> Low-Income Child Coverage 34% >> Spending Comparison 47% 39% 46% >> Physician Payment Rates 34% 43% >> Major Optional Benefits Covered 39% Employer/ >> Overall Generosity 35% Private 59% Medi-Cal and the State Budget 46% 42% 41% 38% 35% 35% Medicaid/ 29% S-CHIP MA NY WA CA NJ FL TX U.S. Average *Percentages may not total 100 percent due to rounding. Less than 200 percent FPL. Source: Urban Institute, 2001. (1999 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 43 Medi-Cal 101 CONTENTS Spending in Other States Introduction Overview Eligibility California spends less per beneficiary than other states due to a Enrollment Benefits variety of factors, including low provider payment levels and its Service Delivery lower percentage of elderly and disabled beneficiaries. Expenditures Beneficiary Experiences Average Spending per Beneficiary Importance of Medi-Cal New York $10,880 Medi-Cal and Other States $9,577 >> Enrollment Comparison New Jersey >> Low-Income Child Coverage Pennsylvania $8,137 >> Spending Comparison >> Physician Payment Rates Ohio $7,435 >> Major Optional Benefits Covered Illinois $6,364 >> Overall Generosity Michigan $6,188 Medi-Cal and the State Budget Texas $6,179 Georgia $5,989 Florida $5,234 California $4,465 U.S. Average $6,528 Source: Kaiser State Health Facts. (Federal FY 2002 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 44 Medi-Cal 101 CONTENTS Physician Payment Rates Introduction Overview Eligibility Medi-Cal pays physicians about two-thirds of Medicare rates. Enrollment Benefits This is less than the national average, but more than the Service Delivery payment rates of several other large states. Expenditures Beneficiary Experiences Physician Payment Importance of Medi-Cal New York 36% (percentage of Medicare rates) Medi-Cal and Other States New Jersey 41% >> Enrollment Comparison >> Low-Income Child Coverage Michigan 60% >> Spending Comparison Pennsylvania 64% >> Physician Payment Rates >> Major Optional Benefits Covered Florida 65% >> Overall Generosity California 65% Medi-Cal and the State Budget Illinois 67% Ohio 73% Texas 78% Georgia 83% U.S. Average 81% © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 45 Medi-Cal 101 CONTENTS Major Optional Benefits Covered Introduction Overview Eligibility Number of States 23 Enrollment ● Medi-Cal covers Benefits 27 out of 29 major 20 Service Delivery optional benefits Expenditures such as prescription Beneficiary Experiences Importance of Medi-Cal drugs, dental Medi-Cal and Other States services, and >> Enrollment Comparison >> Low-Income Child Coverage physical exams >> Spending Comparison >> Physician Payment Rates 8 ● California is among >> Major Optional Benefits Covered >> Overall Generosity the 8 most generous Medi-Cal and the State Budget states in the nation 3 2 in terms of its coverage of ≤ 10 11–15 16–20 21–25 26–28 optional benefits Major Optional B e n e f it s C o v e r e d *Includes both optional and mandatory. Source: Kaiser Commission on Medicaid and Uninsured, 2003. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 46 Medi-Cal 101 CONTENTS State Medicaid Generosity Introduction Overview Eligibility California spends about 2 percent of total personal income on Medi-Cal, Enrollment Benefits comparable to many other states, but less than the national average. Service Delivery Expenditures State Medicaid Spending* Beneficiary Experiences (percentage of Total Personal Income) Importance of Medi-Cal New York 4.6% Medi-Cal and Other States Pennsylvania 2.9% >> Enrollment Comparison >> Low-Income Child Coverage Ohio 2.6% >> Spending Comparison Michigan 2.4% >> Physician Payment Rates >> Major Optional Benefits Covered NewJersey 2.2% >> Overall Generosity California 2.2% Medi-Cal and the State Budget Georgia 2.2% Illinois 2.0% Texas 1.9% Florida 1.8% U.S. Average 2.5% *Includes federal and state funds. Source: CHCF analysis of Kaiser State Health Facts and census. (2001) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 47 Medi-Cal 101 CONTENTS State Budget Distribution Introduction Overview Eligibility Total Budget: $71 billion Enrollment ● Medi-Cal accounts Benefits for the third largest Other Programs (6%) Service Delivery share of the state’s Expenditures General Fund behind Corrections Beneficiary Experiences primary education (8%) Importance of Medi-Cal and all other HHS Medi-Cal and Other States programs combined Higher Education Medi-Cal and the State Budget ● California receives (12%) >> Budget Distribution >> Projected State Budget Trends $1 from the federal >> State Policy Options to Limit government for Medicaid Expenditures Medi-Cal >> Important Challenges in every dollar that it (15%) Medi-Cal’s Future spends on Medi-Cal ● Medi-Cal expendi- Other Health & tures are growing Human Services faster than other (18%) programs K-12 Education (41%) Source: Department of Finance, 2003. (State FY 2003–04 Data) © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 48 Medi-Cal 101 CONTENTS Projected State Budget Trends Introduction Overview Eligibility Since 2000/01, the state has faced growing budget deficits Enrollment Benefits due to slower revenue growth relative to expenditures. Service Delivery Expenditures Beneficiary Experiences $120 Importance of Medi-Cal Expenditures Medi-Cal and Other States Medi-Cal and the State Budget >> Budget Distribution $100 >> Projected State Budget Trends >> State Policy Options to Limit Medicaid Expenditures >> Important Challenges in Medi-Cal’s Future $80 Revenues and Transfers $60 ’99–00 ’00–01 ’01–02 ’02–03 ’03–04 ’04–05* ’05–06* ’06–07* ’07–08* *Projected. Source: Department of Finance and Legislative Analyst’s Office, 2003. © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 49 Medi-Cal 101 CONTENTS State Policy Options to Limit Introduction Overview Medicaid Expenditures Eligibility Enrollment ● Improve efficiency Benefits Service Delivery ● Reduce provider fraud and abuse Expenditures Beneficiary Experiences ● Reduce enrollment in the program Importance of Medi-Cal Medi-Cal and Other States ● Reduce spending on benefits and services Medi-Cal and the State Budget >> Budget Distribution ● Reduce payments to providers and suppliers >> Projected State Budget Trends >> State Policy Options to Limit Medicaid Expenditures >> Important Challenges in Medi-Cal’s Future © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 50 Medi-Cal 101 CONTENTS Important Challenges in Introduction Overview Medi-Cal’s Future Eligibility Enrollment ● Sustain enrollment gains of past decade Benefits Service Delivery ● Control state spending Expenditures ● Ensure reasonable access to care for beneficiaries by Beneficiary Experiences maintaining adequate provider participation Importance of Medi-Cal Medi-Cal and Other States ● Provide appropriate community-based long-term Medi-Cal and the State Budget care per Olmstead vs. L.C. >> Budget Distribution >> Projected State Budget Trends ● Improve quality of care delivered, including >> State Policy Options to Limit Medicaid Expenditures customer service >> Important Challenges in Medi-Cal’s Future ● Simplify the enrollment process by adopting new technologies ● Respond to changing demographic composition of population and increased demand for acute and long-term care services ● Respond to policy changes at federal level © 2004 C ALIFORNIA H EALTH C ARE F OUNDATION 51 About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s healthcare delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality healthcare. Contact us: California HealthCare Foundation 476 Ninth Street Oakland, CA 94607 t: 510.238.1040 f: 510.238.1388 www.chcf.org