Medicaid 101: What Every American Needs To Know

Medicare is the social insurance program America offers to people over 65, as well as people younger than 65 with certain disabilities. Medicaid is also a social health insurance program, offering insurance for persons of all ages whose income and resources are too limited to afford health care. It is governed by CMS—Centers for Medicare and Medicaid Services—which is a branch of the United States Government.

Medicare is wholly funded by the United States Government, while individual state governments provide up to half of the funding for Medicaid, with the federal government providing the rest.

Unlike Medicare, Medicaid is a need-based program. Medicare enrollees pay a premium, but not every Medicaid enrollee pays a premium, dependent upon income and the specific Medicaid program they are enrolled in.

Together with CHIP—Children’s Health Insurance Program—Medicaid offers social health insurance to approximately 60 million Americans. This group includes children, women and men of all ages, pregnant women and people with disabilities. It is the largest funding source for Americans with low income, and is jointly funded by the United States Government and state governments. Each state has the option to participate—it is not mandated. However, every state in the United States currently participates in the program, and each state sets its own eligibility requirements. Each state manages its own program, and recipients must be US citizens or legal permanent residents. Eligibility is determined by each state, and if an enrolled person moves to another state, their eligibility may not transfer to that state. There are certain “mandatory benefits” that each state is required to cover, and there are “optional benefits” that each state can choose to cover, including prescription drugs.

Medicaid was created by the Social Security Amendments of 1965 which added Title XIX to the Social Security Act. The Medicaid Drug Rebate Program and the Health Insurance Premium Payment (HIPP) were created by the Omnibus Budget Reconciliation Act of 1990. This program was formed to control the costs that were being incurred by Medicaid for prescription drugs. The Affordable Care Act significantly expanded both eligibility for and federal funding of Medicaid.

Other changes since its inception include the implementation of an estate recovery program, which requires that states sue the estates of deceased Medicaid recipients for reimbursement of some or all medical and/or long-term care costs incurred by Medicaid, and a repayment of a percentage of medical costs incurred when an insured receives an insurance payment or lawsuit payment due to a physical injury that required this medical care.

CHIP—Children’s Health Insurance Program—provides coverage for nearly 8 million U.S. children whose family incomes are too high for Medicaid, but can’t afford private coverage. CHIP was signed into law in 1997. Like Medicaid, CHIP is jointly funded by the federal and state government. Typically, the federal contribution is 15 percentage points higher than for Medicaid.

Each state has a unique organization devoted to administration of Medicaid. In Kansas, KanCare is the branch of the state government that administers Medicaid.

  • KanCare began in 2013, and serves over 360,000 Kansas consumers. Medicaid and HealthWave ceased to function together on December 31st, 2012, when KanCare became the official state agency administering Medicaid services.
  • Kansas has contracted with three health plans or managed care organizations (MCOs) to coordinate health care for nearly all Medicaid beneficiaries.
  • These three plans are: Amerigroup, Sunflower and United.
  • New services offered by these three groups include: preventive dental care for adults, heart/lung transplants and bariatric surgery.

As health care costs continue to increase, KanCare is dedicated to controlling these costs, while providing optimal health care to its enrollees. KanCare coordinates all the different care a consumer can receive, including doctor visits, inpatient care, behavioral health services, dental and vision care, pharmacy, transportation to and from these appointments, and nursing facility care.

A significant percentage of nursing home care in Kansas is covered by Medicaid. Approximately 60% of nursing home residents receive Medicaid assistance. Income and asset guidelines must be followed in order for Medicaid to cover nursing home expenses. Medicare does not pay for long-term nursing home care, but it can cover most costs for up to 100 days of skilled nursing care as well as physical, occupational and speech therapy if the resident shows consistent progress. An enrolled person can receive both Medicaid and Medicare services, depending upon their eligibility. In some cases, Medicaid will pay the premium for Medicare.

Government-funded health-care spending in the United States has historically been an effective system, but does require continued and ongoing changes and improvements to maintain pace with political, social and medical changes in order to provide cost-effective and appropriate programs for those insured.

The goals of KanCare are to improve overall health outcomes while slowing the rate of cost growth over time. Their preventive services and screenings, as well as management of chronic conditions aim to reduce need for future health care services. They strive to accomplish this by providing the right care, in the right amount, in the right setting and at the right time.