Transcript Seema Verma, MPH

Medicaid Reform & 1115 Waivers
Seema Verma, MPH
President & Consultant
SVC Inc
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Medicaid 50 Year Anniversary
• President Johnson & War on Poverty:
“We want to give the forgotten fifth of our
people opportunity not doles..”
• Changing Health Landscape Over 50 Years
▫ Private Health Insurance Changes
 Copays, deductibles, coinsurance, health savings
accounts
 Managed Care, HMOs
▫ Medical advances, new pharmaceuticals & technology
▫ Rising uninsured as health care costs increase
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Pre Affordable Care Act:
Patchwork Quilt of Programs
Government Programs
 Ryan White Care Act
 Children’s Health Insurance Program- CHIP
 Medicaid
 Low Income Parents
 1115 Waivers (childless adults)
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Medicaid Entitlement Program
Designed for Vulnerable Populations
▫ Aged, Blind, Disabled, Pregnant Women & Children
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Financing Mechanism
Retroactive coverage, presumptive eligibility
Limited cost sharing & enforceability
Choice provisions
Robust benefits
▫ Results:
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Health Outcomes- Oregon Study
Limited incentives for health improvement
Little to no disincentives for undesired behaviors
Seek coverage only when sick, in ER rooms
Lack of focus on prevention, maintaining health, & preventing disease
Access issues
Over-consumption
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State Concerns
▫ Medicaid Growing Proportion of State Budgets
▫ Significant Efforts Around Controlling Growth
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Growing use of managed care
Restrict enrollment
Provider Rates
Limited State Flexibility
▫ Supreme Court Decision
 Reluctance to Expand
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Innovating with Medicaid Expansions
• To date 30 states and D.C. have elected to
expand Medicaid
• Expansion discussion is different in every state
▫ Legislative Approval (?)
• Expansions in 5 states through 1115 waivers
▫ Arkansas, Iowa, Michigan, Indiana, New
Hampshire & Pennsylvania
• Efforts in Utah, Tennessee & Wyoming efforts
stalled
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Reform Themes
• Platform for Reforming the Program
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Promoting Self-Sufficiency Not Dependency
Familiarizing Individuals with Private Market
Personal Responsibility
Improving Health Outcomes
▫ Push for State Flexibility
• Garner support from local legislators
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1115 Waivers
HHS has broad authority to grant waivers & ACA does not limit its authority
Requested Waivers:
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Entitlement Reform Through Increased Personal Responsibility
Provide Health Incentive Programs
Disincentives
Benefit Flexibility
Cost-Sharing* (limited flexibilities)
Retroactivity
Cost-Effectiveness
Work Requirement (not approved)
Policies Structured to Encourage Maintenance of Coverage
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Original Healthy Indiana Plan
(HIP) Structure
Key Features:
$500 Free
Preventive
Care
• Smoking cessation
• Cancer screenings
• Diabetes care • Physicals
Personal Wellness and
Responsibility (POWER) Account
$1,100 individual* & State contributions
Controlled by participant to cover initial
medical expenses
● High deductible plan paired
with a Health Savings like
account
● Comprehensive benefits, but
no dental, vision or maternity
● $1,100 deductible paid by
POWER account
● Required monthly contributions
● No copays, except for nonurgent use of ER
● Enrollment cap
● Medicare payment rates
Insurance Coverage
$300,000 annual coverage
$1 million lifetime coverage
*Individual contribution not to exceed 5% of gross annual household income
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Additional Features
• No Retroactive Coverage
• Effective date:
▫ Must make payment within 60 days to begin
coverage
▫ Once payment is made, plans changes only for
cause
• Plan Choice must be made before payment and
at time of application
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Healthy Indiana Plan (HIP)
Success
HIP improves
health care
utilization
HIP results in
high member
satisfaction
HIP promotes
personal
responsibility
Inappropriate emergency
room use 7% lower than
traditional Medicaid
beneficiaries
96% of enrollees satisfied
with HIP coverage
93% of members make
required Personal
Wellness and
Responsibility (POWER)
account contributions on
time
60% of HIP members
receive preventive care similar to commercial
populations
82% of HIP enrollees
prefer the HIP design to
copayments in traditional
Medicaid
30% of members ask
their healthcare provider
about the cost of services
80% of HIP members
choose generic drugs,
compared to 65% of
commercial populations
98% would enroll again
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HIP 2.0:
Three Pathways to Coverage
HIP Plus
• Initial plan selection for all members
• Benefits: Comprehensive coverage with enhanced
benefits, including vision, dental, bariatric, pharmacy
• Cost sharing:
• Monthly POWER account contribution required.
• Contribution is 2% of income with a minimum of $1 per
month.
• ER copayments only
HIP Basic
• Fall-back for members with income <100% FPL who do
not make POWER account contribution
• Benefits: Minimum coverage, no vision or dental
coverage
• Cost sharing:
• Must pay copayment ranging from $4 to $75 for doctor
visits, hospital stays, and prescriptions
HIP Link
• Employer plan premium assistance paired with
HSA-like account
• Enhanced POWER account to pay for premiums,
deductibles and copays in employer-sponsored plans
• Provider reimbursement at commercial rates
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Non-Payment Penalties
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Members remain enrolled in HIP Plus as long as they make
POWER account contributions (PACs) and are otherwise eligible
Penalties for members not making the PAC contribution:
Income
≤100%
FPL
Moved from HIP
Plus to HIP Basic
Copays for all
services
Income
>100%
FPL
Dis-enrolled
from HIP*
Locked out for
six months**
*EXCEPTION: Individuals who are medically frail.
**EXCEPTIONS: Individuals who are 1) medically frail, 2) living in a domestic violence shelter, and/or 3) in a state-declared disaster area.
If an individual locked out of HIP becomes medically frail, he/she should report the change to his/her former health plan to possibly
qualify to return to HIP early.
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Emergency Department (ED)
Copayment Collection
• HIP features a graduated ED copayment model
• HIP requires non-emergent ED copayments unless:
▫ Member calls MCE Nurse-line prior to visit or
▫ The visit is a true emergency
$8
1st non-emergent
ED visit in the
benefit period
$25
Each
additional
non-emergent
ED visit in the
benefit period
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Final Agreement
• Nation’s first
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Ends traditional Medicaid for Non-Disabled adults
6-Month Lock-Out
$25 ER copayment for non-emergency visits
Defined contribution premium assistance program
Minimum contributions for HIP Plus at all levels of poverty
Two-tiered benefit structure
Preservation of HIP
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Lock-out- Consistency With Exchange Policies
Effective date
Retroactivity
Plan changes
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Activity so far…
• Program began same day as announcement
• In the first month since Governor Pence
announced HIP 2.0:
▫ Transitioned 170,000 from Medicaid into HIP
▫ Approx. 297,0000 applications for health
coverage
▫ 70% Participating into HIP Plus
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Approved Demonstration: Arkansas
Element
Detail
Effective Date
January 2014
Structure
Non-medically frail adults receive premium assistance to enroll in
qualified health plans offered on the federal Marketplace.
Benefits
Offers the QHP benefits that are certified to be EHB to nonmedically frail adults. EPSDT, non-emergency transportation, and
free choice of family planning provider are provided as wrap
around services.
Cost Sharing
State plan copayments are required for individuals over 100% FPL.
Waiver amendment requests cost sharing at state plan amounts to
be applied to individuals over 50% FPL.
Incentives
Waiver amendment requests addition of health savings accounts for
members.
Unique feature: Covers all non-medically frail adults through premium assistance in
the Marketplace.
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New Hampshire
Element
Detail
Effective Date
Approved
Structure
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Non-medically frail individuals will have mandatory enrollment in
QHPs available on the federal marketplace
Individuals with access to cost-effective ESI will be mandatorily
enrolled in ESI
Benefits
QHP benefits with state plan benefit wrap
Cost Sharing
State Plan cost sharing
Incentives
NA
Unique feature: Requires individuals with access to cost effective ESI to enroll in ESI and
mandatorily enrolls non-medically frail individuals in QHPs available on the federal
marketplace.
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Approved Demonstration: Iowa
Element
Detail
Effective Date January 2014
Structure
Individuals with income under 100% FPL served through Medicaid
Accountable Care Organizations. Individuals with income over 100%
FPL enrolled in Marketplace QHPs with premium assistance or ESI.
Benefits
Income under 100% FPL:
Benefits based on state employee benefits with EHB
Income over 100% FPL:
Benefits based on state essential health benefits offered in
QHPs.
Offers dental benefits for those who complete periodic dental exams.
1- Year waiver for non-emergency transportation.
Cost Sharing
Premiums required for all individuals with income at 50% FPL or
more. Copayments for non-emergency use of ER but waived in year 1.
Incentives
Premiums are waived in the subsequent year if beneficiaries
complete health targeted healthy behaviors.
Unique feature: Premium payments authorized beginning at 50% FPL. Premiums
waived if healthy behaviors completed.
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Approved Demonstration: Michigan
Element
Detail
Effective Date April 2014
Structure
Covers the expansion population through the existing Medicaid
Managed Care structure
Benefits
Medicaid Alternative Benefit Plan based on the ACA’s 10 EHBs.
Cost Sharing
• No copayments for the first six months. Copayments for the next
six month period are applied from the State Plan schedule and
are based on care utilization in the previous six months.
• Individuals with income over 100% FPL pay a contribution to a
health savings-like account of 2% of their household income.
Incentives
Cost-sharing is paid into health accounts and can be reduced
through completion of targeted healthy behaviors.
Unique feature: 6 month look-back feature for assessing cost-sharing. Cost sharing
collected through health accounts instead of by providers. Cost sharing reduced
through completion of targeted healthy behaviors.
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Approved Demonstration: Pennsylvania
Element
Detail
Effective Date
January 1, 2015
Structure
Covers the expansion population through private Medicaid managed
care plans.
Benefits
Base benchmark plan for newly eligible not specified, pending future
State Plan amendment. Will not provide non-emergency transportation
services.
Cost Sharing
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Incentives
All demonstration beneficiaries pay state plan copayments in year 1.
In year 2 copayments will only be charged for non-emergency use of
the ER. Beneficiaries with income over 100% FPL will be subject to
monthly premiums of 2% of income.
State will collect and analyze copay data for individuals under 100%
FPL and submit amendment seeking premiums for this group based
on average copayment amounts.
Beneficiaries may reduce their premiums or copayments by completing
healthy behaviors in the prior year. Reductions will be evaluated every 6
months. Provides incentives for job search and work related activities.
Unique feature: Premiums for individuals under 100% FPL will be based on average
copays assessed in year 1.
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New Waiver Issues
• Work Requirements
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Pennsylvania & Utah
Administration Perspective
Welfare Reform
Oklahoma
• Time Limited Benefits
• Cost-Sharing
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Indiana Waiver
HIP 2.0 applicants and members
referred to existing State workforce
training programs and job search
resources if:
Unemployed or working less than 20
hours per week AND
Not full-time students
Notes:
SNAP recipients who have already been sent to Gateway to Work will not be referred again
Not participating in the Gateway to Work program does not impact HIP 2.0 eligibility
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1332 Waivers
• ACA allows for 1332 waivers starting in 1/1/2017
▫ QHPs, Exchanges, Tax Credits, Cost-Sharing
▫ Requires State legislation
• Waivers Must:
▫ (1) provide coverage that is at least as comprehensive
▫ (2) provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at
least as affordable as current provisions
▫ (3) provide coverage to at least a comparable number
of people
▫ (4) will not increase the federal deficit.
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1332 Waivers
Activity Will Pick-Up After 2016 Election
• Coordination with Medicaid/Expansion & 1115
Waivers
• Individual & Employer Mandates
• Rating Rules
• Benefit Design
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Questions
Seema Verma
[email protected]
(317) 809-8536