State Planning Grants for Coverage Strategies

1. Delaware HRSA State Planning Grant Alice Burton, Director AcademyHealth December 2, 2004

2. Presentation • HRSA pilot grants are helping states to further develop coverage strategies • Broad range of state initiatives meet different needs • You are not alone - there are resources to help states move through planning and policy analysis process

3. HRSA Update • Fiscal Year (FY) 2004, HRSA has awarded more than $13 million through: • 9 new state planning grants • 17 continuation planning grants • 9 “pilot project planning” grants—which are new this year.

4. Pilot Project Planning Grants Pilot grants are providing funds to states that have already developed policy options through state planning grant funds to enable them to: • Plan for the implementation of a specific policy option(s) on which consensus has been reached; • Test a particular option in one or more areas and/or for a specific population in the state or territory; and • Implement a plan that will cover a significant portion of the uninsured.

5. Pilot Project Planning Grants, cont. • Nine FY2004 Recipients • Connecticut, Delaware, Georgia, Illinois, Indiana, Kansas, Oklahoma, the U.S. Virgin Islands, and West Virginia

6. Connecticut Pilot Grant • Two different approaches: -Provide premium assistance targeted to low-income workers in firms that already offer coverage; and - Implement a small employer health insurance subsidy pilot targeted to small firms that do not currently offer coverage.

7. Georgia Pilot Grant • Will implement separate pilots in four communities. • Exploring several options, including a three-share pilot program and another pilot that will partner with commercial insurers to reduce costs to a target population.

8. Indiana Pilot Grant • The project team intends to create a small business pool coupled with an employer/employee buy-in and premium-assistance program.

9. Illinois/Kansas/Oklahoma Pilots • INDIANA - looking into contracting with an actuary to develop a three-share program in two counties. • KANSAS - exploring the option of reinsurance and planning a pilot to modify how to model tax credits to employers. • OKLAHOMA - considering creating a small group purchasing pool with their grant funds.

10. U.S. Virgin Islands Pilot Grant • Plans to develop an association health plan as a purchasing collaborative. In the process, they will develop a comprehensive Preferred Provider Organization (PPO) network, implement effective disease management in the PPO, increase Medicaid enrollment, and continue to analyze the costs of uncompensated care.

11. West Virginia Pilot Grant • Developing options to offer affordable health insurance to the pre-Medicare population (aged 50 to 64), specifically those who have lost and are at risk of losing their retiree benefits.

12. Strategies to expand coverage • Expanding Medicaid and SCHIP to new populations • New models for Medicaid/SCHIP and private sector partnerships • Making new private insurance options more affordable • Mandates • Comprehensive (access, cost and quality) approaches

13. New options for Medicaid coverage • SCHIP (1997) • 1115 waivers and HIFA (2001) • Breast and Cervical Cancer (2000) • 50 states (including DC) • Ticket to Work – Working individuals with disabilities (2001 – Medicaid expansion) • 32 states, some states with no income limit

14. States with expanded coverage for parents through Medicaid AK WA ME MT ND MN OR VT NH ID WI SD NY MA MI CT WY RI IA PA NE NJ NV OH IN MD * IL DE UT WV CO KS VA CA MO KY * NC TN AZ OK NM AR SC 0 – 49% FPL 50 - 99% FPL 100 – 199% FPL 200%+ FPL no new enrollment or capped enrollment MS AL GA LA TX FL * Program not implemented HI

15. States that cover childless adults through Medicaid AK WA ME MT ND MN OR VT NH ID WI MA SD NY MI CT WY RI IA PA NE NJ NV OH IN MD IL DE UT WV CO KS VA CA MO KY * NC TN AZ OK NM AR SC no coverage under 100% FPL 100 – 199% FPL 200% FPL and greater no new enrollment or capped enrollment MS AL GA LA TX FL * Program not implemented HI

16. New approaches to benefits and cost sharing • Fewer benefits for higher income groups • Primary care programs • Pharmacy Plus – Rx only benefits • Cost-sharing

17. One state’s example of redesigning Medicaid benefits for new populations Medicaid & SCHIP Benefits Inpatient Services & Outpatient Services Physician & Specialty Services Prescription Drugs OT, PT, ST, DME & Supplies (prosthetics & orthotics) Lab & X-ray Emergent & Urgent Care Home Health Mental Health & Substance Abuse (limits for adults) Increased Benefits Expansion Benefits Inpatient & Outpatient Services Physician & Specialty Services Prescription Drugs OT, PT, ST DME & Supplies (prosthetics & orthotics) Lab & X-ray Emergent & Urgent Care Home Health Mental Health & Substance Abuse Podiatry Dental Optometry & Eyeglasses Long Term Care - ICFMR/Nursing Home/Pre-PACE Personal Care & Home Nursing for Children EPSDT & Early Intervention & Nutrition Targeted Case Management Hospice Transportation & Lodging No Annual Maximum $100,000 Annual Maximum Some limits on services offered Service limits based on medical necessity

18. Private sector partnerships • Meet a broad set of policy & political goals • Current models pay the employee’s contribution for qualifying employer sponsored insurance when it is cost-effective • 14 states, just over 50,000 enrolled out of over 50 million enrolled in Medicaid and SCHIP • Newer models create a new product, targeting working uninsured • Target either employer or employees

19. What is the problem you are trying to solve? Small portion of workers decline ESI. SOURCE: Kaiser Comissionon Medicaid and Uninsured, Key Facts, December 2003

20. Making new private insurance options more affordable: Healthy New York • Eligibility: Small firms w/ low-wage workers, low income self-employed, uninsured workers w/o access to ESI • Reduced premiums through: • Stop-loss fund: state pays 90% claims $5k-75k • Streamlined benefits, in-network only • High cost-sharing • Commercial insurance product that state requires all HMOs to offer

21. Making new private insurance options more affordable: West Virginia • Eligibility: Firms w/2-50 employees • Minimum employer contribution of 50%, 75% of eligible employees must participate • Allows carriers to access State Employees' reimbursement rates and drug purchasing plan

22. New benefit designs • Limited benefits (mandate-lite) • Continued interest despite low enrollment • Popular benefits often drive rates • High deductible health plans • Consumer directed health plans

23. Mandating health insurance • Employer mandates • Several states have considered, only 1 with law on the books • Hawaii’s Prepaid Health Care Act – 30 years old this year • California’s Health Insurance Act of 2003 – defeated in 2004 referendum • Individual mandates • States have talked about, but none have enacted

24. Comprehensive Models: Maine’s Dirigo Health • Voluntary program addressing cost, quality and access • Dirigo Health Insurance (DHI) • Offered to small business (<50 workers), self-employed, workers without offered coverage, low-income in large firms • MaineCare (Medicaid) expansion • 200% FPL for parents; 125% FPL for childless adults; sliding scale subsidies to 300% FPL

25. …Maine’s Dirigo Health • Cost containment • CON moratorium • Voluntary limits on operating margins • Required electronic claims submission by 2005 • Price disclosure • “Savings offset payment” on carriers from UC savings (capped at 4%) • Maine Quality Forum created • Enrollment begins October 1, 2004; Anticipated start date January 1, 2005

26. Help available from AcademyHealth RWJF’s State Coverage Initiatives Program (SCI) TA AcademyHealth State Health Policy Group STATES & TERRITORIES Contract with HRSA to provide TA to SPGs TA

27. State Coverage Initiatives (SCI) Initiative of The Robert Wood Johnson Foundation Direct Technical Assistance (TA) available to all states Meetings Small group consultations on specific issues Publications Statecoverage.net Grants SPG Contract with HRSA Site visits Share lessons from other states Options development Guidance for advisory committees Final report guidance Maintain Web page with SPG reports

28. How Can We Help? • AcademyHealth is available over the phone or onsite for assistance • Ongoing support – Thinking through preliminary ideas, lit. searches, contacts in other states, suggestions on experts, etc. • Kicking off policy process for steering committee • Education of steering committee on coverage options, other state SPG activities • Facilitation of stakeholder meetings to decide on coverage options • Assistance with evaluating options and narrowing recommendations

29. http://statecoverage.net • State Reports • State Coverage Matrix • About Coverage • Grants - HRSA SPG page • SCI Publications • St@teside – monthly e-newsletter