Medicaid Validation: A Case Study

Medicare and Medicaid are programs that have been developed to assist Americans in attainment of quality health care. Both programs were established in 1965 and are federally supported to provide health care coverage to vulnerable populations such as the elderly, the disabled, and people with low incomes. Both Medicare and Medicaid are federally mandated and determine coverage under each program; both are run by the Centers for Medicare & Medicaid Services, a federal agency ("What is Medicare? What is Medicaid?” 2008).

Medicaid is a social health care program that covers nearly 60 million Americans, including children, pregnant women, seniors, parents and individuals suffering with disabilities. Medicaid is the biggest source of funding for health related services and medical needs for the people with low income in the United States. This program is funded jointly by the state and federal level governments, but it is the state’s responsibility to manage this program. The Medicaid program is not a required program that states have to use, but all 50 states have implemented this program. With the introduction of the Affordable Care Act (ACA), and its passing in 2010, the ACA unveiled its plans to expand Medicaid eligibility to nearly all low-income adults as an addition to the other groups that fall into the Medicaid eligibility. The Medicaid program had “many gaps in coverage for adults” because it was only restricted to the low income individuals and other people with needs in their own specific category. In the past, the majority of the states who had adults that did not have children dependent on those parents were not eligible for Medicaid. These low income adults without dependent children would be without medical insurance assistance before the ACA was introduced. Medicaid is now available to all Americans under the age of 65 whose family income is at or below the federal poverty guideline of “133 percent or $14,484 for an individual and $29,726 for a family of four in 2011” (NSCL).

Each state has their own policies for Medicaid eligibility, services and payments. Medicaid plans have three eligibility groups such as categorically needy, medically needy and special groups. Children's Health Insurance Program (CHIP) is a program that offers health insurance coverage for uninsured children under Medicaid. If Medicaid does not cover a service, the patient may be billed if the following conditions have been met such as the physician informed the patient before the service was performed that the procedure was not covered by Medicaid and if the patient has signed an Advance beneficiary Notice form. However, there are also conditions where the patient cannot be billed if necessary preauthorization was not obtained or service

Affordable care act is a law that was passed in March of 2010 to help decrease health care cost and make it more affordable for all Americans. The affordable care act is set to decrease the number of uninsured Americans, qualify more for Medicare and Medicaid, increase the quality of care, promote prevention, extending funding for the children, and help with funding in the communities. The goal for affordable care act is to have everyone insured, no matter what income class you are in. The affordable care act is there to insure everyone so that prevention will increase. It will increase by being able to get check ups and children being able to receive vaccination. If you are not able to qualify for Medicare or Medicaid there

The Affordable Care Act was put in place by President Obama in 2010, providing Americans access to affordable health insurance. But South Carolina’s governor, the republican Nikki Haley is still rejecting the Medicaid expansion. My paper has detailed information on why Governor Haley and republicans made their decision to opt out of the expansion. Also, alternate approaches to expanding access to care and implementing or reconsidering the state’s decision of opting out of the expansion. Finally, recommendations to the state legislature to convey opting out of Medicaid expansion.

Texas has the largest uninsured population with an estimated 6.2 million uninsured citizens within its stateliness, approximately a quarter of the statewide population (Rapoport, 2012). In 2012, then governor, Rick Perry decided that Texas would not expand Medicaid under the Affordable Care Act (ACA). This decision led to much debate over whether or not Perry made the right decision to leave upwards of a million Texans, who did not receive insurance subsidies and did not qualify for Medicaid, uninsured. These Texans fell under what many politicians refer to as the “coverage gap.” Texas decided not to expand Medicaid under the Affordable Care Act because of the effects it would have on hospitals, financial reasons, and increased number of

The Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010, and on June 28, 2012 the Supreme Court decided to uphold the law.¹ Some of the most notable features that the ACA will provide for individuals are access to healthcare for everyone, new consumer protections such as pre-existing condition coverage, free preventative care, protection against healthcare fraud, small business tax credits, as well as many other features.¹

The South Carolina Title XIX State Plan, also known as Medicaid, was designed to maintain the provision of “quality health care to low income, disabled, and elderly individuals” (South Carolina Department of Health and Human Services, 2016). The South Carolina Department of Health and Human Services (SCDHHS) acts as the designee for this administration, managing the state and federal reimbursement of funds for approved medical providers. Services are designed to provide services for diagnosis, treatment, and management of illnesses. The Management Care Organization program provides insurance coverage through a network comprised of contracted, providers who are paid a “per member per month capitated rate” (SCDHHS, 2016). These

Medicaid is the U.S. government’s health insurance program, that furnishes health care coverage to more than 74.7 million eligible adults and children in the country ("Medicaid Enrollees," 2017), with over $553.4 billion reported total health care spending for the fiscal year of 2016 ("Medicaid Spending," 2016). As the number of eligible Medicaid enrollees grows, the amount of health care spending is presumed to accelerate. The 2016-2025 National Health Expenditure Projections showed a 5.6% per year increase in the United States’ national health expenses and a per capita growth of 4.7% per year. However, compared to 2015’s 9.7% Medicaid spending, the projected drop of 6.1% on 2016 is primarily due to the earlier year’s large influx of

As Congress considers potential options to reform Medicaid, it is important to keep in mind patient access to prescription drugs and other healthcare services. Retail community pharmacies believe that Medicaid prescription drug benefit reform efforts should be focused on maintaining a Medicaid prescription drug benefit, maintaining patient access to adequate provider networks, fair and appropriate cost-based provider payments, and facilitating patient access to pharmacist-provided health care services.

How Trumpcare Would Affect Medicaid and Why That’s Dividing Republicans. (2017). Daily Intelligencer . Retrieved 18 September 2017, from http://nymag.com/daily/intelligencer/2017/03/trumpcare-offers-states-short-term-money-for-long-term-cuts.html

On March 23, 2010, President Obama signed the Affordable Care Act (ACA) into law, allowing all Americans access to affordable health care. Despite the urgent need to provide health care to all Americans some Governors and elected Congressmen continue to debate over the necessity to expand Medicaid and the ACA. The Supreme Court on June 28, 2012 ruled in support of the ACA by upholding the individual mandate which require Americans to have health care insurance. Americans without health care insurance, because of this new health care policy will be able to either purchase insurance through the exchange market or through the expansion of Medicaid. Some states are against the expansion of

Medicare and Medicaid are two of the United States largest broken systems, which must sustain themselves in order to provide care to their beneficiaries. Both Medicare and Medicaid are funding by a joint effort between the federal government and the local state government. If and when these governments choose to cut funding or reduce spending, Medicare and Medicaid take the biggest hit. Most people see these two benefits as one in the same, two benefits the government takes out of their pay check to help fund health care. While the government does deduct a sum from paychecks everywhere, Medicare and Medicaid are very two very different programs.

Some families meet the financial qualifications to receive government assistance, but the West Virginia Medicaid program only covers vision care for most adults every three years. Preventive exams are not paid for annually. West Virginia is one of eighteen states that Medicaid will only coverage emergency services for dental care. Preventative care is not covered with Medicaid insurance. (Haney, 2016, July 25, 2017, February 13) The Medicaid expansion program has increased the number of West Virginians on Medicaid. Almost half of the West Virginian population is considered to live in a rural Appalachian area and are more likely to be dependent on Medicaid insurance. West Virginia is the state with the highest percentage of its

The healthcare system underwent reformation in 2010 in the form of The Affordable Care Act. The main goal of the ACA was to extend health care throughout the nation; irrespective of this intention, some people regard the Affordable Care Act as being paternalistic. Chapter 9 covers the issue of how ethical the imposition of new restrictions on people by the ACA is.