Medicare and Medicaid

medicare and medicaid

• two separate government run programs

medicare

• federal program that provides health coverage if you are 65+ or under 65 and have a disability no matter your income

medicaid

• state and federal program that provides health coverage if you have very low income-up to 138% of the federal poverty level

• 21,597$ for an individual in 2025

medicare and medicaid spending

• 1.9 trillion on healthcare programs and services spent by the government

  • Medicare accounted for about 36% which equals roughly 684 billion

  • medicare is the largest single component of federal care spending

• in 2023 medicaid spending reached 871.1 billion accounting for 18% of total national health expenditures

what is Medicare

• medicare is the federal government health insurance program for people age 65 and older and younger people living with certain illness or disability

• has 4 parts Part A- Part D

• about 65 million people are enrolled

• 65 years or older with social security automatically enrolled in meidcare part A and B

• does not cover everything

medicare parts

• Part A:

  • covers hospital care and related services

• Part B:

  • covers doctor appointments and outpatient medical care

• Part C

  • same benefits of Part A and B but is offered by private insurers (medicare advantage)

• Part D

  • covers prescription drugs

can be enrolled in Medicare and Medicaid at the same time: dual coverage

key medicare policy changes

• medicare advantage payments

• 304B overpayment clawbacks

  • accelerated 7.8 billion recovery from hospitals and 1 billio reduction in 2026

• weight-loss drug coverage pilot

  • optional GLP-1 coverage start 2027 35 billion cost estimate

• obesity drug coverage rejected

  • CMS blocked prior proposal l to cover obesity drugs

• drug pricing reform

• telehealth access

  • restriction most services no longer cover home access

• CMS leadership enrollment

  • enrollment/timing concerns raised by AMA

what is medicaid

• provides health coverage to millions of Americans

  • low-income adults, children, pregnant women, elderly adults and people with disability

• medicaid is administered by state according to federal requirements

• funded jointly by the state and federal government

• ACA of 2010 created the opportunity for the states to expand Medicaid to cover nearly all low income Americans underage 65

• medicaid programs in CT are Husky A, c and D

medicaid eligibility

• financial eligibility:

  • modified adjusted gross income (MAGI)

• MAGI- bases methodology considers taxable income and tax filing relationships to determine financial eligibility

• eligibility for children was extended to at least 133% of federal poverty level in every state and states were given the opti0on to extend eligibility to adults with income at or below 133% of the FPL

Childrens health insurance program (CHIP)

• provides low-cost health coverage to children in families that earn too much money to qualify for medicaid but not enough to buyht private insurance

• CHIP covers pregnant women in some states

• each state offers chip coverage and works closely with its Medicaid program

• can apply anytime and can begin immediately if you qualify

• CHIP in CT = Husky B Program

medicaid expansion

• expanded nearly all adults with incomes up to 138% of the FPL

• provided states with and enhanced federal matching rate (FMAP) for their expansion populations

• 40 states and DC have adopted medicaid expansion

medicaid funding structure

• jointly funded by federal government and states

• federal medical assistance percentage (FMAP)

  • federal gov pays a share of each state Medicaid cost ranging from 50-75% depending on the state’s per capita income

• enhanced FMAP

  • states that expanded Medicaid under the ACA receive higher federal match

• state contribution

  • states fund the remaining share through general revenues, provider taxes and other sources

medicaid in CT

• HuskyHealth

• CHIP is Husky B

• Husky A:

  • family income is less than 185% of the poverty level, and pregnant women whose income is less than 250% of the poverty level

• Husky C

  • aged, blind or certain disabilities

• Husky D

  • single adults whose income is below 56% of the federal poverty line