The ACA & Medicaid Expansion: Update

1. The ACA & Medicaid Expansion: Update Washington State Nurses’ AssociationFebruary 24, 2014 MaryAnne Lindeblad, Medicaid Director, Health Care Authority

2. Today’s Topics • Affordable Care Act & Medicaid Expansion Overview • Medicaid Enrollment - Estimates & Actual • Personal Stories • What’s Next for Medicaid?

3. ACA & Medicaid Expansion Overview

4. Washington’s Goals • Streamline administrative processes to capitalize on opportunities • Leverage new federal financing opportunities to ensure the Medicaid expansion is sustainable • Maximize use of technology to create consumer-friendly application/enrollment/renewal experience • Maximize continuity of coverage & care as individuals move between subsidized coverage options • Reform the WASHINGTON WAY—comply with, or seek waiver from, specific ACA requirements related to coverage and eligibility, as needs are identified

5. Key ACA Impacts on Medicaid • “New Eligibles” - Medicaid expansion to 138% of the FPL for adults under age 65 not receiving Medicare* • Modified Adjusted Gross Income (MAGI) methodology defines how income is counted, and how household composition and family size are determined • MAGI will determine eligibility for children, pregnant women, parents and all adults in the new adult category. No resource/asset limits. • Washington’s new Medicaid adult group includes: • Childless adults with incomes below 138% of the FPL • Parents with incomes between ~54% and 138% of the FPL (based on MAGI) • Current Medicaid eligibility standards still apply to aged, blind, disabled, SSI, and foster children • ACA does not impact these groups • The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard – for more details see: http://www.hca.wa.gov/hcr/me/documents/ME2014_Changes_Comparison_Fact_Sheet.pdf

6. ACA: New Coverage Continuum *138% **193% 400% ** 312% % Federal Poverty Level 0%100%200%300%400% Apple Health(Adult Medicaid) Coverage) Apple Health(Pregnancy Medicaid) Apple Health for Kids(Medicaid/CHIP) * Premium Tax Credits & Cost-Sharing Reductions for Qualified Health Plans Qualified Health Plans * The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard ** Based on a conversion of previous program eligibility standards converted to new MAGI income standards

7. 2014 FPL Levels Source: http://aspe.hhs.gov/poverty/13poverty.cfmhttp://www.gpo.gov/fdsys/pkg/FR-2014-01-22/pdf/2014-01303.pdf (released 2-7-2014) Per HHS directive, after inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family sizes.

8. Adult Medicaid Benefits as of Jan 1, 2014 Affordable Care Act – Alternative Benefit Plan for new Medicaid adult group • 10 essential health benefits • Mental health and substance abuse parity • Non-emergency medical transportation • Early Periodic Screening, Diagnosis & Treatment for adults age 18-19 • SBIRT • Shingles vaccination for adults 60+ 2013-15 Budget – Benefit enhancements • Adult benefits standardized except habilitative services benefit only applies to new Medicaid adult group • Dental services restored for all adults • Naturopaths covered for all adults Essential Health Benefits • Ambulatory services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

9. New WA Medicaid Brand Name Capitalizing on the success of “Apple Health for Kids” five years ago, Washington’s Medicaid program will be known as Apple Health. The new name is being phased in slowly, to avoid confusion and give clients and providers time to adjust.

10. Single Door to Find Coverage – Began Oct 2013 This is the first page to get started.

11. Medicaid Enrollment – Estimates & Actual

12. Estimated Medicaid Adults: 2014-2016 Financial models assume New Eligibles and Welcome Mat caseloads will ramp up over time. NEW ELIGIBLES (new adult group eligible for Medicaid as a result of the ACA) 100% federal financing 2014-2016 WELCOME MAT (adults and children who would have been eligible for Medicaid based on standards before the ACA implementation, but they never enrolled at that time. Welcome mat specifically reflects caseload growth resulting from ACA implementation that is beyond historical growth averages. 50% federal financing Based on: Buettgens, et al. The ACA Medicaid Expansion in Washington. The Urban Institute. 12

13. February 19, 2014 Enrollment Snapshot Regular updates available at: http://www.hca.wa.gov/Pages/index.aspx Individuals being converted, re-determined, or renewed under the MAGI standard – they are not considered “new” to Medicaid.

14. Progress Toward April 1, 2014 Medicaid Expansion Enrollment Target

15. Nearly Half Newly Eligible Adults Under Age 35 29% Enrolled October 1, 2013 – December 31, 2013 for coverage beginning January 1, 2014

16. Gender Breakdown by Age for Newly Eligible Adults 29% Enrolled October 1, 2013 – December 31, 2013 for coverage beginning January 1, 2014

17. Medicaid Standard CHIP Medicaid Standard Medicaid Alternative Benefit Plan Family Planning Extension Take Charge Family Planning CHIP Breast & Cervical Cancer Treatment QHP with Subsidy ADATSA Basic Health Program Previous Medicaid Programs Streamlined Programs eliminated or minimal state-only funded program remains for targeted small groups. 2014 Coverage Continuum through Insurance Affordability Programs (IAP) Benefits generally aligned QHP without Subsidy Medical Care Services Program Presumptive SSI (aka DL-X)

18. Unexpected Challenges • Over 40 State Plan Amendments required for: • MAGI-based income changes to all Medicaid groups • MAGI eligibility group definitions • Enhanced federal match claim • General Medicaid requirements • Alternative benefit requirements for new adults (in process) • Waiver amendments required to: • Implement MAGI-based eligibility Oct 1, 2013 (using Exchange portal) • Meet federal requirements for income changes based on MAGI • Transfer adults into New Adult category (100% FMAP) where prior programs eliminated • Estate recovery rules revised for new adult group • Processing of Medicaid renewals delayed • Individuals notified of action needed to sustain coverage have not all responded

19. Personal Stories

20. Washington State Success Stories • Laura • Mother of one working part-time and going to college to become a teacher  • Health compromised 22 years ago making insurance necessary, expensive, and difficult to find—before the ACA • Cost of her premium and deductible constantly increased until it was unaffordable • Learned she qualified for Washington Apple Health while visiting the HealthPlanFinder • So happy to get coverage, posted her experience on Facebook • Laura’s friends are signing up for Apple Health Photo Source: clipart.com

21. Washington State Success Stories • Adam • Homeless single adult  • Unemployed; no resources • Heard about Apple Health through “grapevine” and tried unsuccessfully to apply online • Contacted HCA and reached a receptionist, who connected him with a Medicaid eligibility worker • Medicaid eligibility worker resolved the issues blocking his application • Adam was enrolled in Apple Health by the end of that day Photo Source: clipart.com

22. Washington State Success Stories Washington State Success Stories • Tom • Young adult, previously uninsured • Sporadically employed; no resources • Heard about Apple Health while in the hospital (multiple times during Fall 2013 for which his hospital care cost $250,000 ) • Applied the day he was released from hospital for coverage beginning January 1, 2014 • From Tom: “Wow – if only I’d had Apple Health in November!” Photo Source: clipart.com

23. Washington State Success Stories • Bill • Works under contract as a caterer  • Had insurance, but could no longer afford it • At age 61, made a decision to go without health insurance until he qualified for Medicare at age 65 • One of the first to sign up for Washington Apple Health • Fully covered as of January 1, 2014 • From Bill: “It will give me peace of mind, definitely more peace of mind. …That is one anxiety I don’t have to worry about now. Photo Source: clipart.com

24. What’s next for Medicaid?

25. Further Outreach Planned • Spanish language radio PSAs (Seattle, Skagit, Clark, Yakima counties) • Coordinate JCAs staff—especially rural areas • Commission on Hispanic Affairs collaboration to work on cultural bridges • Coordinate with Dept. of Agriculturein rural areas • Regular Apple Health news mailings (county ministerial associations & school districts) • Editorial board visits • Mailings to clients with other services (e.g. food stamp recipients) • Distribution of Apple Health posters in English and Spanish in Yakima Valley • Posters to food banks in selected areas and possible “bill stuffers” • WA Apple Health Speakers Bureau 25

26. Medicaid Plan Selection - 2015 Ability for Modified Adjusted Gross Income (MAGI) clients to select Medicaid Managed Care Organization (MCO) of their choice • HealthPlanFinder (HPF) will store and display available MCOs • Major system changes required to support: • Real-time MCO selection (ProviderOne) • HPF online system interface with ProviderOne for eligibility data transmission • Real time eligibility interface with ProviderOne (DSHS Automated Client Eligibility System/Eligibility Service - ACES/ES) • Cost based on Rough Order Magnitude (ROM) estimates from HPF and ProviderOne vendors: • HFP enhancements/changes: $3 million (90/10 federal match) • ProviderOne enhancements/changes: $900,000 (90/10 federal match)

27. State Health Care Innovation Plan The Plan’s Core Objectives • Ensure a healthier Washington • Pay for value and outcomes instead of volume of services • Empower communities to improve health and better link with health delivery • Integrate physical and behavioral health to address the needs of the whole person

28. State Health Care Innovation Plan What’s In the Plan? Seven Building Blocks: • Quality and price transparency • Person and family engagement • Regionalize transformation • Create Accountable Collaboratives for Health (ACHs) • Leverage and align state data • Practice transformation support • Workforce capacity and flexibility

29. State Health Care Innovation Plan What’s In the Plan? Three Strategies: • Drive value-based purchasing across the community, starting with the State as “first mover” • Build healthy communities and people through prevention and early mitigation of disease throughout the life course • Improve chronic illness care through better integration of care and social supports, particularly for individuals with physical and behavioral health co-morbidities

30. HCA & Other Contacts

31. HCA Contact Information • Dorothy Teeter, Director dorothy.teeter@hca.wa.gov l 360-725-1523 • MaryAnne Lindeblad, Medicaid Director maryanne.lindeblad@hca.wa.gov l 360-725-1863 • Nathan Johnson, Policy, Planning & Performance Director nathan.johnson@hca.wa.gov l 360-725-1880 • Dan Lessler, MD, Chief Medical Officer daniel.lessler@hca.wa.gov l 360-725-1612 • Dennis Martin, Legislative Affairsdennis.martin@hca.wa.gov l 360-725-9808