Medicaid Presentation for Allied Hospital Associations’ Accounting & Financial Specialists (A 2 HA) 2013 Spring M

1. Medicaid Presentation for Allied Hospital Associations’ Accounting & Financial Specialists (A2HA) 2013 Spring Meeting Laura Tobler, National Conference of State Legislatures, laura.tobler@ncsl.org,

2. Presentation Highlights • Medicaid expansion • Interoperability with exchanges • Churning • Medicaid Cost Containment • State progress on HIT • State budgets

3. Medicaid is a top Issue in 2013

4. Optional Medicaid Expansion

5. Median Medicaid/CHIP Eligibility Thresholds, January 2012 SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012. Minimum Medicaid Eligibility under Health Reform - 133% FPL ($25,390 for a family of 3 in 2012)

6. Eligible But Not Enrolled • The individual mandate may motivate the currently uninsured to seek out affordable health insurance. • Penalties for low-income uninsured are weak or none. • Urban Institute estimates that about 10 million uninsured people are currently eligible for Medicaid but not enrolled. • These potential enrollees would not receive the enhanced federal matching rate--$$$$ for states. • Any exchange outreach becomes Medicaid outreach.

7. Decision Factors • Politics • Costs/Benefits and fiscal climate • Pragmatism • Federal flexibility • Interested parties within the state YOU can be a key player! Make it personal!

8. Based on statements by state leaders (mostly governors) and bill activity as of March 5th Predictions about Medicaid Expansion(The Advisory Board Company and NASUAD) Sources: Kaiser Family Foundation, Wells Fargo, The Advisory Board, NASUAD, NASHP, NCSL

9. Medicaid Expansion, Bills So Far Bills to Urge Gov. To Expand Bills To Expand Bills To Require Legislative Approval For Expansion AL, GA, MI, NJ, PA and SC AR, CA, MS, IL, MN, OK, SC, SD, TX, UT, VA and WY KY Bills To Reject Expansion Other Types of Expansion Related Bills IL, MS, NC, NH, SC, SD, TN and WY AR, CO, HI, IA, TX, IA, IL, MT, MO, MD, ME and MI

10. Recent CMS answers NO NO YES YES YES

11. Will the newly insured have access to appropriate providers?

12. Disproportionate Share Hospital (DSH) Payments, ACAand Expansion • DSH payments are an important source of financing for hospitals. • ACA reduces DSH payments over time. • Jan. 18, 2012 CMS published a proposed rule addressing hospital-specific cap on Medicaid DSH payments. • What does it mean to the Medicaid expansion equation?

13. Interoperability: Exchanges and Medicaid Seamless Eligibility Determination

14. States Address Interoperability

15. Medicaid & Exchange Churning • Medicaid, CHIP, Basic Health Program, and the Exchange all determine eligibility by income level. • If family income or job status change … so will coverage, plans, eligibility, etc. • Concerns • Can increase administrative costs to states. • Can interrupt coverage for consumers. • Creates challenges for providers.

16. Addressing the "Churn" Tennessee's Proposal -- The Bridge Option • "One family, one card across time” approach would enable family members to hold coverage through a common insurer/provider network. • Insurers offering TennCare managed care organizations (MCOs) would also offer a silver-level qualified health plan (QHP), available only to people with a dependent enrolled in TennCare (or CoverKids). • Helps reduce administrative costs and loss of coverage for individuals as income fluctuates.

17. Potential state policies to address churn • Integrating Exchange and Medicaid plans • Basic Health Program • 12-month continuous eligibility • Employer Sponsored Insurance premium assistance • Exchange plan portability Source: The Urban Institute, Churning Under the ACA and State Policy Options for Mitigation,” June 2012.

18. Medicaid Cost Containment • Address overall health care costs: prevention and payment reforms • Move toward managed care • Reduce fraud and abuse • Reforms that focus on high-cost patients • Innovations to improve the value of Medicaid "Do the right thing at the right time, at the right place and to the right body part" • "Controlling costs is all about incentives — for employers, for consumers, for health-care providers, and for insurers.” YevgeniyFeyman, National Review

19. Keeping people healthy "Health improvements and cost savings are achievable by providing targeted, evidence-based, and cost-effective health promotion and disease prevention programs that reduce modifiable risk factors, often the cause of costly chronic diseases. " Ron Goetzel, Emory University • Market-wide payment reform “ It is important to build trust between providers and Medicaid. Providers need to know they are supported, and states need to know they have willing partners and are going to save money.” Scott Leitz, Minnesota

20. Some States Are Trying To Find Stability And Predictability • Managed Care • Fraud and Abuse Reduction • Tying Medicaid growth to revenues or state GDP

21. 42 M 74.2 %

23. Medicaid Managed Long Term Services and Supports (MLTSS)

24. States with MLTSS Programs, 2004 and 2012 Notes: 1. Does not include PACE programs. 2. Three States (Minnesota, New York, and Wisconsin) operate two MLTSS programs each. Source: Presentation by Susan Reinhard, AARP, NCSL’s Fall Forum, 12/5/12

25. States Planning to Implement New MLTSS Programs by January 2014 Note: We included States that have public plans for new MLTSS programs that include: a public planning document, request for information, request for proposals; proposal to CMS or waiver application to CMS. Submitting a letter of intent to CMS for the Medicare-Medicaid Financial Alignment Demonstration was not by itself sufficient to be included here. Source: Presentation by Susan Reinhard, AARP, NCSL’s Fall Forum, 12/5/12

26. Fraud Fighters

27. State Strategies toImprove Program Integrity

29. Focus on Dually Eligible People • Approximately nine million "duals" (eligible for Medicare and Medicaid). • Among the poorest and sickest Medicare and Medicaid enrollees. • Account for disproportionate spending—16 percent of Medicare beneficiaries but 27 percent of spending; 15 percent of Medicaid enrollees but 38 percent of spending. • 23 states are moving forward with proposals to participate in the CMS Medicare-Medicaid Coordination Office’s Financial Alignment Initiative for dually eligible people. When a state meets the standards and conditions for the Financial Alignment Demonstration, CMS and the state develop a memorandum of understanding; four states have MOU: Illinois, Massachusetts, Ohio and Washington.

31. Innovation Awards • ACA funding: $300 million • 25 states recently received federal awards to work on health care system reforms/innovations. • Six states received “model testing awards” to test multi-payer payment and service delivery models on a broad scale: Arkansas, Maine, Massachusetts, Minnesota, Oregon and Vermont. • The other 19 states will use the funds to develop their plans.

32. State Innovation Models Awards

33. State Progress on HIT • Status of Major Medicaid Eligibility System Upgrades • State Progress on Health Information Exchange (HIE) Implementation • State Coverage for Telehealth Services

34. Status of Major Medicaid Eligibility System Upgrades Source: Kaiser Family Foundation, 2013

35. Progress on Statewide HIE Implementation Source: Office of the National Coordinator, 2013

36. State Coverage for Telehealth Services State Coverage for Telehealth Services Source: NCSL, 2013

37. In January 2013, about HALF of state legislators were freshmen or sophomores!

38. Overview Better state fiscal conditions • Few budget gaps • Revenues continue to improve • Year-end balances are rising Performance is uneven & state budgets remain vulnerable • Federal deficit reduction actions • Spending pressures • Sluggish economic recovery • Deep holes

39. Cumulative State Budget Gaps: FY 2002-FY 2014 Source: NCSL survey of state legislative fiscal offices, various years.

40. NCSL Resources Health Reform home page: http://www.ncsl.org/?TabID=160 State legislation database: http://www.ncsl.org/?TabId=22122 Health Reform State Action newsletter: http://www.ncsl.org/default.aspx?TabId=22281 Health Reform two-page briefs: http://www.ncsl.org/default.aspx?tabid=19023 Cost Containment Briefs: http://www.ncsl.org/default.aspx?tabid=19200

41. Questions? Laura.Tobler@ncsl.org 2013