The 130th Annual Meeting of APHA

Abstract #43580

Kathryn Whetten-Goldstein, PhD, MPH, Center for Health Policy, Law and Management, Duke University, Box 90253, 125 Old Chemistry Building, Durham, NC 27708, (919) 684-8012, kwg@hpolicy.duke.edu

Thirty-two states have Medically Needy programs allowing individuals with incomes higher than those set for categorical Medicaid eligibility to periodically incur medical expenses, thereby spending-down to Medicaid eligibility, to meet criteria. While other programs try to fill in the gaps, the process is cumbersome for administrators and patients alike. We examined whether patients who are Medically Needy incur fewer expenses overall relative to those who are categorically eligible, therefore, possibly justifying the spend-down requirements. Date examined include 1,505 in-patient, out-patient and Medicaid records from all patients who received care in one of 3 infectious diseases clinics serving 40% of the reported HIV-population in North Carolina. The patients received Medicaid coverage at some point between 1996-2000. This data is supplemented with a clinical survey. Regression analysis and chi-square tests indicated that those who are Medically Needy incurred significantly higher medical costs than those categorically eligible. The incurred expenses followed a distinctive pattern of extremely high costs, relative to others, when the patient was eligible for Medicaid coverage and very few costs while on spend-down. Clinicians reported not knowing when a patient was about to go on spend-down. Based on this evidence, Medically Needy programs cannot be judged to be efficient and may even be detrimental to care. If States wish to serve persons not currently meeting categorical eligibility criteria, they may wish to consider expanding these criteria, or significantly reduce the frequency with which persons must spend-down, rather than use Medically Needy programs.

Learning Objectives:

• 1)Recognize the difference between being categorically eligible for Medicaid and Medically Needy programs and will know that 32 states have Medically Needy programs for HIV positive persons.
• 2)Recognize that those who are Medically Needy are of higher income and are often healthier than those who are categorically eligible for Medicaid
• 3)Discuss ways to justify the burden placed on State officials and patients by the Medically Needy programs, with one being that the programs should be cost neutral or cost effective.
• 4)Describe an example of one state where the costs for those who are Medically Needy are significantly higher than those who are categorically eligible and that eligibility periods seem to drive care.

Keywords: Medicaid, HIV/AIDS

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.