JULY data book Missouri Health and Health Care

Transcription

1 JULY 2013 data book Missouri Health and Health Care

2 table of contents SECTION 1 Medicaid Overview... 1 SECTION 2 Missouri s Health Status/INDICATORS... 3 Figure 2-1. Missouri s performance in health in Figure Missouri County Health Rankings: Overall Rank... 6 Figure 2-3. Figure Missouri County Health Rankings: Health Outcomes Missouri County Health Rankings: Health Factors... 8 Figure 2-5. Insurance Status for Missourians (Ages 0-64)... 9 Figure 2-6. Insurance Status for Missourians BELOW 138% of the Federal Poverty Level (Ages 0-64)... 9 Figure 2-7. Insurance Status for Missourians Above 138% of the Federal Poverty Level (Ages 0-64)... 9 Figure 2-8. Figure 2-9. Figure Number of Uninsured Missourians under Age Percent of Missourians Under Age 65 without Health insurance MO HEALTHNet enrollment by county, number and percent of population...12 Figure uninsured missourians under age 65 and less than 138% FPL...13 TABLE OF CONTENTS SECTION 3 Eligibility and Enrollment...15 Figure 3-1. Figure 3-2. Figure 3-3. Figure 3-4. Figure 3-5. Figure 3-6. Figure 3-7. Figure 3-8. Figure 3-9. Title XIX Mandatory And Optional Participants and Services...17 Missouri Medicaid Eligibility Thresholds nonelders, January MO HealthNet Enrollees By Large Eligibility Groups, sfy Changes In MO HealthNet Enrollment, sfy MO HealthNet Children s Categories...20 MO HealthNet Pregnant Women Categories...20 MO HealthNet Low Income Adult Categories...21 MO HealthNet Persons With Disabilities Categories...21 MO HealthNet Low Income Elderly Categories...22 i

3 TABLE OF CONTENTS SECTION 4 Medicaid Expenditures...23 Figure 4-1. Total And Per Capita Costs Of Uncompensated Hospital Care in Missouri...25 Figure 4-2. Medicaid Spending Per Capita, FFY figure 4-3. figure 4-4. Figure 4-5. MO HealthNet Enrollees and Expenditures by Large Eligibility Groups in FY MO HealthNet General Revenue Appropriations and total Expenditures by Service Category in FY MO HealthNet Expenditures Annual Cost Per Person, fy Figure 4-6. MO HealthNet Expenditures For Elderly, FY Figure 4-7. Figure 4-8. Figure 4-9. Figure Figure Figure MO HealthNet Expenditures For Persons with Disabilities, FY MO HealthNet Expenditures For Children (Traditional title XIX And State Only), FY MO HealthNet Expenditures For Kids (Children s Health Insurance Program), FY MO HealthNet Expenditures For Custodial Parents, (ADULTS), FY MO HealthNet Expenditures For Pregnant Women, fy MO HealthNet Expenditures For Women s Health services, FY SECTION 5 MO HealthNet Financing...33 Figure 5-1. Figure 5-2. Figure 5-3. Figure 5-4. Figure 5-5. Figure 5-6. MO HealthNet Appropriation In Missouri, General revenue And Provider Taxes, SFY MO HealthNet General Revenue Appropriations sfy MO HealthNet General Revenue And GR Equivalents appropriations SFY mo healthnet expenditures by service with all provider tax funded payments, TOTAL $8,198 MILLION, FY History And Background Of The FRA Program...36 Milestones In The FRA Law...39 ii

4 SECTION 6 Delivery Models...41 Figure 6-1. Figure 6-2. MO HealthNet Managed Care Program...42 MO HealthNet Managed Care Regions...43 Figure 6-3. Managed Care Cost Avoidance Model Figure 6-4. Comparative Analysis Of Quality Of Care And access To Services In MO HealthNet Fee-For-Service Figure 6-5. MO HealthNet fee-for-service programs TABLE OF CONTENTS SECTION 7 Utilization...53 figure 7-1. Figure 7-2. Figure 7-3. Figure 7-4. Figure 7-5. Figure 7-6. Figure 7-7. Figure 7-8. Figure 7-9. Figure Figure Figure Figure FY 2012 Cost by Patient Percentiles for Payer Groups (Ages 0-64)...54 Emergency Department Utilization Percent Change since 2004 By Payer...54 Inpatient Utilization Percent Change since 2004 By Payer Emergency Department Visits per 1,000 population...55 MEDICAID ED Visits Per 1,000 Medicaid enrollees...56 UNINSURED ED Visits Per 1,000 Uninsured Missourians under Age Top Ten Causes Of Medicaid Emergency Department visits And Associated Costs...58 Top Ten Causes Of Uninsured Emergency Department visits And Associated Costs...58 Percent Of Inpatients With Select Chronic Conditions by Payer...59 Percent Of Inpatients With 3 Or More Chronic conditions By Cost And Payer...59 Missouri Psychiatric And Substance Abuse ED Visits percent Change Since 2004 By Payer...60 Medicaid Psychiatric And Substance Abuse ED Visits per 1,000 Medicaid enrollees (Ages 0-64)...61 Uninsured Psychiatric And Substance Abuse ed Visits Per 1,000 Uninsured Residents (Ages 0-64)...62 SECTION 8 Waivers...63 Figure 8-1. Figure 8-2. Figure 8-3. Section 1915 Waivers...64 Section 1115 Demonstrations...65 Missouri MO HealthNet Waivers...66 iii

5 TABLE OF CONTENTS SECTION 9 Medicaid Administration...67 Figure 9-1. Figure 9-2. State Medicaid Programs...68 Total Statewide Medicaid Expenditures...69 SECTION 10 APPENDIX...71 Figure Children In Families on TANF, SFY-12 Enrollees 214, Figure MO HealthNet for Children, SFY-12 Enrollees 228, Figure Children s Health Insurance Program (CHIP), SFY-12 enrollees 70, Figure Children In Care And Custody, SFY-12 Enrollees 27, Figure Presumptive Eligibility For Kids, SFY-12 Enrollees Figure Other Children, SFY-12 Enrollees Figure Figure Figure MO HealthNet For Pregnant Women (MAF Income Limit), SFY-12 Enrollees 9, MO HealthNet For Pregnant Women (Poverty), sfy-12 Enrollees 16, Mo HealthNet For Pregnant Women Presumptive eligibility, SFY-12 Enrollees 1, Figure Adults On TANF, SFY-12 Enrollees 78, Figure Refugee, SFY-12 Enrollees Figure Women With Breast And Cervical Cancer, SFY-12 enrollees 1, Figure Independent Foster Care (Ages 18-21), sfy-12 Enrollees Figure Permanently And Totally Disabled, sfy-12 Enrollees 162, Figure Aid To The Blind, SFY-12 Enrollees 1, Figure Blind Pension, SFY-12 Enrollees 2, Figure Ticket To Work (Premium), SFY-12 Enrollees Figure Ticket To Work (Non-Premium), SFY-12 Enrollees Figure Old Age Assistance, SFY-12 Enrollees 64, Figure Qualified Medicare Beneficiary/Specified Low Income Medicare Beneficiary, SFY-12 Enrollees 13, web links to additional resources...82 iv

6 Medicaid Overview Medicaid is a federal-state partnership to provide health care coverage for lowincome individuals. Nationally, Medicaid currently provides public health insurance coverage to approximately 60 million low-income Americans. Nearly 900,000 Missourians are enrolled in the state s Medicaid program across a broad range of eligibility categories. Among these eligibility categories, differing thresholds based on individual or family income determine program eligibility. Each state administers its own Medicaid program. In Missouri, the Medicaid program, known as MO HealthNet, is administered primarily by the Department of Social Services MO HealthNet Division, with assistance from other state divisions and departments. State participation in Medicaid is voluntary, and all states have participated since Although the program is an entitlement to eligible individuals, enrollment is not mandatory. SECTION 1 MEDICAID OVERVIEW The federal government offers matching funds to states to support the financing of Medicaid. Federal rules stipulate minimum eligibility levels for certain Medicaid programs and offer differing state-federal matching rates to incentivize participation in other programs. The federal Centers for Medicare & Medicaid Services works with states as the primary federal partner in Medicaid operations. 1

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8 Missouri s Health Status/indicators Missouri consistently ranks nationally in the bottom one-third of overall health status as compared to other states and the District of Columbia. Our combination of unhealthy behaviors and poor lifestyle choices contributes to higher than average chronic disease and poorer health outcomes. Among all states, Missouri ranked 42 of 50 in the United Health Foundation s America s Health Ranking for The state ranked above the 50th percentile in only four of the 42 selected categories, placing 23rd among the states in low birth weight, 24th in underemployment, 13th in consumption of vegetables and 9th in high school graduation rate. In eight of the 20 categories, Missouri ranked in the bottom 10 states. Missouri fares poorly in health outcomes which relate to mortality and morbidity, defined as life span and quality of life respectively. The state s performance in health factors measures of healthy behaviors, clinical care, social and economic factors, and physical environment is below average as well. Health outcomes and health factors vary significantly throughout the state. Many of the counties in southeast Missouri, including the state s bootheel region fare especially poorly. The majority of counties in this region fall in the lowest quintile in outcomes, factors and overall. Figure 2-1. Missouri s performance in health in 2012 (Page 5) Figure Missouri County Health Rankings: overall Rank (Page 6) Missouri is ranked in the bottom 10 states nationally for health status according to America s Health Rankings. United Health Foundation SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Figure 2-3. Figure Missouri County Health Rankings: Health Outcomes (Page 7) 2013 Missouri County Health Rankings: Health Factors (Page 8) 3

9 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Health Insurance With 16 percent of the population (ages 0-64) uninsured, Missouri ranks near the middle of the states in health insurance coverage according to the Urban Institute. Many of these uninsured individuals reside in the state s two large metropolitan areas and the smaller cities of Cape Girardeau, Columbia, Joplin and Springfield, and the counties surrounding these cities. However, viewed as a percentage of population, uninsured rates are more pronounced in many of Missouri s rural communities. Figure 2-5. Insurance Status for Missourians (Ages 0-64) (Page 9) Figure 2-6. Insurance Status for Missourians BELOW 138% of the Federal Poverty Level (Ages 0-64) (Page 9) Figure 2-7. Insurance Status for Missourians Above 138% of the Federal Poverty Level (Ages 0-64) (Page 9) Figure 2-8. Figure Number of Uninsured Missourians under Age 65 (Page 10) 2010 Percent of Missourians Under Age 65 without Health insurance (Page 11) Figure MO HEALTHNet enrollment by county, number and percent of population (Page 12) Figure uninsured missourians under age 65 and less than 138% FPL (Page 13) 4

10 FIGURE 2.1. Missouri's national health ranking has fallen 75 percent since from 24th best in the nation in 1990 to 8th worst in SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS 42nd Missouri s performance in health in 2012 MISSOURI NATIONAL HEALTH RANKINGS POOR 26 income disparity 27 unemployment rate annual 28 cholesterol check 29 lack of health insurance, preterm births, personal income per capita occupational fatalities, teen birth rate 32 primary care physicians 33 diabetes, binge drinking, infant mortality, health status 34 poor mental health days 35 poor physical health days, air pollution, suicide 36 children in poverty 37 cardiac heart disease, violent crime 38 high cholesterol 39 obesity, preventable hospitalizations, cancer deaths 40 high blood pressure lifestyle, cardiovascular deaths, 41 sedentary premature deaths, strokes, annual dental visits 42 smoking 43 infectious disease 44 public health funding OUT OF 50 OVERALL, immunization coverage AND TRENDING DOWN 47 heart attacks Source: United Health Foundation, 2012 America s Health Rankings 50 Figure 2-1. AVERAGE Missouri s national health ranking has fallen 75 percent since 1990 from 24th best in the nation in to 8th worst in

11 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS 2013 MISSOURI COUNTY HEALTH RANKINGS OVERALL RANK Figure Missouri County Health Rankings: Overall Rank Worth Putnam Atchison Schuyler Scotland 43 Mercer 32 8 Nodaway Clark Harrison Gentry Sullivan Adair Holt 34 Grundy Knox Lewis Andrew 49 Daviess 6 DeKalb 59 Linn Macon 15 Livingston 75 Shelby Marion Buchanan Caldwell Clinton Chariton Monroe Ralls Platte Carroll Randolph Ray Pike 2 Clay Audrain Saline Howard 57 Lafayette Lincoln Jackson 17 Boone 80 Montgomery 64 4 Cooper Callaway 78 Johnson Warren St. Charles Pettis Cass Moniteau St. Louis St. Louis City 16 Gasconade 13 Cole Osage Henry Morgan 9 11 Franklin Bates 88 Benton Jefferson Miller Maries St. Clair Camden Crawford 103 Hickory Ste. Genevieve Phelps Washington Vernon Pulaski St. Francois Cedar Perry Dallas Polk Laclede Dent Barton 104 Iron Madison 52 Dade Texas Reynolds Cape Girardeau Greene Webster Wright Bollinger 18 Jasper Shannon Lawrence Wayne Scott Christian 94 Newton Douglas Carter Stoddard Mississippi Howell 93 Barry Stone Oregon Butler McDonald Taney Ozark Ripley New Madrid 111 Pemiscot Dunklin st 23rd 24th 46th 47th 69th 70th 92nd 93rd 115th Source: Hospital Industry Data Institute, Robert Wood Johnson Foundation and University of Wisconsin Public Health Institute: 2013 County Health Rankings for Missouri. Overall health rankings represent a combined score of health outcomes and health factors. Health outcomes include two measures how long people live (mortality) and how healthy people feel while alive (morbidity). Health factors represent what influences the health of a county. Four types of health factors are included in this ranking health behaviors, clinical care, social and economic, and physical environment factors. In turn, each of these factors is based on several measures. 6

12 2013 MISSOURI COUNTY HEALTH RANKINGS HEALTH OUTCOMES Figure Missouri County Health Rankings: Health Outcomes Worth Putnam Atchison Schuyler Scotland 57 Mercer Clark Nodaway Harrison Gentry 26 Sullivan Adair Holt 39 Grundy 89 Knox 40 Lewis Andrew 50 Daviess 42 2 DeKalb 38 Linn Macon 8 Livingston 51 Shelby Marion Buchanan Caldwell Clinton Chariton Monroe Ralls Platte Carroll Randolph Ray Pike 4 Clay Audrain Saline Howard 74 Lafayette Lincoln Jackson 11 Boone Montgomery Cooper 6 Callaway 81 Johnson Warren St. Charles Pettis Cass St. Louis City 17 Moniteau Gasconade St. Louis Cole Osage Henry Morgan 16 Franklin 18 Bates 96 Benton Jefferson Miller Maries St. Clair Camden 9 Crawford 105 Hickory Ste. Genevieve Phelps Washington Vernon 58 Pulaski St. Francois Cedar 34 Perry Dallas Polk Laclede 32 Dent Barton Iron Madison 35 Dade Texas Reynolds Cape Girardeau Jasper Greene Webster Wright Bollinger Shannon Lawrence Wayne 95 Scott Christian Douglas Carter 94 Newton Stoddard Mississippi Howell Barry Stone Oregon Butler McDonald Taney Ozark Ripley New Madrid 113 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Pemiscot Dunklin st 23rd 24th 46th 47th 69th 70th 92nd 93rd 115th Source: Robert Wood Johnson Foundation and University of Wisconsin Public Health Institute: 2013 County Health Rankings for Missouri. Health outcomes include two measures how long people live (mortality) and how healthy people feel while alive (morbidity). 7

13 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS 2013 MISSOURI COUNTY HEALTH RANKINGS HEALTH FACTORS Figure Missouri County Health Rankings: Health Factors Worth Putnam Atchison Schuyler Scotland 35 Mercer Nodaway Clark Harrison 78 5 Gentry 68 Sullivan Adair Holt 26 Grundy 74 Knox 18 Lewis Andrew 47 Daviess DeKalb 79 Linn Macon 40 Livingston 104 Shelby Marion Buchanan Caldwell Clinton Chariton Monroe Ralls Platte Carroll Randolph Ray Pike 3 Clay Audrain Saline Howard 43 Lafayette Lincoln Jackson 30 Boone Montgomery Cooper 2 Callaway 64 Johnson Warren St. Charles Pettis Cass Moniteau St. Louis St. Louis City 17 Gasconade Cole Osage 39 Henry Morgan 8 9 Franklin Bates 58 Benton Jefferson Miller Maries St. Clair Camden 60 Crawford 86 Hickory Ste. Genevieve Phelps Washington Vernon 97 Pulaski St. Francois Cedar 46 Perry Dallas Polk Laclede Dent 93 Barton Iron Madison 67 Dade Texas Reynolds Cape Girardeau Greene Webster Wright Bollinger 10 Jasper Shannon Lawrence Wayne Scott Christian Newton Douglas Carter Stoddard Mississippi Howell Barry Stone Oregon Butler McDonald Taney Ozark Ripley New Madrid 105 Pemiscot Dunklin st 23rd 24th 46th 47th 69th 70th 92nd 93rd 115th Source: Robert Wood Johnson Foundation and University of Wisconsin Public Health Institute: 2013 County Health Rankings for Missouri. Health factors represent what influences the health of a county. Four types of health factors are included in this ranking health behaviors, clinical care, social and economic, and physical environment factors. In turn, each of these factors is based on several measures, including tobacco use; diet and exercise; alcohol use; sexual activity; access to care; quality of care; education; employment; income; family and social support; community safety; environmental quality; and built environment. 8

14 Figure 2-5. Insurance Status for Missourians (Ages 0-64) Medicaid 16% Employer Sponsored 20% Medicare/Other Public 4% Uninsured 16% Uninsured 25% Nongroup 3% Nongroup Medicare/Other 4% Public 9% Employer Sponsered 61% Source: Urban Institute analysis, HIPSM Figure 2-6. Insurance Status for Missourians BELOW 138% of the Federal Poverty Level (Ages 0-64) Medicaid 42% SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Source: Urban Institute analysis, HIPSM Figure 2-7. Insurance Status for Missourians Above 138% of the Federal Poverty Level (Ages 0-64) Medicare/Other Public 2% Nongroup 3% Uninsured 11% Medicaid 4% Employer Sponsored 79% Source: Urban Institute analysis, HIPSM

15 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS NUMBER OF MISSOURIANS UNDER AGE 65 WITHOUT HEALTH INSURANCE Figure Number of Uninsured Missourians Under Age 65 Worth Putnam Atchison Schuyler Scotland 352 Mercer Clark Nodaway Harrison 1,091 2,411 Gentry 1,385 Sullivan Adair Holt 1,021 Grundy 1,219 3,392 Knox Lewis Andrew 1,410 1,382 Daviess 2,106 DeKalb 1,538 Linn 1,255 Macon Livingston 1,685 Shelby Marion 2, ,308 Buchanan Caldwell 1,711 10,242 Clinton 1,226 2,427 Chariton Ralls 1,011 1,271 Platte Carroll Randolph Monroe Ray 1,307 1,182 3,019 Pike 7,267 Clay 2,641 2,450 21,875 Audrain Saline Howard 3,016 Lafayette 3,182 1,361 Lincoln Jackson 4,166 Boone Montgomery 104,865 6,837 Cooper 19,630 Callaway 1,704 Johnson Pettis 2,214 5,067 Warren St. Charles Cass 6,572 7,073 3,732 29,228 St. Louis City 10,706 Moniteau St. Louis 2,315 Cole Gasconade 53,134 97,327 7,092 Osage 2,136 Henry Morgan Franklin 1,784 2,933 3,624 12,537 Bates Benton Jefferson 2,548 2,854 Miller Maries 26,963 3,758 St. Clair Camden 1,427 Washington 1,439 Hickory Ste. Genevieve 6,355 Phelps Crawford 3,624 Vernon 1,519 6,045 3,535 2,105 Pulaski 3,056 St. Francois Cedar 5,537 Perry Dallas 7,679 2,138 Polk Laclede 2,575 Dent 2,311 5,211 Barton 4,711 2,374 Iron Madison 1,795 Dade 1,459 1,871 1,287 Texas Reynolds Cape Girardeau 3, ,278 Jasper Greene Webster Wright Bollinger 38,502 6,081 3,161 Shannon 1,812 20,617 Lawrence Wayne 1,537 6,198 1,950 Scott Christian Douglas Carter 5,118 Newton 9,076 10,578 2,182 1,083 Stoddard Mississippi Howell Barry Stone 4,361 1,868 5,967 Oregon Butler McDonald Taney Ozark Ripley 6,040 4,952 5,803 9,574 1,721 1,841 4,568 2,198 New Madrid 2,538 Pemiscot Dunklin 2,219 4, ,500 1,501 2,500 2,501 3,500 3,501 6,500 6, ,000 Source: U.S. Census Bureau, Small Area Health Insurance Program: 2010 Model-Based Small Area Health Insurance Estimates for States and Counties. 10

16 Figure 2-9. PERCENT OF MISSOURIANS UNDER AGE 65 WITHOUT HEALTH INSURANCE 2010 Percent of Missourians Under Age 65 without health insurance Worth Putnam Atchison Schuyler Scotland 21.5 Mercer Clark Nodaway Harrison Gentry 19.7 Sullivan Adair Holt 19.3 Grundy 22 Knox 17.3 Lewis Andrew 17.6 Daviess DeKalb 22.5 Linn Macon 16.2 Livingston 16.4 Shelby Marion Buchanan Caldwell Clinton Chariton Ralls Platte Carroll Randolph Monroe Ray Pike 9.2 Clay Audrain Saline Howard 15.3 Lafayette Lincoln Jackson 15.2 Boone Montgomery Cooper 14.1 Callaway 17.5 Johnson Warren St. Charles Pettis Cass St. Louis St. Louis City 12.6 Moniteau 18.9 Cole Gasconade Osage Henry Morgan Franklin Bates Benton Jefferson Miller Maries St. Clair Camden 19.1 Washington 19.5 Hickory 18.7 Phelps Crawford 17.5 Ste. Genevieve Vernon 22.5 Pulaski St. Francois Cedar 14.2 Perry Dallas Polk Laclede Dent 17.5 Barton Iron Madison 17.6 Dade Texas Reynolds Cape Girardeau Jasper Greene Webster Wright Bollinger Shannon Lawrence Wayne Scott Christian Douglas Carter 15.5 Newton Stoddard Mississippi Howell Barry Stone Oregon Butler McDonald Taney Ozark Ripley New Madrid 16.2 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Pemiscot Dunklin % % % % % Source: U.S. Census Bureau, Small Area Health Insurance Program: 2010 Model-Based Small Area Health Insurance Estimates for States and Counties. 11

17 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Figure MO HEALTHNet enrollment by county, number and percent of population Atchison % Holt % Nodaway 1, % Andrew 1, % Buchanan 16,131 18% Platte 5, % Worth % Gentry % DeKalb 1, % Clinton 2,253 11% Clay 20, % Jackson 109, % Cass 11, % Bates 2, % Vernon 3, % Barton 2, % Jasper 21, % Newton 9, % McDonald 4, % Harrison 1, % Daviess 1, % Caldwell 1, % Ray 3,003 13% Lafayette 4, % Johnson 5, % Henry 4, % St. Clair 1, % Cedar 2, % Dade 1, % Lawrence 6, % Mercer % Grundy 1, % Livingston 2, % Carroll 1,360 15% Saline 4, % Pettis 7, % Benton 3, % Hickory 1, % Polk 5, % Greene 40, % Putnam % Sullivan 1, % Linn 1, % % Adair 3,579 14% Macon 2, % Chariton Monroe Ralls 1,179 Randolph 1,254 1, % 14.4% 11.5% Morgan 3, % Camden 5, % Dallas 3, % Laclede 7, % Boone 17, % Cooper 2, % Moniteau 1,835 Cole 11.7% Webster 5, % 4, % Howard 1, % 10, % Miller 4, % Wright 4, % Christian Douglas 9,581 3,006 12% 22.1% Barry Stone 6,548 Taney Ozark 4, % 8,526 1, % 16.1% 19.3% Schuyler Scotland Clark % Knox % Shelby % Pulaski 5, % Callaway 5, % Gasconade Osage 1,965 1, % 7.9% Maries 1,172 13% Phelps 7, % Texas 4, % 1, % Lewis 1, % Marion 5, % Audrain 3, % Montgomery 2, % Howell 9, % Dent 3, % Pike 2, % Lincoln Crawford 5, % Shannon 2, % Oregon 2, % Warren 4, % 7, % St. Charles Franklin 12, % 21, % Washington 6, % Reynolds 1, % Carter 1, % Ripley 4, % St. Louis 106, % Jefferson 25, % St. Francois 12, % Iron 2, % Wayne 3, % Butler 10, % St. Louis City 82, % Ste. Genevieve 1,944 11% Perry 2, % Madison 2,816 Cape Girardeau 22.6% Bollinger 10, % 2, % Stoddard 6, % Scott 9, % New Madrid 4, % Mississippi 3, % Pemiscot Dunklin 6, , % 31.9% 5.8% 10.6% 10.7% 14% 14.1% 17.1% 17.2% 23.2% 23.3% 34.7% Sources: Medicaid Enrollment - Missouri Department of Social Services, Research and Evaluation Census Data - U.S. Census Bureau, 2012 Estimates 12

18 Figure uninsured missourians under age 65 and less than 138% FPL Worth Putnam Atchison Schuyler Scotland 167 Mercer Clark Nodaway Harrison , Gentry Sullivan Adair Holt 479 Grundy 631 Knox 1,842 Lewis Andrew Daviess 785 DeKalb 726 Linn 517 Macon Livingston 757 Shelby Marion ,461 Buchanan Caldwell 798 4,510 Clinton Chariton Monroe Ralls Platte Carroll Randolph Ray 530 1,427 Pike 2,588 Clay 993 1,114 8,106 Audrain Saline Howard 1,336 Lafayette 1, Jackson Boone Lincoln 1,705 Montgomery 2,599 47,310 Cooper 9,783 Callaway 742 Johnson Pettis 1,027 2,092 Warren St. Charles Cass 3,020 3,387 1,497 9,594 St. Louis City Moniteau St. Louis 3,841 Gasconade 27, Cole Osage 38, Henry Morgan 2,715 Franklin 715 Bates 1,357 Benton 1,699 5,004 Jefferson 1,153 1,379 Miller Maries 9,929 1,731 St. Clair Camden 629 Washington 700 Hickory Crawford 2,711 1,798 Ste. Genevieve Phelps Vernon 1, Pulaski 868 2,919 1,469 St. Francois Cedar 2,320 Perry Dallas 3,481 1,092 Polk Laclede Dent 1, Barton 2,422 2,326 1,099 Iron Madison 784 Dade Texas Reynolds Cape Girardeau Greene Webster Wright 1, Bollinger 4,313 Jasper 18,368 2,681 1,674 Shannon 843 9,580 Lawrence Wayne 827 Scott 2,851 1,023 2,286 Newton Christian Douglas Carter 3,986 4,176 1, Stoddard Mississippi Howell 2,119 Barry Stone 929 2,957 McDonald 2,939 2,284 Taney Ozark Oregon Butler Ripley 2,815 4, ,196 1,175 New Madrid 1,288 SECTION 2 MISSOURI S HEALTH STATUS/INDICATORS Pemiscot Dunklin 1,205 2,254 < ,400 1,401 2,100 2,101 3,500 3,501 5,000 5,001 18,000 >18,000 Source: U.S. Census Bureau, Small Area Health Insurance Program: 2010 Model-Based Small Area Health Insurance Estimates for States and Counties. 13

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20 Eligibility And Enrollment Nearly 900,000 Missourians are enrolled in the state s Medicaid program across a broad range of eligibility categories. Among these eligibility categories, differing thresholds based on individual or family income determine program eligibility. Federal rules stipulate minimum eligibility levels for certain Medicaid programs and offer differing state-federal matching rates to incentivize participation in other programs. Although the program is an entitlement to eligible individuals, enrollment is not mandatory. Figure 3-1. Title XIX Mandatory And Optional Participants and ServiceS (Page 17) In 2012, Missouri s Medicaid program provided health coverage to 893,976 individuals. These enrollees include children, individuals with disabilities, low income elderly Missourians, low income parents and pregnant women. For more than a decade, Missouri s Medicaid program has served between 800,000 and 1 million enrollees annually. Figure 3-2. Figure 3-3. Missouri Medicaid Eligibility Thresholds nonelders, January 2013 (Page 18) MO HealthNet Enrollees By Large Eligibility Groups, sfy (Page 19) Missouri s Medicaid program covered 48 percent of births in the state in Missouri Foundation for Health SECTION 3 ELIGIBILITY AND ENROLLMENT Figure 3-4. Changes In MO HealthNet Enrollment, sfy (Page 19) Significantly more than half of MO HealthNet enrollees 540,824 of 893,976 are children. These children are covered through several different eligibility categories, including Children in Families on Temporary Assistance for Needy Families (TANF), MO HealthNet for Children, MO HealthNet for Kids (CHIP) and Children in Care and Custody. Although children comprise the largest group of enrollees, they represent the lowest cost per enrollee. Figure 3-5. MO HealthNet Children s Categories (Page 20) MO HealthNet for Pregnant Women provided pregnancy care for 27,895 individuals in This program, in addition to the regular Medicaid program, provided coverage for nearly 50 percent of all births in the state in 2012 at a cost of $185.9 million. The MO HealthNet for Pregnant Women program includes two categories one for individuals with incomes below 133 percent of the Federal Poverty Level and the other with incomes between 133 percent and 185 percent of the FPL. Figure 3-6. MO HealthNet Pregnant Women Categories (Page 20) 15

21 SECTION 3 ELIGIBILITY/ENROLLMENT Low income, non-custodial adults under the age of 65 are not eligible for MO HealthNet. However, adults with families eligible for Temporary Assistance for Needy Families are eligible for enrollment if their income does not exceed 19 percent of the FPL. In addition, if they meet certain criteria, individuals between the ages of 18 to 21 years old in Independent Foster Care, Women with Breast and Cervical Cancer, and Refugees, are eligible to enroll. Of the 80,000 adults who are enrolled through these MO HealthNet programs, 78,261 are enrolled through the Adults on TANF eligibility category. Figure 3-7. MO HealthNet Low Income Adult Categories (Page 21) Missourians with disabilities and the blind are eligible for MO HealthNet coverage depending on their income and assets. In 2012, MO HealthNet provided coverage for 162,079 individuals with disabilities through its program for Permanently and Totally Disabled individuals. This eligibility group represents the highest cost per enrollee in the MO HealthNet program. MO HealthNet coverage was extended to approximately 4,000 blind Missourians through the Aid to the Blind program and Blind Pension program. In addition, approximately 1,200 disabled Missourians received coverage through the Ticket to Work program s premium and nonpremium coverage. Figure 3-8. MO HealthNet Persons With Disabilities Categories (Page 21) Seniors with low income and limited assets may be eligible for MO HealthNet s Old Age Assistance program or Qualified Medicare Beneficiaries/Specified Low Income Beneficiaries programs. In 2012, 77,460 Missourians were covered through these programs, with the majority enrolled through the Old Age Assistance Program. The largest single area of expenditure in these programs was for care in nursing facilities. Most seniors are dually eligible for the Medicare program, which is the primary payer for primary and acute care services, and the Medicaid program, which is the primary payer for long term care services. This eligibility group represents the second highest cost per enrollee in the MO HealthNet program. Figure 3-9. MO HealthNet Low Income Elderly Categories (Page 22) 16

22 Figure 3-1. Title XIX Mandatory And Optional Participants.And Service Mandatory Participants Newborns of women who are MO HealthNet participants Children under age 1, in families with income below 185% of the federal poverty level (FPL) Children ages 1 5, in families with income at or below 133% FPL Children ages 6 18, in families with income at or below 100% FPL Foster Care children who are Title XIX eligible Pregnant women with income at or below 133% FPL (eligible for coverage until the last day of the month following the 60 th day after pregnancy ends) Parents, caretakers and children who meet 1996 AFDC program income standards Refugees Persons with disabilities with income at or below the Supplemental Security Income (SSI) maximum Aid to Blind recipients with income at or below the SSI maximum Qualified Medicare Beneficiaries Seniors, age 65 and older, with income at or below the SSI maximum Optional Participants Title XIX Mandatory and Optional Participants and Services Mandatory Services Nursing Facility Hospital Mandatory Services Physician Related (except Podiatry and Clinic) Includes: Lab and X Ray Services Family Planning Federal Qualified Health Clinics Rural Health Clinics Home Health Non Emergency Medical Transportation (NEMT) (Rehab and Specialty Services)* Early Periodic Screening, Diagnosis and Treatment (EPSDT) *Non emergency medical transportation must be assured for most eligibility categories Optional Services SECTION 3 ELIGIBILITY AND ENROLLMENT Children under age 1, in families with income above 185% to 300% FPL Children ages 1 5, in families with income above 133% to 300% FPL Children ages 6 18, in families with income above 100% to 300% FPL Children who are presumed eligible due to income by a qualified entity until an eligibility determination is complete Missouri Children with Developmental Disabilities (MOCDD) Children receiving Child Welfare Services or in the custody of the Juvenile Court who are not Title XIX or IV E eligible Youth in Division of Youth Services custody who are not XIX eligible Young adults, under age 21, who were in Foster Care on their 18 th birthday Pregnant women who are presumed eligible due to income by a qualified provider are eligible until the end of the month following determination or until a determination is complete on a pending MO HealthNet application, whichever is later Pregnant women with income above 133% through 185% of FPL are eligible for coverage until the last day of the month following the 60 th day after pregnancy ends Extended Women s Health Services for uninsured women under 185% FPL are eligible for a limited package of reproductive health care services Women with breast and cervical cancer who are screened under Show Me Healthy Women Program Aid to the Blind recipients above SSI maximum through 100% FPL Blind Pension recipients Ticket to Work participants Persons with Disabilities with income above the SSI maximum up to 85% FPL Seniors, age 65 and older, with income above the SSI maximum up to 85% FPL Nursing Facility for Children Dental** Pharmacy Podiatry (Physician Related)** Clinic Services (Physician Related) In Home Services (except Home Health) Rehabilitation and Specialty (except NEMT) Includes: Optical*** Durable Medical Equipment Mental Health Services Includes: Intermediate Care Facility/Mental Retardation (ICF/MR) **Services are available only to children, pregnant women, the blind and nursing facility residents ***Limited services available to adults who are not pregnant, blind or in a nursing facility Disclaimer: This is intended as a general guide to show who may be eligible to participate in MO HealthNet and the services for which they may qualify. Appearance on this list does not guarantee eligibility. Revised: June 4,

23 SECTION 3 ELIGIBILITY/ENROLLMENT Figure 3-2. Missouri Medicaid Eligibility Thresholds nonelders, January % 300% 250% 200% 150% 100% 50% 0% 300% Source: MO HealthNet 185% Minimum Medicaid Eligibility under Health Reform -138% FPL ($26,951 for a family of 3 in 2013). 18% 18% Children Pregnant Women Working Parents Jobless Parents Childless Adults Non-elderly Individuals with Disibilities 0% 85% 18

24 Figure 3-3. MO HealthNet Enrollees By Large Eligibility Groups, SFY Number of Enrollees 1,000, , , , , , , , , , , , , , , , , ,114 Elderly 530, ,702 Persons with Disabilities Children Custodial Parents (Adults) Pregnant Women 893, , , , , , , ,367 99,073 95,577 94, ,524 82,501 80,431 77,339 76,701 76,885 77,483 77,969 77,460 22,952 27,388 28,635 28,894 28,248 27, Source: Missouri Department of Social Services, MO HealthNet Division, Annual Table 5 for SFY07-09, Annual Table 23 for SFY10-12 Total Medicaid spending by category Elderly 17 percent Persons with disabilities 49 percent Children 25 percent Custodial parents 6 percent Pregnant women 3 percent SECTION 3 ELIGIBILITY AND ENROLLMENT Figure 3-4. Changes In MO HealthNet Enrollment, SFY ,200,000 1,000, , , , , , , , , , , , , , , , ,000 0 SFY 2001 SFY 2002 SFY 2003 SFY 2004 SFY 2005 SFY 2006 SFY 2007 SFY 2008 SFY 2009 SFY 2010 SFY 2011 SFY 2012 Source: Annual Table 5, ; Annual Table 23,

25 SECTION 3 ELIGIBILITY/ENROLLMENT Figure 3-5. MO HealthNet Children s Categories Children s Categories SFY-12 Expenditures SFY-12 Count Children in Families on TANF $577.0 million 214,072 MO HealthNet for Children $703.3 million 228,266 Mo HealthNet for Kids (CHIP) $180.6 million 70,336 Children in Care and Custody $288.5 million 27,719 Presumptive Eligibility for Kids $3.2 million 231 Other Children $9.5 million 200 Total $1,762.1 million 540,824 See Appendix Page 72 for more information. Figure 3-6. MO HealthNet Pregnant Women Categories Pregnant Women Categories SFY-12 Expenditures SFY-12 Count MO HealthNet for Pregnant Women (MAF Income limit) MO HealthNet for Pregnant Women (Poverty) $64.9 million 9,507 $113.7 million 16,819 Presumptive Eligibility $7.3 million 1,569 Total $185.9 million 27,895 See Appendix Page 75 for more information. 20

26 Figure 3-7. MO HealthNet Low Income Adult Categories Low Income Adult Categories SFY-12 Expenditures SFY-12 Count Adults on TANF $411.3 million 78,261 Refugee $.8 million 192 Women with Breast and Cervical Cancer $25.8 million 1,101 Independent Foster Care (Ages 18-21) $2.1 million 876 Total $440.0 million 80,430 See Appendix Page 76 for more information. SECTION 3 ELIGIBILITY AND ENROLLMENT Figure 3-8. MO HealthNet Persons With Disabilities Categories Persons with Disabilities Categories SFY-12 Expenditures SFY-12 Count Permanently and Totally Disabled $3,324.9 million 162,079 Aid to the Blind $17.7 million 1,204 Blind Pension $29.6 million 2,841 Ticket to Work (Premium) $19.2 million 974 Ticket to Work (Non-Premium) $6.7 million 269 Total $3,398.1 million 167,367 See Appendix Page 78 for more information. 21

27 SECTION 3 ELIGIBILITY/ENROLLMENT Figure 3-9. MO HealthNet Low Income Elderly Categories Low Income Elderly SFY-12 Expenditures SFY-12 Count Old Age Assistance $1,194.0 million 64,267 Qualified Medicare Beneficiaries /Specified Low Income Beneficiaries $24.7 million 13,193 Total $1,218.7 million 77,460 See Appendix Page 81 for more information. 22

28 Medicaid Expenditures The high rate of the uninsured, and expanded use of hospital services by the uninsured, has led to a significant increase in hospital uncompensated care costs. In 2011, hospitals provided $1.3 billion in uncompensated care statewide. Moreover, without additional coverage, hospital uncompensated care is expected to increase to $3.5 billion annually by the end of the decade. Hospitals receive some funding through Medicaid and Medicare to offset the costs of providing uncompensated care, but much of the remaining cost of caring for the uninsured is shifted to commercial insurance carriers increasing the cost of premiums paid by employers and/ or individuals. Figure 4-1. Total And Per Capita Costs Of Uncompensated Hospital Care in Missouri (Page 25) Missouri s Medicaid spending and total health care expenditures per capita are very near the national average. Figure 4-2. Medicaid Spending Per Capita, FFY 2009 (Page 26) More than half of all Missourians enrolled in Medicaid are children. These enrollees account for only onequarter of the state s Medicaid spending. SECTION 4 MEDICAID EXPENDITURES MO HealthNet 23

29 SECTION 4 MEDICAID EXPENDITURES Not all MO HealthNet coverage categories are equal in size or cost. Some coverage categories cover large populations with low cost per enrollee, while others cover much more limited populations with significantly higher cost per enrollee. Policymakers must understand the variation between program categories, costs per beneficiary and expenditures within each program to make informed decisions. figure 4-3. figure 4-4. Figure 4-5. MO HealthNet Enrollees and Expenditures by Large Eligibility Groups in FY 2012 (Page 26) MO HealthNet General Revenue Appropriations and total Expenditures by Service Category in FY 2012 (Page 27) MO HealthNet Expenditures Annual Cost Per Person, fy 2012 (Page 27) Figure 4-6. MO HealthNet Expenditures For Elderly, FY 2012 (Page 28) Figure 4-7. Figure 4-8. MO HealthNet Expenditures For Persons With Disabilities, fy 2012 (Page 28) MO HealthNet Expenditures For Children (Traditional title XIX And State Only), FY 2012 (Page 29) Figure 4-9. MO HealthNet Expenditures For Kids (Children s Health Insurance Program), FY 2012 (Page 29) Figure MO HealthNet Expenditures For Custodial Parents, (ADULTS), FY 2012 (Page 30) Figure MO HealthNet Expenditures For Pregnant Women, fy 2012 (Page 30) Figure MO HealthNet Expenditures For Women s Health Services, fy 2012 (Page 31) 24

30 Figure 4-1. Total And Per Capita Costs Of Uncompensated Hospital Care in Missouri $250 $225 $224 $203 $208 $215 $200 $175 $147 $132 $138 $150 $123 $100 $50 $ Uncompensated Care (in millions) Uncompensated Care per Capita Source: Missouri Hospital Association: 2011 Annual Hospital Licensing Survey $699 $755 $792 $849 $1,020 $1,196 $1,234 $1,280 $1,349 $1,347 $1,400 $1,200 $1,000 $800 $600 $400 $200 $ SECTION 4 MEDICAID EXPENDITURES Throughout the last decade, the cost of uncompensated care provided by Missouri hospitals has nearly doubled to a rate of more than $1 billion annually. Uncompensated care is the total of hospital charity care and bad debt at cost. 25

31 SECTION 4 MEDICAID EXPENDITURES Figure 4-2. Medicaid Spending Per Capita, FFY Nevada Utah Colorado Virginia Georgia Florida Alabama Idaho Kansas New Hampshire Nebraska Montana South Dakota Texas North Dakota Indiana Oregon Washington Iowa New Jersey Wyoming Hawaii Illinois Michigan South Carolina California Oklahoma Maryland Arkansas Tennessee Ohio Missouri North Carolina Wisconsin Kentucky Mississippi Louisiana Arizona Pennsylvania West Virginia Minnesota Delaware Alaska Vermont New Mexico Connecticut Rhode Island Massachusetts Maine New York DC Medicaid Spending per Capita FFY 2009 US Avg Medicaid Spending Per Capita Source: Kaiser Commission on Medicaid and the Uninsured, November 2012 figure 4-3. MO HealthNet Enrollees and Expenditures by Large Eligibility Groups in FY % 90% 80% 3% 3% 9% 6% 9% 17% 70% 19% 60% 50% 49% 40% 30% 60% 20% 10% 25% 0% Percent of Enrollees (894,000 total) Percent of Expenditures ($6,998,191,772 total) Children Persons with Disabilities Elderly Custodial Parents (Adults) Pregnant Women Source: MO HealthNet Annual Table 23 26

32 figure 4-4. MO HealthNet General Revenue Appropriations and Total Expenditures by Service Category in FY 2012 MO HealthNet General Revenue Appropriations and Total Expenditures by Service Category in FY % 7% 8% 13% 15% 16% 18% 22% Percent of Total Expenditures ($6,998,191,772 total) Percent of General Revenue Appropriations ($1,243,957,926 total) Other Hospitals Pharmacy Managed Care Nursing Facilities Physician In-Home 17% 11% 25% 26% 2% 12% SECTION 4 MEDICAID EXPENDITURES Source: MO HealthNet Annual Table 23 and Truly Agreed and Finally Passed Appropriation Bills 2012 Figure 4-5. MO HealthNet Expenditures Annual Cost Per Person, FY 2012 Custodial Parents (Adults) $5,533 MO HealthNet for Kids (SCHIP) $2,567 Pregnant Women $6,667 Persons with Disabilities $20,279 Elderly $15,636 Children (Traditional Title XIX and State Only) $3,361 Source: MO HealthNet Annual Table 23 27

33 SECTION 4 MEDICAID EXPENDITURES Figure 4-6. MO HealthNet Expenditures For Elderly, FY 2012 Pharmacy 2% Mental Health 3% Rehab & Spec 7% In-Home 18% Physician 4% Dental 0% Buy-In 7% Hospitals 4% State Institutions 1% EPSDT 0% Managed Care 0% Nursing Facilities 54% ELDERLY FY 2012 Number of Enrollees 77,460 Percent of Total Enrollees 8.7% Percent of Total Expenditures 17.3% Annual Cost Per Person $15,636 Monthly Cost Per Person $1,303 Monthly State Cost Per Person $482 Source: MO HealthNet Annual Table 23 Figure 4-7. MO HealthNet Expenditures For Persons With Disabilities, FY 2012 Buy-In 3% State Institutions 3% Mental Health 20% EPSDT 1% Managed Care 0% Nursing Facilities 8% Hospitals 24% Rehab & Spec 3% In-Home 10% Physician 9% Pharmacy 19% Dental 0% Source: MO HealthNet Annual Table 23 PERSONS WITH DISABILITIES FY 2012 Number of Enrollees 167,367 Percent of Total Enrollees 18.7% Percent of Total Expenditures 48.5% Annual Cost Per Person $20,279 Monthly Cost Per Person $1,690 Monthly State Cost Per Person $625 28

34 Figure 4-8. MO HealthNet Expenditures For Children (Traditional Title XIX And State Only), FY 2012 Nursing Facilities 0% Managed Care 44% EPSDT 6% Hospitals 14% Mental Health State Institutions 6% 6% Pharmacy 17% Physician 6% Buy-In 0% CHILDREN (TITLE XIX AND STATE ONLY) FY 2012 Number of Enrollees 470,489 Percent of Total Enrollees 52.6% Percent of Total Expenditures 22.6% Annual Cost Per Person $3,361 Monthly Cost Per Person $280 Monthly State Cost Per Person $104 Dental 0% In-Home 0% Rehab & Spec 1% SECTION 4 MEDICAID EXPENDITURES Source: MO HealthNet Annual Table 23 Figure 4-9. MO HealthNet Expenditures For Kids (Children s Health Insurance Program), FY 2012 Nursing Facilities 0% Hospitals 10% Dental 1% Managed Care 42% Pharmacy 28% EPSDT 5% Mental Health 5% Physician 7% State Institutions 1% Buy-In 0% In-Home 0% Rehab & Spec 1% Source: MO HealthNet Annual Table 23 KIDS (CHILDREN S HEALTH INSURANCE PROGRAM) FY 2012 Number of Enrollees 70,336 Percent of Total Enrollees 7.9% Percent of Total Expenditures 2.6% Annual Cost Per Person $2,567 Monthly Cost Per Person $214 Monthly State Cost Per Person $56 29

35 SECTION 4 MEDICAID EXPENDITURES Figure MO HealthNet Expenditures For Custodial Parents, (ADULTS), FY 2012 Nursing Facilities 0% Managed Care 46% EPSDT 0% State Institutions 0% Buy-In 1% Mental Health 3% Hospitals 19% Physician 9% In-Home Rehab & Spec 0% 1% Pharmacy 21% CUSTODIAL PARENTS (ADULTS) FY 2012 Number of Enrollees 80,431 Percent of Total Enrollees 9.0% Percent of Total Expenditures 6.4% Annual Cost Per Person $5,533 Monthly Cost Per Person $461 Monthly State Cost Per Person $171 Dental 0% Source: MO HealthNet Annual Table 23 Figure MO HealthNet Expenditures For Pregnant Women, FY 2012 Nursing Facilities 0% Managed Care 32% Hospitals 32% EPSDT 1% State Institutions 0% Mental Health 2% Buy-In 0% Rehab & Spec 1% In-Home 0% Physician 23% Pharmacy 9% Dental 0% Source: MO HealthNet Annual Table 23 PREGNANT WOMEN FY 2012 Number of Enrollees 27,895 Percent of Total Enrollees 3.1% Percent of Total Expenditures 2.7% Annual Cost Per Person $6,667 Monthly Cost Per Person $556 Monthly State Cost Per Person $206 30

36 Figure MO HealthNet Expenditures For Women s Health Services, FY 2012 Physician 81% Hospitals, 2% Pharmacy 17% WOMEN S HEALTH SERVICES FY 2012 Number of Enrollees 63,600 Percent of Total Enrollees NA Percent of Total Expenditures NA Annual Cost Per Person $158 Monthly Cost Per Person $13 Monthly State Cost Per Person NA SECTION 4 MEDICAID EXPENDITURES Source: MO HealthNet Annual Table 23 31

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38 MO HealthNet Financing Missouri finances the state s Medicaid program through general revenue, federal matching funds and state provider taxes. Provider taxes have increased in importance throughout their 20 years of authorization in Missouri, supplanting the need for general revenue expenditures in Medicaid and allowing policymakers to channel general revenue funds to other priorities. The hospital provider tax the Federal Reimbursement Allowance ranks as the third largest source of revenue behind individual income tax and sales and use taxes. The state s reliance on the FRA and other provider taxes to fund the MO HealthNet program has grown significantly in the past five years. Figure 5-1. MO HealthNet Appropriation In Missouri, General revenue And Provider Taxes, SFY (Page 34) Figure 5-2. MO HealthNet General Revenue Appropriations SFY 2013 (Page 34) Figure 5-3. Figure 5-4. MO HealthNet General Revenue And GR Equivalents appropriations SFY 2013 (Page 35) mo healthnet expenditures by service with all provider tax funded payments, TOTAL $8,198 MILLION, FY 2013 (Page 35) Figure 5-5. History And Background Of The FRA Program (Page 36-38) Figure 5-6. Milestones In The FRA Law (Page 39) Provider taxes have significantly reduced the state s general revenue contribution to Medicaid in Missouri. In 1990, 39.5 percent of Medicaid was funded through general revenue, in 2012 only 17.8 percent was general revenue. SECTION 5 MO HealthNet Financing Missouri Hospital Association 33

39 SECTION 5 MO HealthNet Financing Figure 5-1. MO HealthNet Appropriation In Missouri, General Revenue And Provider Taxes, MO SFY HealthNet Appropriations In Missouri Millions $1,800 $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 $1,166 General Revenue and Provider Taxes SFY $1,195 $1,156 $1,139 $1,215 $1,323 $1,148 $1,107 $1,419 $1, General Revenue Provider Taxes Truly Agreed and Finally Passed Appropriation Bills Source: Truly Agreed and Finally Passed Appropriation Bills and MHA FRA History $1,561 $1,136 Provider taxes include the following. Federal Reimbursement Allowance $1,061,306,903 Pharmacy Reimbursement Allowance $177,679,096 Managed Care FRA $385,067 Nursing Federal Reimbursement Allowance (NFRA) $311,758,016 Ambulance Service Reimbursement Allowance Fund $10,162,837 Figure 5-2. MO HealthNet General Revenue Appropriations SFY 2013 Hospital Care $20,943,641 Other 2% $11,296,328 1% Third-Party Insurance $66,023,871 Noninstitutional Home 6% Care $97,405,201 8% Nursing Home Facilities $145,714,470 13% Uninsured Children $27,758,255 2% Dental Services $6,783,972 1% Federally Qualified Health Centers $4,020,000 0% Managed Care Insurance $291,637,169 26% Physician Services $203,716,460 18% Pharmacy $260,659,321 23% Truly Agreed and Finally Passed SFY 2013 Budget 34