0 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Health Care Expansions in the District of Columbia.

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Health Care Expansions in the District of Columbia

Healthy DC and Other Coverage Strategies

Dave ChandraDirectorOffice of Health Care InnovationDepartment of Health Care Finance

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Department of Health Care Finance

Established as separate cabinet-level agency on October 1, 2008

Continues oversight of publicly funded health care programs

New and greater emphasis on private market and access to care for uninsured

Established Office of Health Care Innovation

Department of Health Care

Finance

Department of Health

Medical Assistance

Administration

Department of Mental

Health

Department of Human Services

Department of Health

Department of Mental

Health

Department of Human Services

Mayor Mayor

Prior Structure New Structure

Office of Health Care Innovation

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Coverage Distribution - DC

1District of Columbia: Health Insurance Coverage of the Total Population, states (2007-2008), U.S. (2008), Kaiser Family Foundation,

2 Department of Health Care Finance Enrollment Data (as of September 30, 2009)

3 Current Population Survey 2008, US Census Bureau (2009)

4 percentages summate to over 100% because 1) data is from multiple surveys and 2) Alliance members may be categorized as uninsured in

the Current Population Survey4 State Heath Facts, Kaiser Family Foundation (2008) available at http://www.statehealthfacts.org/profileind.jsp?ind=125&cat=3&rgn=10

Type of Coverage # of DC

Residents Percent of DC

Residents4

Percent of US Population5

Private Coverage1 348,800 58.9% 57.0%Medicare1 59,300 10.0% 12.4%Medicaid2 158,551 26.8% 14.1%DC HealthCare Alliance2 54,784 9.3% n/a Uninsured3 59,000 10.0% 15.4%

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Coverage Distribution - Region

State Heath Facts, Kaiser Family Foundation (2008) available at http://www.statehealthfacts.org/profileind.jsp?ind=125&cat=3&rgn=10

Type of Coverage District of Columbia

Maryland Virginia

Private Coverage 58.9% 64.9% 62.0%Medicare 10.0% 11.2% 12.2%Medicaid 26.8% 9.9% 8.6%Other Public 9.3% 1.0% 3.5%Uninsured 10.0% 12.9% 13.8%

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Safety Net Insurance In DC

Children ParentsSeniors/People w/ Disabilities

Childless Adults

Undocumented Adults

400%

   Uninsured    

300%

Medicaid/CHIP

  Qualified Medicare

Beneficiaries (QMB)

200%Medicaid/ DC

Healthy Families

DC HealthCare Alliance

DC HealthCare Alliance100%

Medicaid

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Safety Net Insurance In DC

Children ParentsSeniors/People w/ Disabilities

Childless Adults

Undocumented Adults

400%

   Healthy DC    

300%

Medicaid/CHIP

  Qualified Medicare

Beneficiaries (QMB)

200%Medicaid/ DC

Healthy Families

DC HealthCare

Alliance

DC HealthCare Alliance100%

Medicaid

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

DC MedicaidPrimarily serves children, parents, low-income seniors and

individuals with disabilities, and certain other populations

SCHIP implemented as Medicaid Expansion

158,551 enrollees (26.9% of DC population):

– 57,378 in fee-for-service

– 101,173 in one of three managed care plans

Enrollment through Single Point of Entry IMA (DHS)

70/30 federal matching percentage (79/21 under ARRA)

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

DC HealthCare AllianceEstablished in 2001 out of closure of DC General Hospital

Covers uninsured DC residents up to 200% FPL

No citizenship documentation requirement

~54,784 enrollees

Coverage through the three Medicaid MCOs

Benefit limits greater than those in Medicaid (no mental health/

long term care, defined formulary, closed pharmacy network)

Supported by DC funds

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Healthy DCHealthy DC legislation passed in 2008

Establishes coverage for uninsured residents up to 400% FPL

Member premiums statutorily capped at 3%/5% of income

Benefit Package/Cost sharing equivalent to large group products

Coverage through managed care plan(s)

Enrollment cap commensurate with available funds

Funded by assessment on health insurance premium revenues

Enrollment to be handled by DHCF

Target launch – Spring 2010

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

BudgetFunded by 2% premium tax on DC HMOs and Hospital and

Medical Services Corporations

FY10 - $11,714,963* (projected available funds)

FY11 - $17,486,000* (projected available funds)

*B18-401 directs an additional $5 million to the Healthy DC Fund as part of a public-private partnership between DC Government and a Hospital and Medical Services Corporation

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

EligibilityTo be eligible for the Healthy DC Program, applicants must:

Be a DC resident for at least 6 months; and

Have a household income at or below 400% FPL; and

Be ineligible for any other local or federal health benefit programs; and

Have been uninsured for at least 6 months; or

Have lost insurance coverage for a qualifying reason

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Member PremiumsHealthy DC Statutory limits for Monthly Member Premiums:

Projected FY10 Monthly Member Premiums:

<300% FPL Adults $35

301% - 400% FPLChildren $40

Adults $70

Individual Family of 4 Limit

<300% FPL <$32,490 >$66,150 3% of income

301% - 400% FPL $32,491 - $43,320 $66,151 - $88,200 5% of income

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Proposed Benefit Package Service Cost-Sharing/ Co-Pay 

Annual Deductible $200 (except for preventive care visits) 

Out of Pocket Max None

Lifetime Benefit Max none 

Annual Benefit Max  none 

Primary Care Visits  $15 

Specialist Visits  $25 

Maternity Visits  $10 

ED Visits  $100 (waived if admitted)

EMS Transport $100 (waived if emergent)

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Proposed Benefit Package Service Cost-Sharing/ Co-Pay 

Pharmaceuticals $10 Tier I/$20 Tier II/$40 Tier III

Inpatient Hospital $100

Behavioral Health $25 per visit

Nursing Home/SNF 15% after deductible (30 days per year)

Home Care Services $40 per visit (25 visits per year)

Dental 30% preventive, 50% basic restorative

DME, Vision, Podiatry etc varying co-pays

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

District-wide public awareness campaign via print,broadcast, and online media

Targeting working DC residents likely to be uninsured:

Guided by findings from pending Urban Institute Insurance Survey

Collaboration with DC business/small business organizations

Will link residents to Healthy DC, or other public assistance programs where appropriate

Marketing and Outreach

- Parents of CHIP children- Restaurant/bar employees- Construction workers

- Sole practitioners- Low-wage/part time workers- Home care aides

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Broad legislative language is preferred to very prescriptive terms

Dedicated tax revenue source ensures level of sustainability

Establishing new enrollment system is administratively cumbersome

Compromises are inevitable to ensure affordability and feasibility

Overhead/infrastructure development cost is extensive regardless of program size

Crowd-out and Adverse Selection remain concerns

Community partnerships are critical to developing benefit design, premium levels, rules, outreach plan etc

Lessons Learned

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

National Health Reform & DCHealthy DC infrastructure to accommodate state-required functions

in health reform legislation

New customer service unit can process eligibility for Health Exchange

Healthy DC can serve as a possible public option in a local exchange

Can establish regional exchange with metro partners

Childless Adult expansion in Medicaid

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

1115 Medicaid Waiver for Childless Adults up to 200% FPL

Refine DSH formula based on new uncompensated care reporting

Establish pilot program high cost/chronically-ill Medicaid members

CareFirst Blue Cross/Blue Shield Open Enrollment Program

Create Premium Assistance Program in Medicaid/Healthy DC

Enhance Purchasing in DC Employee Benefit Plan

Reform Small Group/Non-Group Market

Provider Payment Reform

Other Local Reform

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Government of the District of Columbia Department of Health Care Finance

For Official Government Use Only

Department of Health Care FinanceGovernment of the District of Columbia

Questions?

ContactDave ChandraDepartment of Health Care [email protected]