Catherine HessCatherine HessManaging Director for Coverage & AccessManaging Director for Coverage & AccessThe National Medicaid CongressThe National Medicaid CongressJune 15, 2011June 15, 2011

Medicaid, CHIP and Health Insurance Exchanges

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About NASHPAbout NASHP

NonNon‐‐partisan, nonpartisan, non‐‐profit helping states achieve profit helping states achieve excellence in health policy and practiceexcellence in health policy and practice

Works across states and agencies and branches of Works across states and agencies and branches of government to advance health policy solutionsgovernment to advance health policy solutions

Conducts policy analysis and research Conducts policy analysis and research 

Convenes forums for problem solvingConvenes forums for problem solving

Supports peer learning networks and provides Supports peer learning networks and provides technical assistancetechnical assistance

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NASHP work on health NASHP work on health care reform includescare reform includes……Children in the VanguardChildren in the Vanguard –– 10 state network focused on 10 state network focused on childrenchildren’’s coverage and reforms coverage and reformMaximizing EnrollmentMaximizing Enrollment -- helping 8 states improve systemshelping 8 states improve systemsState Health Reform Assistance NetworkState Health Reform Assistance Network-- part of a TA part of a TA team helping 10 states with coverage system changesteam helping 10 states with coverage system changesState Health Exchange Leadership NetworkState Health Exchange Leadership Network ––supporting peer exchange among all statessupporting peer exchange among all states

National Workgroup on Integrating a Safety Net into National Workgroup on Integrating a Safety Net into Health Care Reform Implementation Health Care Reform Implementation –– Federal, state, Federal, state, health system and provider forum to inform policy health system and provider forum to inform policy

State Refor(u)m State Refor(u)m –– open, webopen, web--based platform for exchangebased platform for exchange

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OverviewOverview

Medicaid/CHIP as health insurance optionsMedicaid/CHIP as health insurance optionsWhere states are nowWhere states are nowMedicaid/CHIP/Exchange requirements, Medicaid/CHIP/Exchange requirements, relationships, and state optionsrelationships, and state options–– Eligibility and enrollmentEligibility and enrollment–– Benefits, plans and providersBenefits, plans and providers

ConclusionConclusion

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““State Health Subsidy OptionsState Health Subsidy Options””available under the ACAavailable under the ACA

1.1. Medicaid for individuals <133% FPLMedicaid for individuals <133% FPL2.2. CHIP for children between 133% FPL CHIP for children between 133% FPL

and state ceilingand state ceiling3.3. Subsidies for Qualified Health Plans Subsidies for Qualified Health Plans

for individuals between 133for individuals between 133--400%FPL400%FPL

4.4. Basic Health Plan for individuals Basic Health Plan for individuals between 133between 133--200% FPL (Optional)200% FPL (Optional)

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Medicaid: From Welfare ProgramMedicaid: From Welfare Programto Health Insurerto Health Insurer

Adapted from: Bachrach, Deborah. MedicaidAdapted from: Bachrach, Deborah. Medicaid’’s s Role in the Exchange. NASHP webina,.Role in the Exchange. NASHP webina,.March 16, 2011March 16, 2011

1965 1996 20192010 2014

Medicaid authorized as welfare-related

program

Medicaid de-linked from cash

assistance

Medicaid covers over 50 million

people, most in working families

Full Exchange operation

2011-2013

Establish Exchange operations

Medicaid 2nd

largest source of coverage (age <65)

The point here is that Medicaid is now a health insurance program and the paper makes the case that Medicaid should be treated like another “subsidized coverage option” in the exchange. Covers more than 50 million lives, most are in working family, and is named as one of the 4 “state health subsidy options”in the ACA

• Add data about newly eligible population/ Medicaid vs. subsidy population

•Research to date is sparse but indicates that half the adults who will gain eligibility in 2014 are

•very poor (income below 50%FPL), •a third have a diagnosed chronic condition, and •many are likely to have pent-up needs for care. (Kaiser Family Foundation 2010a and 2010b). •They will also include many relatively healthy adults (Somers, Hamblin, Verdier, & Byrd 2010). “ -KCMU

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Source: The Kaiser Commission on Medicaid and the UninsuredData: Congressional Budget Office estimates, March 18, 2010

Medicaid/CHIP in Continuum of Coverage in 2019

Employer

Medicaid / CHIP

Nongroup / Other Individual

Private Coverage throughExchange

Uninsured

Total = 280 million people < 65

159m

51m

25m

24m

22m

From: Bachrach, Deborah. MedicaidFrom: Bachrach, Deborah. Medicaid’’s s Role in the Exchange. NASHP webinar.Role in the Exchange. NASHP webinar.March 16, 2011March 16, 2011

CHIP: From Incremental, Targeted CHIP: From Incremental, Targeted Coverage Program to ???Coverage Program to ???

1997 1998-2008 20192009 2015-2016

Children’s Health Insurance Program

enacted afterhealth care reform

fails

CHIP successful in covering millions;

pioneers enrollment simplifications; has impact on Medicaid

policy and enrollment

CHIP reauthorized

with increased funding,

improvements

CHIP funded to ‘15; HHS certifies which

Exchange plans comparable to CHIP;

23% increase in match in 2016

2014

Exchanges Fully

Operational

CHIP (& Medicaid for children)

Maintenance of Effort ends

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Health Insurance Exchanges: Health Insurance Exchanges: New Kids on the BlockNew Kids on the Block

States need to decideStates need to decide–– Whether to create or default to fedsWhether to create or default to feds–– Governance & Operations ResponsibilitiesGovernance & Operations Responsibilities

Current or new state agency or nonCurrent or new state agency or non--profit?profit?Roles of agenciesRoles of agencies-- Medicaid, InsuranceMedicaid, Insurance

–– Goals and Roles in the MarketGoals and Roles in the MarketFrom marketplace to active purchaserFrom marketplace to active purchaser

Utah & Massachusetts models pre ACAUtah & Massachusetts models pre ACA99

Exchanges: Exchanges: Where are States now?Where are States now?

Most still assessing their optionsMost still assessing their optionsHalf dozen passed legislationHalf dozen passed legislationHalf dozen may do without legislationHalf dozen may do without legislationAt least one (LA) defaulting to fedsAt least one (LA) defaulting to fedsOthers, even while opposed to ACA, planning Others, even while opposed to ACA, planning for state Exchange (e.g. VA)for state Exchange (e.g. VA)Many planning public authority or nonMany planning public authority or non--profit profit At least one (DE) planning to build on MedicaidAt least one (DE) planning to build on Medicaid

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Areas of consistency

Governing boards that include state agency leads, consumer/business reps, and health experts

Conflict of interest clauses (keep insurers/providers in advisory role, not voting Board members)

Great variance in “reach” of Exchange: Meeting federal minimums vs. additional powers and duties

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State ContextsState Contexts

Strained state budgets; planning cuts Strained state budgets; planning cuts and expansion at same timeand expansion at same timeReduced staffing to handle increased Reduced staffing to handle increased and complex workand complex workNew administrations in many mean New administrations in many mean slowing pace if not changing directionslowing pace if not changing directionPolitical shifts in executive and Political shifts in executive and legislative branches still sorting outlegislative branches still sorting out

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MEDICAID, CHIP & MEDICAID, CHIP & EXCHANGE REQUIREMENTS EXCHANGE REQUIREMENTS AND RELATIONSHIPS IN AND RELATIONSHIPS IN THE AFFORDABLE CARE ACTTHE AFFORDABLE CARE ACT

Catherine HessCatherine Hess 1313

Eligibility and Enrollment in Medicaid, CHIP and Exchanges““World classWorld class”” system with system with ““no wrong doorno wrong door””::–– Single, streamlined form for all programsSingle, streamlined form for all programs–– ““Secure, electronic interfaceSecure, electronic interface””–– Multiple doorways: internet, mail, phone, in personMultiple doorways: internet, mail, phone, in person–– CHIP/Medicaid have systems, experience to build onCHIP/Medicaid have systems, experience to build on

New Modified Adjusted Gross Income (MAGI) New Modified Adjusted Gross Income (MAGI) standard for all programs standard for all programs –– But other Medicaid rules did not change; But other Medicaid rules did not change;

complicated to reconcile these and IRS approachescomplicated to reconcile these and IRS approaches–– Federal guidance eagerly awaited; expected soonFederal guidance eagerly awaited; expected soon

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Some key issues for states Some key issues for states in eligibility and enrollmentin eligibility and enrollment

Design new or modify eligibility systems?Design new or modify eligibility systems?–– 100% federal $ for Exchange, 90% for Med. 100% federal $ for Exchange, 90% for Med. –– Federal encouragement and coordination to respond Federal encouragement and coordination to respond

to vision and opportunities in ACA to vision and opportunities in ACA –– But time and expertise required dauntingBut time and expertise required daunting–– ““HorizontalHorizontal”” links to human services being links to human services being

approached differently in different statesapproached differently in different statesTracking Tracking ““oldold”” and and ““newnew”” eligibleseligiblesTransitions between programs with changing incomes; Transitions between programs with changing incomes; promoting continuity and reducing churnpromoting continuity and reducing churn

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Income Fluctuations Among Those Income Fluctuations Among Those Below 400% FPL Below 400% FPL

Farley, P., Swartz, K., Uberoi, N., et al. Farley, P., Swartz, K., Uberoi, N., et al. Realizing Health Realizing Health ReformReform’’s Potential: Maintaining Coverage, Affordability, and s Potential: Maintaining Coverage, Affordability, and Shared Responsibility when Income and Employment Shared Responsibility when Income and Employment ChangeChange. (New York, NY: The Commonwealth Fund, 2011). (New York, NY: The Commonwealth Fund, 2011)

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Benefits, Plans and Providers: Benefits, Plans and Providers: State Options for Integrating Medicaid State Options for Integrating Medicaid and the Exchangeand the Exchange

Minimal Integration Maximum Integration

Integration Strategies Contracted Plans

Marketing RulesQuality StrategiesReporting Requirements

Benefits Provider Networks Basic Health Plan

Bachrach, Deborah. MedicaidBachrach, Deborah. Medicaid’’s Role in the s Role in the Exchange. NASHP webinar March 16, 2011Exchange. NASHP webinar March 16, 2011

Integration Goals Facilitating transitionsLeveraging buying

power

Plan Standards Could Be Plan Standards Could Be Aligned to Promote IntegrationAligned to Promote Integration

CertificationCertificationQuality strategiesQuality strategiesReportingReportingConsumer Consumer informationinformationRisk adjustmentRisk adjustment

Bachrach, Deborah. MedicaidBachrach, Deborah. Medicaid’’s Role in the s Role in the Exchange. NASHP webinar March 16, 2011Exchange. NASHP webinar March 16, 2011

Federal Standards for QHPs

State Standardsfor MMC Plans

State Standards forCommercial Plans

Benefits Could Be AlignedBenefits Could Be Aligned

Promote continuity of coverage and Promote continuity of coverage and care for enrolleescare for enrolleesSimplify administration and improve Simplify administration and improve efficiencyefficiencyConsider federal matching ratesConsider federal matching ratesDegree of flexibility in federal Degree of flexibility in federal guidance on essential benefits guidance on essential benefits important; not expected until fallimportant; not expected until fall

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Benefit Essential Benefits

Minimum Benchmark

Maximum Benchmark*

Standard Medicaid

Physician services X X X X

Lab and x‐ray X X X X

Inpatient hospital services X X X X

Prescription Drugs X X X X**

Pediatric services incl. oral and vision care X X X X

Mental Health & Substance Abuse X X X X

Outpatient hospital services X X X X

Rehabilitative and habilitative services X X X X**

EPSDT X X X

Family planning X X X

Non‐emergency medical transportation X X X

Federally Qualified Health Center/Rural Health Center services

X X X

Nursing facility services X X

Home Health Care Services X X**

* Subject to HHS approval

** Optional

Benefit Options in 2014

Bachrach, Deborah. Medicaid’s Role in the Exchange. NASHP webinar March 16, 2011

Provider and Plan Capacity and Provider and Plan Capacity and Continuity for Medicaid, CHIP and Continuity for Medicaid, CHIP and ExchangesExchanges

32 million newly insured 32 million newly insured competing for strained competing for strained provider supplyprovider supplyVariable, generally low Variable, generally low Medicaid reimbursement Medicaid reimbursement State variation in degree State variation in degree to which Medicaid, CHIP to which Medicaid, CHIP and commercial and commercial networks are samenetworks are same–– Incentives for providers Incentives for providers

and plans that participate and plans that participate in all?in all?

MedicaidMedicaid--toto--Medicare Medicare Physician Fee Index, 2008Physician Fee Index, 2008

Physician fees relative to the national average.Source: Statehelthfacts.org

•32 mil from KCMU April 2011 report•Projected 25% increase in Medicaid enrollment

•Large market impact•Varying health needs•Predictions of increased shortages (add fact)

•“Low Medicaid payment rates are considered to be the chief reason that fewer physicians are willing to treat Medicaid patients compared to patients with other coverage (Cunningham & Nichols 2005; Coburn, Long, & Marquis 1999), although many physicians also cite other reasons (Cunningham & O’Malley, 2008; Cunningham & May 2006).” –KCMU•ACA temporarily raises Medicaid payment rates to Medicare payment levels for primary care services•The Medicaid-to-Medicare fee index measures each state's physician fees relative to Medicare fees in each state. These fees represent only those payments made under FFS Medicaid. http://www.statehealthfacts.org/comparemapdetail.jsp?ind=196&cat=4&sub=51&yr=63&typ=1•“Furthermore, there are currently differences between networks and benefits in public and commercial plans, which would necessitate changing providers and adjusting to a new benefit package and cost-sharing obligations. The ACA requirement that qualified health plans in the Exchange include “essential community providers” in their networks could help with the alignment between Medicaid and commercial networks. Federal guidance defining essential community providers is expected in the coming months.” –D.H. http://content.healthaffairs.org.proxygw.wrlc.org/content/28/3/w510.full?keytype=ref&siteid=healthaff&ijkey=Uh5iyYjsJI1hU

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ConclusionConclusion

Role of Medicaid changing, shifting more fully to Role of Medicaid changing, shifting more fully to health insurancehealth insuranceFuture of CHIP unclearFuture of CHIP unclearStates have many decisions to make and details States have many decisions to make and details

to address in short timeframe, with reduced to address in short timeframe, with reduced capacity to do so; federal guidance criticalcapacity to do so; federal guidance criticalWhile not simple, state options and opportunities While not simple, state options and opportunities exist to align if not integrate Medicaid, CHIP and exist to align if not integrate Medicaid, CHIP and ExchangesExchanges

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For more informationFor more information……

Bachrach, D., Boozang, P., Dutton, M., Bachrach, D., Boozang, P., Dutton, M., MedicaidMedicaid’’s Role in the s Role in the Health Benefits Exchange: A Road Map for StatesHealth Benefits Exchange: A Road Map for States. (Maximizing . (Maximizing

Enrollment/National Academy for State Health Policy, 2011) Enrollment/National Academy for State Health Policy, 2011)

chess@nashp.orgchess@nashp.org

www.nashp.orgwww.nashp.orgwww.statereforum.orgwww.statereforum.org

www.maxenroll.orgwww.maxenroll.org

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