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					    Report to the Colorado General Assembly1




                  MEDICAL ASSISTANCE
                         UNDER
                       TITLE XIX




        COLORADO LEGISLATIVE COUNCIL
                RESEARCH    P U B L I C A T I O N NO. 130
I                          nFrcuneD   1nr-r
                              LEGISLATIVE COUNCIL 

                                        OF THE 

                        COLORADO GENERAL ASSEMBLY 



   Represents t i v e s                                                Senators
C. P. (DOC) Lamb,                                               Floyd O l i v e r ,
   Chairman                                                        Vice Chairman
Ray Black                                                       Fay DeBerard
J o s e p h V. C a l a b r e s e                                Frank Kemp, Jr.
C a r l H Gustafson
           m                                                    V i n c e n t Massari
Ben K l e i n                                                   Ruth S. S t o c k t o n
J o h n Vanderhoof, S p e a k e r                               Mark Hogan,
Raymond E. Wilder                                                   L t . Governor




          The L e g i s l a t i v e C o u n c i l , which i s composed of f i v e
S e n a t o r s , s i x R e p r e s e n t a t i v e s , and t h e p r e s i d i n g o f f i -
cers o f t h e two houses, s e r v e s a s a c o n t i n u i n g r e s e a r c h
agency f o r t h e l e g i s l a t u r e t h r o u g h t h e maintenance of a
t r a i n e d s t a f f . Between s e s s i o n s , r e s e a r c h a c t i v i t i e s
a r e c o n c e n t r a t e d on t h e s t u d y of r e l a t i v e l y broad
problems f o r m a l l y proposed by l e g i s l a t o r s , and t h e pub-
l i c a t i o n and d i s t r i b u t i o n of f a c t u a l r e p o r t s t o a i d i n
t h e i r solution.
          During t h e s e s s i o n s , t h e emphasis i s on s u p p l y i n g
l e g i s l a t o r s , on i n d i v i d u a l r e q u e s t , w i t h p e r s o n a l
memoranda, p r o v i d i n g them w i t h i n f o r m a t i o n needed t o
h a n d l e t h e i r own l e g i s l a t i v e problems. R e p o r t s and
memoranda b o t h g i v e p e r t i n e n t d a t a i n t h e form of f a c t s ,
f i g u r e s , arguments, and a l t e r n a t i v e s .
   ~~N~VERSITY

           OF DENVER COLLEGE    OF LAW LlBRARI




    MEDICAL ASSISTANCE 

           UNDER 

         TITLE X I X 





     L e g i s l a t i v e Council
         Report To The
 Colorado General Assembly




Research P u b l i c a t i o n No. 130
      December, 1967
      OFFICERS 	                           COLORADO GENERAL ASSEMBLY                                               MEMBERS
REP. C. P. (DOC) L A M B                                                                                     LT. OOV. MARK HOOAN
 CHAIRMAN
                                                                                                             SEN. FAY DrBERARtJ  ,
SEN. FLOYD OLIVER                                                                                            SEN. FRANK KEMP
 V I C I CHAIRMAN
                                                                                                             SEN. VINCENT MASSARI
        STAFF                                                                                                BEN. RUTH BTOCKTON
L Y L E C. KYLE                                                                                              SPEAKER JOHN D.
 DIRECTOR                                                                                                       VANDERHOOF
DAVID    .
        P MORR181EY                                                                                          REP. BEN K L E I N
 PRINCIPAL ANALYBT                                                                                           REP. RAY BLACK
JANET WILSON                                                                                                 REP. JOSEPH CALABREBE
 # I N I O R ANALYST                                LEGISLATIVE COUNCIL                                      REP. CARL QUSTAPaON
STANLEY ELOPSON
 BENIOR ANAL*BT 	                                     ROOM 3 4 1 , STATE CAPITOL                             REP. RAYMOND WILDER
RAY M. FREEMAN 	                                      DENVER, COLORADO 80203
 SR. R C # I A R C H ABBIBTANT
DAVID H l T L 	
 OR. R I S E A R C H ASBlBTANT
                                                                -
                                                      222-0011 E X T E N S I O N 2285
RICHARD LEVLNOOOO 	                                         AREAC O D E 303
 8R. R I S E A R C H ABBIBTANT

                                                      December 26, 1967


                        To Members of t h e F o r t y - s i x t h Colorado General Assembly:


                                     The L e g i s l a t i v e C o u n c i l i s s u b m i t t i n g h e r e w i t h a
                        r e p o r t on medical a s s i s t a n c e under T i t l e X I X of t h e
                        " S o c i a l S e c u r i t y Act" f o r y o u r c o n s i d e r a t i o n p u r s u a n t
                        t o S e n a t e J o i n t R e s o l u t i o n No. 42, 1966 S e s s i o n .
                                      On November 27, 1967, t h e L e g i s l a t i v e C o u n c i l
                        approved t h e recommendation of t h e committee a p p o i n t e d
                        t o c o n d u c t a s t u d y of w e l f a r e t h a t t h e General Assembly
                        g i v e c o n s i d e r a t i o n t o implementing T i t l e X I X of t h e
                        " S o c i a l S e c u r i t y Act." A t t h i s m e e t i n g , t h e committee
                        r e q u e s t e d t h a t it be g i v e n a d d i t i o n a l t i m e t o c o n t i n u e
                        i t s work on T i t l e X I X and submit a r e p o r t d i r e c t l y t o
                        t h e General Assembly. I n p a r t i c u l a r , t h e committee
                        wished t o c o n s i d e r amendments t o t h e S o c i a l S e c u r i t y
                        Act which were u n d e r c o n s i d e r a t i o n by Congress. The
                        r e q u e s t of t h e committee was g r a n t e d by t h e L e g i s l a t i v e
                        Council.
                                                                 Respectfully submitted,


                                                     /s/ 	       R e p r e s e n t a t i v e C. P. (DOC)Lamb
                                                                 Chairman




                                                                    iii
      OFFICERS                       COLORADO GENERAL ASSEMBLY
RLP. C. P. (DOC) LAMB                                                                              LT. OOV. MARK HOGAN
 CHAIRMAN                                                                                          SEN. PAY DEBERARD     ,
BEN. FLOYD OLIVER                                                                                  SEN. PRANK KEMP
 VICL aHAtRYAN
                                                                                                   S I N . VINCENT MASSARI
        STAFF                                                                                      SEN. RUTH STOCKTON
LYLE C. KYLE                                                                                       SPEAKER JOHN D.
 DlREOTOR                                                                                               VANDSRHOOF
DAVID F. MORRISBIY                                                                                 REP. BEN KLEIN
 PRlNCIPAL ANALYST                                                                                 REP. RAY BLACK
JANET WILSON                                                                                       REP. JOSLPH CALAIIRESE
 SENIOR ANALYST                              LEGISLATIVE COUNCIL                                   REP. CARL OUSTAFSON
STANLEY CLOPSON
 SENIOR ANALYST                                ROOM 341, S T A T E CAPITOL                         R I P . RAYMOND WILDER
RAY   M. FREEMAN                               DENVER, C O L O R A D O 80203
 SR. RESEARCH ASSISTANT
DAVIO HITS
 SR. RESEARCH ASSISYANT
                                               932-991 1 -
                                                         E X T E N S I O N 2288
RICHARD L E V S N G 0 0 0                            ARBA CODB303
 8 % RESEARCH ASSISTANT



                                               December 26, 1967


             R e p r e s e n t a t i v e C. P. ( D O C )Lamb 

             Chairman 

             Colorado L e g i s l a t i v e C o u n c i l 

             341 S t a t e C a p i t o l 

             Denver, Colorado 80203 

             Dear M r . Chairman:
                          Your Committee on Welfare h a s made a s t u d y of t h e v a r i -
             ous problems a s s o c i a t e d w i t h implementation of T i t l e XIX of
             t h e f e d e r a l H S o c i a l S e c u r i t y Act". B r i e f l y , T i t l e XIX t i e s
             t o g e t h e r a l l f e d e r a l a i d f o r medical s e r v i c e s t o w e l f a r e r e c i p -
             i e n t s under a s i n g l e program, a s well a s a s s i s t s t h e s t a t e s i n
             meeting m e d i c a l needs of o t h e r low income f a m i l i e s              --       t h e so-
             c a l l e d " m e d i c a l l y i n d i g e n t . " The S e c r e t a r y of H e a l t h , Educa-
             t i o n and Welfare h a s r e q u i r e d t h a t by J a n u a r y 1, 1970, f e d e r a l
             f i n a n c i a l p a r t i c i p a t i o n i n vendor payments f o r medical s e r v i c e s
             w i l l n o t be a v a i l a b l e under any of t h e o t h e r p u b l i c a s s i s t a n c e
             t i t l e s o f t h e S o c i a l S e c u r i t y Act. For t h i s r e a s o n , t h e
             Colorado G e n e r a l Assembly may wish t o a d o p t T i t l e XIX b e f o r e
             t h e aforementioned d a t e ,
                        The committee b e l i e v e s t h a t immediate c o n s i d e r a t i o n of
             T i t l e XIX i s w a r r a n t e d f o r two r e a s o n s :
                          1 ) The S t a t e Department of P u b l i c Welfare e s t i m a t e s
             t h a t , i n t h e e v e n t T i t l e XIX i s implemented i n Colorado,
             c o n s i d e r a b l e new f e d e r a l f u n d s f o r medical a s s i s t a n c e would be
             made a v a i l a b l e t o t h e s t a t e and c o u l d r e s u l t i n s u b s t a n t i a l
             s a v i n g s f o r c o u n t y w e l f a r e budgets. Medical c o s t s of t h e coun-
             t i e s might be reduced by a b o u t $3,465,000 a n n u a l l y .
                      2 ) E a r l y enactment of T i t l e XIX may p e r m i t t h e s t a t e
             o f Colorado t o have more t i m e t o phase i n t h e broad based medi-
             c a l program r e q u i r e d by t h e f e d e r a l government by 1975,
Gradual expansion of medical s e r v i c e s and p e r s o n s covered could
r e d u c e t h e impact of a broad based program f o r any g i v e n y e a r .
F o r i n s t a n c e , t h e t o t a l e s t i m a t e d c o s t o f t h e minimum pro ram
recommended by t h e department i s $42,288,000, w h i l e John
J o y n t 8 A s s o c i a t e s b e l i e v e t h a t a t o t a l broad based program
                                                                                            1.
c o u l d exceed $95,000,000.
             T h e r e f o r e , t h e Committee on Welfare recommends t h a t t h e
L e g i s l a t i v e C o u n c i l r e q u e s t t h a t t h e Governor i n c l u d e T i t l e X I X
among t h e items t o be c o n s i d e r e d by t h e G e n e r a l Assembly d u r i n g
t h e 1968 s e s s i o n .
                                                     Respectfully submitted,


                                           /s/       S e n a t o r Frank Kemp, Chairman
                                                     Committee on Welfare
                                                     Colorado L e g i s l a t i v e Council
                                             FOREWORD

             The L e g i s l a t i v e C o u n c i l ' s Committee on W e l f a r e was c r e -
a t e d u n d e r t h e p r o v i s i o n s of S e n a t e J o i n t R e s o l u t i o n No. 42, 1966
S e s s i o n , t o c o n d u c t a c o m p l e t e s t u d o f t h e p u b l i c w e l f a r e Laws
                                                          1
and programs o f t h e s t a t e . The f o l owing l e g i s l a t o r s s e r v e d a s
members of t h e committee:

           Sen. Frank Kemp,                               Rep.    J e a n BaPn
             Chairman                                     Rep.    Mildred Cre6swell
           Rep. J o s e p h C a l a b r e s e ,           Rep.    D a n i e l Grove
             V i c e Chairman                             Rep.    Floyd H a s k e l l
           Sen. W i l l N i c h o l s o n                 Rep.    Don H o r s t
           Sen. Sam T a y l o r                           Rep.    R i c h a r d Lamm
           Sen. Anthony V o l l a c k                     Rep.    Paul Morris
           Rep. J o s e p h G o l l o b                   Rep.    Roy S h o r e

              One o f t h e i s s u e s a s s i g n e d t o t h e W e l f a r e Committee f o r
r e v i e w was t h e q u e s t i o n o f t h e impact o f t h e i m p l e m e n t a t i o n of
T i t l e X I X l e g i s l a t i o n i n C o l o r a d o . During t h e p a s t few months,
c o n s i d e r a b l e time was d e v o t e d t o t h e q u e s t i o n of i s s u e s and
e x p e n s e s r e l a t e d t o t h e a d o p t i o n of a T i t l e X I X m e d i c a l program.
The committee r e c e i v e d a d v i c e and i n f o r m a t i o n from w e l f a r e o f f i -
c i a l s a t t h e n a t i o n a l , s t a t e , and l o c a l l e v e l . T h i s committee
wishes t o express s p e c i a l thanks t o C h a r l i n e Birkins, D i r e c t o r ,
Tom N e l s o n , and Mary Nadorff o f t h e S t a t e Department o f P u b l i c
W e l f a r e ; C l y d e L i n d v i l l e and Marion S k i n n e r , Bureau of Family
S e r v i c e s , Department o f H e a l t h , E d u c a t i o n and W e l f a r e ; r e p r e s e n t -
a t i v e s o f t h e C o l o r a d o M e d i c a l S o c i e t y and C o l o r a d o D e n t a l As-
sociation; a s well a s other interested health o f f i c i a l s f o r
a s s i s t a n c e r e n d e r e d t o t h e committee.
              I n c o n s i d e r i n g problems a s s o c i a t e d w i t h i m p l e m e n t a t i o n of
T i t l e X I X , t h e committee was c o n c e r n e d w i t h u n d e r s t a n d i n g t h e
s t a t e ' s r o l e i n p a r t i c i p a t i n g i n a T i t l e X I X program. F o r i n -
s t a n c e , how much f l e x i b i l i t y i s g i v e n t o a s t a t e i n d e t e r m i n i n g
c o v e r a g e and m e d i c a l s e r v i c e s t o v a r i o u s c l a s s e s o f r e c i p i e n t s ?
W i t h i n t h e framework o f f e d e r a l l a w and r e g u l a t i o n s , i s it pos-
s i b l e f o r t h e C o l o r a d o G e n e r a l Assembly t o e s t a b l i s h b r o a d
g u i d e l i n e s o f s t a t e p o l i c y w i t h r e g a r d t o a T i t l e X I X program?
I f t h e G e n e r a l Assembly e s t a b l i s h e d s u c h g u i d e l i n e s , would t h e
implementing l e g i s l a t i o n h a n d i c a p t h e d e p a r t m e n t i n m e e t i n g con-
s t a n t l y c h a n g i n g f e d e r a l r u l e s and r e g u l a t i o n s ? I n any e v e n t ,
s t a t e o f f i c i a l s must make a d e c i s i o n a s t o t h e s c o p e of m e d i c a l
s e r v i c e s t o be p r o v i d e d and t h e c a t e g o r i e s o f r e c i p i e n t s t o b e
made e l i g i b l e f o r m e d i c a l a s s i s t a n c e u n d e r a T i t l e X I X program.
The committee a l s o c o n s i d e r e d t h e a l t e r n a t e s o l u t i o n s t o r e c o n -
c i l i n g A r t i c l e XXIV of t h e C o l o r a d o C o n s t i t u t i o n (which a u t h o r -
i z e s t h e S t a t e Board of W e l f a r e t o e s t a b l i s h a m e d i c a l program
f o r p e n s i o n e r s , a s w e l l a s l i m i t i n g t h e amount o f s t a t e money
t h a t may be expended f o r medical          c a r e f o r Old Age P e n s i o n e r s )
and t h e implementing l e g i s l a t i o n   f o r T i t l e XIX. F i n a l l y , t h e
committee reviewed t h e f i n a n c i a l     impact of T i t l e X I X b o t h a s t o
an i n i t i a l program and t h e broad       based program r e q u i r e d by t h e
f e d e r a l government i n 1975.
             A s s i s t i n g t h e committee i n t h e s t u d y were Bob H o l t of t h e
L e g i s l a t i v e Reference O f f i c e , who provided b i l l d r a f t i n g s e r -
v i c e s , and Dave Morrissey of t h e Council S t a f f , who had primary
r e s p o n s i b i l i t y f o r t h e s t a f f work.




December 27, 1967                                                        Lyle C. Kyle
                                                                         Director




                                           viii
                                 TABLE OF CONTENTS




LETTERS OF TRANSMITTAL              .....................................                  iii 

FOREWORD ...................................................                               vii 

TABLE OF CONTENTS ..........................................                                ix 

LIST OF TABLES .............................................                                 x

COMMITTEE RECWNDATIONS ..................................                                   xi 

MEDICAL CARE FOR L W INCOME FAMILIES I N COLORADO ...........
                              O                                                              1

     F e d e r a l "Medicaren and "Medicaid" Programs ............                           1

     P e r s o n s E l i g i b l e f o r T i t l e X I X B e n e f i t s ...............
     Medical S e r v i c e s Under T i t l e X I X ......................
                                                                                             3

                                                                                             6

     T i t l e X I X L e g i s l a t i o n i n O t h e r S t a t e s .................       8

               Medical S e r v i c e s .................................                     8

              M e d i c a l l y Needy P e r s o n s ..........................               9

     S t a t e P l a n s f o r T i t l e X I X .............................                12 

              Medical S e r v i c e s O f f e r e d Under S t a t e P l a n s .......       12 . 

     Comparison of Medical E x p e n d i t u r e s . 50 S t a t e s .......
                                                                   .                        18 

     Department E s t i m a t e s of Medical C o s t s of a
        Proposed T i t l e X I X Program ............................                       21 

               P r o j e c t e d C o s t s f o r Proposed T i t l e X I X 

                   Program f o r Colorado ...........................                       21 

               F i n a n c i a l Impact t o F e d e r a l . S t a t e and
                   County Governments .............................                         23 

               E s t i m a t e d C o s t s f o r a Complete T i t l e
                            ....................................
                 X I X Program
              C o n s i d e r a t i o n of t h e Optional-Medically
                                                                                            24 

                 Needy Groups..................................                             24 

     Summary and I s s u e s t o be Resolved .....................                          27 

APPENDIX A . STATE OF OREGON. TITLE X I X LEGISLATION .......
            .                                                                               29 

                               L I S T OF TABLES




      MEDICAL SERVICES FOR COLORADO WELFARE 

      RECIPIENTS, EFFECTIVE JULY. 1, 1 6 . . . . . . . . . .
                                      96..........                         2

      CHARACTERISTICS OF TITLE XIX LEGISLATION 

      ADOPTED I N VARIOUS STATES..................*..........             10 

                                          ....................
      COMPARISON OF T I T L E XIX PROGRAMS..                              15 

      NUMBER OF STATES PROVIDING VARIOUS TYPES OF
      MEDICAL SERVICES .............................~........             17 

      AMOUNT EXPENDED PER INHABITANT FOR WELFARE 

      PAYMENTS TO MEDICAL VENDORS FOR VARIOUS SIX-

      MONTH PERIODS.........................................              19 

      ESTIMATED COSTS OF A PROPOSED PROGRAM OF 

      MEDICAL SERVICES TO THE CATEGORICALLY NEEDY 

      I N COLORADO........................................                22 

VII   ESTIMATED COSTS OF A TOTAL PROGRAM OF MEDICAL
      SERVICES TO THE CATEGORICALLY AND MEDICALLY
      NEEDY IN COLORADO       --
                           FISCAL YEAR 1968-69.......           .......   25 

                               COMMITTEE RECOMMENDATIONS

              When C o n g r e s s a d o p t e d "Medicare" i n 1965, a n amendment was
added t o p r o v i d e f e d e r a l a s s i s t a n c e t o t h e s t a t e s f o r a s i n g l e
program o f m e d i c a l c a r e f o r needy f a m i l i e s ( s i m i l a r t o t h a t
e s t a b l i s h e d f o r t h e a g e d u n d e r t h e "Kerr-Mills ~ c t " ) . While t h e
K e r r - M i l l s Act p e r m i t t e d m e d i c a l a s s i s t a n c e t o needy p e r s o n s 6 5
y e a r s o f a g e a n d o l d e r o n l y , t h e 1965 amendments t o t h e " S o c i a l
S e c u r i t y Act" --     T i t l e XIX  --    include benefits t o families with
dependent c h i l d r e n , t h e b l i n d and d i s a b l e d , a s w e l l a s o t h e r
m e d i c a l l y needy p e r s o n s .      In general, t h e s t a t e s a r e obliged t o
p a r t i c i p a t e i n t h e T i t l e X I X program by J a n u a r y 1, 1970, s i n c e
f e d e r a l m e d i c a l v e n d o r payments f o r w e l f a r e r e c i p i e n t s w i l l no
l o n g e r be a v a i l a b l e under any o t h e r t i t l e of t h e "Social Securi-
t y Act."
            T h e r e a r e two b a s i c c a t e g o r i e s o f r e c i p i e n t s u n d e r T i t l e
XIX:       1 ) t h e " c a t e g o r i c a l l y needy" and 2 ) t h e " m e d i c a l l y i n d i -
g e n t . " B r i e f l y , t h e c a t e g o r i c a l l y needy i n c l u d e w e l f a r e r e c f p i -
e n t s o r welfare-*related persons (families e l i g i b l e f o r welfare
e x c e p t f o r r e s i d e n c e o r o t h e r s t a t e r e q u i r e m e n t s ) . The c a t e g o r i -
c a l l y needy must be i n c l u d e d i n a T i t l e X I X p l a n by J a n u a r y 1,
1970. The m e d i c a l l y needy program, however, i s o p t i o n a l u n t i l
1975. L i m i t e d f e d e r a l p a r t i c i p a t i o n i s a v a i l a b l e f o r t h i s l a t -
t e r program.

Budqet E s t i m a t e s o f t h e Department
              T e n t a t i v e e s t i m a t e s o f t h e S t a t e Department of P u b l i c
W e l f a r e r e v e a l t h a t t h e c o s t o f a minimum program o f m e d i c a l
s e r v i c e s f o r t h e c a t e g o r i c a l l y needy, f o r t h e f i r s t y e a r o f
o p e r a t i o n , would be a b o u t $42,000,000.                   Of t h i s amount, o v e r 55
p e r c e n t would b e p a i d by t h e f e d e r a l government ($23,260,000) ,
w h i l e t h e s t a t e o f C o l o r a d o would pay t h e r e m a i n i n g s h a r e .
             F i n a n c i n q Non-f e d e r a l S h a r e . Under T i t l e X I X , t h e f e d e r a l
government r e q u i r e s t h a t t h e n o n - f e d e r a l s h a r e must b e p a i d from
s t a t e funds o r , i n t h e event t h e counties a r e t o p a r t i c i p a t e i n
t h e program, a n e q u a l i z a t i o n f o r m u l a must be i n s t i t u t e d t o
i n s u r e t h a t l a c k of l o c a l funds w i l l n o t r e s u l t i n lowering t h e
a v a i l a b i l i t y of m e d i c a l s e r v i c e s .  I n 1966, t h e C o l o r a d o L e g i s l a -
t i v e C o u n c i l Committee on W e l f a r e recommended t h a t T i t l e X I X
s h o u l d b e f i n a n c e d by f e d e r a l and s t a t e f u n d s . T h i s committee
a l s o a g r e e s w i t h t h e recommendation f o r f i n a n c i n g t h e n o n - f e d e r a l
s h a r e from s t a t e monies o n l y .
             I f a minimum program t o implement T i t l e X I X i s a d o p t e d ,
t h e department o f f i c i a l s b e l i e v e t h a t over nine m i l l i o n d o l l a r s
i n a d d i t i o n a l f e d e r a l monies w i l l be made a v a i l a b l e a n n u a l l y by t h e
f e d e r a l government f o r m e d i c a l v e n d o r payments f o r low income
f a m i l i e s i n C o l o r a d o . A t t h e same t i m e , s t a t e e x p e n d i t u r e s f o r
c a t e g o r i c a l a i d w i l l remain about the same, while a savings t o
the counties of a s much as. $3,465,000 could be r e a l i z e d .
         I n view of t h e apparent i n i t i a l economic advantage i n
adopting Title X I X , as w e l l a s t h e mandatory d e a d l i n e established
by Congress (~anuary1, 1970), t h e committee recommends t h a t t h e
General Asoembly give c o n s i d e r a t i o n t o implementing a Title X I X
program i n Colorado. To minimize t h e f i n a n c i a l impact of a
broad based program o f coverage and s e r v i c e s required by 1975,
t h e committee a l s o recommends t h a t s e r v i c e s and c a t e g o r i e s of
coverage gradually be expanded between t h e i n i t i a l d a t e of en-
actment of Title X I X l e g i s l a t i o n and t h e 1975 d a t e .




                                        xii 

                              MEDICAL CARE FOR LOW INCOME
                                 FAMILIES IN COLORADO


              T r a d i t i o n a l l y , t h e s t a t e of Colorado has been a l e a d e r i n
p r o v i d i n g medical a s s i s t a n c e f o r low income aged persons. For
example, A r t i c l e XXIV, S e c t i o n 7 , Colorado C o n s t i t u t i o n , e s t a b -
l i s h e s a $10 000,000 medical a s s i s t a n c e fund f o r Old Age Pen-
sioners.         oilo om in^           a d o p t i o n of t h i s amendment i n 1956, t h e
S t a t e Board of Welfare a u t h o r i z e d t h e department t o p r o v i d e Colo-
r a d o Old Age P e n s i o n e r s w i t h 7 0 d a y s o f h o s p i t a l i z a t i o n p e r y e a r ,
p h y s i c i a n s e r v i c e s i n h o s p i t a l s and n u r s i n g homes, s k i l l e d nurs-
i n g home c a r e , l i m i t e d p h y s i c i a n s e r v i c e s f o r home and o f f i c e
c a l l s , d r u g s i n n u r s i n g homes, some home h e a l t h a i d s , and, on a
l i m i t e d b a r i s , ambulance s e r v i c e s were made a v a i l a b l e f o r a
s h o r t p e r i o d . Medical a s s i s t a n c e a l s o h a s been provided t o o t h e r
c l a s s e s of w e l f a r e r e c i p i e n t s i n Colorado i n c l u d i n g p e r s o n s par-
t i c i p a t i n g i n t h e f e d e r a l program o f Aid t o F a m i l i e s w i t h De-
pendent C h i l d r e n ( A D C ) , b l i n d p e r s o n s ( A B ) , and t o t h e needy d i s -
a b l e d (AND). Medical s e r v i c e s i n t h e s e l a t t e r c a t e g o r i e s ,
however, have been l i m i t e d .
              Although a l l r e c i p i e n t s o f w e l f a r e may be c l a s s e d a s
needy, t h e medical b e n e f i t s a v a i l a b l e t o t h e v a r i o u s c l a s s e s of
r e c i p i e n t s a r e n o t uniform ( s e e Table I ) . I n o t h e r words, a
s e p a r a t e s t a t e p l a n e x i s t s f o r e a c h c a t e g o r y of r e c i p i e n t s under
t h e v a r i o u s p u b l i c a s s i s t a n c e t i t l e s o f t h e S o c i a l S e c u r i t y Act.
For i n s t a n c e , p a r t i c i p a n t s i n t h e Aid t o t h e Needy D i s a b l e d
program a r e n o t e l i g i b l e f o r medical a s s i s t a n c e f o r h o s p i t a l i z a -
tion, physician's services, out-patient hospital care, etc.,
w h i l e p e n s i o n e r s a r e provided a broad range of h e a l t h s e r v i c e s
i n c l u d i n g home h e a l t h c a r e , h o s p i t a l i z a t i o n , and o t h e r b e n e f i t s .
                                    D
P a r t i c i p a n t s i n t h e A C program a l s o have a f a i r l y comprehensive
                                            D
h e a l t h program, b u t t h e A C program d i f f e r s from t h a t provided
t o pensioners.
        This diversity i n                medical s e r v i c e s t o low income f a m i l i e s
i s common t o many s t a t e s           and i s one of t h e r e a s o n s Congress
adopted a s i n g l e program             t o p r o v i d e f e d e r a l monies t o t h e s t a t e s
                                          of w e l f a r e r e c i p i e n t s and o t h e r low
t o meet medical expenses
income f a m i l i e s     --
                        Title             X I X of t h e S o c i a l S e c u r i t y Act.

F e d e r a l "MedicareM and "MedicaidN Proqrams
              llMedicare." I n 1965 Congress e n a c t e d an amendment t o t h e
S o c i a l S e c u r i t y Act which e s t a b l i s h e d a program of medical c a r e
f o r p e r s o n s 65 y e a r s of a g e and o v e r . T h i s program, T i t l e X V I I I
of t h e S o c i a l S e c u r i t y Act, i s commonly r e f e r r e d t o a s I l M e d i ~ a r e . ~
Medicare p r o v i d e s f o r f e d e r a l p a r t i c i p a t i o n i n two k i n d s of i n -
surance: 1) h o s p i t a l i n s u r a n c e , which i n c l u d e s s k i l l e d n u r s i n g
c a r e and o t h e r s e r v i c e s i n an extended c a r e f a c i l i t y a f t e r hos-
p i t a l i z a t i o n , o u t p a t i e n t h o s p i t a l d i a g n o s t i c s e r v i c e s , and home
                                                           ~    C   A SERVICES
                                                                       L            R
                                                                                   m COLORAIX) WELFARE RECIPIENTS,
                                                                               EFFECTIVE JlJLY 1, 1%6

                                                        Nursing Home                                                  M e Nursing
                                                            Care                 Phvsicians' Services                  Services                                          W B B e n e f i t s 4/
    Old Age
  Pensioners               60 da s p e r s p e l l         Unlimited             Unlirni t e d                              Yes                I n hospital 8                     Yes
    O M ( A)               of i l l n e s s                                                                                                    i n m i n g hsnac
Medical Assist-
 ance f o r Aged           60 days p e r s p e l l         Unlimited             Unlimited       y                          Yes                I n hospital 8                     Yes JJ
    M A A ~                of i l l n e s s                                                                                                    nursing ttcmmc
                           70 days a y e a r               Unlimited             I n h o s p i t a l 8 nuts-                Yes                In hospital 8                      No
                                                                                 i n g hame; c e r t a i n '                                   nursing h m
                                                                                 outpatient services;
                                                                                 4 home o r a f f i c e
                                                                                 c a l l s p e r year.
 Aid t o Needy                                             Unlimited             I n n u r s i n g home                     No   2/            I n nursing               SIB* p d u m on1
   Disabl d                                                                                                                                    bane 8 i n                paid for r e c i p e
    AND    d                                                                                                                                   own holm                  ents 6 3or o v e r .
                                                                                                                                                                                   ?
                                                                                                                                                                         No payment of d e -
                                                                                                                                                                                        . ar
                                                                                                                                                                         d u c t i b l e ~ co-
                                                                                                                                                                         insurance
  Aid t o Blind           120 days      --
                                      Blue                 Unlimited             I n h o s p i t a l and                    No   2/           I n hospital.              S a m as for AND
      AB   2l             Cross-Blue S h i e l d
                          coverage
                                                                                 n u r s i n g hawe                                           nursing home
                                                                                                                                              8 own hame
Aid t o Deeend-           120 days      --
                                      Blue                 NA                    I n hospital                               No   3'           I n hospital 8             Same a s far AND
    m9
 e n t Chi1 r e n         Cross-Blue S h i e l d
                          coverage
                                                                                                                                              f a r children
                                                                                                                                              i n own home


    E l i g i b i l i t y of c e r t a i n MAA r e c i p i e n t s f o r HIB+*and SMIB c o n t i g e n t on t h e i r enrollment f o r b e n e f i t s . 

    Those 6 5 o r over would q u a l i f y f o r HIB b e n e f i t s , s u b j e c t t o payment of d e d u c t i b l e s . 

    Except t h o s e 65 o r o v e r would q u a l i f y f o r SMIB b e n e f i t s , which i n c l u d e home h e a l t h v i s i t s , s u b j e c t t o payment of d e d u c t i b l e s 

    and coinsurance, 

    SMIB b e n e f i t s i n c l u d e p h y s i c i a n s ' s e r v i c e s . home h e a l t h s e r v i c e s (100 v i s i t s a year). X-ray s e r v i c e s , e t c . ; i n c l u d e some d r u g s 

    o u t s i d e of h o s p i t a l o r n u r s i n g home, i f p r o f e s s i o n a l l y administered. 

*   Supplementary Medical I n s u r a n c e B e n e f i t s .
*   H o s p i t a l Insurance B e n e f i t s .
h e a l t h s e r v i c e s f o l l o w i n g a h o s p i t a l s t a y ; and 2 ) supplementary
medical i n s u r a n c e (SMIB) which a s s i s t s i n meeting b i l l s f o r d o c t o r
s e r v i c e s , o t h e r medical s e r v i c e s and s u p p l i e s , a s well a s home
h e a l t h c a r e u n r e l a t e d t o h o s p i t a l i z a t i o n . The l a t t e r program i s
v o l u n t a r y , and t h e f e d e r a l government p a r t i c i a t e s i n t h e c o s t
                                                                         R
of monthly premiums on a matching b a s i s . A l t ough t h e h e a l t h
i n s u r a n c e program pays a l a r g e p a r t o f t h e c o s t of h e a l t h c a r e
f o r most aged p e r s o n s , t h e s t a t e s may need t o a s s i s t some low
income p e r s o n s 6 5 and o v e r i n meeting a d d i t i o n a l medical needs.
T i t l e X I X of t h e S o c i a l S e c u r i t y Act p r o v i d e s f e d e r a l f u n d s t o
                                                                                       e
t h e s t a t e s t o a s s i s t t h e s e o l d e r i n d i v i d u a l s i n msetin c o s t s not
covered by Medicare. The S t a t e Board o f Welfare pays he c o s t of
SMIB f o r Old Age P e n s i o n e r s .
             Opponents of t h e Medicare program e x p r e s s e d concern t h a t
Medicare d o e s n o t d i f f e r e n t i a t e between p e r s o n s i n need and
p e r s o n s w i t h t h e r e s o u r c e s t o meet medical c o s t s . Perhaps t h i s
o p p o s i t i o n was r e s p o n s i b l e , a t l e a s t i n p a r t , f o r t h e enactment
of T i t l e X I X of t h e S o c i a l S e c u r i t y Act, t h e s o - c a l l e d nMedicaid
Program. "
              IiMedicaid.           B r i e f l y , nMedicaida ( T i t l e XIX) t i e s t o g e t h e r
a l l f e d e r a l a s s i s t a n c e f o r medical s e r v i c e s t o welfare r e c i p i e n t s
under a s i n g l e program. The S e c r e t a r y of H e a l t h , Education, and
Welfare h a s r e q u i r e d t h a t by J a n u a r y 1, 1970, f e d e r a l f i n a n c i a l
p a r t i c i p a t i o n i n vendor payments f o r medical s e r v i c e s w i l l n o t be
a v a i l a b l e under any of t h e o t h e r p u b l i c a s s i s t a n c e t i t l e s of t h e
S o c i a l S e c u r i t y Act. Thus, Colorado i s o b l i g a t e d t o d e v e l o p a
s t a t e p l a n t o implement T i t l e X I X o r l o s e f e d e r a l f u n d s f o r medi-
c a l a s s i s t a n c e . Under T i t l e X I X , t h e f e d e r a l government w i l l pay
f o r 55.39 p e r c e n t of t h e m e d i c a l c a r e c o s t s i n c u r r e d f o r low
income f a m i l i e s e l i g i b l e f o r f e d e r a l reimbursement under T i t l e
X 1 X . U T h i s medical a s s i s t a n c e p e r c e n t a g e i s e f f e c t i v e t h r o u g h
J u l y of 1969. Another i m p o r t a n t a s p e c t o f T i t l e X I X i s t h e pro-
v i s i o n t o a s s i s t t h e s t a t e s i n f i n a n c i n g medical a s s i s t a n c e t o
an e n t i r e l y new group o f f a m i l i e s       --     t h e nmedically indigent."
g e n e r a l , t h i s c a t e g o r y i n c l u d e s low income f a m i l i e s ( n o t on wel-
                                                                                                      In
f a r e ) whose income i s i n s u f f i c i e n t t o meet medical c o s t s .

Persons E l i q i b l e f o r T i t l e X I X Benefits
              " C a t e q o r i c a l l y need^.^ B r i e f l y , t h e r e a r e two c l a s s e s of
p a r t i c i p a n t s u n d e r T i t l e XIX:       1 ) n c a t e g o r i c a l l y needyn and 2 )
"medically indigent.                       The c a t e g o r i c a l l y needy a l s o i s d i v i d e d




J Medical , A s s i s t a n c e P r o rams Under T i t l e
I                                                           X I X of the S o c i a l
     S e c u r i t y Act, H a n d b & u b l i c A m a n c e       Administration,
     Supplement Q, H.E. W., ~ z t w 8 5 2 3 . 1 1 .
i n t o t h r e e s u b c l a s s e s : 1 ) w e l f a r e r e c i p i e n t s r e c e i v i n g a i d under
T i t l e s I , I V , X, and X I V of t h e S o c i a l S e c u r i t y Act           --       pensioners,
f a m i l i e s w i t h dependent c h i l d r e n , b l i n d , and d i s a b 1 e d ; z . 2 ) per-
s o n s e l i g i b l e f o r a i d under t h e aforementioned T i t l e s e x c e p t
t h a t t h e y do n o t meet s t a t e r e s i d e n c y s t a n d a r d s o r some o t h e r
s t a t e r e q u i r e m e n t n o t p e r m i t t e d under X I X y ( f o r example, c h i l -
d r e n under 21 who c a n n o t q u a l i f y a s dependent because o f t h e
s t a t e ' s age r e q u i r e m e n t s--       i n Colorado a y o u n g s t e r 16 t o 21 who
i s n o t a t t e n d i n g s c h o o l i s i n e l i g i b l e f o r ADC); and 3 ) needy
p e r s o n s w i t h incomes low enough t o q u a l i f y f o r c a s h g r a n t s under
t h e v a r i o u s t i t l e s b u t e i t h e r have n o t a p p l i e d f o r a s s i s t a n c e o r
a r e i n e l i g i b l e under t h e v a r i o u s s t a t e p l a n s . T h i s l a t t e r sub-
c l a s s of c a t e g o r i c a l l y needy i s an o p t i o n a l program. Examples of
t h e l a t t e r subclass include:
                1 ) persons e l i g i b l e f o r p a r t i c i p a t i o n i n a
                s t a t e p l a n b u t have n o t a p p l i e d f o r a s s i s -
                tance;
                2 ) p e r s o n s i n a n u r s i n g home, mental i n s t i -
                t u t i o n , o r t u b e r c u l o s i s s a n i t a r i u m who would
                q u a l i f y f o r a s s i s t a n c e i f l i v i n g o u t s i d e of
                such a f a c i l i t y ;
                3 ) persons f i n a n c i a l l y e l i g i b l e f o r p a r t i c i -
                p a t i o n i n a s t a t e p l a n b u t who c a n n o t q u a l i f y
                because t h e s t a t e p l a n i s more r e s t r i c t i v e
                t h a n f e d e r a l r e q u i r e m e n t s (example    --
                                                                          defini-
                t i o n of permanent and t o t a l l y d i s a b l e d ) ;
                4 ) c h i l d r e n i n f o s t e r homes o r p r i v a t e i n s t i -
                t u t i o n s n o t p a r t i c i p a t i n g i n t h e ADC program
                b u t who q u a l i f y f i n a n c i a l l y ; and
                5)      r e l a t i v e s c a r i n g f o r c h i l d r e n under a
                s t a t e ' s ADC ~ r o g r a m . 3 /
A s t a t e may i n c l u d e any one o r a l l f i v e of t h e aforementioned
o p t i o n a l c a t e g o r i c a l l y needy programs i n a s t a t e plan t o imple-
ment T i t l e X I X .
            "Medically I n d i q e n t . 'I Perhaps t h e most c o n t r o v e r s i a l
            o
a s ~ e c t f T i t l e X I X i s t h e a v a i l a b i l i t y of f e d e r a l monies t o a s -
s i s t t h e s t a t e s i n p r o v i d i n g medical c a r e and s e r v i c e s t o i n d i -




2/ P e r s o n s t h a t must be i n c l u d e d i n any s t a t e p l a n t o implement
   T i t l e X I X andbo book of P u b l i c A s s i s t a n c e A d m i n i s t r a t i o n ,
     Supp.,)I S e c t i o n 4 0 2 m .
     Handbook of P u b l i c A s s i s t a n c e ,       sup^. Il, s e c t i o n D 4040.
     v i d u a l s who would, i f needy, q u a l i f y f o r a i d u n d e r any of t h e
     f e d e r a l c a t e g o r i e s of w e l f a r e a s s i s t a n c e . I n o t h e r words, a
     s t a t e may e x e r c i s e t h e o p t i o n o f p r o v i d i n g m e d i c a l c a r e t o per-
     s o n s whose incomes a r e s u f f i c i e n t t o d i s q u a l i f y them from f e d e r a l
     w e l f a r e programs b u t whose incomes a r e below a l e v e l e s t a b l i s h e d
     by t h e s t a t e a s n e c e s s a r y t o meet m e d i c a l c o s t s . The w m e d i c a l l y
     i n d i g e n t n o r " m e d i c a l l y needy" c a t e g o r y i s o p t i o n a l u n t i l 1975;
     however, f e d e r a l f u n d s a r e now a v a i l a b l e t o a s s i s t c e r t a i n per-
     s o n s i n t h i s c l a s s i f i c a t i o n . F o r i n s t a n c e , p e r s o n s covered by a
     m e d i c a l l y needy program must i n c l u d e a s i m i l a r c l a s s of p a r t i c i -
     p a n t s t o t h a t p r o v i d e d f o r i n t h e c a t e g o r i c a l l y needy program,
     e x c e p t , of c o u r s e , t h a t income and r e s o u r c e r e q u i r e m e n t s a r e
     different.
                    '4       Thus anyone who q u a l i f i e s f o r a i d u n d e r one o f t h e
     p u b l i c a s s s t a n c e t i t l e s of 	 t h e S o c i a l S e c u r i t y A c t , e x c e p t f o r
     income w i t h i n a s p e c i f i e d range, would b e e l i g i b l e f o r a f e d e r -
     a l l - a i d e d m e d i c a l l y needy p r o ram. The 1967 amendments t o t h e
         1                                           ?
     $oc a 1 S e c u r i t y Act e s t a b l i s h imits on t h e amount of income
     t h a t c o u l d b e s e t a s i d e o r r e s e r v e d f o r maintenance of a f a m i l y
     o r i n d i v i d u a l . Any income o v e r and above t h a t r e s e r v e d f o r
     maintenance must be a p p l i e d t o m e d i c a l and d e n t a l s e r v i c e s i n
     o r d e r f o r an i n d i v i d u a l o r f a m i l y t o q u a l i f y f o r T i t l e X I X
     b e n e f i t s u n d e r t h e f e d e r a l l y - a i d e d program. I n H. R e 12080, Con-
     g r e s s p r o v i d e s t h a t t h e maximum amount o f income t h a t a s t a t e
     may p e r m i t t o be s e t a s i d e f o r maintenance of a f a m i l y i s
     133 1/3 p e r c e n t of t h e h i g h e s t amount o r d i n a r i l y p a i d t o a fam-
     i l y o f comparable s i z e p a r t i c i p a t i n g i n t h e Aid t o F a m i l i e s w i t h
     Dependent C h i l d r e n program. Of c o u r s e , a s t a t e c o u l d a l l o w a
     l a r g e r p o r t i o n of a f a m i l y ' s income t o b e used f o r maintenance,
     b u t t h e f e d e r a l government would n o t p a r t i c i p a t e i n s u c h a pro-
*	   gram. O t h e r r e a s o n a b l e s t a n d a r d s a l s o must b e u t i l i z e d i n
     e s t a b l i s h i n g a medically i n d i g e n t category. For instance, a s t a t e
     could n o t write a plan f o r t h e medically i n d i g e n t l i m i t e d t o
     p e r s o n s o v e r 6 0 y e a r s o f a g e o r c o n t a i n some o t h e r s p e c i a l r e -
     quirement and e x p e c t t h e f e d e r a l government t o p a r t i c i p a t e i n t h e
     program. I n o t h e r words, t h e s t a t e of Colorado c o u l d n o t l i m i t
     a m e d i c a l l y i n d i g e n t p r o ram t o c l a s s B Old Age P e n s i o n e r s
                                            3
     ( p e n s i o n e r s u n d e r a g e 6 5 and r e c e i v e f e d e r a l s u p p o r t f o r t h e
     program.
                  I n summary, p e r s o n s e l i g i b l e f o r f e d e r a l a s s i s t a n c e u n d e r
     a s t a t e p l a n t o implement T i t l e X I X must meet t h e income r e q u i r e -
                                                                           r
     ments f o r low income f a m i l i e s e s t a b l i s h e d b t h e s t a t e , a s w e l l
     a s meet one o f t h e f o l l o w i n g c o n d i t i o n s : 1 u n d e r t h e a g e of
     21; 2 ) a mother, f a t h e r , o r o t h e r r e l a t i v e l i v i n g w i t h a depen-
     d e n t c h i l d u n d e r a g e 21; 3) 65 y e a r s of a g e o r o l d e r ; 4 ) b l i n d ;
     o r 5 ) 18 y e a r s of a g e and o l d e r and permanently and t o t a l l y d i s -
     a b 1 e d . V On t h i s b a s i s , t h e a v e r a g e a d u l t between 21 and 6 5




     & T6IiI.,
     4    Ibid.,     Supp. D , S e c t i o n D 4030.

                     Supp. D, S e c t i o n D 4050. 

y e a r s of a g e who i s not l i v i n g w i t h a dependent c h i l d ( u n d e r a g e
21) would n o t be e l i g i b l e f o r f e d e r a l a s s i s t a n c e f o r medical
c a r e under T i t l e X I X r e g a r d l e s s o f income s t a t u s .

Medical S e r v i c e s Under T i t l e X I X
              I n p r o v i d i n g f o r medical s e r v i c e s u n d e r T i t l e XIX, t h e
f e d e r a l government c o n s i d e r s t h e c a t e g o r i c a l l y needy and t h e medi-
c a l l y needy a s s e p a r a t e , i n d i v i s i b l e groups. I n g e n e r a l , t h e
s e r v i c e s provided w i t h i n e a c h group must be e q u a l , b u t t h e ser-
v i c e s between g r o u p s need n o t be e q u a l . However, a h i g h e r l e v e l
                                                                                  r
o f s e r v i c e s c a n n o t be provided t o t h e m e d i c a l l y need group t h a n
i s made a v a i l a b l e t o t h e c a t e g o r i c a l 1 needy, S p e c i i c medical
                                                          1
s e r v i c e s a r e r e q u i r e d f o r a l l c a t e g o r c a l l y needy p e r s o n s , 4 /
e x c e p t t h a t s k i l l e d n u r s i n g home s e r v i c e s may be l i m i t e d t o
s o n s 2 1 y e a r s o f age o r o l d e r , and s e r v i c e s t o mental and t u e r -       rr-

                                                                                  d
c u l o s i s p a t i e n t s may b e r e s t r i c t e d t o t h o s e o v e r 65.7
must medical programs be uniform w i t h i n e a c h group, u t t h e o! a e
c a n n o t r e d u c e t h e medical s e r v i c e s a v a i l a b l e under a n e x i s t i n g
                                                                                                      '
                                                                                                    ent
program i n d e v e l o p i n g a p l a n u n d e r T i t l e XIX.
            S e c t i o n 1902 ( a ) ( 1 3 ) of t h e S o c i a l S e c u r i t y Act, r e q u i r e s
t h a t t h e f o l l o w i n g f i v e b a s i c s e r v i c e s be provided t o c a t e g o r i -
c a l l y needy r e c i p i e n t s of T i t l e X I X b e n e f i t s :
                1 ) i n p a t i e n t h o s p i t a l services (other than
                services i n an i n s t i t u t i o n f o r tuberculosis
                o r mental d i s e a s e s ) ;
                2)    outpatient hospital services;
                3)    o t h e r l a b o r a t o r y and X-ray s e r v i c e s ;
               4)       s k i l l e d n u r s i n g home s e r v i c e s ( o t h e r
                than s e r v i c e s i n an i n s t i t u t i o n f o r tubercu-
                l o s i s o r mental d i s e a s e ) f o r i n d i v i d u a l s 2 1
                y e a r s of a g e o r o l d e r ; and
                5 ) p h y s i c i a n s 1 s e r v i c e s , whether f u r n i s h e d
                i n t h e o f f i c e , t h e p a t i e n t ' s home, a h o s p i t a l ,
                o r a s k i l l e d n u r s i n g home, o r elsewhere.
           The aforementioned f i v e b a s i c s e r v i c e s a r e n o t mandatory
f o r t h e m e d i c a l l y i n d i g e n t . For i n s t a n c e , under r e c e n t amend-




46   S e c t i o n . 1902 ( a
     Handbook of Publi:
     Secfion~          5120.
                                  lo), T i t l e X I X , t t S o c i a l S e c u r i t y Act."
                                   Assistance Administration,                 m.          P,
 ments t o t h e S o c i a l S e c u r i t y Act a n o p t i o n i s g i v e n whereby a
 s t a t e may e l e c t t o p r o v i d e t h e f i v e b a s i c s e r v i c e s t o t h e medi-
 c a l l y i n d i g e n t o r s e v e n o u t of 1 4 m e d i c a l s e r v i c e s a u t h o r i z e d
 u n d e r t h e S o c i a l S e c u r i t Act. I n a d d i t i o n t o t h e f i v e b a s i c
                                         1
 s e r v i c e s , m e d i c a l c a r e i ems e n u m e r a t e d u n d e r t h e S o c i a l S e c u r i t y
 Act include:

                  6 ) m e d i c a l c a r e , o r a n y o t h e r t pe o f reme-
                d i a l c a r e recognized under s t a t e law fur-
                n i s h e d by l i c e n s e d p r a c t i t i o n e r s w i t A i n t h e
                s c o p e o f t h e i r p r a c t i c e a s d e f i n e d by s t a t e
                law:
                  7)     home h e a l t h c a r e s e r v i c e s ;
                  8)    private duty nursing services;
                  9)     clinical services;
                10)      dental services;
                11)      physical therapy:
                1 2 ) p r e s c r i b e d d r u g s , d e n t u r e s , and p r o s t h e -
                t i c devices including eyeglasses;
                13) other diagnostic, screening, preventive
                and r e h a b i l i t a t i v e s e r v i c e s ; and
                1 4 ) i n p a t i e n t h o s p i t a l s e r v i c e s and s k i l l e d
                n u r s i n g home s e r v i c e s f o r i n d i v i d u a l s , 65
                y e a r s o f age o r o v e r , i n an i n s t i t u t i o n f o r
                t u b e r c u l o s i s o r mental d i s e a s e s ,
               niformit
              s o t7 tego
                            .      I n g e n e r a l , T i t l e X I X r e q u i r e s t h a t medical
s e r v i c e%e c+ r i c a l l y n e e d y and t h e m e d i c a l l y i n d i g e n t be
                               a
uniform. However, b e c a u s e o f t h e e x t e n s i v e b e n e f i t s o f f e r e d
u n d e r Medicare ( ~ i t l e V I I I ) many s t a t e s were r e l u c t a n t t o "buy-
                                      X
i n " t o t h e s u p p l e m e n t a r y m e d i c a l i n s u r a n c e program o f f e r e d u n d e r
Medicare f o r t h e i r o l d a g e a s s i s t a n c e r e c i p i e n t s . The s t a t e s
d i d n o t " b u y - i n n t o M e d i c a r e , b e c a u s e t h e y assumed t h a t t h e same
s e r v i c e s p r o v i d e d f o r o l d a g e a s s i s t a n c e r e c i p i e n t s would a l s o
have t o b e p r o v i d e d t o o t h e r w e l f a r e r e c i p i e n t s u n d e r T i t l e X I X .
The S t a t e Board o f W e l f a r e , however, e l e c t e d t o "buy-in" t o Medi-
c a r e f o r C o l o r a d o Old Age P e n s i o n e r s .
              I n o r d e r n o t t o d i s c o u r a g e t h e s t a t e s from a s s i s t i n g
p e n s i o n e r s t o p a r t i c i p a t e i n M e d i c a r e , C o n g r e s s a d o p t e d a n amend-
ment t o t h e S o c i a l S e c u r i t y A c t , p r o v i d i n g t h a t m e d i c a l c o v e r a g e
f o r r e c i p i e n t s u n d e r a g e 65 need n o t p r o v i d e t h e same s e r v i c e s
r e c e i v e d u n d e r t h e s u p p l e m e n t a r y m e d i c a l i n s u r a n c e program o f
Medicare. I n o t h e r words, C o l o r a d o ' s T i t l e X I X program d o e s n o t
have t o p r o v i d e t h e same s e r v i c e s t o p e r s o n s u n d e r 65 a s cur-
r e n t l y provided t o Old Age P e n s i o n e r s .


                     T i t l e X I Y LesLslation i n Other Stateg

              A s of J u l y 1, 1967, some 37 s t a t e s have a d o p t e d T i t l e XIX.
The C o u n c i l s t a f f reviewed l e g i s l a t i o n i n 32 s t a t e s i n o r d e r t o
d e v e l o p i n f o r m a t i o n on a p p r o a c h e s made b v a r i o u s s t a t e l e g i s l a -
t u r e s t o implement
laws were s t u d i e d :
                                                                   1
                                                                  b a s c a s p e c t s of t h e s e s t a t e
                                                              r e q u i r e m e n t s f o r r i c k i p t of
medical a s s i s t a n c e ;                                   m e d i c a l s e r v i c e s provided:
and 3 ) t h e amount of r e s p o n s i b i l i t y d e l e g a t e d t o a d m i n i s t r a t i v e
a e n c i e s t o e s t a b l i s h a program u n d e r T i t l e X I X . A summary of
 g
t e a f o r e m e n t i o n e d c h a r a c t e r i s t i c s of T i t l e X I X l e g i s l a t i o n i s
c o n s t a i n e d i n T a b l e 11.

Medical S e r v i c e s
              S e v e n t e e n o f t h e t h i r t y - t w o s t a t e laws reviewed made no
a t t e m p t t o o u t l i n e t h e t y p e of s e r v i c e s t h a t must be provided
u n d e r T i t l e XIX, I n o t h e r words, t h e a d m i n i s t r a t i v e a g e n c i e s
were g i v e n c o m p l e t e d i s c r e t i o n t o e s t a b l i s h any l e v e l o f m e d i c a l
s e r v i c e s t h a t would meet f e d e r a l s t a n d a r d s , s u b j e c t , of c o u r s e ,
t o a v a i l a b l e s t a t e f u n d s . The l e g i s l a t u r e s o f 13 s t a t e s however,
i t e m i z e d a broad b a s e of m e d i c a l s e r v i c e s i n t h e i r enabl!ng l e g -
i s l a t i o n . Only two s t a t e s        --       Georgia and Wyoming          --            anK
s i g n i f i c a n t a t t e m p t t o l i m i t t h e s c o p e of m e d i c a l s e r lneds e s w i c h
                                                                                         vic
c o u l d b e made a v a i l a b l e . Even u n d e r Wyomin ' s law, s e r v i c e s can
                                                                         i!
b e expanded w i t h o u t f u r t h e r l e g i s l a t i v e a c t on. S e c t i o n 3 o f t h e
Wyoming "Medical A s s i s t a n c e and S e r v i c e s Act of 1967" d e f i n e s
medical a s s i s t a n c e a s f o l l o w s : ~
                 "..   .means payment t o p r o v i d e r s o f p a r t o r
                 a l l o f t h e o r d i n a r y and r e a s o n a b l e c h a r g e s
                 o f t h e f o l l o w i n g s e r v i c e s and s u p p l i e s f o r
                 q u a l i f i e d i n d i v i d u a l s and f a m i l i e s i n c l u d -
                 ing: i n p a t i e n t h o s p i t a l s e r v i c e s [ o t h e r
                 than services i n a public i n s t i t u t i o n f o r
                 tuberculosis); outpatient hospital services;
                 o t h e r l a b o r a t o r y and X-ray s e r v i c e s ; s k i l l e d
                 n u r s i n g home s e r v i c e s ( o t h e r t h a n s e r v i c e s
                 i n a public i n s t i t u t i o n f o r tuberculosis);
                 t h e p r o f e s s i o n a l s e r v i c e s of a l i c e n s e d physi-
                 cian, o r osteopathic physiciansn




J
8     S e s s i o n Laws   of Wvominq,          1967, C h a p t e r 238.
Although t h e i n t e n t of s e c t i o n 3 of t h e Wyoming a c t a p p e a r s t o
mean t h a t t h e medical s e r v i c e s s h a l l be l i m i t e d t o s e r v i c e s
itemized, t h e s e c t i o n does n o t a c t u a l l y r e s t r i c t s e r v i c e s t o
t h e s e items. Furthermore, s e c t i o n 1 7 s t a t e s t h a t t h e a c t s h a l l
be l i b e r a l l y c o n s t r u e d s o a s t o b e n e f i t p e r s o n s r e q u i r i n g medical
a s s i s t a n c e and conform w i t h t h e p r o v i s i o n s of T i t l e X I X , s u b j e c t
t o the limitations set forth in the act.
              The Georgia a c t , on t h e o t h e r hand, i s q u i t e e x p l i c i t i n
l i m i t i n q t h e medical s e r v i c e s t o be provided. The "Georgia Pub-
l i c A s s i s t a n c e Act of 1965," a s amended, d e f i n e s medical a s s i s t -
ance a s payment of p a r t o r a l l t h e c o s t of t h e f i v e b a s i c services
r e q u i r e d under T i t l e X1X. W
M e d i c a l l y Needy Proqrams
              S i m i l a r t o t h e l e g i s l a t i o n f o r medical s e r v i c e s , t h e T i t l e
X I X laws o f 14 s t a t e s do n o t a c t u a l l y d e t e r m i n e whether a m e d i c a l
a s s i s t a n c e program f o r t h e m e d i c a l l y i n d i g e n t i s t o be e s t a b l i s h e d
o r n o t . These 1 4 s t a t e s a d o p t e d p e r m i s s i v e l e g i s l a t i o n which a l -
lows t h e s t a t e a g e n c i e s t o p r o v i d e a program f o r t h e m e d i c a l l y
needy w i t h i n t h e scope of a v a i l a b l e s t a t e f u n d s . Of t h e 1 4 s t a t e s
with permissive l e g i s l a t i o n , s i x s t a t e s provide f o r t h e medicall
indigent       --
v a n i a , and Utah.
                       C o n n e c t i c u t , Kansas, Kentucky, M a s s a c h u s e t t s , Pennsy          1-
              The l e g i s l a t u r e s of 1 2 s t a t e s r e q u i r e t h e e s t a b l i s h m e n t
of a program f o r t h e m e d i c a l l y i n d i g e n t        --
I l l i n o i s , Maryland, Michigan, Minnesota, New Hampshire, New
                                                                      C a l i f o r n i ? , Delaware,
York, North Dakota, Oregon, Rhode I s l a n d , and Wisconsin.
        The Delaware a c t d e f i n e s a s s i s t a n c e t o t h e m e d i c a l l y i n d i -
gent a s follows:l0/
                H...means medical c a r e f u r n i s h e d on b e h a l f
                o f i n d i v i d u a l s who would, i f needy be e l i -
                  i b l e f o r a s s i s t a n c e i n any of t h e c a t e g o r i e s
                f i s t e d i n s u b s e c t i o n s ( 1 ) . ( 2 ) . and ( 3 ) of
                s e c t i o n 504 of t h i s t i t l e o r f o r a s s i s t a n c e
                t o t h e needy b l i n d , and on b e h a l f o f i n d i v i d -
                u a l s who a r e u n d e r t h e a g e o f 2 1 y e a r s , pro-
                v i d e d s u c h i n d i v i d u a l s have i n s u f f i c i e n t
                income and r e s o u r c e t o meet t h e c o s t s of nec-
                e s s a r y medical o r r e m e d i a l c a r e and s e r v i c e s . "
                                           Table I1
                   CHARACTERISTICS OF TITLE X I X LEGISLATION 

                         ADOPTED I N VARIOUS STATES* 


                                  Medical S e r v i c e s                 Medically I n d i a w
                      Selection                                                               No
                      delegated        Act l i s t s   Limitation         Act        Act    provi-
                      to state         extensive       p l a c e d on    estab-      per-     sion
                        aaency          services         services        lishas mita..-
Alabama
California
Connecticut
Delaware
Georgia
Hawaii*
Idaho
Illinois
Iowa**
Kansas
K e n t l ~ky
           c                x
Louisiana                   x
Maine                       x
Maryland                    x
Massachusetts               x
Michigan
Minnesota
Montana
Nebraska
Nevada
New Hampshi e               x
New M e x i c o 2
New York
North Dakota                 x
Ohio                         x


*	     Table c o n t a i n s i n f o r m a t i o n on implementing l e g i s l a t i o n o n l y and
       d o e s not r e f l e c t t h e c o n t e n t of s t a t e p l a n s . Source: review of
       legislation i n various states.
**   	 Enabling l e g i s l a t i o n n o t a v a i l a b l e .
       Only i f r e q u i r e d by f e d e r a l law a s a c o n d i t i o n f o r f e d e r a l
       participation.
       C a t e g o r i c a l l y r e l a t e d only.
       Apparently a u t h o r i t y t o e n t e r i n t o a T i t l e XIX program e x i s t s
       under g e n e r a l l e g i s l a t i o n e s t a b l i s h i n g w e l f a r e programs.
       L i s t s s e r v i c e s t o be. provided t o a l l covered groups. l i s t may
       be expanded by s t a t e agency.
                                         Table 11 

                                        (Continued)
                                 Medical S e r v i c e s                Medically Indiqent          '




                       Selection                                                             No
                       delegated     Act l i s t s   Limitation        Act        Act      provi-
                       to state      extensive       placed on        estab-      per-      sion
                         aqency       services        services        lishes      m e       made
0klahornY
oregod
Pennsylvania
Rhode I s l a n d
Texas
South Dakota
Utah
Vermont
Washington**
West V i r g i n i a
Wisconsin
Wyoming
       Totals


a*    Enabling l e g i s l a t i o n not a v a i l a b l e . 

f
a     Only i f r e q u i r e d by f e d e r a l law a s a c o n d i t i o n f o r f e d e r a l 

      participation.

      Apparently a u t h o r i t y t o e n t e r i n t o a T i t l e X I X program e x i s t s 

      under general l e g i s l a t i o n e s t a b l i s h i n g welfare programs. 

J
d     Act l i s t s e x t e n s i v e s e r v i c e s , but executive agency makes f i n a l
      determination of scope and c o n t e n t of medical care.
The Delaware a c t d o e s n o t p r o v i d e f o r income s t a n d a r d s , l e a v i n g
t h i s t o t h e d i s c r e t i o n of t h e a d m i n i s t r a t i v e agency. The a c t
d o e s , however, l i s t c r i t e r i a t o be c o n s i d e r e d by t h e a d m i n i s t r a -
t i v e agency i n e s t a b l i s h i n g s u c h s t a n d a r d s . F o r example, t h e
a d m i n i s t r a t i v e agency must t a k e i n t o c o n s i d e r a t i o n c o s t s of
p r o v i d i n g h e a l t h services, a b i l i t y o f a p p l i c a n t s t o pay s u c h
c o s t s , c o n s i d e r a t i o n o f a d e q u a t e s t a n d a r d s o f l i v i n g , e t c . The
laws o f o n l y f o u r s t a t e s
Wisconsin        --
                                           --       Michigan, Minnesota, Oregon, and
                          a c t u a l l y s p e l l o u t income s t a n d a r d s f o r d e t e r m i n i n g
e l i g i b i l i t y f o r t h e m e d i c a l l y needy program. Oregon law, how6
e v e r , s p e c i f i c a l l y l i m i t s t h e m e d i c a l l y i n d i g e n t program t o
a v a i l a b l e f u n d s . I n t h e o t h e r 18 s t a t e s w i t h m e d i c a l l y needy
programs, t h e e x t e n t of c o v e r a g e i s l i m i t e d by t h e a v a i l a b i l i t y
of f e d e r a l and s t a t e f u n d s o n l y .
t h e Oregon Act i s c o n t a i n e d i n Appendix A.
                                                           o or         7
                                                                     pur o s e s of i l l u s t r a t i o n ,

           The a c t s o f s i x s t a t e s ( ~ e o r g i a , I d a h o , Montana, Nebraska,
Texas, and ~ y o m i n g )r e s t r i c t t h e development o f m e d i c a l l y i n d i -
g e n t s e r v i c e s . I n Idaho and Texas t h e m e d i c a l l y i n d i g e n t program
may o n l y b e d e v e l o p e d t o meet t h e r e q u i r e m e n t s o f f e d e r a l law,
while t h e enabling l e g i s l a t i o n i n t h e remaining f o u r s t a t e s does
n o t provide f o r an i n d i g e n t category.


                                S t a t e Plans f o r T i t l e XIX

              Thirty-seven s t a t e s have, o r a r e i n t h e process of i n i t i -
a t i n g , s t a t e p l a n s t o implement T i t l e X I X . T a b l e I11 p r o v i d e s a
summary of t h e s e s t a t e programs. P e r h a p s t h e development o f
T i t l e X I X programs i n t h e v a r i o u s s t a t e s h a s been b a s e d , a t l e a s t
i n p a r t , on t h e income r e s o u r c e s o f r e s p e c t i v e s t a t e s . F o r i n -
s t a n c e , of t h e t w e n t y s t a t e s w i t h h i g h e r p e r c a p i t a incomes t h a n
Colorado, a l l b u t t h r e e s t a t e s
Jersey      --
                                                     --A l a s k a , I n d i a n a , and New
                  have a d o p t e d T i t l e X I X programs. More s i g n i f i c a n t ,
however, i s t h e p a t t e r n of development o f t h e m e d i c a l l y i n d i g e n t
programs. F o r i n s t a n c e , t w o - t h i r d s o f t h e s t a t e s a d o p t i n g medi-
c a l l y i n d i g e n t programs have a h i g h e r p e r c a p i t a income t h a n
C o l o r a d o . I n a d d i t i o n , s e v e n of t h e t e n w e a l t h i e s t s t a t e s pro-
v i d e a program f o r t h e m e d i c a l l y needy ( C o n n e c t i c u t , Delaware
I l l i n o i s , New York, C a l i f o r n i a , Washington, and ~ a s s a c h u s e t t s ) ,
w h i l e Kentucky i s t h e o n l y s t a t e i n t h e t e n l o w e s t p e r c a p i t a
income s t a t e s t o i n i t i a t e a program f o r t h e m e d i c a l l y i n d i g e n t .
I n any e v e n t , 20 s t a t e s w i t h l e s s p e r c a p i t a income t h a n Colo-
r a d o a l r e a d y have a d o p t e d T i t l e X I X ; however, a l i t t l e l e s s t h a n
o n e - t h i r d of t h e s e s t a t e s provide f o r t h e medically i n d i g e n t .

Medical S e r v i c e s O f f e r e d Under S t a t e P l a n s
            The b a s i c m e d i c a l program r e q u i r e d u n d e r T i t l e X I X i n -
c l u d e s i n p a t i e n t and o u t p a t i e n t h o s p i t a l c a r e , . a s w e l l a s n u r s i n g
home, p h y s i c i a n , and o t h e r l a b o r a t o r y and X-ray s e r v i c e s . The
f e d e r a l government, of c o u r s e , p a r t i c i p a t e s i n o t h e r t y p e s of
medical c a r e which may b e needed. With t h i s i n mind, o n l y
Georgia l i m i t s t h e medical s e r v i c e s t o t h e aforementioned f i v e
b a s i c s e r v i c e s . I n g e n e r a l , o f f i c i a l s of t h e Bureau of Family
S e r v i c e s p o i n t o u t t h a t i n developing a program o f medical a s -
s i s t a n c e , a system of p r i o r i t i e s needs t o be e s t a b l i s h e d . F o r
i n s t a n c e , perhaps two of t h e most i m p o r t a n t a r e a s i n a d d i t i o n t o
t h e f i v e b a s i c s e r v i c e s a r e d r u g s and t r a n s p o r t a t i o n .      If trans-
p o r t a t i o n i s n o t a v a i l a b l e r e c i p i e n t s may n o t be a b l e t o g e t t o
a c l i n i c t o r e c e i v e medicai a s s i s t a n c e a t t h e p r o p e r time. And
w i t h o u t t h e a v a i l a b i l i t y of d r u g s , monies s p e n t f o r p h y s i c i a n ' s
s e r v i c e s may be wasted. Most s t a t e s have recognized t h e s e prob-
lems and 30 of t h e 35 s t a t e s f o r which i n f o r m a t i o n i s a v a i l a b l e
p r o v i d e f o r t r a n s p o r t a t i o n and p h a r m a c e u t i c a l s , a t l e a s t t o some
degree ( s e e Table 1 I ) .     1
             "Home h e a l t h s e r v i c e s a i n c l u d e i n t e r m i t t e n t o r p a r t - t i m e
n u r s i n g o r home h e a l t h a i d s , a s w e l l a s i n c l u d i n g medical sup-
p l i e s and a p l i a n c e ~recommended by a p h y s i c i a n f o r use by a
                  R
p a t i e n t i n i s home. T h i r t y s t a t e s have adopted home h e a l t h c a r e
programs, E x t e n s i v e p r i v a t e d u t y n u r s i n g s e r v i c e s , on t h e o t h e r
hand, which cannot be met under home h e a l t h c a r e a r e a v a i l a b l e i n
o n l y 1 4 s t a t e e . S i x s t a t e s ( ~ o n n e c t i c u t ,New York, Washington,
                                                                        a
Massachusetts, Minnesota, and North ~ a k o t ) have i n c l u d e d p r i v a t e
d u t y n u r s i n g f o r t h e m e d i c a l l y i n d i g e n t under t h e i r r e s p e c t i v e
s t a t e plans.
            D e n t a l S e r v i c e s . Although some d e n t a l c a r e i s provided
under county g e n e r a l a s s i s t a n c e programs i n Colorado, no provi-
s i o n i s made under t h e v a r i o u s s t a t e p l a n s f o r p a r t i c i p a t i o n by
t h e s t a t e of Colorado i n d e n t a l a s s i s t a n c e under t h e f e d e r a l l y -
a i d e d c a t e g o r i c a l programs. N e v e r t h e l e s s , d e n t a l s e r v i c e s have
been i n c l u d e d i n 80 p e r c e n t of t h e s t a t e p l a n s under T i t l e X I X .
Even 1 6 of t h e 21 s t a t e s w i t h m e d i c a l l y needy programs i n c l u d e
d e n t a l c a r e f o r t h e m e d i c a l l y i n d i g e n t , According t o o f f i c i a l s
o f t h e Bureau of Family S e r v i c e s , d e n t a l c a r e i s n o t a l a r g e i t e m
f o r o l d e r r e c i p i e n t s ; however d e n t a l c a r e f o r c h i l d r e n can be
expensive. For i n r t a n c e , a s i x month s t u d y of I d a h o ' s T i t l e X I X
program ( ~ a n u a r yt o J u n e       --     1967) r e v e a l e d t h a t of $276,326
s p e n t f o r d e n t a l c a r e on c a t e g o r i c a l l y needy, f a m i l i e s w i t h de-
pendent c h i l d r e n accounted f o r $222,442.
             E x t e n s i v e use a l s o is made of o t h e r c a t e g o r i e s of medical
s e r v i c e s by s t a t e s p a r t i c i p a t i n g i n T i t l e XIX. Some 26 s t a t e s
provide f o r eye c a r e and/or e y e g l a s s e s ; 24 s t a t e s p a r t i c i p a t e i n
p h y s i c a l t h e r a p y programs; and 20 s t a t e s pay p a r t of t h e c o s t of
d i a g n o s t i c , s c r e e n i n g , and r e h a b i l i t a t i v e s e r v i c e s .
           O t h e r O p t i o n a l S e r v i c e s Provided. I n i t i a l p r o rams of
                                                                                        P

borne s t a t e s , such a s C o n n e c t i c u t , a l r e a d y p r o v i d e med c a l s e r -
v i c e s above and beyond t h o s e r e q u i r e d by HEW t o be a v a i l a b l e by
1975. These e x t r a s e r v i c e s i n c l u d e such items a s blood bank
                                                                              W   X   X    X   K   X    Y


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                       X   X   X    x	 x     X              X     X   X       X   X   X    X   x   x    x       X



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                       X   X   X    X	   X   X    X         X     X   X   X   X   X   X    M   X   X    X       X    X



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                       X   X   X    x    X   X    x    X ' X      X   X   X   X   X   X    X   x   x    x       X    X


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                                    W    X   X    X	   X    X     X   X   X   X   X   X    X   X   X    X   M   X    X
                                                                                                       TM9.E 1 1 (Continued) 

                                                                                                              1
                                                                                              COWARISON OF TITLE XIX PROGRW& 


   S t a t e s Ranked 	                                                        Appliances.                   Eyeglasses               Ambulance                          H o s p i t a l and        P h y s i c a l Therapy
   By P e r C a p i t a
         --
  Personal In-
                               Five            Home
                                           Health                     Pi;;mi;?;d
                                                                   h u g s and P r o s t h e t i c
                                                                                   and/or
                                                                                                               and/or
                                                                                                             Optometrlc
                                                                                                                                        and/or
                                                                                                                                 T r a t p o r t 8 t i o n Duty
                                                                                                                                    CSe~i~es
                                                                                                                                                           Private      Nursing Home f o r
                                                                                                                                                                         TB and mental
                                                                                                                                                                                                             and/or
                                                                                                                                                                                                      Rehabilitative                Clinic
 F ome         196&
                                          M                       	
                                                                                Yhotic
                                                                                              M .
                                                                                                              Frvices
                                                                                                                      M                           M 
     3u.y
Texas
     (22.511)
     - -
Utah                       X          X                       X   x
     (S2rW)
Oklahoma                   X          X    X         X
     (62.4%)
Idaho                      X
     (82,441)
Maine                      X               X
     ( 82,438)
North Dakota               X      X       X      X        X       X
     (52,400)
South Dakota 	             X               X                  X
     ( 52,335)
Geo i a                    L e g i s l a t i o n enacted.
   ?52,311)
New Mexico
     (82.310)
~ouisianr .
     (92,257)
North Carolina
     (82.235)
                           X	      X      X      X        X       X    X          X

 Tennessee
      (32,199)
 West V i r g i n i a      X               X                  X        X                  X                    X                    X
      (sa,195)
 Alabama                   W i l l not i m p l u e t a t present, hut l e g i s l a t i o n h a s been enacted.
     ( 52,039)
 South Carolina
     (92.027)




 2
     Act.
           rove?andiin
                                +
       a t a on e r v c e s p r o v i e t a e n rom- S e l e c t e d C h a r a c t e r i s t i c s of S t a t e Medical A s s i s ance P
                                      era;:odn
     b u ~ n ~ n a ona s u p ~ i i d f v c i d !t
                                                   A t o f E e c & b e n , Department o
                                                           a
                                                                                                                   f      ~        i      e        n       t       ~
                                                                                                                                                                        m a Unde T i t 1 X I X pf he S
                                                                                                                                                                           d      &        S    i   c    e

 -/ C = C a t e g o r i c a l l y needy. i.e., persons who a r e r e c i p i e n t s o r who c o u l d be e l i g i b l e f o r a i d u n d e r T i t l e s I. N. X, a d XIV o f t h e S o c i a l S e c u r i t y
                                                                                                                                                                                                                  s
                                                                                                                                                                                                                     a1 S s c u r i t A c t
                                                                                                                                                                                                                         ~      a        &     ~   i


	3
 J   M = Medically needy, i.e., t h o s e who e x c e p t f o r income, would be e l i g i b l e f o r a s s i s t a n c e under one o f t h e p u b l i c a s s i s t a n c e t i t l e s of t h e S o c i a l
     S e c u r i t y Act, and whose income, t h e s t a t e , d e f i n e s a s i n a d e q u a t e t o meet t h e c o s t s of medical care.
     Surve of Current Business,                          ril, 1%7, U.S. Department of Commerce, O f f i c e of Business Economics.
 vp-r;Ll ~	and t~ t ta ihn c l_ d en dhee vaap teiuotni ,c rand/orl o g y h a r tyves aofa t lei m i t e d p s andh iiast rprovided o n l o f ava-rying snpai tt u rl iez a trieo n i n c a s eisn otfh malignancy. 
-

       syc o
     Oklahoma
                       i~ es ng e
                                      i      u
                                                     *f
                                                   t r
                                                         ua
                                                                   adio
                                                                             ot e
                                                                                     s a sep r              program
                                                                                                                       yc             i c srrvlces
                                                                                                                                                          y f t e r ho            a
                                                                                                                                                                                         a   included
                                                                                                                                                                                                       -
                                                                                                                                                                                                               e progrr.

                                                                                                                                                                                                          .
 I/ 	The f i v e b a s i c s e r v i c e s i n c l u d e : a) i n p a t i e n t h o s p i t a l s e r v i c e ; b ) o u t p a t i e n t h o s p i t a l s e r v i c e ; c ) s k i l l e d nursing home s e r v i c e : d l p h y s i c i a n s
                                                                      .
     s e r v i c e s ; e ) o t h e r l a b o r a t o r y and X-ray s e r v i c e s .
     H o s p i t a l i z a t i o n f o r mental p a t i e n t s on1
     Drugs provided only d u r i n g - h o s p i t a l i z a t i o n and/or when administered d i r e c t l y by a physician.
     Information i s n o t p r e s e n t l y a v a i l a b l e .
     Connecticut a l s o p r o v i d e s f o r c a r e i n " r e s t homem with n u r s i n g s u p e r v i s i o n .
     New Mexico includes: a) t h e s e r v i c e s of m a t e r n i t y homes which m e e t s k i l l e d n u r s i n g home s t a n d a r d s and a r e approved by t h e C h i l d Welfare S e r v i c e s
     Division; and b) o b s t e t r i c a l s e r v i c e s provided by a l i c e n s e d midwife.
s e r v i c e s , h e a r i n g a i d s , m a t e r n i t y c a r e c e n t e r s , and t r e a t m e n t
c e n t e r s l i c e n s e d a s medical i n s t i t u t i o n s . Minnesota's s t a t e plan
s u p p l i e s a s i m i l a r broad range of s e r v i c e e , b u t r a t h e r than swll-
i n g o u t a l l t h e t y p e s of c a r e , s e r v i c e s a r e made a v a i l a b l e if a
d o c t o r ' s r e f e r r a l o r p r e s c r i p t i o n deems them necessary.
             A d d i t i o n a l S e r v i c e s f o r Medically In a e n t . P r i o r t o t h e
1967 amendments t o t h e S o c i a l S e c u r i t y Act,%edical c a r e f o r t h e
medically i n d i g e n t had t o i n c l u d e t h e f i v e b a s i c s e r v i c e s . Sur-
p r i s i n g l y , however, s t a t e s adopting i n d i g e n t programs have gone
well beyond t h e f i v e b a s i c s e r v i c e e i n m e ~ t i n gmedical needs of
t h e medically i n d i g e n t , For i n s t a n c e , l 9 of t h e 21 s t a t e 8 adopt-
ing a program f o r t h e medically needy i n c l u d e drugs; 18 s t a t e s
meet home h e a l t h c a r e c o s t s ; t r a n s p o r t a t i o n expenses a r e provided
i n 16 s t a t e s ; d e n t a l c a r e i n 16 s t a t e s - and p h y s i c a l t h e r a p - a n d
o r t h o p e d i c supply expenses a r e met i n 13 s t a t e s ( s e e Table V).
I n any e v e n t , f o r s t a t e s adopting t h e i n d i g e n t program, s e r v i c e s
                                                                                              1
f o r t h e medically needy g e n e r a l l y p a r a l l e l t h a t provided f o r
categorically-related recipients.
                                              TABLE IV
                     NUMBER O STATES PROVIDING VARIOUS TYPES 

                             F
                               OF MEDICAL SERVICES 

                                                Number o f S t a t e s       Number o f S t a t e s
                       T o t a l number o f     providing service            roviding service t o
    Medical
    Service
                       S t a t e s provid-
                          i n s service
                                                t o Categorically
                                                    Needy only
                                                                            E0th categorically 8
                                                                              m e d i c a l l y needy
Basic f i v e
services                       35
Transporta-
t i o n and/or
ambulance                      30
Prescribed
drugs, phar-
maceuticals                    30**
Prosthetic
d e v i c e s and/
or orthotic
appliances                     30
Home h e a l t h
care                           30
Dental                         28                         12                            16
Eyeglasses
and/or
eye c a r e                    26
P h y s i c a l and/
or rehabilita-
t i v e therapy                24
Private duty
nursing                        14
Clinic                         16                           6	                           10
Other diag-
n o s t i c , screen-
ing, preventive
and r e h a b i l i t a -
tive                           20


++ 	   Two s t a t e s , Idaho and Michigan, l i m i t d r u g s ' t o t h o s e provided d u r -
       i n g h o s p i t a l i z a t i o n and one s t a t e , Maine, l i m i t s d r u g s t o t h o s e
       provided d u r i n g h o s p i t a l i z a t i o n o r a d m i n i s t e r e d d i r e c t l y by a
       physician.
            Comparison of Medical E x p e n d i t u r e s               -- 5 0 S t a t e %
             T r a d i t i o n a l l y , t h e s t a t e o f C o l o r a d o h a s expended r e l a -
t i v e l y l a r g e r amounts o f money f o r m e d i c a l programs f o r w e l f a r e
r e c i p i e n t s , p a r t i c u l a r l y f o r o l d a g e p e n s i o n e r s , t h a n many o t h e r
s t a t e s . F o r example, t h e C o l o r a d o Department of W e l f a r e s p e n t
more money p e r i n h a b i t a n t ($5.84) f o r m e d i c a l a s s i s t a n c e i n t h e
f i r s t s i x months o f 1965 t h a n a l l b u t f i v e s t a t e s
($9.01) , Minnesota ( $ 8 . 1 2 ) , N e w York ( $ 5 . 9 3 ) , Washington ($6.84),
                                                                                    --       Massachusetts
and Wisconsin ( $ 6 . 0 1 ) .                (See Table V).            I n comparison t h e a v e r a g e
f o r a l l 50 s t a t e s f o r t h e same p e r i o d was $3.45 p e r i n h a b i t a n t .
              I n f o r m a t i o n c o n c e r n i n g v e n d o r payments f o r t h e f i r s t s i x
months o f 1966 a p p e a r t o b e h i g h e r t h a n u s u a l i n C o l o r a d o . F o r
i n s t a n c e , v e n d o r payments o f C o l o r a d o ' s W e l f a r e Department f o r 30
s e l e c t e d months follow.k&/
                          J a n u a r y - J u n e 1965               $5.84
                          July
                          January
                                   - - December 1965
                                          J u n e 1966
                                                                      6.20
                                                                      7.23
                          July
                          January
                                   - - December 1966
                                          J u n e 1967
                                                                      6.58
                                                                      6.11
F l u c t u a t i o n s i n v e n d o r payments may b e due i n p a r t t o r e p o r t i n g
procedures, b i l l i n g procedures, e t c . Nevertheless only f i v e
s t a t e s e x c e e d e d C o l o r a d o ' s m e d i c a l v e n d o r payments f o r w e l f a r e i n
t h e f i r s t s i x months o f 1966. The a v e r a g e p e r i n h a b i t a n t f o r
m e d i c a l payments i n t h e f i r s t s i x months o f 1966 amounted t o
$4.37     --      r o u g h l y 6 0 p e r c e n t o f t h e amount s p e n t by C o l o r a d o .
              The i n c r e a s e d m e d i c a l s e r v i c e a c t i v i t y u n d e r T i t l e X I X be-
comes a p p a r e n t i n t h e f i r s t s i x months o f 1967. F o r t h e 2 6
s t a t e s w i t h T i t l e X I X programs i n e f f e c t i n t h e f i r s t s i x months
of 1967, a v e r a g e p e r p e r s o n m e d i c a l v e n d o r payments i n t h e s e
s t a t e s amounted t o $7.11, e x c e e d i n g C o l o r a d o ' s $6.11 c o s t by
$1.00 p e r i n h a b i t a n t . S p e c i f i c a l l y , m e d i c a l vendor payments i n
15 s t a t e s w e r e i n e x c e s s o f t h e amount s p e n t p e r i n h a b i t a n t i n
C o l o r a d o . A l l o f t h e s e s t a t e s have a d o p t e d T i t l e X I X .
             From 1965 t o 1967, m e d i c a l vendor payments more t h a n
d o u b l e d i n t h e s t a t e s o f Delaware, New York, C a l i f o r n i a , Maryland,
Hawaii, Rhode I s l a n d , Vermont, and Oklahoma. The most e x p e n s i v e
m e d i c a l a s s i s t a n c e programs a p p e a r t o b e i n C a l i f o r n i a and New
York; b o t h o f t h e s e programs exceeded $14 p e r c a p i t a f o r t h e
f i r s t s i x months o f 1967. These s t a t e s o f f e r b r o a d b a s e d pro-
grams w i t h e x t e n s i v e c a r e t o t h e m e d i c a l l y i n d i g e n t . I n a d d i t i o n
t o C a l i f o r n i a and New York, s e v e n o t h e r s t a t e s have e x t e n s i v e
programs f o r t h e m e d i c a l l y i n d i g e n t . T h e v e n d o r payment c o s t s p e r



          on
m ~ a s e d d a t a o b t a i n e d from Bureau of Family S e r v i c e s , H.E.W.
            AMOUNT WENDED   PEB M E I T A N T FOR MELFARE   P
                                                            A-     TO MEDICAL -V       F R VAEU(XIS SIX--
                                                                                        O                        PEBIODS

                                                                                                 Per Cbpita M w d i c a l Vendor P a y m a t s
                                                                                                        BY Ylslfara Deoaxtments
                                                                                              Janwry             January               January
                    Per               Date             Includes          Max. Income             to                 to                    to
                                     Program-          Medically          Family of             Juru                June                 June
      -
      State       -
                  Capita
                  Income            Jnitiated            Needv              Feu*             19hi5b              lssab                   1967c




Connecticut        53,678          July      1966            Yes
Delaware            3,563          Oct.      1966            Yes
Illinois            3,511          Jan.      1966            Yes
New York            3,480                    1966            Yes
California          3,449          gz.       1966            Yes
Nevada
Washington
                   3,330
                   3,280
                                      N.A.
                                   July      1966
                                                             ---
                                                             Yes
Massachusetts      3,271           Sept.     1966            Yes
Mawland            3,220           July      1966            Yes
Michigan           3,219           Oct.      1966            Yes
Hawaii
Ohio
Rhode Island
                   3,143
                   3,027
                   2,980
                                   Jan.
                                   July
                                             1966
                                             1966            ---
                                                             Yes
                                   July      1966            Yeo
Pennsylvania       2,951           June      1966            Yes
Oregon             2,938               LA.                   Yes
Wisconsin                          July      1966           Yes             3,700
Iowa                               July      1967           Yes             N.A.
Minnesota
Nebraska
                                   Jan.
                                   July
                                             1966
                                             1966            ---
                                                            Yes             3.036
Kansas                                N.A.                  Yer
New Harapshire     2,761              N.A.                  Yes
Wyoming
Montana
                   2.686
                   2,615
                                   July
                                   July
                                             1967
                                             1967
                                                             ---
                                                             ---
Vermont
Texas
                   2,590
                   2,511
                                   July
                                   Sept.
                                             1966
                                             1967
                                                             ---
                                                             ---
Utah               2,300           July      1966           Yes
Oklahoma           2,456           Jan.      1966           Yea
Idaho
Maine
                   2,441
                   2,438
                                   July
                                   July
                                             1966
                                             1966
                                                            ---
                                                            ---
North Dakota       2,400           Jan.      1966           Yes
South Dakota
Georgia
                   2,395
                   2,311
                                      N.A.
                                   Oct.    1967
                                                            ---
                                                            ---
New Mexico         2,310           Rec.    1966             ---
                                                                                   Table V
                                                                                  (continued)

                                                                                                                                   Per C a p i t a l Medical Vendor Payments
                                                                                                                                         BY Welfare Department
                                                                                                                                January               January          January
                                         Per             Date                                       Max. Income                    to                    to               to
                                       Capita           Pro ram             Medically                Family of                    June                 June             June
-
Rank               State
                   7
                                       Income          1nityatea             Needv                     Foura                      1965b                196613           1967C

           Louisiana                    $2,257        July    1966              ---                      -----                   $4.39             84.76             94.77
           Kentucky                      2,205        July    1966              Yes                     S3.420                    3.12              3.35              4.63
                                                                                ---                      -----
           West Virginia
           Alabama
                                         2,195
                                       . 2,039
                                                      July
                                                         N.A.
                                                              1966
                                                                                -- -                     -----                    3.34
                                                                                                                                  2.45
                                                                                                                                                    3.57
                                                                                                                                                    2.77
                                                                                                                                                                      2.67
                                                                                                                                                                      2.02

                  Totals o r                                                    ?T                     m
                                                                                                       a                         -                -                  85.98
                  Average




           New J e r s e y             $3.414
           Alaska                       3,272
           Indiana                      3,061
           Colorado                     2,872
           ~icsourid                    2,845
           Virginia                      2,581
           Florida                       2,576
           Arizona                       2,528
           North Carolina                2,235
           Tennessee                     2,199
           South c a r o l i n a d -     2.027
           Arkansas                      2,015
           Mississippi                   1,751
                                                                                       Average of A l l F i f t y S t a t e s    83.45




       Maximum income allowed f o r maintenance of a family of f o u r persons f o r purposes of detemting e l i g i b i l i t y f o r medically meedy program. 

       Source: S t a t e Let e r No. 96, Bureau of Family Services, H.E.W. 

       Information based n "Advance Release of h n t h l y S t a t i s t i c s , " H.E.W.
                                :
       s t r a c t of t h e United S t a t e s . 1964, U. S. Department of Connnerce. 

                                                                                          Population e s t i m a t e s (provisional f i g u r e s )    --
                                                                                                                                                    S t a t i s t 5 c a l Ab- 

 d)    Missouri and South Carolina apparently adopted T i t l e X U r e c e n t l y .
i n h a b i t a n t i n t h e s e s t a t e s , although h i g h e r than Colorado (except
Illinois      --      $4.50). a r e s u b s t a n t i a l l y less t h a n t h a t e x p e r i e n c e d
i n C a l i f o r n i a and New York. F o r i n s t a n c e , v e n d o r payment c o s t s
f o r t h e f i r s t s i x months o f 1967, p e r i n h a b i t a n t , f o r t h e s e
s t a t e s were a s f o l l o w s : M a s s a c h u s e t t s ($12.49). Minnesota
  $10.11), Washington ($7.44). N o r t h Dakota ($7.13), C o n n e c t i c u t 

  36.40). Maryland ($6.27), and I l l i n o i s ($4.50). 



              Department E s t i m a t e s o f Medical C o s t s o f A
                      Proposed T i t l e X I X Prosram
              P e r h a p s one o f t h e most d i f f i c u l t t a s k s f a c i n g e a c h s t a t e
c o n t e m p l a t i n g a d o p t i o n of a T i t l e X I X program i s t h e development
o f r e l i a b l e c o s t e s t i m a t e s . Medical c o s t s , o f c o u r s e , depend on
t h e s c o p e o f s e r v i c e s t o be p r o v i d e d ; t h e number o f p e r s o n s
e l i g i b l e f o r a program; f e e s c h e d u l e s o f p h y s i c i a n s and i n s t i t u -
t i o n s ; c o s t s of d r u g s , a p p l i c a n c e s and o t h e r items; a s w e l l a s
r e c i p i e n t u t i l i z a t i o n o f m e d i c a l s e r v i c e s . To a s s i s t t h e de-
p a r t m e n t i n d e v e l o p i n g methods f o r p r o j e c t i n g m e d i c a l c o s t s u n d e r
T i t l e X I X , a management c o n s u l t i n g f i r m (.John 8. J o y n t 8 A s s o c i -
a t e s ) was h i r e d i n t h e f a l l of 1966. The methodology employed
i n t h e J o y n t r e p o r t h a s been u t i l i z e d by t h e d e p a r t m e n t i n pre-
p a r i n g e s t i m a t e s f o r a proposed T i t l e X I X program. The department,
however, i s n o t u s i n g t h e J o y n t r e p o r t i n r e g a r d t o n u r s i n g home
c o s t s . With t h e e x c e p t i o n of t h e n u r s i n g home program, t h e de-
p a r t m e n t ' s t e n t a t i v e r e v i s e d e s t i m a t e s f o r f i s c a l y e a r 1969 ex-
ceed t h e e s t i m a t e s c o n t a i n e d i n t h e J o y n t r e p o r t by 2 . 8 p e r c e n t .
The i n c r e a s e i n t h e d e p a r t m e n t ' s e s t i m a t e s are due t o t h e i n c l u -
s i o n of c h i l d w e l f a r e r e c i p i e n t s i n t h e proposed T i t l e X I X program.
Department o f f i c i a l s a l s o r e p o r t t h a t d r u g c o s t s p r o b a b l y w i l l
be h i g h e r t h a n t h e i n i t i a l e s t i m a t e s c o n t a i n e d i n T a b l e I; how-
e v e r , l o w e r c o s t s f o r o t h e r m e d i c a l s e r v i c e s may o f f s e t e s t i -
mated d r u g i n c r e a s e s , s u g g e s t i n g t h a t t h e e s t i m a t e d t o t a l e x p e n s e
of a T i t l e X I X program o u t l i n e d i n T a b l e V I i s r e a s o n a b l e .

P r o j e c t e d C o s t s f o r Proposed T i t l e X I X Proqram f o r C o l o r a d o
             F o r f i s c a l y e a r 1968-69, t h e d e p a r t m e n t b e l i e v e s t h a t
c o s t s o f a proposed T i t l e X I X program would amount t o $42,288,000.
C o s t e s t i m a t e s a r e based on 1 2 m e d i c a l s e r v i c e s o u t l i n e d i n T a b l e     '


V I . The f i v e b a s i c s e r v i c e s r e q u i r e d by T i t l e X I X a c c o u n t f o r
a l m o s t 9 0 p e r c e n t o f t h e m e d i c a l e x p e n s e o f t h e program. T h a t
i s , i n p a t i e n t and o u t p a t i e n t h o s p i t a l c a r e , s k i l l e d n u r s i n g home
c a r e ( i n c l u d e s p o s t - h o s p i t a l c a r e ) , l a b and x - r a y s e r v i c e s , and
p h y s i c i a n ' s s e r v i c e s a r e e s t i m a t e d t o c o s t a b o u t $37,619,000 f o r
t h e c a t e g o r i c a l l y needy i n f i s c a l y e a r 1968-69. An a d d i t i o n a l
$4,669,000 would f i n a n c e p r e s c r i b e d d r u g s , home h e a l t h c a r e ,
t r a n s p o r t a t i o n , p r o s t h e t i c s u p p l i e s and equipment, and h e a l t h c a r e
f o r p e r s o n s o v e r 6 5 y e a r s o f a g e who a r e e i t h e r i n a m e n t a l i n s t i -
t u t i o n o r a home f o r t u b e r c u l i n p a t i e n t s .
                                         Table VI 

                    ESTIMATED COSTS O A PROPOSED PROGRAM 

                                     F
                              OF MEDICAL SERVICES TO THE
                            CATEGORICALLY NEEDY I N COLORADO

                                           (1) 	                         (2)
                                                   F i s c a l Year 	1968-69
                                                                     Department Estimates
                                 Estima tas Contained                   Based o n Joynt
 Medical Servicea                  i n J o y n t Reports                    Re~ort
Inpatient h o s p i t a l
  care                               $ 5,992,000

Outpatient h o s p i t a l
 care                                      544,000
Lab and x-ray                              734,000                         797,000
Post-hospital care                      1,346,000                      1,375,000
S k i l l e d nursing home
   care                                32,000,000
Physician1s Services                    6,474,000                      6,615,000
Prescribed Drugs                        2,121,000                      2,246,000
Home health care                            76,000                          82,000
Transportation                             188,000                         197,000
Prosthetics                               4 84,000                         532,000
Over 65
  stitution
           --
            mental i n -
                                        1,512,000                      1,512,000
Over 	65   --   T. B.                     100.000
       Totals                         $51,571,000
    C o s t of f i v e basic
       services                       $47,090,000
    Other h e a l t h s e r -
      v i c e s enumerated
      by t h e department             $ 4,481,000


a ) 	 Estimates prepared by John B. Joynt & Associates    February    --
    1967.
b) 	Department estimates a r e not based on assumptions used i n t h e
    Joynt study.
         The a f o r e m e n t i o n e d c o s t e s t i m a t e s f o r T i t l e X I X program
do n o t i n c l u d e m e d i c a l care f o r t h e m e d i c a l l y i n d i g e n t .

F i n a n c i a l Impact t o F e d e r a l . S t a t e and County Governments
              The A d m i n i s t r a t i v e Management D i v i s i o n of t h e Department
o f Welfare e s t i m a t e s t h a t C o l o r a d o ' s i n i t i a l e n t r y i n t o a pro-
posed T i t l e X I X program p r o b a b l y would r e s u l t i n a t o t a l i n c r e a s e
i n v e n d o r payments f o r m e d i c a l s e r v i c e s o f o v e r $5,529,000.
D e s p i t e t h i s i n c r e a s e , t h e i n i t i a l c o s t t o t h e s t a t e of a pro-
posed T i t l e X I X program f o r t h e c a t e g o r i c a l l y needy ( ~ e r s o n s
meeting f e d e r a l s t a n d a r d s f o r p a r t i c i p a t i o n u n d e r t h e v a r i o u s
a s s i s t a n c e t i t l e s of t h e S o c i a l S e c u r i t y ~ c t p r o b a b l y would n o t
                                                                             )
exceed t h a t e s t i m a t e d f o r p r e s e n t programs. Medical c o s t s t o
t h e c o u n t i e s , on t h e o t h e r hand, c o u l d b e r e d u c e d s u b s t a n t i a l l y
under T i t l e X I X      --     by a s much a s $3,465,000.                The r e d u c t i o n i n
c o u n t y m e d i c a l c o s t s p l u s e x p e n s e s o f an e n l a r g e d m e d i c a l program
w i l l be met by t h e f e d e r a l government. The w e l f a r e d e p a r t m e n t
e s t i m a t e s t h a t T i t l e X I X w i l l r e s u l t i n more t h a n n i n e m i l l i o n
d o l l a r s i n a d d i t i o n a l f e d e r a l money f o r m e d i c a l s e r v i c e s t h e
f i r s t y e a r of operation.
             S a v i n s s t o t h e C o u n t i e s . S a v i n g s of o v e r t h r e e m i l l i o n
d o l l a r s a n n u a l l y t o t h e c o u n t i e s c o u l d be a c h i e v e d f o r two r e a -
sons: l ) The proposed T i t l e X I X program would be s u p p o r t e d from
f e d e r a l and s t a t e f u n d s o n l y ; and 2 ) a l a r g e p o r t i o n o f c o u n t y
g e n e r a l a s s i s t a n c e monies i s u t i l i z e d f o r m e d i c a l s e r v i c e s , and
a s i g n i f i c a n t p a r t o f c o u n t y m e d i c a l c o s t s would b e c o v e r e d by
T i t l e XIX.
              Impact t o t h e S t a t e o f C o l o r a d o . With t h e e x p a n s i o n o f
m e d i c a l s e r v i c e s , p l u s t h e p r o v i s i o n t h a t m e d i c a l s e r v i c e s would
be p r o v i d e d by t h e s t a t e and f e d e r a l governments w i t h o u t c o u n t y
p a r t i c i p a t i o n , it a p p e a r s l o g i c a l t h a t t h e s t a t e ' s r e l a t i v e s h a r e
o f c o s t s u n d e r X I X must i n c r e a s e . Although a n i n c r e a s e i n c o s t s
i s f o r e c a s t i n t h e y e a r s ahead, department o f f i c i a l s b e l i e v e
t h a t a d d i t i o n a l s t a t e money i s n o t needed a t p r e s e n t .                For in-
s t a n c e , f e d e r a l p a r t i c i p a t i o n i n money payments u n d e r t h e v a r i o u s
a s s i s t a n c e T i t l e s o f t h e S o c i a l S e c u r i t y Act i s l i m i t e d t o c e r -
t a i n maximum amounts. I n g e n e r a l , c a s h g r a n t s t o r e c i p i e n t s
p a r t i c i p a t i n g i n t h e f e d e r a l l y - a i d e d programs a l r e a d y exceed what
t h e f e d e r a l government w i l l a l l o w f o r b o t h m e d i c a l and monetary
a s s i s t a n c e . Thus, i n e f f e c t , t h e f e d e r a l government i s n o t p a r -
t i c i p a t i n g i n t h e c o s t of m e d i c a l s e r v i c e s o v e r and above t h a t
a l l o w e d by t h e f e d e r a l matching f o r m u l a . S i n c e m e d i c a l payments
w i l l be s e g r e g a t e d from c a s h a s s i s t a n c e u n d e r T i t l e X I X , i f
a d o p t e d , t h e f e d e r a l government w i l l have t o meet 55.39 p e r c e n t
of m e d i c a l e x p e n s e s i n which t h e r e may be no f e d e r a l p a r t i c i p a -
t i o n a t present.
Estimated C o s t s F o r A Complete T i t l e X I X Prosram
              T a b l e VII i l l u s t r a t e s t h e p o s s i b l e c o s t of T i t l e X I X , i f
a program of complete medical s e r v i c e s and coverage i s f u l l y
implemented i n Colorado i n f i s c a l y e a r 1968-69. Table V I I a l s o
p r o v i d e s i n f o r m a t i o n a s t o e s t i m a t e d expenses of s p e c i f i c medi-
c a l s e r v i c e s t h a t t h e committee o r t h e General Assembly may
c o n s i d e r i n any proposed a l t e r n a t e program t o "phase-in" T i t l e
XIX. C o s t e s t i m a t e s f o r medical s e r v i c e s t o w e l f a r e and r e l a t e d
r e c i p i e n t s a r e c o n t a i n e d i n Column ( l ) , w h i l e Columns ( 2 ) and
( 3 ) l i s t e s t i m a t e d e x p e n d i t u r e s f o r v a r i o u s medical s e r v i c e s f o r
t h e s o - c a l l e d m e d i c a l l y i n d i g e n t . The f i v e b a s i c s e r v i c e s re-
q u i r e d under T i t l e X I X , a t t h e t i m e t h e program i s made a v a i l -
a b l e t o any c l a s s of r e c i p i e n t s , a r e l i s t e d under Group I. The
o p t i o n a l medical s e r v i c e s , which must be provided by 1975 t o a l l
p a r t i c i p a n t s under T i t l e X I X , a r e a l s o i t e m i z e d under Groups I1
and 111.
              Department P r o p o s a l . The proposed program o f t h e S t a t e
Department of P u b l i c Welfare i n v o l v e s t h e " c a t e g o r i c a l l y needym
o n l y and it i s c o n t a i n e d i n Column (1). Groups I and I1 of Table
V I I . The department e s t i m a t e s t h e t o t a l c o s t of t h i s program a t
$42,288,000.          B r i e f l y , i n a d d i t i o n t o o l d age p e n s i o n e r s , r e c i p i -
e n t s of a i d t o t h e needy d i s a b l e d , f a m i l i e s w i t h dependent
c h i l d r e n , and t h e b l i n d , t h e department e s t i m a t e s i n c l u d e medi-
c a l services t o children p a r t i c i p a t i n g i n t h e department's c h i l d
w e l f a r e program. A few o t h e r c a t e g o r i c a l l y r e l a t e d p e r s o n s a r e
included i n t h e d e p a r t m e n t ' s program.
              I n a d d i t i o n t o t h e f i v e b a s i c s e r v i c e s which a r e r e q u i r e d
by law, t h e department p r o p o s a l i n c l u d e s a number of a d d i t i o n a l
s e r v i c e s . These s e r v i c e s a r e provided t o some w e l f a r e r e c i p i e n t s
i n e x i s t i n g programs and would be expanded t o i n c l u d e a l l c a t e -
g o r i c a l l y needy r e c i p i e n t s . T h i s e x t e n s i o n of s e r v i c e i s i n
compliance w i t h t h e maintainence of e f f o r t p r o v i s i o n i n T i t l e
X I X which r e q u i r e s t h a t r e c i p i e n t s i n t h e f e d e r a l l y - a i d e d c a t e -
g o r i e s must r e c e i v e medical s e r v i c e s e q u i v a l e n t t o t h e h i g h e s t
l e v e l provided under e x i s t i n g programs. The e s t i m a t e d c o s t of
Group I1 f o r t h e " c a t e g o r i c a l l y needy" i s $4,669,000.                      Again,
under t h e 1967 amendments t o t h e S o c i a l S e c u r i t y Act, b e n e f i t s
t o Old Age P e n s i o n e r s a t t a i n e d t h r o u g h Medicare's supplementary
medical i n s u r a n c e program need n o t be extended t o T i t l e X I X
r e c i p i e n t s under age 65. A q u e s t i o n e x i s t s a s t o whether a l l
t h e s e r v i c e s i t e m i z e d by t h e department must be i n c l u d e d i n any
p l a n t o implement T i t l e X I X i n Colorado, a t l e a s t i n t h e f i r s t
year   .
C o n s i d e r a t i o n of t h e Optional-Medically Needy Groups
             The l a r g e group of p e r s o n s f o r whom t h e d e p a r t m e n t ' s pro-

p o s a l makes no p r o v i s i o n i s t h e m e d i c a l l y needy o r m e d i c a l l y 

i n d i g e n t . Although it i s o p t i o n a l f o r a s t a t e t o d e c i d e t o i n - 

                                                                                          Table V I I

                                                               ESTLUATED CDSTS OF A TOTAL PFSGUM OF MEDICAL SER'XCES 

                                                                                          --
                                                                      TO THE CAT8GDMCALLY AND hEDICIUlY WEEDY 

                                                                         IN -RAW        FISCAL Y W 1968-69 

                                                                    ( 1) 	
                                                                                  --
                                                     Department E s t i m a t e s F o r
                                                      C a t e g o r i c a l l y Needy
                                                                                                       (2)
                                                                                                   Optimal
                                                                                                    Ibcdically
                                                                                                                 --                       (3)
                                                                                                                                      Optional
                                                                                                                                       Medically
                                                                                                                                                    --              Total    &!
                                                                                                                                                                              it
                                                                                                                                                                               Of
                                                                                                                                                                    Programs To A l l
   Medical S e r v i c e s                           Based On J o v n t ~ e p o r &                    v
                                                                                                 ~ e d u n d e r 2181                Needy 21-6&                    Groups of Needy

I FIVE BASIC SERVICES
        I n p a t i e n t H o s p i t a l Care 

        O u t p a t i e n t H o s p i t a l Care 

        Lab and X-ray 

        Post Hospital Care 

        S k i l l e d Nursing Home C a e 

        Physicians Services 

             Subtotal f o r Basic 

             Services 

1 	 ADDITIONAL MEDICAL SER-
 I
                       Y
   VICES RECOhCHPlDED B DE-
                          -

   PARTMENT :
        P r e s c r i b e d Drugs 

        Home H e a l t h Care 

        Transporaation 

        Prosthetics 

        Over 65      --      Mental
                                                                                                                                             rnE
                     --
            Institutions 	
        Over 65              T.B.
              S u b t o t a l f o r Addi- 

                                                                                                                                             NONE 


              tional Services                                                                                                         S 5.5L1.000 


             Subtotal             .                       942,288,000

    OPTIONAL PROGRAMS: 

      Other Licensed Care 

      P r i v a t e Nursing Duty 

      Clinical Services 

      Dental S e r v i c e s 

      P h y s i c a l Therapy 

      Dental Appliances 

      Eyeglasses 

      Diagnostic. Screening, 

            P r e v e n t a t i v e and Re- 

            h a b i l i t a t i v e Services 

            Subtotal f o r Optional 

            Programs 


    TOTAL COST OF ALL SERVICES 

               O
    ACOJRDING T CATEtORTES                                S48.835.000 




                e c o s t e s t a t e s o r roups                an        u n d e r column ( 1 ) r e p r e s e n t t h e proposed p r o                   of t h e S t a t e Department of P u b l i c
            E l f a r e . T h z e fig:re;also               i ~ c l u ~ e l ~ . d i ccaalr e c o s t s f o r p a r t i c i p a n t s i n t h e c h ( f ; a r l f m program o f t h e department.
    	
    J
    B       E s t i m a t e s prepared by John 8. J o y n t 8 A s s o c i a t e s . E l i g i b i l L t y based on maximum income of 83.000 f o r a f a m i l y of four.
            The f i g u r e s f o r groups I and 1 w i l l v a r y from t h o s e c o n t a i n e d i n t h e J o y n t report because e s t i m a t e s f o r c h i l d w e l f a r e
                                                              1
            a r e i n c l u d e d u n d e r column I.
            t s t i m a t e s prepared by John B. J o y n t 8 A s s o c i a t e s . E l i g i b i l i t y based on a n income maintenance s t a n d a r d o f S3.000 f o r f a m i l y o f f o u r .
            P o s t H o s p i t a l C a r e and S k i l l e d Nursing Home C a r e a r e l i s t e d a s a s l n g l e c a t e g o r y under T i t l e XIX requirements. 

            Department e s t i m a t e s a r e not based on assumptions used i n t h e J o y n t study. 

            A l l of t h e f i g u r e s f o r t h e O p t i o n a l Programs a r e based on J o y n t R e p o r t e s t i m a t e s . 

c l u d e t h i s g r o u p o f p e o p l e i n i t s m e d i c a l services program
b e f o r e 1975, f e d e r a l f u n d s have been made a v a i l a b l e f o r c e r t a i n
p e o p l e i n t h i s c a t e g o r y . F e d e r a l p a r t i c i p a t i o n i n m e d i c a l ser-
v i c e s i s a v a i l a b l e f o r p e r s o n s who e x c e p t f o r income would be
e l i g i b l e f o r a i d u n d e r T i t l e s I , I V , X , and X I V of t h e S o c i a l
S e c u r i t y Act, and whose income t h e s t a t e d e f i n e s a s i n a d e q u a t e
t o meet t h e c o s t s o f m e d i c a l c a r e . E s t i m a t e s f o r t h e m e d i c a l l y
needy programs a r e based on a n e l i g i b i l i t y c r i t e r i o n o f a main-
t e n a n c e s t a n d a r d o f $3,000 f o r a f a m i l y o f f o u r . T h i s income
which would b e s e t a s i d e f o r m a i n t e n a n c e f a r e x c e e d s t h e c r i t e r i a
now p e r m i t t e d by C o n g r e s s i n t h e amendments t o t h e S o c i a l Secur-
i t y Act. Thus t h e c o s t e s t i m a t e s c o n t a i n e d i n T a b l e V I I a r e
much h i g h e r t h a n c o s t s o f a m e d i c a l l y i n d i g e n t program t h a t c o u l d
qualify f o r federal aid.
             Although t h e s t a t e s a r e n o t r e q u i r e d t o e n t e r i n t o t h e
i n d i g e n t program o r t o p r o v i d e a l l t h e m e d i c a l s e r v i c e s l i s t e d
i n t h e accompanying T a b l e b e f o r e 1975, t h e committee and t h e
G e n e r a l Assembly may w i s h t o g i v e c o n s i d e r a t i o n t o t h e t o t a l i m -
p a c t o f p h a s i n g i n a c o m p l e t e m e d i c a l program. The e s t i m a t e d c o s t
o f a t o t a l program i s $95,996,000, based o n t h e income s t a n d a r d
o f $3,000 f o r t h e m e d i c a l l y i n d i g e n t .          I f Congress continues t o
r e q u i r e t h e development o f broad-based m e d i c a l s e r v i c e s t o low
income f a m i l i e s and t h e c o s t b u r d e n of s u c h a program t o t h e
s t a t e of C o l o r a d o c o n t i n u e s t o b e a b o u t 45 p e r c e n t o f t o t a l pro-
gram e x p e n d i t u r e s , p r e p a r a t i o n may need t o be made f o r d e v e l o p -
i n g a d e q u a t e r e v e n u e f o r t h e program. P e r h a p s , t h e r e i s need f o r
t h e G e n e r a l Assembly t o c o n s i d e r a time p e r i o d f o r p h a s i n g i n a n
o v e r - a l l T i t l e X I X program i n o r d e r t h a t t h e t o t a l impact o f
a d d i n g s e r v i c e s and b r o a d e n i n g e l i g i b i l i t y i s minimized f o r any
given year.
              Many s t a t e s which have a l r e a d y a d o p t e d T i t l e X I X have
i n c l u d e d s e r v i c e s t o t h e m e d i c a l l y needy i n t h e i r s t a t e p l a n s .
A s r e q u i r e d by f e d e r a l r e g u l a t i o n s , a l l o f t h e s e s t a t e s i n c l u d e d
t h e f i v e b a s i c s e r v i c e s i n t h e m e d i c a l l y needy program, and a
number o f s t a t e s went beyond t h i s l e v e l t o o f f e r o p t i o n a l s e r v i c e s
t o t h e m e d i c a l l y needy.
              I n viewing laws i n o t h e r s t a t e s , one of t h e most s i g n i f i -
c a n t aspects of T i t l e X I X l e g i s l a t i o n i s t h e amount of d i s c r e t i o n
given t o a d m i n i s t r a t i v e a g e n c i e s t o implement pro rams. For i n -
                                                                                   ?
s t a n c e , more t h a n h a l f t h e s t a t e l e g i s l a t u r e s imp ementing T i t l e
X I X made no a t t e m p t t o o u t l i n e t h e medical s e r v i c e s t h a t a r e
provided under r e s p e c t i v e s t a t e programs. I n o t h e r words, d i s -
c r e t i o n a s t o t h e s e l e c t i o n of t y p e s of medical c a r e has been
l e f t t o t h e s t a t e w e l f a r e departments i n many i n s t a n c e s . Even
more s u r p r i s i n g i s t h e d e l e g a t i o n of r e s p o n s i b i l i t y t o adminis-
t r a t i v e a g e n c i e s f o r d e f i n i n g and e s t a b l i s h i n g programs f o r t h e
medically i n d i e n t . O f t h e 2 1 s t a t e s p r o v i d i n g programs f o r t h e
Oregon, and Wisconsin
                       ?             --
i n d i g e n t , t h e aws of o n l y f o u r s t a t e s        --    Minnesota, Michigan,
                                            set f o r t h income s t a n d a r d s a s t o program
e l i g i b i l i t y . I n any e v e n t , a b a s i c d e c i s i o n w i l l have t o be made
by t h e Colorado General Assembly whether t o :                               1 ) follow t h e pat-
t e r n of many o t h e r s t a t e s and a l l o w t h e S t a t e Board of Welfare t o
determine t h e scope of medical c a r e under T i t l e X I X programs; o r
2 ) provide g u i d e l i n e s i n t h e e n a b l i n g l e g i s l a t i o n a s t o t h e
implementation of a program. I f t h e f i r s t o p t i o n i s s e l e c t e d ,
l e g i s l a t i v e c o n t r o l of t h e programs could o n l y be achieved
through t h e budgetary p r o c e s s .
              I n o r d e r t o implement a program of medical s e r v i c e s under
T i t l e X I X of t h e S o c i a l S e c u r i t y Act, a number of d e c i s i o n s must
be made by Colorado g o v e r n m e n t a l . o f f i c i a l s . Not only must de-
c i s i o n s be made a s t o t h e e x t e n t of coverage and type, of s e r v i c e s
t o be i n c l u d e d i n C o l o r a d o l s medical a s s i s t a n c e program, b u t t h e
fundamental q u e s t i o n of who i s t o make t h e s e d e c i s i o n s a l s o must
be r e s o l v e d . I n any e v e n t , t h e f o l l o w i n g i t e m s may need t o be
c o n s i d e r e d by s t a t e o f f i c i a l s :
          1 ) I n a d d i t i o n t o w e l f a r e r e c i p i e n t s , what o t h e r p e r s o n s
a r e t o be c o n s i d e r e d e l i g i b l e f o r a program under T i t l e XIX?
              2 ) I n t h e e v e n t medical s e r v i c e s a r e t o be provided t o
persons n o t p a r t i c i p a t i n g i n e x i s t i n g w e l f a r e programs, what
p o i n t i n t i m e a r e t h e v a r i o u s c a t e g o r i e s of p e r s o n s t o be made
e l i g i b l e f o r medical c a r e under T i t l e XIX?
             3) The f i v e b a s i c s e r v i c e s must be provided t o t h e c a t e -
g o r i c a l l y needy ( w e l f a r e r e c i p i e n t s o r w e l f a r e r e l a t e d i n d i v i d u -
a l s ) ; however, any seven of 14 s e r v i c e s i t e m i z e d i n t h e S o c i a l
S e c u r i t y Act may be provided t o t h e medically i n d i g e n t . What
s e r v i c e s a r e t o be provided t o b o t h t h e s e groups?
           4)  Are a l l medical s e r v i c e s t o be provided a t once?                              If
n o t , how a r e s e r v i c e s t o be phased i n ?
            5) what t y p e s of vendors may provide medical s e r v i c e s t o
T i t l e XIX recipients?
          6 ) An o p t i o n i s provided i n t h e f e d e r a l law t o permit
reimbursement of medical c o s t s t o t h e r e c i p i e n t p a r t i c i p a t i n i n
t h e I4medically i n d i g e n t t 4 program, r a t h e r t h a n payment d i r e c t y
t o t h e vendor. Is t h i s o p t i o n t o be provided i n t h e Colorado
                                                                                           7
program i n t h e e v e n t a m e d i c a l l y i n d i g e n t program i s i n i t i a t e d ?
            7 ) Under T i t l e X I X , t h e s t a t e must l i c e n s e n u r s i n g home
a d m i n i s t r a t o r s by 1972. Are l i c e n s e s t o be r e q u i r e d by r e g u l a -
t i o n o r law?
              8 ) What i s t h e l e v e l of reimbursement t o be f o r n u r s i n g
homes, h o s p i t a l s , and o t h e r vendors? What c r i t e r i a needs t o be
e s t a b l i s h e d t o i n s u r e t h a t vendor payments a r e w i t h i n t h e scope
of 1 e g i s L a t i v e i n t e n t ? I n o t h e r words, what kind of c o n t r o l
program i s t o be e s t a b l i s h e d f o r vendor payments?
       9 ) Is t h e r e need t o e s t a b l i s h r e s t r i c t i o n s on t h e drug
program i n o r d e r t o c o n t r o l drug c o s t s ?
         1 0 ) How i,s a program t o guard a g a i n s t unnecessary u t i l i z a -
t i o n of h e a l t h f a c i l i t i e s t o be e s t a b l i s h e d ?
            1 1 ) Is t h e r e need f o r t h e s t a t e t o provide a s t a t e program
f o r low income persons, 65 y e a r s of age and o v e r (who a r e n o t
r e c i p i e n t s of t h e o l d age p e n s i o n ) , t o *buy-int4 t o t h e medicare
p r o v i s i o n s ? (There is no f e d e r a l reimbursement f o r t h e s e c o s t s . )
           1 2 ) S t a t e s may e x e r c i s e an o p t i o n t o make a p r o v i s i o n f o r
d e d u c t i b l e s i n t h e i r m e d i c a l l y i n d i e n t programs. Should t h e
                                                     ?
Colorado program i n c l u d e a d e d u c t i b e p r o v i s i o n ?
                             Appendix A
                          S t a t e of Oregon

                        TITLE XIX LEGISLATION


                               CHAPTER 502

                                   AN ACT                               ~
                                                                    t x 17681
Relating to medjcal assistance: creatin new provisions; amending OR8
                                          k
   411.325, 414.025, 414.065, 414.075, 41 .095 and 414.105; repealing ORS
   414.035 and 414.045; and declaring an emergency.
Be It Enacted by the People of ihe State of Oregon:
   Section 1. Sections 4 to l l a of this Act are added to and made a part
of ORS chapter 414.
   Note: Section 2 was deleted by amendment. To avoid extensive amend-
ments, other sections were not renumbered.
     Section 3. ORS 414.025 is amended to read:
     414.025. As used in,-       W M wt? 4444W3 +e 4444% m d kt eeker
 &+M                h wiGM+w and Iwufices +e needy pws+ this chapter
 unless the context or a specially applicable statutory definition requires
 otherwise f;3 :
     (I) "Category clj aid" means old-age assistan.ce, aid to the blind, aid to
 the disabled or aid to dependent children.
     (2) "Categorically needy"*means a person who is a resident of this
 state and who:
     (a) Is receiving a category of aid.
     (b) Would be eligible for a category of aid, except for duration of
 residence requirement of a particular category.
     (c) Would be eligible for, but is not receiving a category of aid.
    (d) Is in a medical facility and, if he left such facility, would be
        f
eligible or a category of aid.
    (e) s under the age of 21 years and, except for age o r duration of
residence o r both, would be a dependent child under the program for aid
t o dependent children.
    ( ) 1s a caretaker relative named in paragm h (e) of subsection (I) of
     J
                                                  I'
OR 418.035 who has in his care a dependent chi d who, except for duration
of residence, would be a dependent child under the program for aid to
dependent children.
     (g) Is under the age of 21 years, is in a foster home or licensed child-
caring agency or institution under a purchase of care agreement and is one
for whom the state commission is assuming financial responsibitity, in
whole or in part.
     (3) "Income" means income as defined in subsection (3) of ORS
41 3.005.
   (4) "Medical assistance" means so much of the following medical and
remedial care and services as may be prescribed by the state commission
according to the standards established pursuant to ORS 414.065    fttttdt?
aveICttklek,--*.                          .      .&t?lic..ikillkW&
ens~kRteettsePakirkR*.=Cke&ai~. 

~ w h e H y e p p + w & & & e t r ~ d ~ ~ 4 i f i k m e e ~ :
   fCrff (a) In atient hospital services, other than services in a n institu-
                   I?
tion for tubercu osis or mental diseases; 

   W (b) Outpatient hospital services; 

          (c)
   +@j+ Other laboratory and X-ray services;
            (d) Skilled nursing home services , other than services in an
institution for tuberculosis or mental diseases;
   W (e) Physicians' services, whether furnished in the office, the pa-
tient's home, a hospital, or a skilled nursing home, or elsewhere;
   +f6# (f) Medical care, or any other type of remedial care recognized
under state law, furnished by licensed practitioners within the scope of
their practice as defined by state law;
   +(?++(g) Home health care services; 

    -ff8f3. (h) Private duty nursing services; 

   +@&)+(i) Clinic services; 

             (j) Dental services;
   +o+ (k) Physical therapy and related services;
    +fS+)(L) Prescribed drugs, dentures, and prosthetic devices; and eye-
glasses prescribed by a hysician skilled in diseases of the eye or by an
                       F,
optometrist, whichever t e individual may select;
    +@-3++ (m) Other diagnostic, screening, preventive and rehabilitative
services;
    (n) In atient hospital services and skilled nursing home services f o ~
         f'
individua s 65 vears of age or over in an institution for tuberculosis or
mental diseases; and
                         - -
         ++   l   +
    + (0) Any other medical care, and any other type of remedial
care recognized under state law;
                                                             +
except that fweh eer-ttt) "medical assistance" does not include          any
care or services for any individual who is an inmate of a public institution,
 I
-+ cxccpt as a patient in a medical institution ff;) or ftlr(Ff3 any care or
services for any individual who has not attained 65 years of age and who
is a palicnt in an institrltion for trlberculosis or mental diseases.
    (5) "Medicnll?~ needv" m.eans a person who is a resident of this state 

          does not have income and resources sufficient to provide himself 

and ~ o h o
and his dependents with essential naintejtnnce and medical needs as are 

neces-sary to nfford a reasonable sustenance compatible with decency and 

health, as determined pursuant to section 5 of this 1967 Act, and who, 

except for dt~rntionof residence or financial need requirement, would be 

eligible for a category of aid. 

    (6) "ResourcesJy means resources as defined in subsection (4) of O ~ S '
413.005.
   Section 4. (1) Within the limits of funds available therefor, medical 

assistance shall be made available to persons who are categorically needy. 

    (2) Within the limits of funds expressly appropriated and available 

for medical assistance to the mcdically needy, medical assistance shall be 

available to persons who are medically needy. 

   Section 5. (1) Except as provided in subsection (2) of this section, the 

minimum amount of income and resources considered sufficient to meet 

maintenance needs for the medically needy is fixed at: 

    (a) An annual income of $1,750 for one person, plus $750 for the first 

and $480 for each additional dependent person; 

    (b) Life insurance with a cash surrender value of not more than $2,500 

for one person, plus $500 for each additional dependent person; 

    (c) Liquid assets other than life iilsuranre of not more than $500 value 

for one person, plus $500 for the first and $100 for each additional de- 

pendent person; and 

    (d) Real property occupied as his own residence.
    (2) Exccpt with respcct to short-term convalescent care, the minimum 

amount of income considered sufficient to meet maintenance needs for a 

person receiving care provided by a nursing home, as defined in ORS 

 678.510, is fixed at an annual income of $240 for the person receiving 

 nursing home care, plus $1,750 for the first and $480 for each additional 

 dependent person. 

    Section 6. (1) The need for and the amount of medical assistance to be 

 madc available shall be determined,.in accordance with the rules of the 

 state commission, taking into account: 

    ( a ) The rcquircmcnts and needs of the p@rdan,hjg npbuse and other
depctidcnls;
     (b) The income, rcsourccs nnd maintennnce ~vaItaGle the person;
                                                           to
     (c) The responsibility of his spouse, and, with reapeat to 8 pewen
la blind, or la pcrmnne~rtlynnd totally disabled, or Is undep the rgte 21
years, the responsibility of the parents; and
     (d) The conditions existing in each case.
    (2) Such amounts of income and resources may be disregarded as the
state cummission may prescribe by rules. The amounts to be disre rd&
       be within the limits required or permitted by federal law,
orders applicable thereto.
                                                                    rd&    or
    (3) In the determination of the amount of medical assistance available
to a medically needy person, all income and resources available to the
person in excess of the amounts prescribed in section S of this 1967 Act,
within limits prescribed by the state commission, shall be applied first
to costs of needed medical and remedial care and services not available
under the medical assistance program and then to the costs of benefits
under the medical assistance program.
    Section 7. (1) Application for any category of aid shall also constitute
application for medical assistance.
    (2) Except as otherwise provided in this section, each erson request-
                                                            fl
ing medical assistance shall make application therefor to t e county com-
mission of the county in which he resides. Sub'ect to the a proval of the
                                                 1            f
state commission, the county commission sha 1 receive a 1 applications
made in the county, shall ascertain the facts supporting such application,
shall determine eli ibility for and fix the date on which such assistance
                   f
may begin, and sha 1 obtain such other information required by the rules
of the state commission.
    (3) If an a plicant temporarily resides outside the county of his
               S
permanent resi ence, his application for medical assistance may be made
through the county department of the county in which he temporarily
resides to the county commission in which he permanently resides.
     (4) If an applicant is unable to make a plication for medical assistance,
                                           P
an application may be made in his behal by someone acting responsibly
 for him.
    Section 8. Upon the receipt of pro erty or income or upon any other
                                       P
 change in circumstances which direct y affects the eligibility of the re-
cipient to receive medical assistance or the amount of medical assistance
 available to him, the recipient shall immediately notify the county de-
 partment of the receipt or ossession of such property or income, or other
                           #
 change in circumstances. ailure to give the notice shall entitle the state
 commission to recover from the recipient the amount of assistance im-
 properly disbursed by reason thereof.
     Section 9. In lieu of providing one or more of the medical and remedial
 care and services available under medical assistance by direct payments to
 providers thereof and in lieu of providing such medical and remedial care
 and services made available pursuant to ORS 414.065, the state commission
 may use available medical assistance funds to purchase and pay premiums
 on policies of insurance, or enter into and pay the expenses on health care
 service contracts, or medical or hospital service contracts that provide one
 or more of the medical and remedial care and services available under
 medical assistance for the benefit of the categorically needy or the med-
 lcall needy, or both. The policy of insurance or the contract by its terms,
    K
 or t e insurer or contractor by written acknowledgment to the state
 commission, must guarantee:
     (1) To provide medical and remedial care and services of the type, to
 the extent and according to standards prescribed under ORS 414.065;
    (2) To pay providers of medical and remedial care and services the
amount due, based on the number of days of care and the fees, charges and
costs established under ORS 414.065, except as to medical or hospital
~ervice contracts issued by a hospital association which employe a method
of accounting or payment on other then a fee-for-service basis;
    (3) To provide medical and remedial care and services under policies
of insurance or contracts in compliance with all laws, rules and regula-
tions applicable thereto; and
    (4) To provide such statistical data, records and reports relatin.
                                                                     %
provision, administration and costs of providing medical and reme ialocare
                                                                       t the
and services to the state coinmission and the county commission as may be
required by the state commission for its records, reports and audits.
    Scction 10. (1) Any payment of available medical assistance funds for
policies of insurance or service contracts shall be accordin to such uniform
                                                            'i
state-wide rates as the state commission shall have estab ished and which
it may revise from time to time as may be necessary or practical.
    (2) No premium or other periodic charge on any policy of insurance,
health care service contract, or medical or hospital service contract shall be
paid from available medical assistance funds unless the insurer or con-
tractor issuing such policy or contract is by law authorized to transact
business as an insurance company, health care service contractor or hos-
pital association in this state.
    Section 11. The state commission may enter into nonexclusive con-
tracts under which funds available for medical assistance may be adminis-
tered and disbursed by the contractor to direct providers of medical and
remedial care and services avai!able under medical assistance in considera-
tion of services rendered and supplies furnished by them in accordance
with the provisions of this chapter. Payment shall be made according to
the rules of the state commission pursuant to the number of days and the
fees, charges and costs established under ORS 414.065, The contractor must
guarantee the state commission by written acknowledgment:
    (1) To make all payments under this chapter promptly but not later
than 30 days after receipt of the proper evidence establishing the validity
of the provider's claim.
    (2) To provide such data, records and reports to the state commission
as may be required by the state commission.
   Section l l a . The provisions of section 9, I0 or I1 of this 1967 Act may
be implemented whenever it appears to the Department of Finance and
Administration that such implemcntation will rovide comparable benefits
at equal or less cost than provision thereof by g r e e t payments by the state
commission to the providers of medical assistance.

    Section 12. ORS 414.065 is amended to read:
    414.065. (1) With respect to medical and remedial care and services to
be provided in medical assistance during any period, end within the limits
of funds available therefor, the state commission shall determine     Iiitf,
subjcct to such revisions as it may make from time to time:
              r+
              C
     (a) The ty es and extent of mcdical and remedial care and services
to be provide                    4
                     q+irftHkl m t.e+kwh].
     (h) State-widc uniform standards to be observed in the provision of
medical and remedial care and serviccs.
     (c) The +w~tmmtt)number of days of medical and remedial care and
services toward the cost of which public assistance funds will be expendrd
 in the carc of any +a-pf++kf~i&w
                               t
                               w         e person.
                             -
     (d) +%lwH.fMt~~ 4 M 4 Reasonable fces, chargcs and daily rates
 to which public assistance funds will be applied toward meeting the costs
 of providing medical artd remedicrl care and serviccs to an applicant or
 recipient.
    (e) Reasonable fees for professional medical and dental serutces which
may. be based on usual and customary fees in the locality for similar
servtces.  '

    (2) The types ~ n d    extent of medical and remedial care and services
and the amounts to be paid in meeting the costs thereof, as determined
and fixed by the state commission and within the limits of funds available
therefor, shall be the total +++died e w e d RePui&            +
                                                       available   epptkt~k
~4rectiphk& for medical assistance and ayments for such medical assist-
                                         1
ance shall be the total amounts from pu lic assistance funds available to
providers of medical and remedial care and services in meeting the cosb
thereof.
    (3) Except for payments under a cost-sharing plan, payments fd+
                              d
made by the state commission or medical assistance shall constitute pay-
ment in full for all medical an remedial care and services for which such
payments of medical assistance were made.
    (4) Medical benefits and limits established pursuant to parawaphs
(a) and (c) of subsection ( 1 ) of this section for the eligible medically
needy may be less but shall not exceed medical benefits and limit8 eatab-
lished for the eligible categoricatty needy.
    Section 13. ORS 414.075 is amended to read:
    414.075. (1) Medical assistance provided to any individual who is
+66 ym Bf: e g ~ ftkkfP i w 4 whe iffF covered by the hospital insurance
                   w
benefits or supplementary health insurance benefits, or either of them,
as established by federal law, may include:
    (a) The full amount of any deductible imposed with respect to such
individual under the hospital insurance benefits; and
     (b) All or any part of any deductible, cost sharing, or similar charge
                          to
jm~osedwith r e s ~ e c t such individual under the health insurance bene-
fiti.
     (2) With respect to any individual who is 66 years of age or older,
medical assistance may include medical artd remedial core and services
 for patients in institutions for tuberculosis or mental diseases.
    Section 14. ORS 414.095 is amended to read:
    414.095. Neither medicnl assistance nor amounts payable to vendors
 out of public assistance funds are transferable or assignable at law or in
 e uity and none of the money paid or payable under the provisions of
                                  44W
 0 %411.405 ++I&H%+ and f 1 ( C *t 4444%+ 
 this chapter is subject to
        ~
 execution, levy, attachment, garnishment or other legal process. 

    Section 15. ORS 414.105 is amended to read:
    414.105. (1) The state commission may recover from any person the
amounts of medical assistance incorrectly paid on behalf of such person.
    (2) Medical ~ssistance  pursuant to ORS 411.405 f-;        and +i-WWi
k 4 4 4 W + this cl~apterpaid on behalf of an individual who was 65 years of
age or older when he received such assistance may be recovered from his
estate; provided, however, that claim for such medical ~ssistancecor-
rectly paid to him may be established against his estate, but there shall
be no adjustment or recovery thereof until after the death of his surviv-
ing spouse, if any, and only at o time when he has no surviving child who
is under 21 years of age or is blind or permanently and totally disabled.
    (3) The amounts of medical assistance pursuant to ORS 411.405
f; 4XHGCiif. and +44-0% k, 4-Wl-M+ this chapter provided on behalf of a
recipient shall not be recovered by the state commission under ORS 416.010
to 416.270 nor under ORS 416.510 to 416.610.
   Section 16. ORS 411.325 is amended to read:
   411.325. (1) fett t b d k e (kff LettHt dny i&we+y d t z ) Except with
                      v
respect to children in foster homes or other child-caring institutions, each
county department on or before the 10th drry of eaclr rnon'th shall cause to
be prepared a complete report showing the names of all -f-pwl+k ft-
recipients within the cor~nty-fw d I,ke l e d tkty. d +he prec?c.cFittg mfmUtr
       HP
        +-          ffF d y t l   &+t~teff     h &he wed tntd cAd&w   iff   h k e ~
b w
 *         e k t ekiltl-eftt.iv             who are receiving otd-age assist-
ance, aid to the blind, aid to the disabled, aid to dependent children or
general assistance, together with the amounts paid to each during the
preceding month. The address of any such recipient shall be provided upon
the specific request of a person who is qualified to inspect such report.
    (2) Subject to ORS 411.330 and 411.335, such re orts shall be open to
                                                                 \
public inspection during the regular office hours of t e county department.
    Section 17. Sections 18 to 20 are added to and made a part of ORS
chapter 414.
    Scctlon 18. (1) A medical advisory committee is established, consisting
of not more thnn 15 members to be appointcd by the Governor from among
persons in the health professions, providers of medical and remedial care
and services and the general public. In making his appointment, the Gov-
ernor shall consult with appropriate professional and other interested
organizations.
    (2) Members shall serve at the pleasure of the Governor.
    (3) Members of the advisory committee shall receive no compensation
for lhcir services, but subject to any applicable state law, shall be allowed
actual and necessary travel expenses incurred in the performance of their
duties from the Public Welfare Account.
    Section 19. The medical advisory committee shall advise the State 

Public Welfare Commission on: 

    (1) Health and medical care and services to be provided pursuant to 

this chapter. 

     (2) Matters referred to it for study by the state commission.
    Scction 20. (1) The State Public Welfare Commission shall consult
with the medical advisory committee concerning the determinations re-
quired under ORS 414.065.
    (2) The state commission shall provide secretarial services to the med- 

ical advisory committee. 

    Scction 21. ORS 414.035 and 414.045 are repealed.
    Section 22. (1) Medical assistance for the categorically needy, as de- 

fined in ORS 414.025, shall be provided to the categorically needy on and 

 after July 1, 1987, provided that state and federal funds are available 

therefor. 

     (2) Medical assistance for medically needy persons, as defined in ORS 

 414.025, may be provided to medically needy persons on and after July 1, 

 1967, provided that state and federal funds are available thercfor. 

     (3) The state and county departments shall take any actions that appear 

 necessary under the provisions of this Act to obtain the implementation 

thereof. 

    Seetion 23. This Act being necessary for the immediate preservation of 

 the public peace, health and safety, an emergency is declared to exist, and 

 this Act shall take effect July 1, 1967. 

    Approved by the Governor Junc 23, 1967. 

    Fllcd In Ihc office of Sccrctary of Stalc Junc 26, 1967. 


				
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