Transcript MUST: A Learning Module for Nurses

MOVE: MEDICAID ORIENTATION
AND VIRTUAL EXERCISE
A Module for Nurses
Funded by Michigan Department of
Community Health, The University of
Michigan School of Nursing, and W. K.
Kellogg Foundation
Prepared by Suzanne Begeny, RN, BSN, MS
Authors
• Suzanne Begeny, MS, BSN, RN,
Doctoral Student in collaboration with
• Faculty/staff:
• Trudy Esch
• Barbara Guthrie
• Phil Kalisch
• Carol Loveland-Cherry
• Patricia McCargar
• Joanne Pohl
• Rosemary Rowney
Medicaid: The Basics
•
Medicaid is the cornerstone of the nation’s health care
safety net. (Kaiser Family Foundation (KFF), 2002)
•
Medicaid is health coverage that helps many people
who cannot afford medical care pay for some or all of
their medical bills.
•
In the state of Michigan, 1.4 million residents are
covered under Medicaid.
•
Medicaid is available only to certain low-income
individuals and families who fit into an eligibility group
that is recognized by federal and state law. (Centers for Medicare
and Medicaid Services (CMS), 2004)
Medicaid: The Basics
• Begun in 1965 as a program primarily covering
people who qualified for cash assistance, Medicaid
now provides health and long-term care services to
more than 50 million low-income families and
elderly and disabled individuals.
• It insures more than one in seven Americans and
accounts for more than 15 percent of our nation’s
spending on health care.
• $199 billion has been appropriated for Medicaid
from the federal government. This is approximately
7.7% of the federal budget and 28.7% of the state
budget or 2/3 of the community health budget.
(KFF, 2002)
Medicaid Basics: In the State of Michigan
FY 2005 EXECUTIVE BUDGET
p. 44
http://www.michigan.gov/documents/FY05Document1_116216_7.pdf
Medicaid: The Basics
• Medicaid is a STATE run program that grants assistance to those who
need health coverage. It has a federal component that helps to set
the guidelines for the states.
• Medicaid is the primary source of federal financial assistance to the
states, and represents a major shared state and federal commitment
to improving the lives and the health of America’s low-income
population. (KFF, 2002)
• To be eligible for Medicaid, every applicant must meet certain tests to
assess whether the household has the “means” (income and
resources/assets) to cover the cost of health care.
• Applicants will be questioned regarding their income
• Eligibility for benefits is based upon an individual’s lack of means, which is
measured by his or her income and/or resources.
• The individual must disclose personal financial information as a condition
of eligibility.
(KFF, 2002)
Medicaid: The Basics
• Medicaid is an entitlement program, in that a
state cannot limit the number of persons it will
cover under its program if they meet the
established criteria for coverage.
• Medicaid is sometimes described as a joint state
and federal “partnership.”
(CMS, 2004)
Medicaid: The Stats
As the largest health care
program in America, in 2004
Medicaid will:
• Cover 26 million children – more than 1 child in 4 in the US.
• Offer coverage to certain children in America in a family with
income below the federal poverty level, by federal law.
(KFF, 2002)
• Coverage available
for U.S citizens, certain
permanent residents,
and emergency services for
illegal immigrants
Medicaid: The Stats
• Pays for over 1.3 million births annually (37 percent
of the US total)
• Pays for services for persons with disabilities
• Pays for over half of HIV/AIDS care
• Pays for nursing care for two-thirds of all nursing
facility residents (primarily older adults) in America,
accounting for almost half of all nursing facility
(skilled nursing care) revenues
• Pays for chronically mentally ill
(KFF, 2002)
Medicaid: Learning the Lingo
• Beneficiary - An individual who is eligible
for and enrolled in the Medicaid program in the
state in which he or she resides. Many
individuals may qualify for Medicaid but have
not applied and are therefore not program
beneficiaries.
(KFF, 2002, p.165)
Medicaid: Learning the Lingo
• Co-payment - A fixed dollar amount paid by a
Medicaid beneficiary at the time of receiving a
covered service from a participating provider.
• Co-payments may be imposed by state Medicaid
programs:
• only upon certain groups of beneficiaries,
• under beneficiaries with respect to certain services,
• and in nominal amounts as specified in federal
regulation.
• Co-payment, or the amount that must be paid,
are set by the state and can vary from state to
state.
(KFF, 2002, p. 166)
Medicaid: Learning the Lingo
• Fee-For-Service – A traditional method of
paying for medical services under which doctors
and hospitals are paid for covered services
they provide. The provider submits the bill for
services to the patient’s insurance carrier for
reimbursement. The provider bills the State
Medicaid program for services. (KFF, 2002, p. 168)
Medicaid: Learning the Lingo
• Managed Care – “A term used to describe health care
systems that integrate the financing and delivery of
appropriate health care services to covered individuals by:
arrangements with selected providers to furnish a
comprehensive set of health care services; explicit standards
for selection of health care providers; formal programs for
ongoing quality assurance and utilization review; and
significant financial incentives for members to use providers
and procedures associated with the plan.” (National Conference of State
Legislators, 1997).
Medicaid: Learning the Lingo
• Managed Care Organization (MCO)- “An
MCO is an entity that has entered into a risk
contract with a state Medicaid agency to provide
a specified package of benefits to Medicaid
enrollees in exchange for an actuarially sound
monthly capitation payment on behalf of each
enrollee.”
(KFF, 2002, p. 169)
Medicaid: Learning the Lingo
• Mandatory – “State participation in the
Medicaid program is voluntary. However, if a
state elects to participate, as all do, the state
must at a minimum offer coverage for certain
services to certain populations. These eligibility
groups and services are referred to as
“mandatory” in order to distinguish them from
the eligibility groups and services that a state
may, at its option, cover with federal Medicaid
matching funds.”
(KFF, 2002, p. 169)
Medicaid: Learning the Lingo
Means Testing – “The policy of basing eligibility
for benefits upon an individual’s lack of means,
as measured by his or her income or resources.
Means testing by definition requires the
disclosure of personal financial information by
an applicant as a condition of eligibility.”
(KFF, 2002, 169)
Medicaid: Learning the Lingo
• State Plan- No federal Medicaid funds can
be awarded to the state unless its state
Medicaid Plan has been submitted and
approved by the Secretary of Health and
Human Services. This was enacted under
Title XIX of the Social Security Act. The
state plan must also meet 64 federal
statutory requirements. (KFF, 2002, p. 173).
Medicaid: Learning the Lingo
• Medically Needy- Those individuals
assigned the optional Medicaid
eligibility group who qualify because of
high medical expenses. These
expenses are most commonly hospital
or nursing home care.
(KFF, 2002, p. 169)
Medicaid: Learning the Lingo
• Financial Eligibility – “In order to qualify for
Medicaid, an individual must meet both nonfinancial and financial eligibility requirements.
Financial eligibility requirements vary from state
to state and from category to category, but they
generally include limits on the amount of
income and the amount of resources an
individual is allowed to have in order to qualify
for coverage.”
(KFF, 2002, p. 168)
Questioning the Basics
1) Medicaid pays for all of the medical services
billed?
• True
• False
Answer: False
• Some states do not cover the entire cost of the
health care services. In many states such as
Michigan a co-payment may be required of the
beneficiary. This co-payment amount varies
from state to state.
• Medicaid does not pay for all medical
services.
Questioning the Lingo
• What is a beneficiary?
a.) An eligible individual
b.) An eligible, low income and enrolled individual
c.) The health care provider
d.) All children
The Answer
• b.) An eligible, low income and enrolled
individual.
Millions of individuals are eligible for Medicaid
but not enrolled and are therefore not program
beneficiaries. Not all children are covered under
Medicaid as a beneficiary. The families of the
infants or children must be in the low income
category.
Questioning the Lingo
• Because Medicaid requires the disclosure of
personal financial information by an applicant as
a way to determine eligibility, Medicaid is
considered what type of program?
a.) Deterministic
b.) Means Tested
c.) Evaluative
d.) Fiscally Sound
The Answer
• b.) Means Tested Program
The policy of basing eligibility for benefits upon an
individual’s lack of means, as measured by his or
her income or resources. Means testing by definition
requires the disclosure of personal financial
information by an applicant as a condition of
eligibility.
Medicaid: Eligibility
• Parents and Children - In 2001 Medicaid enrolled
more than half of the poor children (55%) and onethird (34%) of near-poor children.
• Historically, most women and children eligible for
Medicaid were also eligible for cash assistance
through the Aid to Families with Dependent Children
(AFDC) program. The repeal of the AFDC program
by the 1996 welfare law broke the 30-year link
between receipt of cash assistance and eligibility for
Medicaid.
• 37 percent of the children enrolled in Medicaid
receive cash assistance.
(State of Michigan, 2005)
(CMS, 2005)
Medicaid: Eligibility
Medicaid: Eligibility
• Elderly- More than 4 million adults 65 and over were covered
by Medicaid in 1998. About half were eligible because they
were receiving cash assistance through the Supplemental
Security Income (SSI) program.
• Others have too much income to qualify for SSI but may
“spend down” to Medicaid eligibility by incurring high medical
or long-term care expenses. In both cases, these elderly
beneficiaries are covered for nursing home care and
prescription drugs as well as other Medicaid services.
(KFF, 2002)
Medicaid: Eligibility
• Disabled- Nearly 7 million individuals with
disabilities were covered by Medicaid in 1998.
• Almost 80 percent were eligible because they
received cash assistance through the SSI program.
• The remainder generally qualified for Medicaid by
incurring large hospital, prescription drug, nursing
home, or other medical or long-term care expenses
to meet their “spend down” obligation.
(KFF, 2002)
Medicaid Eligibility: State of Michigan
FY 2005 EXECUTIVE BUDGET
http://www.michigan.gov/documents/FY05Document1_116216_7.pdf
Pg. 45
Medicaid: Mandatory Services
• Inpatient hospital services
• Outpatient hospital services
• Physician services
• Medical and surgical dental services
• Nursing facility (NF) services for individuals aged 21 or older
• Home health care for persons eligible for nursing facility
services
• Family planning services and supplies
• Rural health clinic services and any other ambulatory services
offered by a rural health clinic that are otherwise covered
under the State plan
(KFF, 2002)
Medicaid: Mandatory Services
• Laboratory and x-ray services
• Nurse practitioner (NP) services (NP services are state specific)
• Federally-qualified health center services and any other
ambulatory services offered by a federally-qualified health
center that is otherwise covered under the State plan
• Nurse-midwife services (to the extent authorized under State
law)
• Early and periodic screening, diagnosis, and treatment
(EPSDT) services for individuals under age 21
(KFF, 2002)
Nurse Practitioners (NP) Services in
Michigan
• All Primary Care NPs can be directly reimbursed in
Michigan, not just Family and Pediatric NPs.
• In Michigan NPs are reimbursed at 100% of the
Medicaid rate; NPs need a collaborative
agreement with a physician
to be reimbursed directly.
• Medicare: 85% rate, physician
collaborative agreement needed
Medicaid: Mandatory Services for
Optional Groups
If a State chooses to include the medically needy
population, the State plan must provide, as a
minimum, the following services:
• Prenatal care and delivery services for pregnant women
• Ambulatory services (hospital or other inpatient services beyond room and
board and other professional nursing or physician services, e.g. pharmacy,
physical therapy) to individuals under age 18 and individuals entitled to
institutional services
• Home health services to individuals entitled to nursing facility services
• Mental health care services either in institutions for mental diseases or in
intermediate care facilities for the mentally retarded (ICF/MRs)
(KFF, 2002)
(Shi and Singh, 2004)
Medicaid: Optional Services
• States may also receive Federal funding if they elect
to provide other optional services. The most
commonly covered optional services under the
Medicaid program include:
•
•
•
•
•
•
Clinic services
Nursing facility services for the under age 21
Intermediate care facility/mentally retarded services
Optometrist services and eyeglasses
Prescribed drugs
TB-related services for TB infected
persons
• Prosthetic devices
• Dental services
(KFF, 2002)
Medicaid: Managed Care
• States have the flexibility to contract with
managed care plans to deliver Medicaid
benefits, to use a traditional fee-for-service
approach, or Primary Care Case
Management (PCCM).
• The federal Medicaid program allows states
substantial flexibility to design their own
benefits packages subject to certain minimum
requirements.
(KFF, 2002)
(Shi and Singh, 2004)
Medicaid: Managed Care
• Medicaid beneficiaries enrolled in Medicaid MCOs
may receive more preventive and primary care
services than they would in traditional fee-forservice Medicaid.
• Medicaid MCOs may also improve beneficiary
access to services in general by providing care
coordination through a clearly identifiable
primary care provider.
(Shi and Singh, 2004)
Medicaid: Managed Care
• In most cases, the managed care plans
are managed care organizations, or
MCOs, that assume much of the financial
risk of providing hospital, physician, and
other covered Medicaid services to the
beneficiaries who are enrolled in them.
(KFF, 2002)
(Shi and Singh, 2004)
Medicaid: Managed Care
• There is no federally-defined Medicaid managed
care benefits package.
• Thus, states may determine which services to
purchase through the MCO and which to “carve
out,” either by continuing to pay for the service
(e.g., prescription drugs) directly on a fee-forservice basis or by purchasing the services
(e.g., mental health care).
(KFF, 2002)
(Shi and Singh, 2004)
Medicaid: Payment
• Medicaid operates as a vendor payment program, with
payments made directly to the providers.
• Providers participating in Medicaid must accept the Medicaid
reimbursement level as payment in full or the Medicaid’s
capitation fee.
• Each State has relatively broad discretion in determining
(within federally-imposed upper limits and specific restrictions)
the reimbursement methodology and resulting rate for
services, with three exceptions:
• 1) For institutional services, payment may not exceed amounts
that would be paid under Medicare payment rates
• 2) For disproportionate share hospitals (DSHs), different limits
apply. The DSH program provides payments to certain hospitals
to defray a portion of the costs incurred by serving large numbers
of uninsured patients.
• 3) For hospice care
(KFF, 2002)
Medicaid: Payment
• States may impose nominal deductibles,
coinsurance, or co-payments on some Medicaid
recipients for certain services.
(KFF, 2002)
Medicaid: Payment
• The portion of the Medicaid program which is paid by the
Federal government, known as the Federal Medical
Assistance Percentage (FMAP), is determined annually
for each State by a formula that compares the State's
average per capita income level with the national
average.
• Under this formula, a state’s federal Medicaid matching
rate is based on the ratio of its per capita income,
squared, to the U.S. per capita income, squared.
• By law, no state can have a matching rate lower than 50
percent or greater than 83 percent.
• As of 2001, Michigan’s FMAP was 56.2%
(KFF, 2002)
SCHIP
• SCHIP: State Children's Health Insurance
Program
• Established through the Balanced Budget Act of
1997 to address the growing concern of children
without health insurance.
• Designed as a Federal/State partnership, similar
to Medicaid, with the goal of expanding health
insurance to children whose families earn too
much money to be eligible for Medicaid, but not
enough money to purchase private insurance.
(CMS, 2005)
SCHIP
• Provides coverage to "targeted low-income
children."
• A "targeted low-income child" is one who resides in a
family with income below 200% of the Federal Poverty
Level (FPL) or whose family has an income 50% higher
than the state's Medicaid eligibility threshold.
• Some states have expanded SCHIP eligibility beyond
the 200% FPL limit, and others are covering entire
families and not just children.
(CMS, 2005)
SCHIP
• SCHIP offers states three options when
designing a program. The state can either:
• Use SCHIP funds to expand Medicaid eligibility to
children who previously did not qualify for the
program
• Design a separate children's health insurance
program entirely separate from Medicaid, or
• Combine both the Medicaid and separate program
options.
(CMS, 2005)
Medicaid vs. Medicare
• Medicaid
• State run program
• Entitlement program
that is needs based
• Medicare
• Federally run program
• Entitlement programImposes a legal obligation
on the federal government
to any person, business, or
unit of the government that
meets the criteria set in the
law. They are referred to as
“direct” or “mandatory”
spending. (KFF, 2002, p. 167)
Medicare
• Currently, Medicare provides coverage to
approximately 40 million Americans. Medicare
is the national health insurance program for:
• People age 65 or older
• Some people under age 65 with disabilities
• People with End-Stage Renal Disease (ESRD),
which is permanent kidney failure requiring
dialysis or a kidney transplant (CMS, 2005)
Medicare
• Medicare has four parts:
Medicare Part A
• Medicare Part A (Hospital Insurance) helps cover
inpatient care in hospitals, including critical
access hospitals, and skilled nursing facilities
(not custodial or long-term care).
• It also helps cover hospice care and some home
health care. Certain conditions must be met to
get these benefits.
(CMS, 2005)
Medicare
Medicare Part B
• Medicare Part B (Medical Insurance) helps cover
doctors’ services and outpatient care. It also
covers some other medical services that Part A
does not cover, such as some of the services of
physical and occupational therapists, and some
home health care.
• Part B helps pay for these covered services and
supplies when they are medically necessary.
(CMS, 2005)
Medicare Part C
Medicare Advantage (replaced Plus Choice) is a set
of heath care options created by the Balanced
Budget Act (BBA); it is a ‘managed care’ plan and
includes:
•
•
•
•
•
•
Health Maintenance Organization (HMO)
Point of Service (POS)
Provider Sponsored Organization (PSO)
Preferred Provider Organization (PPO)
Medical Savings Account (MSA)
Religious fraternal benefit society plan (RFP)
• Private fee for-service plan.” (CMS, 2005, p. H-11)
Medicare Part D
Pharmacy Benefit- “Provides
beneficiaries with a Medicare drug
benefit through private health plans.
Anyone enrolled in Medicare Parts A or
B are eligible to join Part D.
Beneficiaries can elect to receive
prescription drug coverage through
either drug-only or a Medicare
Advantage plan that provides
comprehensive benefits.” (CMS, 2005, p. H-11)
A Virtual Exercise
• Please Choose a Case:
Case Study One: Henry Jamison
Henry Jamison is a 82 year old retired
mechanic from Michigan with
Parkinson’s Disease. His wife Jane,
passed away four years earlier.
Between his wife’s high medical bills
and his small pension being used for
the bills, Henry’s monthly income is
below the poverty level. He receives
$900 a month from his pension and his
total savings amounts to $3500. Henry
has been living at home. His two
daughters and his grandchildren check
in on him three times a week. Henry is
your patient since he had a stroke.
The family has decided that they can
no longer care for him to the level that
he needs. They have no choice but to
place him in a nursing home. Henry
and his family have questions for you.
Henry Jamison
Henry’s daughter asks you if he will be eligible
to apply for Medicaid services. You answer…
a.) Yes, because of your father’s income he will
be eligible.
b.) No, your father makes too much money.
c.) I am sorry, I wish I could answer that
question, but there are many factors that
are considered for eligibility. I would
suggest you contact the Department of Health
and Human Services or Michigan Department of
Community Health. I will get you that number.
Answer
C.) In order to be eligible for Medicaid, Henry
would have to go through a thorough screening
process. Many factors have to be considered
and the information provided would not allow
you to make a determination of eligibility. It is
best to refer the patient to the Department of
Health and Human Services or the Michigan
Department of Community Health.
Case Study Two: Linda and James
Linda a 18 year old single mother
who just gave birth to James. She
is part-time manager at a grocery
store and makes $1,000 a month.
She is also working to get her
associate degree during the day.
Because of child care expenses,
school expenses, and the cost of
daily living, Linda is struggling.
She applied for Medicaid, but
because of her income was not
eligible. Linda is concerned that
her son James will not have health
insurance. She comes into your
clinic to get vaccinations for her
son, and has some questions for
you about health care coverage.
Case Two: Linda and James
Linda has explained her situation to you and
asks you what health care coverage options she
has for her son. You answer…
a.) SCHIP
b.) Medicare
c.) Medicaid
Answer
A.) SCHIP
Under SCHIP the state can use SCHIP funds to
expand Medicaid eligibility to children who
previously did not qualify for the program
James is a "targeted low-income child" who
resides in a family with income below 200% of
the Federal Poverty Level (FPL) or whose family
has an income 50% higher than the state's
Medicaid eligibility threshold
Case Two: Linda and James
She then asks you if she will be covered. You
respond that…
a.) Only she will be covered
b.) Only James will be covered
c.) She and James will be covered
d.) You refer her to the Department of Health
and Human Services or the Michigan
Department of Community Health.
Answer
D.) You refer to the Department of Health and
Human Services or the Michigan Department of
Community Health.
Since SCHIP is a state regulated program under
Medicaid, Linda is not necessarily covered. In
some states they will cover the parent if she is
under 18 or pregnant. It is best to refer Linda to
determine whether Michigan covers both her
and James .
Case Three: Sarah RN
Sarah recently finished her
FNP program. She accepted
a position at a nurse run
clinic sponsored by a
university. Many of the
patients she will see will be
covered under Medicare and
Medicaid. Sarah is confused
about the difference
between the programs and
what type of reimbursement
she will be receiving. Sarah
comes to you for assistance
and has these questions.
Sarah wonders…
Will I be reimbursed for my Medicaid
patients and how much?
a.) You will be reimbursed 100% of the Medicaid
rate.
b.) You will be reimbursed 100% of the
Medicaid rate. However you will need a
collaborative agreement with a physician to
be reimbursed directly.
c.) You will be reimbursed 85% of the
Medicaid rate. However you will need a
collaborative agreement with a physician to
be reimbursed directly.
d.) You will be reimbursed 85% of the Medicaid
rate.
Answer
B.) You will be reimbursed 100% of
the Medicaid rate. However you will
need a collaborative agreement with a
physician to be reimbursed directly.
Sarah wonders…
What optional services would she have to look into
to see if it covers her Medicaid patients.
a.) Prenatal care and delivery services for pregnant
women
b.) Ambulatory services to individuals under age 18 and
individuals entitled to institutional services
c.) Home health services to individuals entitled to
nursing facility services
d.) Mental health care services either in institutions for
mental diseases or in intermediate care facilities for
the mentally retarded
e.) All of the above
Answer
E.) All of the above
Sarah should contact the Department of Health
and Human Services or the Michigan
Department of Community Health to find out
what services can be reimbursed in the state of
Michigan.
She asks…
Which program is run by the state?
a.) Medicare
b.) Medicaid
c.) Both Medicaid and Medicare
c.) Neither, they are both run by the
federal government.
The Answer
B.) Medicaid
Medicare is a federally run program
The Future of Medicaid in
Michigan
• In the state of Michigan, Medicaid alone accounts
for $447 million of the unavoidable spending
pressures. (pg. 10)
• The federal government is increasing mandates on
the state, and significantly reducing its financial
commitment to the Medicaid program, at a time
when the state is least able to absorb the costs.
• In addition, the federal government is eliminating
special financing arrangements, costing the state
over $150 million next year and an additional $150
million in 2006.
(FY 2005 EXECUTIVE BUDGET, 2005)
Sustainability of Medicaid
• Every State is having to make difficult
decisions
• Considering 15 % or more of state money is
spent on Medicaid funding currently, the
concern is raised that this spending is
expected to grow by close to 10% by the
year 2012. (KFF, 2004)
• Changes must be made
State of Michigan Changes for 2006
• Medicaid costs for fiscal year 2005 are expected to reach $6.1 billion.
• Some of the changes that will occur for 2006 are:
• A freeze on Medicaid enrollment for 19 and 20 year old young adults.
• Implementation of a limited benefit package for 19 and 20 year old young
adults, and low-income adults who are caring for their own, or related,
children.
• Implementation of a Medicaid estate recovery program that recoups
taxpayer funds spent on nursing home care from the patient’s estate.
• Closure of loopholes in Medicaid eligibility for long-term care to prohibit
the sheltering of financial assets that can be used to pay for the patient’s
care.
• Implementation of a physician provider assessment to increase physician
reimbursement rates while saving $40 million in state funds.
• Elimination of the current 3-month retroactive Medicaid eligibility period
prior to the date of application
• Implementation of a Medicaid Family Planning Waiver that will help reduce
unintended pregnancies and infant mortality rates while saving $6.5
million on childbirth costs.” (State of Michigan, 2005, B-12).
References
Centers for Medicaid and Medicare Services (CMS) (2004). Retrieved September 15, 2004
from
http://www.cms.hhs.gov/medicaid/
CMS (2005). Reference H: Glossary. Retrieved July 31st, 2005 from
http://www.cms.hhs.gov/medlearn/billingguideB/referenceH.pdf.
Kaiser Family Foundation (KFF) (2002). The Medicaid Resource Book. Retrieved September
15th, 2004 from http://www.kff.org/medicaid/2236-index.cfm.
Kaiser Family Foundation (2004). States Respond to Fiscal Pressure: State Medicaid Spending
Growth and Cost Containment in Fiscal Years 2003 and 2004 Results from a 50-State
Survey. Retrieved July 31st, 2005 from http://www.kff.org/medicaid/upload/StatesRespond-to-Fiscal-Pressure-State-Medicaid-Spending-Growth-and-Cost-Containment.pdf
National Conference of State Legislatures (1997). What Legislatures Need to Know about
Managed Care. Retrieved July 31st, 2005 from
http://www.ncsl.org/public/catalog/6642ex.htm.
Shi, L. & Singh, D.A. (2004). Delivering health care in America: A systems approach, 3rd ed.
Jones and Bartlette Publishers: Boston.
State of Michigan (2004). Fiscal Year 2005 Executive Budget. Retrieved March 22nd, 2005
from http://www.michigan.gov/documents/FY05Document1_116216_7.pdf
State of Michigan (2005). Health and Human Services Fiscal Year 2006 Executive Budget
Recommendation. Retrieved July 31st, 2005 from
http://www.michigan.gov/documents/B15-22_115965_7.pdf
United States Department of Health and Human Services (2004). 2004 Federal Poverty
Levels. Retrieved April 6th, 2005 from http://aspe.hhs.gov/poverty/04poverty.shtml.