Maximizing coverage and access to care under PPACA State Coverage Initiatives Program August 4, 2010 Stan Dorn The Urban Institute [email protected]@urban.org.

Maximizing coverage and access to care under PPACA

State Coverage Initiatives Program

August 4, 2010

Stan Dorn

The Urban Institute

[email protected] 202.261.5561

Overview

Maximizing enrollment and retention of eligible individuals

Improving affordability and continuity of coverage and care above Medicaid income levels

Increasing Medicaid beneficiaries’ access to care

But first: a quick review Medicaid to 138% FPL

MAGI Rules for newly eligible adults

o Definition: would not have qualified under state rules as of 12/1/09o Highly enhanced FMAPo “Benchmark benefits”

Standard FMAP for other adults Subsidies in the exchange up to 400% FPL

OOP cost-sharing subsidies to 250% FPL – higher AV Integrated eligibility system for Medicaid and exchange Individual mandate raises the stakes on enrollment Caveat: much hinges on how CMS interprets the law

Part I

Maximizing enrollment and retention of eligible

individuals

The need for public education and application assistance

The Massachusetts story Major public education effort Application assistance

o “Virtual gateway”o CBO contractso Provider incentiveso > ½ of all successful applications came from CBOs and

providers

Other states have facilitated enrollment – CA, NY, WI, etc.

Behavioral economics

Public education and application assistance under PPACA

Responsibility of exchange Patient navigators Call centers Federal funding through 12/31/14

Partner with local philanthropy Hospital-based presumptive eligibility Follow MA precedent in terms of safety net

providers? Must be done carefully, to avoid deterring access to care

Limit application forms to questions relevant to eligibility Need to distinguish the newly eligible from others

Claim enhanced FMAP Provide benchmark benefits

Requires information irrelevant to eligibility Parents

o Assetso Deprivation

Childless adults and empty nesters o Disabilityo Pregnancy

Solutions To claim FMAP, use sampling Provide standard Medicaid benefits as “Secretary-approved”

benchmark coverage, Social Security Act Section 1937(b)(1)(D)

Asking for help without completing a traditional form

Eligibility is determined based on data when an individual applies “by requesting a determination of eligibility and authorizing disclosure of … information [described in Social Security Act Sections 1137, 453(i), and 1942(a)] … to applicable State health coverage subsidy programs for purposes of determining and establishing eligibility.” PPACA Section 1413(c)(2)(B)(ii)(II)

Precedents EITC amount CA income tax Medicare Parts B and D – automatic, without request

Requirements

Consumer must Request for disclosure Provide SSNs needed for data-matching

State and exchange must gather data 1137 – IEVS, SAVE 453(i) – National Directory of New Hires 1902(a) – public benefit programs, new hires data,

state tax records, Medicaid TPL data showing private coverage, vital statistics records in any state

Basing eligibility on receipt of other benefits

Express Lane Eligibility remains an option for children

New SSA Section 902(e)(13)(D)(i)(I) says that MAGI does not apply to people “who are eligible for medical assistance … as a result of eligibility for, or receipt of, other Federal or State aid or assistance” [in addition to SSI]

Implies that states can base Medicaid income-eligibility on receipt of other benefits Logical if other program’s eligibility is far below

138% FPL

Basing eligibility on income data

Subsidies in exchange Based on prior-year tax data Chance to supplement at application Year-end reconciliation

Medicaid Initial determination based on income at time

application is processed Post-application changes? Not clear, under PPACA What happens if application submitted to exchange?

Suppose states cannot base Medicaid eligibility on data

Pay stubs required or self-attestation Consequences for consumer

Two-tier system obstructing participation Successful programs have used data-driven eligibility

o Massachusetts enrollmento Louisiana renewalo Medicare subsidies for Parts B and D

Consequences for states Administrative costs higher Caseload costs lower Higher likelihood of PERM liability

Possible approach

If prior-year tax data show Medicaid eligibility, consumer automatically receives Medicaid If after a certain point in the calendar year, could supplement

with more recent data (new hires, quarterly earnings) If prior-year tax data show ineligible for Medicaid,

receive an opportunity to apply for Medicaid using traditional procedures, including pay stubs, etc. In the meantime, subsidies in the exchange Precedent: ELE

Legal support “Less restrictive methodology” PPACA requires Medicaid, CHIP, and the exchange “to the

maximum extent practicable, to determine … eligibility on the basis of reliable, third party data.” Section 1413(c)(3)(A)(ii)

Integrated eligibility determination Basic model

Exchange, Medicaid, and CHIP compile a data warehouse for each applicant

States need better eligibility IT Will CMS develop modules? Will CMS makes grants to states under PPACA Section 1561?

Revisit the denial of MMIS FMAP to eligibility systems? Can administrative funding for the exchange help with

Medicaid? Exchange can contract with Medicaid to determine

eligibility for subsidies in exchange Massachusetts model Must meet HHS “requirements ensuring reduced administrative

costs, eligibility errors, and disruptions in coverage.” 1413(d)(2)(A)

o Single, statewide office, as in Massachusetts?

Part II

Improving affordability and continuity of coverage above

Medicaid eligibility levels

Concerns about affordability in the exchange

Subsidy levels lower than any state program covering this income level

Example: single adult at 160% FPL $1,444 in monthly pre-tax income in 2009 PPACA requires $64 in monthly premiums Coverage could include

o $25-30 office visit copayso Prescription drug copays between $10 and $40

Contrast: most CHIP programs impose no charges or nominal charges at this income level

Basic health program (BHP)

Covered individuals Income at or below 200% FPL Ineligible for Medicaid or CHIP because of

o Income; oro Legalization of immigration status during the past 5 years.

State Contracts with health plans to provide coverage at least as generous as

in the exchange Receives 95% of what the federal government would have spent in

subsidies State could use BHP to provide Medicaid look-alike coverage

Federal dollars roughly 50% higher than Medicaid average for adults Could use excess to raise reimbursement, improve access Makes it easier to end optional Medicaid coverage above 138% FPL

Another approach

State can supplement subsidies in the exchangeCan apply above BHP income levels or

instead of BHPCould limit to high-value plans implementing

delivery system reforms Trade-off: state general fund cost

Can limit subsidies to the lowest-income households, not all the way to 400% FPL

Continuity

Income changes could shift people between Medicaid and the exchange Involuntary changes of plan and provider

State policy options Include Medicaid MCOs in the exchange

o When income changes, so do premiums and OOP costs, but not the health plan or provider

Massachusetts model

Part III

Increasing access to care for Medicaid beneficiaries

PPACA

Raises reimbursement to Medicare levels, but…Only for evaluation and management servicesOnly for primary care providers

o Not for mental health, dentistry, specialists100% FMAP ends after 2013 and 2014

Provides other infrastructure funding$11 billion for community health centers

MACPAC

Alternatives to raising rates

Streamline Medicaid claims processing Increase permitted scope of practice for

non-physiciansEspecially for Medicaid, potentially for other

payors to address workforce shortages Rural tele-health Incentives to take Medicaid patients

Link to other coverage

Conclusion

No matter what, PPACA is likely to dramatically increase coverage and access to care

The amount of that increase will depend, in significant part, on state policy decisions