All About Medicaid

 

Here at NeedyMeds we regularly refer people to their state’s Medicaid program, and in today’s blog post we are going to explain exactly what Medicaid is and how it functions. Are you currently enrolled in Medicaid? Share your experience with us in the comments section.

How is it Financed?

Medicaid, sometimes called Medical Assistance, is a joint federal and state entitlement program for people with limited income that helps to pay for medical costs. It receives a combination of funding from both the state and federal government. The amount paid to each state by the federal government, also known as the Federal Medical Assistance Percentage or FMAP, varies depending on multiple criteria, notably per capita income. From Medicaid.gov,The regular average state FMAP is 57%, but ranges from 50% in wealthier states up to 75% in states with lower per capita incomes. FMAPs are adjusted for each state on a three-year cycle to account for fluctuations in the economy.” State participation in the program is voluntary, but currently all 50 states do participate. In most instances, the states pay for services under a fee-for-service or managed care arrangement. Medicaid.gov explains, “Under fee-for-service arrangements, states pay providers directly for services. Under managed care arrangements, states contract with organizations to deliver care through networks and pay providers. Approximately 70% of Medicaid enrollees are served through managed care delivery systems.”

Who does it Serve?

Eligibility for Medicaid varies from state to state, however there are certain groups of people that are guaranteed coverage. “Federal law requires states to cover certain population groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). States set individual eligibility criteria within federal minimum standards.” One of the most common eligibility requirements is for the patient to be low-income. “The Affordable Care Act of 2010, signed by President Obama on March 23, 2010, creates a national Medicaid minimum eligibility level of 133% of the federal poverty level.” For more information on the federal poverty level guidelines click here. Another requirement is that the patient must be a legal resident and U.S. citizen. Services covered include inpatient and outpatient hospital services, home health services, family planning, and laboratory and X-ray services among many others.

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Effects of the Affordable Care Act

The effects of the Affordable Care Act, also known as Obamacare, have been very beneficial to Medicaid. One major change that has been put into place in 2014 is the expansion of Medicaid eligibility. From Medicaid.gov, “As of January 1, 2014, Americans under age 65 who have income less than 133 percent of the federal poverty level ($14,500 for an individual and $29,700 for a family of four in 2011) who are not pregnant and not otherwise eligible for Medicaid, will be eligible to enroll in Medicaid. This new coverage ends the long-time exclusion of low-income adults from Medicaid coverage.” Other changes include an increase in the Medicaid prescription drug rebate percentage, additional state grants for the Prevention of Chronic Diseases Program, and additional funding to the Children’s Health Insurance Program among many others. For a full list of changes click here.

 

How to Enroll

We recommend contacting your state’s Medicaid office directly to get more information on enrollment. Every state has a different set of guidelines and have their own unique application process. You can find your state’s Medicaid program on the NeedyMeds site here.

Finding Help with Allergies and Asthma

With spring beginning to bloom we here at NeedyMeds would like to highlight some of the many resources out there for asthma and allergy sufferers.

What is the Difference between Allergies and Asthma?

While some of the symptoms are the same, allergies and asthma are two entirely different diseases, but there can be overlap. The primary difference is that allergies are a disease of the immune system whereas asthma is a disease of the lungs. Over 20 million Americans are affected by asthma. There are two types of asthma, allergic and non-allergic, with similar symptoms caused by airway obstruction and inflammation. The most common symptoms are shortness of breath, chest tightness, coughing and wheezing. The difference between the two is that non-allergic asthma is triggered by a variety of causes (such as cold air, exercise, smoke, or stress and anxiety) while allergic asthma is triggered by pollen, mold, pet dander, or other inhaled allergens. Allergies are much more common than asthma, affecting an estimated 50 million Americans. Allergies are broken down into seven types: indoor, outdoor, food, latex, insect, skin and eye. If the spring air is causing you to experience symptoms, you more than likely have outdoor allergies.

Where to Find Help

There are a number of different resources for asthma and allergies available on the NeedyMeds site. The first place to check is the Asthma and Allergies Disease Information Page – which ties together all of the assistance listings we have in one place. This page includes a list of patient assistance programs for asthma and allergy medications. We have also highlighted four helpful groups for asthma and allergy sufferers:

1. Asthma and Allergy Foundation of America – An organization dedicated to “improving the quality of life for people with asthma and allergic diseases through education, advocacy and research.”
2. Allergy & Asthma Network – An education, outreach, and advocacy group whose mission is “to eliminate unnecessary suffering and death due to asthma, allergies and related conditions.”
3. American Academy of Allergy, Asthma & Immunology – An organization of over 6,800 allergists, immunologists, and healthcare professionals dedicated to “the advancement of the knowledge and practice of allergy, asthma and immunology for optimal patient care.”
4. Treatment Diaries – An innovative social network that privately connects patients so they can share their experiences.

There is also a list of diagnosis-specific programs on the bottom of the page. This list includes both state and national programs that offer assistance in a variety of ways ranging from co-pay assistance to medications, testings and treatments.

Another place to check is our listings of camps by diagnosis. There are three camps available for allergy sufferers and 60 camps for those with Asthma.

All of this information can also be found in our Patient Assistance Program listings and Diagnosis-Based Assistance Programs listings.

All About State Grants for Assistive Technology

Routine “everyday tasks” can be quite burdensome for many people living with a disability. For a long time there was little one could do to help in these situations, causing many people with disabilities to require personal assistance, which oftentimes would lead to depression and low self-esteem issues. Throughout the last few decades, however, much work has been done in developing and launching new technologies to help people with a variety of disabilities. Commonly referred to as “assistive technology,” these new devices are designed to help those living with a disability to easily perform common tasks. Thanks to the Assistive Technology Act, the federal government now works along with each state to help provide assistive technology to disabled individuals nationwide.

 

What is Assistive Technology and Who Does it Help?

Screen Shot 2014-04-03 at 9.59.47 AMAssistive technology (or AT), as defined by the Assistive Technology Act, is “any device, piece of equipment, or product system, whether acquired commercially or off the shelf, modified or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities.” Examples of assistive technology range from computer programs and hardware to prosthetics and wheel chairs, and much more. Assistive technology services are also covered such as doctor evaluations, training on a device, or coordination of use of physical therapy on an AT device. In order to qualify for assistive technology a patient must have a disability. The exact definition of a person with a disability, according to the U.S. Department of Education is “any individual of any age, race or ethnicity who has a disability and who is or would be enabled by an assistive technology device or an assistive technology service to minimize deterioration in functioning, to maintain a level of functioning, or to achieve a greater level of functioning, in any major life activity.”

 

How Does it Work?

Screen Shot 2014-04-03 at 9.55.51 AMThe way the program works is a bit more complicated than other programs we have highlighted on the NeedyMeds Voice. As opposed to direct-to-patient programs, the Assistive Technology Act provides funding through grants to the states in order to “maintain comprehensive, statewide programs (Statewide AT Programs) that are designed to increase access to assistive technology for individuals with disabilities. In addition, the AT Act provides grants to each state for protection and advocacy related to AT (PAAT).” These programs, available at the state level, actually help the patients directly with providing assistive technology. In many states there are two programs, one that provide assistive technology directly and another that provides a loan directly to the patient to reduce the cost for assistive technology.

 

Screen Shot 2014-04-03 at 10.07.53 AMFinding Help on NeedyMeds

We list all of the state programs for assistive technology on the NeedyMeds website under Diagnosis-Based Assistance. To find a program, go to Diagnosis-Based Assistance and search by diagnosis: disability. The program name varies from state to state. For instance, in Arizona the program is listed as the “Arizona Technology Access Program.”

 

The Affordable Care Act and the Future of Assistance Programs

We’ve been getting a lot of questions from our readers about how the resources we list on our website, especially the pharmaceutical patient assistance programs, will be affected by the Affordable Care Act. While we are still far away from having all the answers, we do have some additional information we can provide you after attending a recent PAP Conference. The overarching consensus is that PAPs will continue to exist to help those in need that fall into the gaps.  Here is an overview of what we learned at the CBI PAP 2014 Conference, held in Baltimore on March 6-7.

Background

→ There are currently no shared processes between programs.

→ Open Enrollment ends March 31st

  • Negative image of Affordable Care Act in the media.
  • For those working with the disabled – visit the National Disability Navigator Resource Collaborative for resources http://www.nationaldisabilitynavigator.org.
  • Many advocates are having trouble enrolling the population that has been uninsured for a long time, as they are not informed about how health insurance works at all.

→ Medicaid Donut Hole

  • In the states that have not expanded Medicaid, there are going to be folks too poor to be eligible for subsidies under the marketplace and not poor enough to qualify for Medicaid in their states.

→ Not everyone between 100% and 400% of Federal Poverty Level are eligible for subsidies. This, for example, can depend on age.

 

Pharma Priorities and Considerations

→ Priorities are to contain costs, increase quality, encourage innovation while enhancing patient access.

→ Legal Considerations.

  • Anti-kickback statute – always a legal issue for companies. Pharmaceutical companies cannot induce (or even appear to induce) patients to use a certain drug.
  • November 2013
    • HHS Secretary Kathleen Sebelius wrote a letter saying that plans purchased on a state or federally run market place are not counted as government sponsored programs.
    • Absent further guidance – these plans are going to be treated as private plans by Patient Assistance Programs (PAPs), foundations, etc.

→ Lingering question – what happens when someone doesn’t pay or defaults on their premium? There is currently a grace period to pay. Are they considered uninsured or insured?

 

The Future of PAPs

→ Bulk replacement programs will likely decline over time.

→ Possible application requirements that could change.

  • Medicaid Denial Letter/Proof – programs may request this more in future.
  • FPL level eligibility could change.
  • More flexibility to help underinsured.

→ Companies will do more benefits investigation of applicants. Patient Assistance Programs (PAPs) will:

  • Educate patients on what‘s available to them.
  • See if they can find a foundation or an insurance plan for the applicant – leaving the free drug program as the last resort for those who truly have no other option.
  • Increasingly consider the applicant’s co-insurance, copayments and out of pocket costs.

→ Increasing use of electronic applications.

 

Overall Themesphoto

→ PAP Processes will generally remain the same.

→ Companies will treat marketplace programs as commercial for now.

→ With less standardized coverage options with more diverse patient needs, companies will be developing programs that handle complexity. Programs will continue to adapt and evolve.

→ One company projected that 49% of those currently on their PAPs by 2019 will still be on PAPs, so there will be a continued need for assistance programs.

→ PAPs will spend more time determining if applicants are eligible for programs.

7 Tips to Get the Most from Your Doctor Visit

by Rich Sagall, MD

You have an appointment to see your doctor about a health issue. It may be a new problem, a chronic issue, or an acute illness. No matter the reason, you are ready for a 10-minute visit filled with quick questions, a prescription or two, and some instructions. If you are lucky, some of your questions will be answered and you may remember a portion of what your doctor tells you.

Doctor

It doesn’t have to be this way. There are steps you can take to have a more satisfying and productive visit. You may not be able to do all of these at every visit and some may make you feel a little uncomfortable, but they are worth trying.

 

  1. Expectations – Before scheduling an appointment, think about why you want to see the doctor and what you hope to get from the visit. For example, if you are seeing the doctor for new back pain, are you looking for an x-ray, do you want strong pain medicine or do you want reassurance it’s nothing serious? At some point you need to tell the doctor what you want. That’s not to say you will get it, but being forthright makes it easier for everyone.
  2. Take a friend or family member – Many studies have shown that patients remember little of what doctors tell them during a visit, and doctors generally overestimate how much patients remember. A second person in the room, someone who is not experiencing the stress of being a patient, can better remember what occurs and help you better follow the doctor’s instructions. Remember – this person may hear very personal and potentially embarrassing things about you.
  3. Bring a list of questions – Actually writing down what you want to ask the doctor serves many purposes and helps to make the visit more productive. First, it forces you to really think about what you want to learn and state it succinctly. Second, it helps your doctor know what you want to learn. Bring an extra copy of the questions and give it to your doctor. Third, the list provides a place for you (or your companion) to write down answers. This will help you better remember what transpired.
  4. Have a good history – Doctors depend heavily on the history of a problem to make the diagnosis. This has to come from you. Keeping a symptom diary is a great way to quantify problems. For example, if you are being seen for headaches, keep a diary for a few weeks. Enter the dates and times you have headaches, how long each headache lasts, what the headaches are like, what you are doing when the headache occurs, what helps lessen the pain and what doesn’t, etc. You get the idea. This information will help your doctor better understand what you are experiencing.
  5. Ask about tests – It’s easy to order tests and doctors tend to do it a lot. Many patients expect to have them. Before having any tests performed, you should ask, “How will the test results affect my treatment?” You’d be surprised how often the answer is it won’t. If the results won’t change anything, then a good question is why do the test?
  6. Get your test results – It’s important for you to receive a copy of every test result. Never accept the “no news is good news” response. No news may mean all is fine, but it can also mean many other things. Perhaps the doctor never received the results and didn’t know it. Perhaps the results came back and were filed without the doctor reviewing the results. Perhaps the doctor misread the results. Or perhaps the doctor saw an abnormal result, but the office staff forgot to call you. You have a legal right to demand the lab send you results, and you have a right to all results in your medical file.
  7. Ask for a copy of the doctor’s notes – You have a right to the contents of your medical record. The doctor may “own the paper”, but the information is yours. You want to make sure the doctor got it right and, perhaps more important, recording what happened correctly. Depending on your state, the doctor may be able to impose a reasonable charge, but it’s well worth it.You should understand what is recorded. If you don’t understand something, either give the doctor a call or ask at your next visit.Once something is recorded, it’s next to impossible to change or correct it. Doctors are told to never go back and change what’s in a patient’s record. It looks back if there’s ever a legal issue. However, doctors can and do include an addendum if something in the record is entered incorrectly. If you find a mistake or disagree with a statement, you should send your complaint in writing to your doctor. Ask that your statement become part of the official record.

 

I know some physicians will not agree with some of the above – or even all of it. When I was in practice, I followed many of these steps and encouraged my patients to bring lists, get copies of results, and become active participants in their healthcare. I encourage you to do the same.

Rich Sagall MD

 

Rich Sagall, MD, a retired family physician, is the president and founder of NeedyMeds, a national non-profit that has information on programs that help people in medical need. He is aslso the editor and publisher of Pediatrics for Parents, a children’s health newsletter.

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