Planning for Expansion Populations

Massachusetts’ Experience Covering Non-Traditional Populations

National Governors AssociationApril 2012

Stephanie Sullivan Chrobak Director of Program ManagementMassachusetts Health Insurance Connector Authority

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Agenda

• Introduction– Massachusetts’ Health Connector– Commonwealth Care Program – Massachusetts’ Experience with Health Care Reform

• Eligibility & Enrollment • Expansion Population – what we know about this unique group

– Demographics– Utilization – Outreach, Education & Marketing

• Lessons Learned

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Massachusetts Health ConnectorOverview

• An independent, quasi-governmental state authority

• Governed by a independent Board

• Operates health insurance Exchange

• Assists and advises other state agencies with their health insurance programs

• Policy making body supporting implementation of MA health reform (e.g. Affordability standards and MCC rules)

• Conduct ongoing outreach and public education – Goal is to help individuals obtain and retain coverage – Inform public of rules under health reform– Notify small businesses of savings opportunities when purchasing

through Health Connector

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Outreach By Health Connector

Public education and outreach has evolved over the years, was critically important early on, and remains a strong core competency of the Health Connector

● Public Information Unit

● During initial launch, partnerships were formed with corporate and civic organizations including the health care community, faith communities, unions, business groups, sports teams, etc.

● Media Outreach/Direct Mail

● Seminars and forums, working with Medicaid team

● Grants to Community Organizations

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Massachusetts Health ConnectorPrograms

• Commonwealth Care Program (subsidized)– 190,000 low income individuals– 5 MCOs participate throughout the state – Strong collaboration with Medicaid

• Commonwealth Choice Program (for non-subsidized individuals

and small businesses) – About 41,000 members– 8 Commercial health plans participate

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Current State of Massachusetts Health Connector

• Celebrating 5-year anniversary this year– Strong starting point– High rates of coverage and employer-sponsored insurance– Existing insurance market reforms (guaranteed issue, no pre-

existing coverage limitations, modified community rating, no medical underwriting)

– Political “stars aligned”

• 1.9% uninsured after 5 years (reduced disparities and improved access)

• 97% compliance with mandate

• Planning for 2014

• Heightened focus on cost containment

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Overview of Commonwealth Care

Program

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Commonwealth CareProgram Elements

• Eligibility requirements– Uninsured individuals who do not access to ESI, paying full COBRA– Age 19 or older (childless, non-pregnant, non disabled)– Family’s annual gross income at or below 300% FPL

Plan Type Salary Requirements

MembershipMarch 2012

Percent

1 < 100% FPL 78,533 45%

2 100 – 200% FPL 67,428 39%

3 201 – 300% FPL 27,477 16%

Total 173,438 100%

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Commonwealth Care Membership by Health Plan (April 2012)

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MCO Commonwealth Care

Membership

%

BMCHP 35,874 21%

CeltiCare 34,818 20%

Fallon 5,831 4%

Neighborhood Health Plan 34,161 20%

Network Health 63,926 38%

TOTAL 174,610 100%

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Eligibility process

• Must complete Medical Benefit Request (MBR) form

• Same application used for – MassHealth (Medicaid) – Children’s Medical Security Plan (CMSP)– Healthy Start– Health Safety Net (formerly known as the Uncompensated

Care Pool)

• May seek assistance from staff at hospitals and community health centers

• Providers have online MBR access via EOHHS Virtual Gateway  

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Enrollment process

• Once deemed eligible, there are 3 ways a member can enroll – Majority of members call the Commonwealth Care– Online at www.MAhealthconnector.org– Through the mail

• From application to enrollment, process takes about 1 month

• Individuals must choose a plan in order to have coverage. They choose from approved health plans based on the service area they live in and certain member attributes

• Progressive enrollee premiums and copayments – Plan Type 1 benefit plan mirrors Medicaid, no premiums– Plan Type 2 & 3 members pay monthly premiums(similar to private

insurance) and can make payments via web or mail

• Yearly Open Enrollment (similar to private insurance) – Existing members can change health plan for any reason

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Commonwealth Care ProgramProcurement

• Yearly procurement, with capitation based on Actuarially Sound Rate Range– Innovative programmatic changes introduced while monitoring utilization,

quality of care, access to care and overall member satisfaction

• Stop-loss insurance and aggregate risk sharing features in place

• Use of predictive modeling to adjust payment rate – minimizing practice of “risk selection” by health plans

• Closed insurance pool thereby negating “adverse selection”

• Incentives in place to encourage MCOs to bid low

• Heavy use of claims data and analytics to understand enrollment and cost dynamics

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Massachusetts’ Experience with

Expansion Population

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Looking back: Massachusetts’ population for coverage

Newly insured Massachusetts residentsActual 364,000 (September 2009)

MassHealthActual 34%

(123,000 residents)

MassHealthActual 34%

(123,000 residents)

Individualinsurance

Actual 14%(50,000 residents)

Individualinsurance

Actual 14%(50,000 residents)

Private insuranceActual 25%

(91,000 residents)

Private insuranceActual 25%

(91,000 residents)

Commonwealth CareActual 41%

(150,000 residents)

Commonwealth CareActual 41%

(150,000 residents)

Employer-sponsored insurance (ESI)

Actual 11%(41,000 residents)

Employer-sponsored insurance (ESI)

Actual 11%(41,000 residents)

Source: www.mahealthconnector.org, “Health Reform Facts And Figures — Summer 2010,” September 13, 2010

Commonwealth ChoiceActual 6%

(22,000 residents)

Commonwealth ChoiceActual 6%

(22,000 residents)14

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Expansion population overview: Prior health insurance

Source: Commonwealth Health Insurance Connector Authority, April 2011

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Expansion population overview: Member insights

• Demographically diverse• Many uninsured adults had not accessed care in years; most

had no ties to a primary care provider but wanted one• Key concerns were economic

– Allocated resources to take care of their families• Lack of insurance not a choice

– No sense of control or empowerment• Health insurance not a priority

– Healthy, won’t get sick, and can get free care if needed• People did not expect great coverage for free, but wanted

value for their money

Source: Network Health focus groups, 2006

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Expansion population overview: Member demographics

• 66% are employed; 16% had more than one job• 53% are women• 82% are Caucasian, 5% are African American, 5%

are Asian, and 12% are Hispanic or of Latino descent

• 80% were born in the United States• 56% were uninsured at some point during the

12-month period before enrolling in Commonwealth Care

Source: Commonwealth Health Insurance Connector Authority survey, Fall 2010

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Expansion population overview:Member source of care

• 81% have a usual source of health care and have seen a general doctor at least once during the past 12 months since becoming a Commonwealth Care member

• 72% visited a health care provider, and 52% visited a specialist

• 33% sought care in an emergency room; of those, 39% indicated that it was a low-acuity, non-emergency visit

Source: Commonwealth Health Insurance Connector Authority survey, Fall 2010

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Expansion population comparisonwith Medicaid: Age

• Expansion population is older than expected

Source: Network Health, February 2012

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Expansion population comparisonwith Medicaid: Gender

• Expansion population has balanced gender distribution

Source: Network Health, February 2012

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Expansion population comparisonwith Medicaid: Tenure

• Expansion population has shorter tenure

Source: Network Health, February 2012

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Expansion population comparisonwith Medicaid: Medical claims

• Expansion population had pent-up demand initially

Source: Network Health, February 2012

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Expansion population comparisonwith Medicaid: Admitting diagnoses

• Abdominal pain• Pancreatitis• Ethanol withdrawal or delirium• Cellulitis• Chronic obstructive pulmonary

disease

Top five admitting diagnoses for

Commonwealth Care members

• Ethanol withdrawal or delirium• Pancreatitis• Cellulitis• Postoperative infection• Morbid obesity

Top five admitting diagnoses for MassHealth

members ages 19+

Source: Network Health, February 2012

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Expansion population comparisonwith Medicaid: Utilization

Utilization metricsCommonwealth

CarePlan Type I

MassHealth

Rating Category I (Ages 19+)

Medical/Surgical admissions per 1,00073 57

Medical/Surgical days per 1,000322 186

Medical/Surgical average length of stay per 1,000 4.4 3.3

Emergency room visits per 1,000741 848

Pharmacy prescriptions per 1,00018,194 14,418

Source: Network Health, February 2012

• Expansion population has higher claims costs

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Expansion population comparisonwith Medicaid: Utilization (cont’d.)

•Behavioral health•Medical/Surgical•Office visits•Other facility inpatient•Therapies

Top five services that cost more for

Commonwealth Care Plan Type I members than for MassHealth

Rating Category I members ages 19+

•Clinic•Emergency department•Obstetrics•Other professional services•Well newborn

Top five services that cost less for

Commonwealth Care Plan Type I members than for MassHealth

Rating Category I members ages 19+

Source: Network Health, February 2012

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Expansion population comparisonwith Medicaid: Member satisfaction

SurveyCatergories

Commonwealth Care summary

rates*

MassHealth summary

rates*

Rating of health plan

68.7% 81.9%

Getting needed care 82.6% 81.0%

Customer service 81.2% 81.4%

* Summary rate represents the percentage of respondents who chose the top two answers of “usually” and “always” from four possible responses: “never,” “sometimes,” “usually,” and “always.”

Source: Network Health Consumer Assessment of Healthcare Providers and Systems (CAHPS), 2011

Future 2014: Lessons Learned

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Lessons Learned

• Importance of shared responsibility– Individuals, employers, government, insurers

• Value of a phased approach

• Importance of ongoing outreach, education, and stakeholder engagement– Leverage all the help you can – Advocate group involvement is critical

• Be creative with outreach – leverage technology

• Must understand and value stakeholders’ interests

• Every state must assess their starting point– Each state is different

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Lessons Learned (cont)

• Learn as much as possible about your population– Are they similar to Medicaid?– Are populations are difficult to reach?

• Must balance the ideal with the realities – State budgets, competing interests, etc

• Use this time to find efficiencies and leverage technology

• Create guiding principles and re-visit them often– Collaborate with other state agencies

• Develop strong relationships with health care and opinion leaders

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