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THE HENRY L
KAISER
FAMILY
MEDICAID FACTS
FOUNDATION
THE KAISER COMMISSION ON THE FUTURE OF MEDICAID
November 1997
THE MEDICAID PROGRAM AT A GLANCE
What is Medicaid?
The diverse Medicaid population is comprised of:
Medicaid is the nation's major public financing program for
17.5 million children
providing health and long-term care coverage to millions of
8.0 million adults in families
low-income people. Initially designed to pay for the health
3.9 million elderly persons
care of recipients of welfare assistance and certain other
5.8 million blind and disabled persons
needy people, by 1995, 35.2 million people-more than 1
in 10 Americans-were covered by Medicaid at a cost of
Although adults and children in low-income families make up
$152.4 billion.
nearly three-fourths of beneficiaries, they account for only 28
percent of Medicaid spending. The elderly and the disabled
Authorized under Title XIX of the Social Security Act,
account for the majority (60 percent) of spending because of
Medicaid is a means-tested entitlement program financed
their intensive use of acute and long-term care services.
by the state and federal governments and administered by
Disproportionate share hospital (DSH) payments account for
the states. Federal financial assistance is provided to
about 12.5 percent of Medicaid spending (Figure 1).
states for coverage of specific groups of people and
benefits through federal matching payments based on the
What Services are Covered Under Medicaid?
state's per capita income. The federal share ranges from
50 to 80 percent of Medicaid expenditures.
Medicaid covers a broad range of services to meet the
complex needs of beneficiaries. Because of the limited
financial resources of beneficiaries, cost-sharing
Who is Covered by Medicaid?
requirements are nominal. Federally mandated services
include:
Being poor does not automatically qualify an individual for
Medicaid. Only persons who fall into particular
inpatient and outpatient hospital
"categories" such as low-income children, pregnant
physician, midwife, and certified nurse practitioner
women, the elderly and people with disabilities are eligible.
Under the new welfare program, Temporary Aid to Needy
laboratory and X-ray
Families (TANF), Medicaid eligibility is no longer automatic
nursing home and home health care
for families who receive cash assistance. Within federal
early and periodic screening, diagnosis, and treatment
guidelines, states set their own income and asset eligibility
(EPSDT) for children under age 21
criteria for Medicaid. As a result, there are large state
family planning
rural health clinics/federally qualified health centers
variations in coverage. Although Medicaid has
increasingly been used to expand coverage to the low-
States have the option to cover additional services and still
income population, it covers only half of poor Americans.
While the new State Child Health Insurance Program will
receive federal matching funds. Commonly offered services
include prescription drugs, clinic services, prosthetic
expand coverage to low-income uninsured children either
devices, hearing aids, dental care and intermediate care
through Medicaid or a separate program, millions of low-
facilities for the mentally retarded (ICF/MR).
income people will remain uninsured.
Figure 1
Figure 2
Medicaid Beneficiaries and Expenditures
Medicaid Expenditures by Service, 1995
by Enrollment Group, 1995
Payments to
Elderly
Inpatient
Medicare 2 5%
DSH
DSH Payments*
Hospital 17 7%
Payments 12.5%
11.0%
12.5%
Blind &
Disabled
Elderly
Home
16.6%
26 3%
Health 6.8%
Drugs 5 5%
Adults
Mental Health 2.0%
22.6%
Blind &
Disabled
Physician/
33 7%
Outpatient
ICF/MR 6.6%
12 6%
Children
Adults
Acute Care
52.1%
49.7%
10 9%
Long-Term Care
Children
35.4%
16.7%
Other Acute
Nursing Facility
7 3%
Beneficianes
Payments
Care 20.0%
Expenditures*
to MCOs 6 5%
Total = 35 2 million people
Total = $152.4 billion
Total = $152.4 billion
Disproportionate share hospital payments.
Note: Total expenditures exclude administrative expenses, adjustments and the lemtones
SOURCE Urban institute Estimates, 1997
SOURCE. Urban Institute Estimates. 1997.
1450 G STREET, N.W.
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FAX (202) 347-5274
Figure 3
Of the $152.4 billion Medicaid spent in 1995 (Figure 2):
Medicaid Beneficiary Growth by
Enrollment Group, 1988-1995
Acute care services comprised about half (52.1
Beneficiaries (in millions)
35.2
34.2
32 4
percent) of spending. This includes 6.5 percent of
29.8
spending on Managed Care Organization (MCO)
26 9
premiums.
241
22 0
22 6
Elderly
Long-term care services accounted for 35.4 percent
Blind &
of expenditures. Medicaid pays for half of total
Disabled
Adults
nursing home care (47 percent) and 14 percent of
Children
all home health spending in the United States.
Payments to Medicare accounted for 2.5 percent.
Payments to hospitals with a disproportionately
large population of indigent patients (DSH)
1988
1989
1990
1991
1992
1993
1994
1995
comprised 12.5 percent of total expenditures.
SOURCE Urban Institute Estimates, 1997
How is Care Delivered Under Medicaid?
Medicaid has become a major budgetary commitment for
both the federal and state governments. Medicaid
As states try to expand insurance coverage to low-income
expenditures escalated rapidly between 1988 and
people, improve access, and contain costs, many are
1992-more than doubling (Figure 4). The rise in spending
adopting new care delivery and financing arrangements
under Medicaid. While traditional fee-for-service still
in that period was attributable to a combination of health
care inflation, state use of alternative financing mechanisms,
predominates, an increasing number of states are
and an increase in enrollment. Only a small fraction of
enrolling their Medicaid populations in managed care.
spending growth was attributable to the expansions in
As of June 1996, 13.3 million Medicaid beneficiaries were
coverage of low-income pregnant women and children.
enrolled in managed care, a fourfold increase from 2.7
The rate of growth in Medicaid spending has now returned to
million in 1991. Medicaid managed care models range
historic levels-rising 11.2 percent from 1994 to 1995. This
from HMOs that use prepaid capitated care to loosely
structured networks that contract with selected providers
suggests that legislation enacted to limit states' capacity to
raise funds through provider taxes and DSH payments has
for discounted services and use gatekeeping to control
utilization. States have initially targeted low-income
played a role in slowing Medicaid spending growth. The BBA
of 1997 further reduces the growth in DSH payments by
families for managed care enrollment rather than aged or
$10.4 billion over the next five years and lowers the state-
disabled beneficiaries.
specific ceilings on federal Medicaid DSH matching
Until recently, states have used waivers of Section
payments.
1915(b) and Section 1115 of the Social Security Act to
Figure 4
undertake mandatory managed care programs. However,
Medicaid Spending by Enrollment
the Balanced Budget Act (BBA) of 1997 permits states to
mandate managed care enrollment for most Medicaid
Group, 1988-1995
Dollars (In billions)
$152 4
beneficiaries without a waiver (except special needs
$137.1
children, Medicare beneficiaries and Indians.) As a result,
$127.4
$115 2
mandatory managed care enrollment is likely to rise.
$89.1
DSH
Payments*
Long-term care is a major component of Medicaid. While
$70.5
Elderly
$59.6
over three-fourths of Medicaid spending for long-term care
$52 6
Blind &
Disabled
is on institutional services, Home- and Community-Based
Adults
Services (HCBS) waivers are often used by states to
Children
deliver community-based care. Although all states have
HCBS waivers, the population served remains small.
1988
1989
1990
1991
1992
1993
1994
1995
. Disproportionate Share Hospital payments
States also now have the option to provide dual eligibles
Note Total expenditures exclude administrative expenses
SOURCE Urban Institute Estimates 1997
(Medicaid/Medicare) with acute and community-based
long-term care services under the Program for All-
Since its enactment in 1965, Medicaid has improved access
Inclusive Care for the Elderly (PACE).
to health care for the poor, pioneered innovations in health
Recent Beneficiary and Expenditure Growth
care delivery and community-based long-term care services,
and stood alone as the primary source of financial
Medicaid enrollment rose dramatically in the early 1990's,
assistance for long-term care. Medicaid has been
reaching 35.2 million beneficiaries in 1995 (Figure 3). This
consistently shown to improve access to health care for the
growth is mostly attributable to expanded coverage of low-
population it serves. Low-income people without insurance
income pregnant women and young children and
coverage use care at considerably lower levels than those
increases in blind and disabled beneficiaries. However,
with Medicaid coverage. As Medicaid struggles to meet
enrollment growth appears to have leveled somewhat,
multiple responsibilities under continued fiscal pressure, the
increasing by only 3 percent from 1994 to 1995.
program plays a critical role in providing acute and long-term
care services to our nation's most vulnerable people.
The Kaiser Commission on the Future of Medicaid was established by the Henry J. Kaiser Family Foundation in 1991 to function as a Medicaid policy institute
and serve as a forum for analyzing. debating and evaluating future directions for Medicaid and other health reforms affecting low-ine ome Americans.
The Kaiser Family Foundation is an independent national health care philanthropy and not associated with Kaiser Permanente or Kaiser Industries.
THE HENRY I
KAISER
FAMILY
MEDICAID FACTS
FOUNDATION
THE KAISER COMMISSION ON THE FUTURE OF MEDICAID
November 1997
MEDICAID AND MANAGED CARE
Medicaid provided health and long-term care coverage to
MODELS OF MEDICAID MANAGED CARE
approximately 35 million low-income Americans at a cost of
$152 billion in 1995. In its role as a purchaser of health
Managed care includes a broad array of health financing and
services for low-income families, Medicaid increasingly relies
delivery arrangements designed to reduce costs by
on managed care to deliver services. About 40% of
eliminating inappropriate and unnecessary services and
Medicaid beneficiaries, predominately poor children and their
relying more heavily on primary care and coordination of
parents, now receive health care services through a broad
care. Managed care arrangements are characterized by
array of managed care arrangements.
formal enrollment of individuals in a managed care
organization; contractual agreements between the provider
MEDICAID MANAGED CARE ENROLLMENT
and a payer; and some gatekeeping and utilization control.
Medicaid's use of managed care has grown dramatically in
The major Medicaid managed care models include:
recent years in response to pressure to contain the growth in
Medicaid spending while maintaining access to care for low-
Full-Risk Plans (HMOs or HIOs): Under a fully
income individuals. In 1996, 13.3 million Medicaid
capitated plan, a health plan is paid a fixed monthly fee
beneficiaries were enrolled in managed care, up from 2.7
per enrollee and assumes full-risk for the delivery of a
million in 1991, a four-fold increase (Exhibit 1).
comprehensive range of services. The major types of full-
Today, all states (except Alaska) are pursuing some
risk plans are Health Maintenance Organizations
(HMOs), in which the contracting entity and the providers
Exhibit 1
Growth in Medicaid Managed Care Enrollment,
are integrated into one plan, and Health Insuring
1986-1996
Organizations (HIOs), which operate as fiscal
intermediaries.
Millions of Medicaid Beneficiaries
16.0
14.0
13.3
Limited-Risk Prepaid Health Plans (PHPs): A PHP is
12.0
an entity, usually a clinic or large group practice, that
9.8
10.0
either contracts on a non-risk basis or a prepaid,
7.8
8.0
capitated-risk basis to provide services that are not
6.0
4.8
comprehensive (often ambulatory care only).
4.0
3.6
2.3
2.7
1.7
1.8
2.0
2.0
2.0
Fee-for-Service Primary Care Case Management
00
(PCCM): In a PCCM plan, a specific provider, usually the
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
patient's primary care physician, is responsible for acting
Health Maintenance Organization/
Pnmary Care Case Management
Prepaid Health Plan
as a "gatekeeper" to approve and monitor the provision of
Source: HCFA. 1997 and PPRC, 1997.
covered services to beneficiaries. These gatekeepers
managed care initiatives. As of June 1996, 36 states and
contract directly with State Medicaid agencies, do not
the District of Columbia had more than one-quarter of their
assume financial risk for the provision of services, and
Medicaid population enrolled in managed care (Exhibit 2).
are paid a per-patient monthly case management fee, as
Of these, 8 states have more than 75% of their Medicaid
well as fee-for-service payment for medical care.
beneficiaries enrolled in managed care.
As of June 1996, 511 Medicaid managed care plans,
primarily full-risk HMOs, were in operation - almost double
the number of plans in 1993. The predominance of full-risk
Exhibit 2
plans is reflected in the distribution of enrollees: 67% of all
Medicaid Managed Care Enrollment,
Medicaid managed care beneficiaries were enrolled in HMOs
by State, 1996
or HIOs, 2% in PHPs, and 31% in PCCMs and other
managed care arrangements (Exhibit 3).
STATE MANAGED CARE OPTIONS
States have long had the option to voluntarily enroll Medicaid
beneficiaries in managed care plans. Legislative authority to
require mandatory enrollment has evolved over time. Until
recently, states have used Section 1915(b) freedom-of-
choice waivers or Section 1115 research and demonstration
1.10.25 percent (14 states)
25-50 percent (16 states)
waivers to undertake mandatory managed care programs.
50-75 percent (13 states")
Includes the District of Columbia
75 percent (8 states)
Source HCFA 1997.
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Exhibit 3
Medicaid Managed Care
Medicaid Managed Care Enrollment,
Selected Provisions in the Balanced Budget Act of 1997
by Type of Plan, 1996
Enrollment/Marketing: Allows states to mandate managed care
enrollment, to guarantee managed care enrollment for 6 months
HMO 63%
for adults and 12 months for children, and to "lock-in"
(8.0 million)
beneficiaries for up to 12 months; prohibits door to door
HIO 4%
marketing; and requires state default enrollment systems to
(0.5 million)
consider existing beneficiary-provider relationships and traditional
PHP 2%
Medicaid providers.
(0.2 million)
Plan Choice: Permits states to limit Medicaid beneficiaries to a
choice of two MCOs in urban areas and one MCO in rural areas.
PCCM 31%
(4.0 million)
Plans may serve Medicaid beneficiaries exclusively.
Access: Requires MCOs to comply with a "prudent layperson"
Note Excludes enrollees in Behavioral and Dental Health Plans.
Source: PPRC, 1997.
emergency care coverage standard and prohibits physician "gag
rules."
Under 1915(b) waivers, in place in 42 states, mandatory
managed care has been implemented in part of the state or
Consumer Protections: Requires MCOs to provide information
for certain categories of beneficiaries. Section 1115 waivers
regarding participating providers, enrollee rights and
have been used to implement statewide mandatory
responsibilities, information on covered services, and grievance
mandatory managed care enrollment, as well as to waive the
and appeals procedures (an internal grievance process is
requirement that 25% of a plan's enrollment be privately
required).
insured (the 75/25 rule). As of May 1997, 10 states have
implemented Section 1115 waivers (AZ, DE, HI, MN, OH,
MCO Payment Rates: Requires state Medicaid agency
capitation payment rates be made on an "actuarially sound
OK, OR, RI, TN, VT).
basis", and requires DSH payments go directly to providers, not
incorporated into capitation payments.
The Balanced Budget Act (BBA) of 1997 gives states new
authority to mandate enrollment in managed care
Plan Requirements: Requires plans to demonstrate adequate
organizations (MCOs) for Medicaid beneficiaries without
capacity, including an appropriate range of services and access
obtaining a federal waiver (except for special needs children,
to preventive and primary care services and a sufficient number,
Medicare beneficiaries and American Indians). Furthermore,
mix, and geographic distribution of providers.
the new law permits the establishment of Medicaid-only
Quality/Oversight: Increases the threshold for prior federal
plans by eliminating the 75/25 rule. Finally, the law
approval of managed care contracts to $1 million; requires states
establishes certain new managed care consumer
to develop and implement a quality assessment and improvement
protections, but exempts Section 1915 and Section 1115
strategy by 1999 consistent with standards to be established by
waivers from the new requirements (Exhibit 4).
the Secretary of HHS; and establishes external independent
review of MCO performance.
ISSUES IN MEDICAID MANAGED CARE
managed care remains low and is complicated by difficulties
Medicaid beneficiaries are economically disadvantaged,
in setting appropriate capitation rates, limited plan
frequently reside in medically underserved areas, and often
experience in providing specialized services, as well as lack
have more complex health and social needs than do higher-
of systems to coordinate Medicare and Medicaid benefits for
income Americans. The success of managed care depends,
"dual eligibles."
in large part, on the future adequacy of the capitation rates
and the ability of states and the federal government to
Changes in the delivery system can be made to accomplish
monitor access and quality.
savings, but in order to be effective and preserve access to
needed services, these changes will require sufficient time to
As a public program, Medicaid has operated under tight
implement, the development of an adequate infrastructure to
budget constraints. This has resulted in provider payment
deliver care, oversight of program implementation, and more
rates that are often substantially below market rates,
experience with enrolling the elderly and disabled.
contributing to access problems. Capitation rates need to be
sufficient to assure that plans are able to adequately serve
The BBA provides new standards to assure plan capacity
Medicaid enrollees. Adequate payment levels are
and enforce consumer protections. However, the
particularly important in the context of mandatory enrollment
development of access and quality performance standards
of beneficiaries in Medicaid-only MCOs because these plans
for Medicaid MCOs, and the measurement of compliance
are wholly dependent on Medicaid financing and do not have
with those standards, is evolving. Ensuring that plans have
other payers to cover Medicaid shortfalls.
provider networks in place, educating both providers and
beneficiaries about managed care, and responding to the
Broadened use of managed care for low-income children
unique needs of the Medicaid population are critical to
and families, the target of most managed care initiatives, is
assuring access and quality of care in a managed care
unlikely to accomplish large overall savings for Medicaid.
environment.
Acute care services for low-income children and adults
account for a quarter of program spending, whereas
approximately 60% of spending is for the elderly and the
disabled. Enrollment of elderly and disabled populations into
The Kaiser Commission on the Future of Medicaid was established by the Henry J. Kaiser Family Foundation in 1991 to function as a Medicaid policy institute
and serve as a forum for analyzing, debating and evaluating future directions for Medicaid and other health reforms affecting low-income Americans.
The Kaiser Family Foundation is an independent national health care philanthropy and not associated with Kaiser Permanente or Kaiser Industries.
THE HENRY
I.
KAISER
FAMILY
MEDICAID FACTS
FOUNDATION
THE KAISER COMMISSION ON THE FUTURE OF MEDICAID
November 1997
MEDICAID'S ROLE FOR CHILDREN
In 1995, 17.5 million children -- one-quarter of all children
children, older children are less likely to qualify for Medicaid.
under age 18 -- had Medicaid coverage for health care
Medicaid covers 22% of children between the ages of 6 to 12
services. Medicaid, the federal/state health program for the
years and 17% of teens between the ages of 13 to 18 years.
poor, pays for a broad range of services for children including
well-child care, immunizations, prescription drugs, doctor
Medicaid Coverage of Children:
visits, and hospitalization, and a range of long-term care
services for children with disabilities.
States are mandated to cover certain groups of children based
on age and income criteria. By 2002, all states will be required
Medicaid plays a particularly strong role for low-income
to have phased-in coverage of children under age 19 with
children, covering two-thirds (64%) of all poor children and a
incomes below poverty. States can choose to expand Medicaid
quarter( 27%) of children with incomes between 100% and
eligibility beyond federal minimum standards by raising age and
199% of the federal poverty level (FPL). While employer-
income levels for children (Figure 2). They can also use Section
based insurance coverage of children declined from 1987 to
1115 research and demonstration waivers to broaden eligibility.
1995, expansions in Medicaid have resulted in greater
In total, 41 states have expanded Medicaid coverage to children
coverage of children in low-income families (Figure 1).
in one or more age or income levels. Federal coverage
During this same period, Medicaid enrollment grew from
requirements for children are as follows:
about 10 million -- 15.5% of all children -- to 17.5 million
children (23.2%).
Up to age 6 with family incomes up to 133% FPL. For
Figure 1
infants, 35 states have chosen to expand coverage beyond
Trends in Coverage for Children,
133% FPL and 13 have expanded for children age one to six.
1987-1995
Age 6 to 14 with family incomes below 100% FPL. Fifteen
75%
Employment-Based
states have opted to expand eligibility beyond 100% FPL.
66.7%
Age 15 to 19 if family income meets the AFDC criteria of
58.6%
August 1996 (state average is 41% of FPL) with coverage
50%
phased-in for poor children born before 9/30/83. 25 states
Medicaid
Uninsured
have opted to accelerate this phase-in to cover older children
23.2%
up to age 18 with income below 100% FPL (Figure 2).
25%
15.5%
Children with disabilities also qualify for Medicaid assistance
13.1%
13.8%
on the basis of SSI eligibility. Medicaid covers about 1 million
0%
additional children with physical or mental disabilities.
1987
1988
1989
1990
1991
1992
1993
1994
1995
Figure 2
States Opting to Accelerate Coverage of
Note: Children under age 18
SOURCE: Employee Benefit Research Institute, 1997.
Poor Children, 1997
Despite the importance of Medicaid today, about 10 million
children are uninsured. Lack of insurance is particularly high
among low-income children. Seventy percent of uninsured
children are in families with incomes below 200% of poverty.
The new State Child Health Insurance Program, enacted as
part of the Balanced Budget Act of 1997, is intended to
provide coverage to this group.
ELIGIBILITY
Being poor does not automatically qualify a child for
Accelerated phase-in to 18 years up to 100% FPL up to age 18 (13)
Medicaid. In the past 15 years, Medicaid eligibility for children
Accelerated phase-in up to age 18 above poverty (12)
No Accelerated phase-in (25)
has been broadened considerably through federal legislation
SOURCE: National Governors' Association, 1997
and state optional expansions. Prior to 1986, Medicaid
Because states established varied Medicaid income eligibility
primarily served children who received AFDC cash
levels for children, and because of state variations in per capita
assistance. Today, children qualify for Medicaid based on
income there is considerable variation in Medicaid coverage,
their age and income.
ranging from 13% of children in Colorado to 47% in West
Virginia. Similarly, Medicaid pays for 39% of all births
Medicaid coverage is especially prominent among young
nationally, but coverage varies from 21% of births in
children, covering 33% of infants and 29% of children ages 1
Massachusetts to 61% in Georgia.
to 5. Because recent expansions focused on young
1450 G STREET. N.W. SUITE 250 WASHINGTON, D.C. 20005
TEL (202) 347-5270 FAX (202) 347-5274
The Balanced Budget Act (BBA) of 1997 creates new options
In 1995, Medicaid spent $25.4 billion on health care services for
for states to strengthen and expand Medicaid coverage for
17.5 million children in low-income families and about $7.1 billion
children. The new State Children's Health Insurance Program
for one million disabled children. The majority (93%) of the
(CHIP) was enacted as part of the Balanced Budget Act
expenditures for non-disabled children are for acute care
(BBA) of 1997. This new capped federal program allocates
services, with one third for inpatient hospital care.
$20.3 billion over five years in the form of a matched grant to
states to expand coverage to uninsured low-income children
While low-income children represent half of the 35 million
through either a separate state program or by broadening
Medicaid beneficiaries, they account for only 16.7% of overall
Medicaid -- or both. The funds became available on October
Medicaid spending. In 1995, Medicaid spent an average of
1, 1997 and are targeted to uninsured children under 19 with
$1,175 per low-income child enrolled in the program. On
income below 200% of poverty who are not eligible for
average, children cost less to care for than older Medicaid
Medicaid or not covered by private insurance.
beneficiaries, but some disabled children have very costly health
and long-term care needs. Medicaid spent an average of $6,421
Provisions of the Balance Budget Act also included some
per year per child qualifying on the basis of disability (Figure 4).
important changes to Medicaid. It clarifies the state Medicaid
Figure 4
option to accelerate the phase-in for children born before
Medicaid Spending Per Enrollee By Age
September 30, 1983. In addition, the new law gives states
and Eligibility Group, 1995
the option to extend presumptive eligibility to children,
$9,223
meaning that services provided to low-income uninsured
$8,542
children will be covered by Medicaid before the Medicaid
eligibility determination process is complete. States can also
$6,421
offer 12 month continuous eligibility to children, regardless of
any changes in family income during that period.
SERVICES AND COSTS
$1,731
$1,175
Federal guidelines require that Medicaid cover a
comprehensive set of services with nominal or no cost-
sharing for children. Access to these services is important
Children
Adults
Children
Adults
Age 65+
because poor children experience more health problems than
Low-Income Families
Disabled
more affluent children. Children with Medicaid are eligible to
SOURCE: The Kaiser Commission on the Future of Medicald, 1997.
receive physician and outpatient services, prescription drugs,
ISSUES AND CHALLENGES
inpatient hospital care, and long-term care services.
Medicaid coverage also entitles children to early and periodic
Expanding Coverage. To broaden coverage of low-income
screening, diagnostic, and treatment (EPSDT) services
uninsured children, Congress enacted the new State Child
including a comprehensive health and developmental history
Health Insurance Program and included provisions to allow
and physical exam, immunizations, laboratory tests including
states to facilitate enrollment and continuity of coverage under
blood lead levels, and health education. Children found to
Medicaid. Key issues facing state Medicaid agencies include
have conditions requiring further attention are covered for
how the new children's program will be structured, financed, and
needed treatment.
implemented, as well as how it will be integrated with or build on
the state's existing Medicaid program.
The importance of health insurance in securing access to
health care services is well documented. Despite their
Participation. An estimated 3 million of the 9.8 million
complex health and social needs, children with Medicaid
uninsured children are eligible for but not enrolled in Medicaid.
coverage have access to care that is similar to higher income
This is largely due to enrollment barriers or lack of awareness of
privately insured children (Figure 3).
the program. States can streamline the eligibility process and
facilitate enrollment. For example, 25 states allow mail-in
Figure 3
eligibility applications and 29 states have dropped the asset test.
Access to Care for Children by
Medicaid eligibility policy has also changed markedly as a result
Insurance Status, 1993
of the 1996 welfare law, which eliminated the automatic link
between cash assistance and Medicaid. Ongoing and
intensified outreach and educational efforts will be necessary to
39%
No Physician Visit
assure that all the children who are eligible for assistance under
16%
In Last Year
Medicaid are enrolled.
20%
Managed Care. In 1996, 40% of beneficiaries were enrolled in
21%
No Regular
managed care, mostly low-income children and their parents.
6%
Source of Care
The BBA of 1997 expands state flexibility by allowing states to
3%
mandate Medicaid managed care enrollment without requiring
states to obtain a Section 1115 or 1915(b) waiver. States will
13%
Uninsured
Delayed Care
still need a waiver to mandatorily enroll special needs children,
2%
Medicaid/Other Public
Due to Cost
but will be able to enroll other non-disabled children. Managed
3%
Private
care has the potential to improve access to preventive and
Source: National Center for Health Statistics, 1997, Kaiser/Commonwealth Survey, 1997.
primary care, but given the vulnerable nature of the Medicaid
population, it requires careful implementation and monitoring to
assure quality and access.
The Kaiser Commission on the Future of Medicaid was established by the Henry I. Kaiser Family Foundation in 1991 to function as a Medicaid policy institute
and serve as a forum for analyzing. debating and evaluating future directions for Medicaid and other health reforms affecting low-income Americans.
The Kaiser Family Foundation is an independent national health care philanthropy and not associated with Kaiser Permanente or Kaiser Industries.
THE HENRY L.
KAISER
LEGISLATIVE SUMMARY
FAMILY
FOUNDATION
THE KAISER COMMISSION ON THE FUTURE OF MEDICAID
December 1997
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
Nearly 10 million children are uninsured, often resulting in
If states use the Medicaid option, children become entitled to
difficulties in obtaining needed health care. To expand coverage
full Medicaid coverage. States that have already broadened
to low-income uninsured children, Congress enacted the State
Medicaid income eligibility levels above 150% of the federal
Children's Health Insurance Program (CHIP) as part of the
poverty level (FPL) can expand coverage to children up to 50
Balanced Budget Act (BBA) of 1997 (P.L. 105-33). This new
percentage points above the current level. For example, a state
program allocates $20.3 billion in federal matching funds over
with eligibility set at 175% FPL could expand to 225% FPL.
five years to states to expand insurance for children. States
can use the federal funds to expand coverage either through a
BENEFITS AND COST-SHARING
separate state program or by broadening their Medicaid
programs -- or both.
The benefit package options available to states fall into three
general categories: Benchmark, benchmark-equivalent, or
ELIGIBILITY
Medicaid.
The intent of CHIP is to expand health insurance coverage to
Benchmark Packages: States can offer one of three
uninsured children under age 19 in families with incomes below
existing benefit packages: including the Federal Employees
200% of poverty (Figure 1). Children with private insurance or
Blue Cross/Blue Shield PPO plan; coverage available to
who are covered by or qualify for Medicaid are ineligible for
state employees; or coverage offered by the HMO with the
CHIP, as are those who are residents of public institutions or
state's largest commercially enrolled population.
whose families are eligible for state employee health benefits.
Benchmark-Equivalent Coverage: States can use a
Figure 1
Health Insurance Coverage of
package with aggregate value greater than or equal to a
benchmark plan. Hospital, physician, laboratory and x-ray,
Children, by Poverty Level, 1995
and well baby/child services must be included at a value at
least actuarially equivalent to the benchmark benefit
Total < 18
23%
14%
(71.1 Million)
package. If prescription drugs, mental health, vision, and
hearing services are included in the benchmark plan, then
< 100% FPL
64%
22%
they must be part of the benchmark-equivalent coverage
(15.2 Million)
with a value of at least 75% of the benchmark plan's
actuarial value.
100-199% FPL
27%
23%
(15.9 Million)
Medicaid: States that expand Medicaid must provide the
complete benefit package, which includes well-child care,
200+% FPL
6%
7%
Medicaid
Uninsured
(40.0 Million)
immunizations, prescription drugs, doctor visits,
hospitalization, and EPSDT, as well as long-term care for
Note: Federal Poverty Level (FPL) is $12,158 for a family of three.
disabled children. The Medicaid benefit package for children
Source: Employee Benefits Research Institute, 1996.
is broad and should satisfy the benchmark requirement in a
Undocumented children and legally resident children arriving in
state that administers a separate CHIP program.
the U.S. after August 22, 1996 are ineligible for coverage but
may qualify for emergency Medicaid assistance. States that
The Secretary has the authority to approve a different benefit
implement their child health insurance programs through
package that is determined to be appropriate for low-income
Medicaid may use federal funds to cover legally resident
children. The existing New York, Florida, and Pennsylvania
children in the country prior to August 22, 1996.
child health programs are deemed to satisfy federal
requirements for benefits.
States that choose to operate a separate state child insurance
program can establish eligibility based on geographic area, age,
Under the new CHIP program, states cannot impose cost-
income and resources, residency, and disability status, as well
sharing for preventive services including well-baby and well-
as limit duration of coverage. States cannot exclude children
child care and immunizations. For children with family incomes
based upon a preexisting condition or diagnosis, and cannot
at or below 150% FPL, cost-sharing must be "nominal" as under
cover higher income children before lower income children.
the Medicaid statute. Medicaid currently permits premiums of
$15 to $19 per month per family and co-payments of up to $3
per service.
1450 ( STREET, N.W.
SUITE
250
WASHINGTON, D.C. 20005
TEL (202) 347-5270 FAX (202) 347-5274
Cost-sharing for children with incomes above 150% FPL can
apply to the newly covered group of children. States would
be imposed based on an income-related sliding scale, but total
continue to receive the regular Medicaid matching rate after
cost sharing cannot exceed 5% of family income. Coverage
their CHIP allotment was depleted.
can be provided directly by the state Medicaid program, an
insurer, or any other entity qualified by the state.
While the states have considerable latitude in designing and
structuring their CHIP programs, there are some limits on what
FINANCING
federal CHIP payments can be used for:
The BBA authorizes $20.3 billion in federal funds from FY 1998
No more than 10 percent of federal and state spending can
through FY 2002 and $19.4 billion over the second five years.
be used for outreach, administrative costs or direct service
Over the ten-year period, the funds are allocated as follows:
payments to clinics or hospitals. The Secretary can
$4.295 billion in FY 1998, $4.275 billion per year in FY 1999-
authorize waivers to allow states to create community-based
2001, falling to $3.15 billion annually in FY 2002 through 2004,
programs or to purchase family coverage.
and then rising to $4.05 billion from FY 2005 through 2006, and
reaching $5 billion for 2007, for a total of $40 billion.
If states create a new program, they cannot adopt Medicaid
eligibility criteria that are more restrictive than those in effect
Figure 2
as of June 1, 1997. If states expand coverage under
Federal Allocations for SCHIP,
Medicaid, they must maintaintain eligibility standards in
FY 1998-2007
effect as of March 31, 1997.
Billions of Dollars
$5.0
Maintenance of effort is also required in state-only programs
$4.295
$4.275
$4.05
in New York, Pennsylvania, and Florida.
$3.15
Abortions cannot be covered by federal or state funds except
to save the life of the mother or in the case of rape or incest.
CHILD-RELATED MEDICAID PROVISIONS
In addition to the creation of the new state child health
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
insurance program, several changes to Medicaid were made to
Source: Federal Register, 1997.
strengthen coverage for children under the Balanced Budget
Act of 1997. States can now opt to:
Annual federal allocations to states are based on the states'
share of low-income and uninsured children using estimates
Extend presumptive eligibility to children -- This means
from the Current Population Survey, conducted by the U.S.
that services provided to uninsured children will be covered
Census Bureau. The allotment formula changes over time to
by Medicaid before eligibility determination is complete. For
adjust for reductions in the number of uninsured children.
children who are determined to be eligible for the new
program, the costs will be paid through new program funds.
States do not receive their allotments automatically. States
must have their child health plan approved by HHS and are
Offer 12 month continuous eligibility to children States
required to contribute state funds in order to draw down, or
can choose to provide up to one year of continuous eligibility
"match" their federal allotment. The state share cannot include
for children under Medicaid, regardless of any changes in
beneficiary cost-sharing and is subject to the same provider tax
family income during that period.
and donation limitations specified in the Medicaid statute.
Accelerate the phase-in to cover poor children born
Under the new state program, states receive an "enhanced"
before September 30, 1983. In the past, states could
federal matching rate based on their Medicaid matching rate.
cover these children under Section 1902(r)(2) at state option
The CHIP enhanced rate essentially reduces by 30 percent the
or through a Section 1115 waiver. The BBA of 1997
share states pay as compared to what they would contribute
clarifies this option. Some 27 states have used these
under their Medicaid match. For example, a state with a federal
options to expand coverage to older children.
match of 60% under Medicaid would receive an "enhanced" rate
of 72% under the new program. In essence, the state would
States must also restore Medicaid eligibility to disabled children
pay 28 cents of every dollar spent under the new children's
who lost SSI under the 1996 welfare reform legislation. The
program. No state may receive a matching rate greater than
Balanced Budget Act also includes numerous provisions that
85% and the minimum annual payment for a state is $2 million.
grant states increased flexibility over their Medicaid programs.
These include the ability to mandate managed care enrollment
States can receive an enhanced matching rate for providing
without a waiver, greater control over provider payment through
Medicaid coverage to an expanded group of children. All
the repeal the Boren Amendment, and a phase-out of cost-
Medicaid rules, including the entitlement to coverage, would
based reimbursement for Federally Qualified Health Centers.
The Kaiser Commission on the Future of Medicaid was established by the Henry] Kaiser Family Foundation in 1991 to function as a Medicaid policy institute
and serve as a forum for analyzing, debating and evaluating future directions for Medicaid and other health reforms affecting low-income Americans.
The Kaiser Family Foundation is an independent national health care philanthropy and not associated with Kaiser Permanente 01 Kaiser Industries.
THE HENRY J.
KAISER
FAMILY
FOUNDATION
THE HENRY J. KAISER FAMILY FOUNDATION
November 1997
MEDICAID'S FINANCIAL PROTECTIONS FOR MEDICARE'S POOR AND NEAR-POOR
Medicare offers nearly universal coverage to the nation's
Health expenses consume nearly one-third of the family
elderly population and is an important source of coverage for
income of Medicare's poor and near poor beneficiaries
persons with disabilities. Despite the significance of
compared to about 21% of family income for all beneficiaries
Medicare's protections, gaps in the scope of benefits and
(Exhibit 3). High out-of-pocket costs are due to the financial
beneficiary financial obligations can result in significant out-of-
requirements of the Medicare program, the limited coverage of
pocket expenses for Medicare's poor and near poor. Medicaid
helps to supplement Medicare by paying premiums and cost-
Exhibit 3
sharing for some low-income beneficiaries, but participation is
Health Spending by the Elderly as a Percent of
limited with less than half of the eligible population covered.
Family Income, 1996
INCOME, HEALTH STATUS, AND HEALTH SPENDING
40%
30%
31%
Nearly 15 million elderly and disabled Medicare beneficiaries
30%
26%
(42.5%) are poor or near-poor with incomes below 200 percent
of the federal poverty level (Exhibit 1). An even greater share
20%
18%
of Medicare's beneficiaries who are women (48%), age 80 and
11%
older (52%), and African American (63%) have an income
10%
below twice the poverty level.
0%
Exhibit 1
<100%
100-125%
125-200%
200-400%
400%+
Medicare Population by Poverty Level, 1995
of Poverty
of Poverty
of Poverty
of Poverty
Less than 100% of Poverty
Note. Excludes institutionalized population.
12.2%
SOURCE M. Moon. C. Kuntz, and L. Pounder, Protecting Low-Income Medicare
100%-120%
of Poverty
Beneficiaries. The Commonwealth Fund, December 1996.
6.2%
120%-135%
of Poverty
4.9%
Less than
200% of
certain benefits, and lack of coverage for outpatient
200% of
Poverty
or more
135%-175%
Poverty
prescription drugs. The 1998 Medicare financial obligations
57.6%
of Poverty
42.5%
for beneficiaries include a $764 hospital deductible, a $100
12.1%
Part B deductible, 20% co-insurance for physician services,
175%-200%
and Part B premium of $43.80 per month ($525.60 per year).
of Poverty
7.0%
Total = 34.3 Medicare Beneficiaries
Although the majority of Medicare beneficiaries have Medigap
Note. 1995 federal poverty level was $7,470 for individuals; $10,030 for couples
or retiree health benefits to fill the gaps in the Medicare benefit
SOURCE: M Moon estimates of non-institutionalized population based on analysis of
March 1996 Current Population Survey.
package, lower income beneficiaries are much more likely
than their higher income counterparts to rely solely on
Low-income Medicare beneficiaries are more likely to be in
Medicare. Beneficiaries without any supplemental coverage
poor health and have problems that require medical attention
experience the greatest access and financial barriers to care.
than their higher income counterparts (Exhibit 2). Because of
Thus, Medicaid is an important source of supplemental health
their low-incomes, poor and near-poor beneficiaries are less
coverage for the low-income Medicare population.
able to afford basic medical services and prescription drugs.
MEDICAID'S BUY-IN PROTECTIONS
Exhibit 2
Percent of Elderly Medicare Beneficiaries Reporting
Medicaid, the federal/state health financing program for the
Fair or Poor Health, 1992
poor, provides benefits which vary based on income and
40%
assets for about 6 million Medicare beneficiaries,.
35.9%
32 4%
30%
Full Medicaid Benefits: The majority of Medicare
24 5%
beneficiaries eligible for Medicaid qualify because they
20%
16.7%
are entitled to SSI or have incurred large health expenses.
These "dual eligibles" receive full Medicaid benefits (such
10%
as prescription drugs) as defined under each state's
program. Medicaid also pays Medicare's premiums,
0%
deductibles, and cost-sharing requirements, known as
<100%
100-125%
125-200%
200%+
of Poverty
of Poverty
of Poverty
QMB benefits (5.4 million beneficiaries in 1995).
SOURCE: D. Rowland and B. Lyons, "Medicare, Medicaid, and the Elderly Poor."
Health Care Financing Review 1996
2400 SAND HILL ROAD MENLO PARK. CALIFORNIA 94025 (650) 854-9400 FAX (650) 854-4800
WASHINGTON OFFICE: 1450 G STREET, N.W., SUITE 250 WASHINGTON, DC 20005 (202) 347-5270 FAX (202) 347-5274
WEBSITE: WWW.KFE.ORG PUBLICATION REQUEST LINE: (800) 656-4KFF
Exhibit 5
Qualified Medicare Beneficiaries (QMBs): For Medicare
LEGISLATIVE HISTORY OF MEDICAID BUY-IN
beneficiaries with incomes below 100% of the poverty
PROGRAMS
level and limited assets (less than $4,000 per individual),
Medicaid pays Medicare's premiums, deductibles, and
1965: (P.L. 89-97) Medicare and Medicaid enacted. States
cost-sharing (367,000 QMB-only beneficiaries in 1995).
permitted to enroll certain eligible Medicaid recipients in
Medicare Part B by paying their Part B premium.
Specified Low-income Medicare Beneficiaries
(SLMBs): For Medicare beneficiaries with incomes
1968: (P.L. 90-248) Federal payments prohibited for Medicaid
between 100-120% of poverty and limited assets,
services that could have been paid for by Medicare Part B if the
recipient had been enrolled.
Medicaid pays only the Medicare Part B premium
(195,000 beneficiaries in 1995).
1986: (P.L. 99-509) States permitted to pay Medicare
premiums and cost-sharing for Medicare beneficiaries with
In 1996, only 63 percent of those eligible for QMB benefits and
incomes up to 100% of poverty who are "not otherwise eligible"
only 10 percent of those eligible for SLMB benefits received
for Medicaid.
financial assistance under Medicaid (Moon, 1996). While
1988: (P.L. 100-360) States required to pay Medicare
some, but not most states, have taken steps to ease the
premiums and cost-sharing for Medicare beneficiaries up to
QMB/SLMB enrollment process, requirements to apply in
100% of poverty (QMB).
person at Medicaid and welfare offices, lengthy application
forms, and the lack of effective outreach are barriers to
1989: (P.L. 101-239) States required to pay Medicare Part A
Medicaid participation (Exhibit 4).
premiums for certain qualified disabled working individuals
(QDWI) with incomes up to 200% of poverty.
Exhibit 4
1990: (P.L. 101-508) States are required to pay the Part B
States Using Simplified Application Processes for
premium for Medicare beneficiaries with incomes up to 120%
QMB/SLMB Benefits
of poverty (SLMB).
1997: (P.L. 105-33) States provided a $1.5 billion block grant
(100% federal dollars) to pay the Part B premium, beginning in
1998, for individuals with incomes to 135% of poverty and a
portion of the Part B premium for those with incomes up to
DCC
175% of poverty. States permitted to pay cost-sharing based
on the Medicaid payment rate instead of the Medicare rate.
Source: Adapted from P. Nemore, Variations in State Medicaid
Buy-In Practices for Low-Income Medicare Beneficiaries, The
Henry J. Kaiser Family Foundation, November 1997.
Both simpler application process and
shorter application form (8 states)
SOURCE P Nemore. Variations in State Medicaid Buy-In
Simpler application process or
Practices for Low-Income Medicare Beneficiaries The
shorter application form (16 states)
Henry J. Kalser Family Foundation November 1997
Neither (26 states DC)
poverty (Exhibit 5). In contrast to the QMB/SLMB programs,
the block grant is not an individual entitlement and states are
not required to contribute matching funds. Thus, the block
The emerging role of managed care under Medicare and
grant is estimated to cover only one-third of those eligible
Medicaid offers the promise of coordinated care for dual
(Moon, 1997).
eligibles. However, few states have systems in place to
coordinate Medicare and Medicaid benefits for beneficiaries
The BBA 97 also permits states to limit their QMB cost-sharing
enrolled in HMOs (Nemore, 1997). Lack of coordination limits
contributions to providers if the Medicaid rates are lower than
the capacity of states to pay cost-sharing benefits for low-
the Medicare rates. This provision may result in access
income beneficiaries in Medicare HMOs. Medicaid programs
problems because Medicaid reimbursement rates are
are often unable to determine if beneficiaries are enrolled in
generally lower than Medicare rates and may not be accepted
Medicare HMOs and may be paying for benefits already
by some providers.
included in the Medicare capitation rate. Finally, for
beneficiaries, enrollment in Medicaid managed care plans may
limit access to Medicare-covered services outside the
ISSUES AND CHALLENGES
Medicaid HMO (Feder, 1997).
While federal policymakers have historically relied on Medicaid
BALANCED BUDGET ACT OF 1997
to provide financial protections for low-income Medicare
beneficiaries, state Medicaid programs have multiple
The Balanced Budget Act of 1997 (BBA 97) increases financial
responsibilities and may lack the capacity to absorb rising
obligations for beneficiaries under Medicare by raising the
premiums and cost-sharing expenses for Medicare's poor and
monthly Part B premiums. The new law is expected to
near-poor. At the same time, a significant share of the
increase Medicare Part B premiums from $43.80 per month in
Medicare population (more than 4 in 10) have incomes below
1997 to $67 in 2002 and to $105.40 per month in 2007.
200% of poverty ($15,780 in 1997) and already incur high
financial burdens for their health expenses. The challenge
To help offset these costs for low-income beneficiaries, the
facing policymakers is to make Medicaid work more effectively
BBA 97 established a new block grant to states ($1.5 billion
for low-income Medicare beneficiaries, minimize Medicare's
over 5 years) to cover the premium for those with incomes
financial burdens on the poor and near-poor, and preserve the
between 120 and 135% of poverty and a portion of the
Medicare program for future generations.
premium for those with incomes between 135 and 175% of
The Henry J. Kaiser Family Foundation. based in Menlo Park. California, is a non-profit. independent national health care philanthropy and is not associated with
Kaiser Pemanente or Kaiser Industries. The Foundation's work is focused on four main areas: health policy, reproductive health, and HIV/AIDS policy in the
United States. and health and development in South Africa.
THE HENRY
The Kaiser Commission on
KAISER
FAMILY
THE FUTURE OF MEDICAID
R DUNDATION
December 1997
Dear Interested Party:
Today, Medicaid continues to provide important health and long-term care assistance to more than
35 million low-income Americans. The Balanced Budget Act of 1997 (BBA) made many important
changes to the Medicaid program, including broadening state discretion to mandate enrollment in
managed care organizations and reducing federal Disproportionate Share Hospital (DSH) payments.
The BBA also creates a new option for states to expand coverage for children through the State
Children's Health Insurance Program.
To assist policymakers and others concerned about the Medicaid program and the low income
people it serves, we are pleased to send you the following new Commission publications: 5 fact
sheets, the third edition of Medicaid Expenditures and Beneficiaries, and a background paper on the
provisions in the BBA relating to Medicaid managed care.
Fact sheets
Medicaid At A Glance (update) (#2004);
Medicaid and Managed Care (update) gives an overview of enrollment in Medicaid
managed care and reviews the major models of managed care delivery (#2068);
Medicaid's Role for Children (update) provides an overview of the eligibility, benefits and
financing of coverage for children and a summary of recent legislative changes (#2078);
NEW!
State Children's Health Insurance Program: Legislative Summary reviews the new child
health legislation enacted as part of the BBA (#1345);
NEW!
Medicaid's Financial Protections for Medicare's Poor and Near-Poor reviews Medicaid's
role in providing financial assistance to Medicare's low-income beneficiaries (#1334).
Data book and Background paper
Medicaid Expenditures & Beneficiaries: National and State Profiles and Trends
NEW!
1990-1995 (update) revises earlier editions and presents a comprehensive overview of
Medicaid spending and enrollment both nationally and at the state level (#2045).
NEW!
Overview of Medicaid Managed Care Provisions in the Balanced Budget Act of 1997
reviews the provisions in the BBA relating to Medicaid managed care, prepared by Andy
Schneider of the Center on Budget and Policy Priorities (#2102).
For more information, contact Lynda Bogatz at the Commission's office at (202) 347-5270.
Additional copies of these publications are available by publication number at (800) 656-4KFF.
Sincerely,
Diane Roweard
Diane Rowland
Executive Director
1450 G STREET, NW, SUITI 250, WASHINGTON, DC 20005
TIL (202) 347-5270
FAX (202) 347-5274
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Basics of the Family & Medical Leave Act
http://hi-tec.twc.state.tx.us/medical/family.htm
Texas Workforce Commission
Basics of the Family & Medical Leave Act
FAMILY AND MEDICAL LEAVE ACT SIGNED INTO LAW
After eight years of frequently bitter debate, Congress passed the Family and Medical Leave Act of 1993
(the Act) on February 4, 1993 and President Clinton signed the measure into law the following day.
The Act becomes effective on August 5, 1993 and requires employers with 50 or more employees within
a 75-mile radius to offer eligible workers up to 12 weeks of unpaid leave during a 12-month period for
birth or adoption, to care for a seriously ill parent, spouse or child or to undergo medical treatment for
their own serious illness. State and local governments are covered by the Act under the same conditions
as private employers. It is estimated the Act will affect five percent of America's employers and 40
percent of all employees.
Family Leave
To be eligible to take family leave, a worker must have been employed for at least 12 months and have
worked a minimum of 1,250 hours (this an average of 25 hours per week). While the year of service to
the employer does not have to be performed consecutively, the 1,250 hours of work must have been
performed during the 12 calendar months immediately prior to the beginning of the leave. The Act does
not cover seasonal or part-time employees working fewer than 1,250 hours per year, however they must
be included when calculating the number of employees stationed at a particular worksite.
Employers are not required to provide family leave to the highest paid top 10 percent of their executive
employees if granting such a leave would "create substantial and grievous injury to the business
operations."
The right to take leave applies equally to male and female workers: fathers and mothers will be eligible
to take family leave for the birth of a child. While the Senate Report does not specifically mention a
father taking leave when a child is adopted or a foster child is placed in a home, because the right to take
leave applies equally to the sexes, it appears a father is also entitled to take leave when a child is placed.
While both parents may be eligible to take leave, if both spouses work for the same employer, that
employer may limit their combined total weeks of leave to 12 during any one-year period for the birth or
adoption of a child. This provision is apparently designed to remove any disincentive to the hiring of
married couples.
One of the most frequently asked questions is whether the 12 weeks of leave must be taken
consecutively; this was also one of the most hotly debated issues in Congress. While a number of large
businesses already have some sort of family leave policy in place, many smaller employers asserted that
allowing frequent intermittent periods of leave was much more disruptive in the workplace than longer
periods of leave. Apparently, the compromise Congress reached here is that intermittent leave cannot be
taken for the birth or adoption of a child; however, medical leave can be taken on an intermittent basis or
on a "reduced leave schedule" if it is "medically necessary."
Eligible employees may take up to 12 weeks of unpaid leave during a one-year period to care for a son,
daughter, spouse or parent if that individual has a "serious health condition" which is defined as an
"illness, injury, impairment or any physical or mental condition that requires inpatient medical care or
continuing treatment by a health care provider." The Senate Report on the Act cites as examples of such
serious health conditions emphysema, appendicitis, severe respiratory distress conditions, heart
conditions requiring bypass or valve operations, back conditions requiring surgery or extensive therapy
and severe nervous disorders. The Report also makes it clear this is not to be considered an exhaustive
list of "serious health conditions."
An eligible employee may take up to 12 weeks of unpaid leave during any one year period for that
1 of 3
06/18/97 17:16:42
Basics of the Family & Medical Leave Act
http://hi-tec.twc.state.tx.us/medical/family.hm
An eligible employee may take up to 12 weeks of unpaid leave during any one year period for that
employee's own "serious health condition." While a worker is allowed to take leave to care for a family
member who simply has a "serious health condition," it is clear a higher standard must be met before an
employee qualifies to take leave for a personal health condition: a worker must be able to demonstrate he
or she is medically unable to perform the functions of their job before being eligible to take leave.
As previously mentioned, Congress has provided for intermittent leave in cases of "serious health
conditions" if it is "medically necessary." This means a worker could take off for short periods of leave
not to exceed 12 weeks in the aggregate during a one year period. The Senate Report defines
"intermittent leave" as taking off for several hours, a single day or a week as a worker's medical needs
require. A "reduced leave" schedule might include working only in the morning or adopting a regular
three-day work week.
The Act also provides that the two types of leave - family and medical - may be combined. For example,
if a woman takes six weeks of leave when her child is born, she would still be eligible to take leave that
same year if her child experiences intermittent health problems. Under certain narrow circumstances, an
employer can temporarily transfer an employee to another job with equivalent benefits and pay if
granting intermittent leave would be inordinately disruptive to the workplace.
An employer can require medical certification regarding the need to take leave and of the worker's
release to return to work after the leave. Such certification should include the date the serious health
condition began and the estimated duration of the condition. If the employee is taking the leave to care
for a family member, the certification should include a statement indicating it is necessary for that
worker to care for the child, spouse or parent. If an employer doubts the validity of a worker's medical
certification, it may require the eligible employee to get a second opinion from an independent health
care provider of the employer's choosing. This is done at the employer's expense. If the two physicians
do not agree on the prognosis, the employer and the eligible employee together must agree on a third
physician whose opinion will be binding on the parties.
Other Important Provisions of the Act
The Act also provides that:
1. When an employee returns to work after taking leave, an employer must guarantee the employee can
return to the job they held before the leave or a comparable position. While there is certain to be debate
regarding the interpretation of these terms, the Senate Report indicates the job reinstatement requirement
is to be strictly construed: a "similar" or "comparable" position is probably not an "equivalent" position.
To be an "equivalent" position, all privileges, duties, terms and conditions of the worker's previous job
must arguably correspond.
2. Employers may force an employee to use vacation, sick or other accumulated leave before granting a
leave under this Act.
3. Employers must continue providing health care coverage while an employee is on leave. Taking such
a leave does not constitute a qualifying event which would trigger the continuation of health benefits
under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). However, a qualifying
event triggering COBRA coverage could occur when an employer learns an employee will not be
returning to work and therefore ceases to be entitled to leave under the Act. The Act also permits
employers to require employees to pay for any health care benefits the employer paid for during the
leave if the worker does not return to work. However, if the failure to return from leave is caused by
factors beyond the worker's control, repayment is not required.
4. An employer may require a worker on leave to periodically report their status and intent to return to
work. The Report states this provision is to allow the employer to require such reports at "reasonable
intervals."
5. Employees must give their employers 30 days' notice of their intent to take leave for foreseeable
events such as childbirth, adoption or necessary medical treatment. However, if the birth or placement of
2 of 3
06/18/97 17:16:42
Basics of the Family & Medical Leave Act
http://hi-tec.twc.state.tx.us/medical/family.htm
a child or medical treatment requires leave to begin in less than 30 days, the employee must provide
notice "as practicable."
6. The 12 weeks of leave provided under the Act is cumulative of whatever leave an employer already
allows. For example, if an employer currently provides six weeks of paid leave, the new Act only
requires the addition of six weeks of unpaid leave.
7. The penalties for violating the Act include an employee claim for lost wages and benefit costs plus
interest and an additional 100 percent penalty for lost wages, benefits and interest. Reasonable attorneys
fees and various costs (including payment of expert witnesses) are also allowed. The penalties are quite
similar to those prescribed under the Fair Labor Standards Act.
8. The Office of Personnel Management of the Department of Labor (DOL) will enforce the Act. DOL
has set a June 4, 1993 deadline for accepting public comment on the regulations which will be drafted to
implement the Act. Hopefully, guidelines and regulations will be available before that Act goes into
effect on August 5, 1993.
Those in favor of a national standard for family leave have argued for years that employers who have
adopted family and medical leave policies have already experienced cost savings through reduced
employee turnover and decreased hiring and training expenses. Such policies are viewed as a way to
protect a company's investment of time and money in its most valuable commodity: its workers.
Supporters have also argued the Act will be cost effective from a public policy standpoint and the
benefits outweigh the problems because society as a whole often pays the price for failed, fragmented
family units. On the other hand, many smaller employers see the new law as just the latest in a series of
expensive, bureaucratic nightmares that will disrupt the workplace and result in lost productivity.
Which of these arguments proves valid on a national basis remains to be seen. The only thing that can be
said with certainty at this time is that millions of American employers and employees are hopeful the
Act can be implemented in a manner that maximizes benefits and minimizes burdens on both employers
and employees.
This file is available for downloading in the Medical Files Library as FAMILY.ASC
Texas Workforce Commission
Last Modified: August 05, 1993
Return to the TWC Home Page.
3 of 3
06/18/97 17:16:42
MEMORANDUM
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General Services Administration
* U.S. GOVERNMENT PRINTING OFFICE: 1995-385-890
PRESIDENT CLINTON IS MEETING AMERICA'S CHALLENGES:
A REPORT ON THE SUCCESS OF THE
FAMILY AND MEDICAL LEAVE ACT
May 1, 1996
"The law guarantees the right of up to twelve weeks of unpaid leave per year when it's urgently
needed at home to care for a newborn child, or an ill family member. This bill will strengthen
our families, and I believe it will strengthen our businesses and our economy as well."
- President Clinton, signing ceremony, February 5, 1993
Strengthening America's families, achieving economic security. Today's report shows
that the Family and Medical Leave Act, which was the first bill President Clinton signed into
law, has been a tremendous success in helping America's families find security in today's
economy. By allowing working Americans to take leave of up to twelve weeks to care for
sick relatives or new children without fear of losing their jobs, the FMLA provides the peace
of mind that Americans will never have to choose between work and their family's health
again.
A clear report. The Family and Medical Leave Act of 1993 established the bi-partisan
Commission on Leave to study the impact of the Act. Their comprehensive, national survey
concludes that the FMLA is helping families without causing significant hardship to most
businesses.
*
Helping our families cope with serious illness. Almost 80 percent of leave is taken to
care for a seriously ill child, spouse or parent, or for one's own serious health condition.
Easy to administer. More than nine out of ten employers find it "very" or "somewhat
easy" to administer the FMLA.
*
Not costly to business. For 89.2 to 98.5 percent of worksites, complying with the FMLA
entails either little or no costs.
*
Helping America's businesses. The vast majority of leave-takers (84 percent) return to
their same employer, leading some businesses to testify that the new law has helped
them reduce employee turnover, enhance productivity and improve the morale of
their workforce.
*
A significant effect. More than half of America's workers are eligible to take leave under
the FMLA, and more than one in six of all employees have taken leave for a reason
covered by the Act.
Helping Americans meet our challenges. The Family and Medical Leave Act takes a
significant step with its signature features of guaranteed job protection and maintenance of health
benefits. The Act is helping a larger cross-section of working Americans meet their medical and
family caregiving needs while still maintaining their jobs and economic security, achieving the
workable balance the President, and the nation, intended.
President Clinton Announces New Family-Friendly Workplace Proposals:
Expanded Family & Medical Leave and Employee-Choice Flex-Time
June 24, 1996
"Family and medical leave is a matter of pure common sense and a matter of common decency.
It will provide Americans what they need most: peace of mind. Never again will parents have to
fear losing their jobs because of their families."
-- President Clinton, Family and Medical Leave Act Signing
February 5, 1993
Today, President Clinton attends the Vice President's annual Family Conference in Nashville to
announce two new proposals to help parents care and provide for their families. A company's
success in the new global economy depends on smart, flexible and committed workers. These
days, a company loses half its workers every five years. In creating a family-friendly workplace,
companies build loyalty, increase productivity and attract the workers they need to stay
competitive.
Family and Medical Leave Act of 1993. In his first month in office, President Clinton
delivered on his promise and signed the Family and Medical Leave Act into law. The law allows
workers at businesses with 50 or more employees to take up to 12 weeks of unpaid, job-protected
leave to care for a newborn or adopted child, to attend to their own serious health needs, or to
care for a seriously ill parent, child or spouse.
*
More than 12 million eligible workers have taken leave since its enactment.
More than 85% of companies covered by the Act found that it neither adds to their
costs nor takes away from their profits.
40% of all workers believe they will need to take leave under the Act at some
time in the next five years.
Building on and expanding the Family and Medical Leave Act. President Clinton proposes
expanding the law to cover more family obligations to better help workers care for their children
and elderly relatives without sacrificing their work obligations. Under the proposed expansion,
workers could take up to 24 hours of leave each year to meet additional specified family
obligations, including the following:
*
Attending parent-teacher conferences.
Accompanying a child, spouse or elderly parent for routine medical and dental care.
New employee-choice flex-time. The President also proposes a flex-time initiative that will give
workers the opportunity to receive extra paid time-off "flex-time" -- rather than working
overtime for cash pay. Under this proposal, workers would get time-and-a-half in flex-time for
each hour of overtime and could choose to use their flex-time for family and medical leave
purposes whenever they need it. Workers would maintain ultimate control of when to use flex-
time, as long as they provide two weeks notice to their employers.
To protect against the potential of abuse, the President's proposal includes explicit protections
against coercion:
*
Employees and employers would have a written flex-time agreement.
*
Private-sector workers can get cash for their accumulated flex-time within two
weeks of notice.
*
Workers from businesses that go bankrupt would be protected by special
safeguards for unpaid flex-time in bankruptcy proceedings.
Creators Syndicate
310-337-7003
3/11/97
8:27 PM
2/3
TALKING IT OVER
BY HILLARY RODHAM CLINTON
FOR IMMEDIATE RELEASE
For years, Sarah Clay supported her two children with low-wage jobs in child
care and retail sales, relying occasionally on food stamps to make ends meet. Again
and again, she was turned down for better-paying jobs because she didn't have a
college degree. "I was running into a brick wall as far as being able to make a livable
income," she said.
So, at the age of 42, the single mother decided to go back to school. Pell grants,
student loans and academic scholarships covered the cost of her tuition. But there was
still the issue of transportation. She lived more than an hour away from campus and
had no money for gas.
Then, Clay heard about the Single Parent Scholarship Fund, a privately
supported Arkansas program that offers grants of up to $500 a semester to single
parents living at or near the poverty level who are also enrolled in college or
vocational training programs. She applied for and received a scholarship that covered
the cost of gas and maintenance on her car. While modest, the scholarship made a
huge difference in her ability to do well In class and be a good mother to her young
son and teen-age daughter. Clay graduated from the University of Central Arkansas in
1994 and earned a master's in social work two years later. She now works with
children and families through the Arkansas Department of Human Services.
I met Sarah and four other women helped by the fund at a dinner earlier this
week in Little Rock. The fund got its start in a northwest Arkansas county more than 10
years ago. Its founder, a man named Ralph Nesson, noticed that many poor, single
parents were having difficulty going to college or vocational school to earn the
degrees they needed to find better jobs.
Nesson, who worked in a community-action agency, discovered that a number
of factors conspired against these single parents: the high cost of tuition and books,
the absence of extended family or friends to help with child care, a lack of
transportation and a lack of Information about available scholarships and other
assistance. So, Nesson and his colleagues raised a scholarship fund to help single
parents meet the challenges of raising children and going to college.
I first heard of the Single Parent Scholarship Fund in 1989, when its founders
invited me to help introduce the program throughout Arkansas. Over the past seven
years, local scholarship committees across the state have awarded 3,148 grants worth
Creators Syndicate
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08:27 PM
3/3
TALKING IT OVER 3/11/97
Page 2
$1.2 million and have posted success rates that are the envy of many institutions of
higher learning. Seventy-five percent of the scholarship recipients have remained in
school or graduated from college, and 72 percent now have careers in fields such as
nursing, education, engineering and social work.
I have met dozens of scholarship recipients like Sarah Clay who just needed
the helping hand provided by the fund to keep them on the road to greater economic
Independence. They weren't people looking for a handout or a free ride but women
eager to make the sacrifices and commitments necessary to further their education,
acquire the skills they needed to succeed and improve conditions for themselves and
their families.
The only thing standing in their way was the ability to go back to or stay in
school.
Today, education is critical to every citizen's economic security. We live in an
Information Age -- an age when education can mean the difference between having a
job or no job; between a decent job or a dead-end job; between a sense of fulfillment
or a sense of futility.
Nearly one-third of all American families are headed by single parents. And at a
time when a woman with a college degree can earn more than double what a woman
without one earns, single parent scholarships are needed more than ever. They can
be important tools in our efforts to help the many single mothers who are striving to
free themselves from welfare dependence. For many of these women, a scholarship
can offer not only much needed financial help on the long, hard road to independence
but also a vote of confidence In their ability to learn and succeed.
There is no reason that this wonderful idea can't work in places beyond
Arkansas. Single parent scholarships can be replicated in communities all across the
country. Local businesses, foundations, churches, civic organizations and private
citizens can join together to form their own scholarship funds and committees to help
single parents in their communities lift themselves and their families out of poverty and
off public assistance
The investment is minimal. But the rewards for the recipient and our
communities are great. "I feel self-sufficient. I don't have to depend on anyone
anymore," Clay said. "I've got the tools I need to be productive and to make a
contribution to society. I have a real sense of freedom because of that."
COPYRIGHT 1997 CREATORS SYNDICATE, INC.
ALL RIGHTS RESERVED
March 11, 1997
PRESIDENT CLINTON ANNOUNCES ADVISORY COMMISSION ON CONSUMER
PROTECTION AND QUALITY IN THE HEALTH CARE INDUSTRY
March 26, 1997
Today, President Clinton will announce the members of the Advisory Commission on
Consumer Protection and Quality in the Health Care Industry. The President will call on the
Commission to develop a "Consumer Bill of Rights" to promote and assure patient protections
and health care quality. The Advisory Commission was created through an Executive Order
signed by President Clinton in September, 1996 to build on the Clinton Administration's
commitment to improve the quality of the nation's health care system.
The 32-member Commission will review rapid changes in the health care financing and
delivery systems and make recommendations, where appropriate, on how best to preserve and
improve the quality of the nation's health care system. The purpose of the Commission is to
advise the President on how unprecedented changes in the health care delivery system are
affecting quality, consumer protection and the availability of needed services. Through a series
of public meetings, it will collect and evaluate information and develop recommendations on
improving quality in the health care system. The Commission will be co-chaired by the
Secretary of Health and Human Services and the Secretary of Labor.
Acting Labor Secretary Cynthia Metzler will make opening remarks. Secretary Shalala
will then make remarks and introduce the President.
Attached is a fact sheet on the Commission and brief bios on the members. In addition to
those members named today, three additional individuals selected to serve on the Commission
are expected to be named shortly.
THE ADVISORY COMMISSION ON CONSUMER PROTECTION AND QUALITY IN
THE HEALTH CARE INDUSTRY
REPRESENTING BROAD-BASED INTERESTS AND EXPERTISE
Co-chaired by the Secretaries of Health and Human Services and Labor, the Advisory
Commission has broad-based representation from consumers, businesses, labor, health care
providers, insurers, and quality and financing experts. The Advisory Commission members have
vast expertise on a wide range of health issues including the unique challenges facing rural and
urban communities, children, women, older Americans, minorities, people with disabilities, mental
illness and AIDS. There are also members with extensive backgrounds in privacy rights and
ethics. Advisory Commission members come from all parts of the country and reflect America's
diverse population.
FOCUSING ON CONSUMER RIGHTS AND QUALITY
The President charged the Commission with developing a "Consumer Bill of Rights" to ensure
that patients have adequate appeals and grievance processes. In developing the "Consumer Bill of
Rights," the Commission will study and make recommendations on consumer protections, quality,
and the availability and treatment of services. Using the best research to measure real outcomes
and consumer satisfaction across all providers of health care, the Commission will work to give
Americans the tools they need to measure and compare health care quality. It will submit a final
report by March 30, 1998. The Vice President will review the final report before it is submitted
to the President. In addition, the Advisory Commission will play a consultative role should
relevant legislative initiatives move through the Congress prior to the due date of the final report.
BUILDING ON THE ADMINISTRATION'S COMMITMENT TO HEALTH CARE
QUALITY
The Clinton Administration has a long history of strong support for consumer protection in health
plans, including executive actions and legislative initiatives barring gag rules; limiting physician
incentive arrangements; increasing choice and consumer information; and requiring health plans to
allow women to stay in the hospital for 48 hours after a mastectomy or after the delivery of a
child. The President has called for this Commission to develop a broader understanding of the
numerous issues facing a rapidly evolving health care delivery system and to help build consensus
on ways to assure and improve quality health care.
- 7 -
work and live, I believe we must expand family leave so that workers
can take time off for teacher conferences and a child's medical
checkup. We should pass flex-time, so workers can choose to be paid
for overtime in income or trade it in for time off to be with their
families. (Applause.)
We must continue -- we must continue, step by step, to
give more families access to affordable, quality health care. Forty
million Americans still lack health insurance. Ten million children
still lack health insurance -- 80 percent of them have working
parents who pay taxes. That is wrong. (Applause.)
My balanced budget will extend health coverage to up to
5 million of those children. Since nearly half of all children who
lose their insurance do so because their parents lose or change a
job, my budget will also ensure that people who temporarily lose
their jobs can still afford to keep their health insurance. No child
should be without a doctor just because a parent is without a job.
(Applause.)
My Medicare plan modernizes Medicare, increases the life
of the trust fund to 10 years, provides support for respite care for
the many families with loved ones afflicted with Alzheimer's. And
for the first time, it would fully pay for annual mammograms.
(Applause.)
Just as we ended drive-through deliveries of babies last
year, we must now end the dangerous and demeaning practice of forcing
women home from the hospital only hours after a mastectomy.
(Applause.) I ask your support for bipartisan legislation to
guarantee that a woman can stay in the hospital for 48 hours after a
mastectomy. With us tonight is Dr. Kristen Zarfos, a Connecticut
surgeon whose outrage at this practice spurred a national movement
and inspired this legislation. I'd like her to stand so we thank her
for her efforts. Dr. Zarfos, thank you. (Applause.)
In the last four years, we have increased child support
collections by 50 percent. Now we should go further and do better by
making it a felony for any parent to cross a state line in an attempt
to flee from this, his or her most sacred obligation. (Applause.)
Finally, we must also protect our children by standing
firm in our determination to ban the advertising and marketing of
cigarettes that endanger their lives. (Applause.)
To prepare America for the 21st century, we must build
stronger communities. We should start with safe streets. Serious
crime has dropped five years in a row. The key has been community
policing. We must finish the job of putting 100,000 community police
on the streets of the United States. (Applause.) We should pass the
Victims Rights Amendment to the Constitution.
And I ask you to mount a full-scale assault on juvenile
crime, with legislation that declares war on gangs, with new
prosecutors and tougher penalties; extends the Brady Bill so violent
teen criminals will not be able to buy handguns; requires child
safety locks on handguns to prevent unauthorized use; and helps to
keep our schools open after hours, on weekends, and in the summer, so
our young people will have someplace to go and something to say yes
to. (Applause.)
This balanced budget includes the largest antidrug
effort ever: to stop drugs at their source, punish those who push
them, and teach our young people that drugs are wrong, drugs are
illegal, and drugs will kill them. I hope you will support it.
(Applause.)
MORE
human SERVICES USA
DEPARTMENT OF HEALTH & HUMAN SERVICES
Health Care Financing Administration
HEALTH
Director,
Office of Managed Care
of
FTB 20 1997
Dear State Medicaid Director:
The purpose of this letter is to clarify Federal law and regulations regarding physicians' and
other health care providers' advice and counsel to beneficiaries enrolled in Medicaid managed
care plans. A similar letter was sent in November 1996, to Medicare-contracting health
maintenance organizations (HMOs) and competitive medical plans (CMPs).
Federal law and regulations state clearly that beneficiaries enrolled in Medicaid HMOs must
have access to the same services available to Medicaid beneficiaries in the fee-for-service
(FFS) program. Medicaid contracting HMOs must make the services they provide under their
contracts "accessible
to the same extent as such services are made accessible to individuals
not enrolled with the organization." (See Section 1903(m)(1)(A) of the Social Security
Act.) In addition, relevant regulations require Medicaid managed care plans with risk
contracts to make services accessible to Medicaid HMO enrollees to the same extent that those
services are available to Medicaid beneficiaries not enrolled in an HMO.
Beneficiaries are entitled to the full range of their health care providers' opinions and counsel
about the availability of medically necessary services under Medicaid FFS or managed care
programs. Any contractual provisions -- including so-called gag ruies -- that restrict a health
care provider's ability to advise patients about medically necessary treatment options violate
Federal law and regulations.
In order to ensure that all Medicaid beneficiaries have access to the same advice and counsel
from their health care providers, I encourage you to review relevant contract provisions, as
well as the policies and procedures of HMOs contracting with the State, to ensure that health
care providers' advice and counsel regarding medically necessary treatment are unrestricted.
Thank you for your attention to this important matter. Please contact Rachel Block, Director
of the Medicaid Managed Care Team, if you require additional information.
Sincerely,
Bruce Merlin Fried
Director
2/20/97 10:00 A.M.
PRESIDENT WILLIAM J. CLINTON
STATEMENT ON MEDICAID GAG-RULE
THE WHITE HOUSE
FEBRUARY 20, 1997
Acknowledgments: [By V.P.]
Today, I am pleased to announce that we are taking steps to see to it that Medicaid
beneficiaries continue to get access to the fullest possible range of high-quality medical care.
In recent years, the medical community and the insurance industry have joined with us to
reform and improve American health care. Much of this progress has come through managed
care plans, which emphasize prevention, provide better care, and at the same time control costs.
The growth of managed care has been a good thing for America. At the same time, we
must make absolutely sure that this rapid transformation does not lead to a decline in the quality
of health care. That is why I have been concerned about so-called gag-rules in some HMOs and
other health care plans. These rules restrict the ability of health-care professionals to administer
proper medical care. They prevent doctors and nurses from telling patients about alternate,
sometimes more expensive treatments, that are not covered by the plans.
That is unacceptable. Patients in HMOs and other health care plans should know that
their doctors will give them the best information, the most complete information, the widest
possible range of information when it comes to their treatment. On this, there should be not a
shadow of a doubt.
In December, as Secretary Shalala just pointed out, we took action to give Medicare
beneficiaries the right to know about all their treatment options. Today, we will take the next
step. We will act to protect 13 million Medicaid beneficiaries -- children, the disabled and elderly
Americans. I am directing Secretary Shalala to inform all state Medicaid directors that it is illegal
for health care plans to prohibit doctors from discussing any treatment options with their patients
Families facing illness should not have to worry that the doctor they trust does not
have the freedom to tell them what they need to know. Patients have the fundamental right
to know they are getting the best medical treatment -- not just the cheapest.
This must only be the beginning. We can act today to protect Medicare and Medicaid
beneficiaries because they are federal programs -- and because the government is the largest
purchaser of managed care in the country. But to protect the 130 million Americans enrolled in
managed care plans through the private sector, Congress must act. That is why I am so pleased
that members of Congress, from both parties, have come together, with the support of doctors,
nurses, health-care professionals, and consumers to craft legislation that will ban all gag-rules,
for all Americans, in all HMOs and other health-care plans. I urge Congress to send me this
legislation, and when they do, I will sign it into law.
This bipartisan legislation shows how we can work together as we continue, step by step,
to give more families access to quality, affordable health care. I hope we will build on t
his record of accomplishment, and that Congress will join with me to pass a balanced budget that
extends health coverage to children helps people who temporarily lose their jobs to keep their
health insurance and reforms Medicare for the next decade.
Together, we have built a strong foundation for the health of American families. With
these efforts, we will make sure that foundation lasts a good long time.
2