Health Care Reform Implementation in Colorado

1. Health Care Reform Implementation in Colorado

2. HEALTH IN COLORADO

3. GOVERNOR HICKENLOOPER’S VISION

4. Coverage & affordability framework

5. Insurance reforms Insurance market reforms

6. Individual mandate • All citizens and legal residents required to have coverage starting 2014 • Exceptions: religious objection; Native Americans; financial hardship; lowest cost plan > 8% of income; undocumented immigrants; gaps of 3 months or less • Penalties assessed through federal income tax for each uninsured family member to be phased in starting in 2014 at $95/individual or 1 percent of household income. • In 2016 penalty = $695/adult, $375/child or 2.5% of income. Maximum of $2,085 per family or 2.5% of income, whichever is greater.

7. Affordability Provisions Affordability protections • Medicaid expansions: all non-disabled under age 65 eligible up to 133% of poverty • Premium tax credits available up to 400% of poverty • Cost sharing subsidies up to 250% of poverty (limits out of pocket spending) • New marketplace for accessing coverage

8. Coverage access points health reform coverage access points Employer based coverage Medicaid Medicare Health insurance exchanges and nongroup Uninsured

9. Coverage Options by Income (2014) Family Income Family income based on 2011 federal poverty guidelines for a family of four; Source: Center for Public Policy Priorities, cppp.org

10. Medicaid • Medicaid will be expanded to 133% of federal poverty in 2014. • Income eligibility based on modified adjusted gross income + 5% income disregard for nondisabled persons <65. • Option for states to allow patients with chronic conditions to designate a health home (mental health included) and get increased federal match. • The federal government will provide states 100% funding for expansion through 2016 with a gradual reduction to 90% in 2020. • Medicaid primary care payment rates will increase to 100% of Medicare rates in 2013 and 2014. • State must maintain coverage levels until 2014 for adults, 2019 for children and until 2019 for CHP+.

11. Employer Coverage • Small employers (<50) are not required to provide employee coverage. Have access to an Exchange. • Tax credits available for small businesses (up to 25 employees with average wages under $50,000, if 50% of premium paid) to provide employer coverage starting 2010. • Up to 35% now, 50% 2014-2016 • Large employers (>50) pay a penalty per full-time employee if an employee receives subsidized coverage in the exchange. • Employees who have an offer of employer coverage generally cannot purchase in the exchange, with a few exceptions.

12. Medicare • Eliminate the “donut hole” by 2020 starting with $250 rebate in 2010, 50% discount on name brand drugs in 2011. • Expands number of covered preventive services and eliminates cost sharing starting 2011. • 10% bonus payment for primary care physicians and general surgeons in health care shortage areas (2011-15). • Improved care coordination and integration for dual Medicare/Medicaid eligible enrollees. • Restructure Medicare Advantage payments • Require 85% medical loss ratio for Medicare Advantage • Extend Medicare solvency by 12 years to 2029.

13. Implementation in Colorado

14. SB11-200: CO HEALTH BENEFIT EXCHANGE ACT OF 2011 • Passed in May 2011 • SB200 establishes the framework for the state Exchange • Not to duplicate the functions of the DOI • Governed by a Board of Directors • Legislative Implementation Review Committee   • Mission is to increase access, affordability, and choice for individuals and small employers purchasing health insurance in Colorado.

16. Colorado Health Benefit Exchange Activities • Policy Decision-Making Process • Certification criteria for plans sold in the exchange • Navigator Program • Management of eligibility appeals • What information to display to consumers when shopping for plans • Supplemental plans • Creation of Advisory Groups

17. COST CONTAINMENT

18. Accountable Care Collaborative Program Created in response to: • 85% in an unmanaged Fee-For-Service (FFS) system • Unprecedented economic situation, highest caseload and expenditures • Desire not to continue to pay for higher volume/ utilization No change to current Medicaid Benefit Package. • Delivery System Reform: • Improve health outcomes and reduce costs • Improve the client and provider experience • Introduce unprecedented data and analytics

19. Accountable Care Collaborative Map

20. Responsibilities

21. Payment • FFS reimbursement to PCMPs for medical services • HB12-1281 • Per Member Per Month (PMPM) payment for care coordination • Incentive Payments • Initial Phase: RCCOs select small “focus communities” within their region • 60,000 clients and increased enrollment to 123,000/budget action • Expansion Phase: increased enrollment after attainment of budget goals beginning July 2012

22. Contact for RCCO regions • RCCO 1: Rocky Mountain Health plans 800-667-6434 • RCCO 2: Colorado Access 855-267-2094 • RCCO 3: Colorado Access 855-267-2095 • RCCO 4: Integrated Community Health Partnership 855-959-7340 • RCCO 5: Colorado Access 855-384-7926 • RCCO 6: Colorado Community Health Alliance 877-919-2888 • RCCO 7: Community Care of Central Colorado 866-938-5091

23. QUESTIONS & ANSWERS George Lyford Health Care Attorney Colorado Center on Law and Policy 303 573-5669, ext. 310 GLyford@cclponline.org Lorez Meinhold Senior Policy Director Governor John Hickenlooper 303-866-5856 Lorez.meinhold@state.co.us colorado.gov/healthreform