EXPANDING AND REFORMING MEDICAID BUDGET BACKGROUND January 2014

1. EXPANDING AND REFORMINGMEDICAIDBUDGET BACKGROUNDJanuary 2014 Office of Administration Division of Budget and Planning

2. Temporary MO HealthNet during Pregnancy (TEMP) • Presumptive eligibility program for pregnant women- Better to apply for ongoing coverage through the Family Support Division • Determinations by qualified providers with staff trained to complete the determinations • Eligibility is based on patient attestation of: • Pregnancy • Income under 196% of the Federal Poverty Level • Eligible patients receives a Medicaid card at the time of the determination • Only covers ambulatory prenatal care. • Will not cover delivery, inpatient medical care, non-pregnancy related medical services, or care for the newborn. • TEMP coverage • begins on the date of the determination and continues through: • Date regular MHN coverage, or • Last day of the month following the month of the TEMP determination. • Since January, 2014 only one episode per pregnancy allowed

3. Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) • EMCIA provides coverage for emergency medical care of non-citizens who meet all eligibility requirements for a federally funded MO HealthNet program except: • Ineligible alien status, and • Emergency medical condition. • Ineligible alien status includes • non-citizens lawfully admitted who have not met the five-year period of ineligibility, lawfully admitted for a temporary period, • lawfully admitted but whose period of admission is expired, • non-citizens not otherwise qualified, and • undocumented non-citizens.

4. Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) • Ineligible non-citizens are eligible only for the dates of the emergency medical care. • An emergency medical condition must exist or have existed in the month of application, or in one of the prior three months. • The individual does not have to enter the hospital or medical facility via an emergency room to qualify.

5. Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) • Emergency Medical conditions could reasonably be expected to result in: • Placing the patient's health in serious jeopardy; • Serious impairments to bodily functions; or • Serious dysfunction of any bodily organ or part. • All labor and delivery is considered emergency labor and delivery. • Standard labor and delivery covered by EMCIA is defined as: • One day prior to delivery and 2 days after for normal delivery, or • One day prior to delivery and 4 days after for Caesarean-section. • Labor and delivery excludes pre- and post-partum care. • No Medical Review Team (MRT) required for standard labor and delivery.

6. Early Elective Delivery (EED) Elective delivery 37 to < 39 weeks gestation(26.3%) • 9.8% born by Early Elective C-Section • 16.5% by Early Elective Vaginal delivery after induction. • American College of Obstetricians and Gynecologists advises against non-medically indicated deliveries prior to 39 weeks • EED identified as key quality indicator for obstetric hospital care – National Goal is 5% • The Joint Commission • National Quality Forum • Leapfrog Group • March of Dimes

7. EED Maternal and Infant Consequences • Increase in obstetrical procedures and maternal complications • Increased NICU admissions • Increased transient tachypnea of the newborn (TTN) • Increased respiratory distress syndrome (RDS) • Increased ventilator support • Increased suspected or proven sepsis • Increased risk of death in the first year of life • Problems with brain development, including long-term psychological, behavioral, and emotional morbidity • Increased newborn feeding problem

8. MHD EED Initiative • Convened clinicians and other stakeholders to discuss and develop policy • Reviewed MHD EED data and came to consensus • Developed an evidenced-based, best practice regulation • “Early elective deliveries, or deliveries before thirty-nine (39) weeks gestation without a medical indication, shall not be reimbursed by the MO HealthNet Division (MHD). • Has been implemented in other states – New York, Texas, New Mexico, and South Carolina • Regulation filed and open

9. Impact of the Affordable Care Act March, 2014

10. Today… It’s not just Missouri • Status of our Nation • Healthcare delivery and payment “change” strategies

11. Four key elements of the Affordable Care Act

12. 2010 • Prohibits lifetime benefit limits • Dependent coverage up to age 26 is mandated • Cost-sharing obligations for preventive services are prohibited • Cancellation of individual policies (Recessions) are prohibited • Pre-existing condition exclusions for dependent children (under 19 years of age) are prohibited • Coverage for emergency services at in-network cost-sharing level with no prior-authorization is mandated

13. Duncan • 24 Years Old • Works full time • Minimum Wage • Pays all his housing, and personal expenses • Insured on parents employer based policy

14. More 2010 • Require coverage of tobacco cessation programs for pregnant women under Medicaid free of cost-sharing • Begin Community Health Centers and National Health Service Corps Fund expanded funding to total $11 billion over five years • Begin Medicaid global payments demonstrations to fund large, safety-net hospitals in five states to alter payment from fee-for-service to a capitated, global payment structure. • Establish Patient-Centered Outcomes Research Institute. Create a private, nonprofit Patient-Centered Outcomes Research Institute to set a national research agenda and conduct comparative clinical effectiveness research.

15. 2011 • 85% MLR for large group (with refund) is mandated • 80% MLR for individual and small group (with refund) is mandated • Primary care physicians and General surgeons in shortage areas begin 10 percent Medicare payment bonus for next 5 years • Medicare adds annual wellness visit with no copayment or deductibleand eliminates cost-sharing for evidence-based preventive services

16. 2012 • Medicaid starts option funding Health homes for persons with chronic conditions • Prohibit federal payments for Medicaid services related to hospital-acquired conditions. • Begin Medicaid Emergency Psychiatric Care Demonstration Project. to expand the number of emergency inpatient psychiatric care beds available.

17. 2013 • Medicaid payment rates to primary care physicians for furnishing primary care services raised no less than 100 percent of Medicare payment rates in 2013 and 2014. • Medicaid coverage of preventive services approved by the U.S. Preventive Services Task Force with no cost-sharing will receive an increased federal funds

18. 2014 • Health insurance exchanges established • Guarantee issue is required • Community rating required limits use of age and illness as a rating factor • All annual and lifetime limits prohibited • Essential Benefit established and required to cover MH and SA at Parity • Individual Mandate Starts

19. Emily • Pediatric myopathic pseudo-obstruction • TPN Dependent with permanent Central Line • Averages 4-8 hospital admissions per year • Full Time College Sophomore • Uninsurable outside of large groups pre-ACA • Now able to get affordable coverage

20. Insurance Exchanges • To Date: • 16 states have selected a state-based model, • 7 are partnering with the federal government and • 26 states have chosen federally-run exchanges. • Current enrollment deadline is March 31, 2014 • In non- expansion states low-income individuals may experience more difficulty finding affordable coverage because they are not Medicaid-eligible and do not qualify for federal subsidies in the exchange.

21. Kathy • 58 y.o., Single, Self-Employed • Before ACA had a high deductible Health Savings Account Policy • Now has a Comprehensive Policy • Lower premium • Much lower deductible • Lower annual out of pocket maximum • No more Lifetime limit

22. Kathy’s Insurance Before and After ACA

23. 2014 Medicaid Expansion • Enrollment system went live in ALL STATES on October 1, 2013. Insurance will became effective on January 1, 2014. Scope is all uninsured adults above 133 percent of poverty (plus discounted 5 percent of income). • To date, 26 states are planning to expand coverage in 2014 • Some include non-traditional models such as Medicaid premium support. • Decisions to expand Medicaid or discontinue Medicaid expansion in 2015 will impact bids that insurers submit in the spring of 2014 for the 2015 enrollment period.

25. Delayed Changes • Employer mandate delayed from 2014 to 2015 • First reduction of Disproportionate Share Hospital (DSH) funds delayed from 2014 to 2016 • Compliance of small business Existing Plans with new Rules • CMS has delayed until September 2015 • 15 States will permit renewal of non-compliant plans • 18 States will not • 17 States are undecided

26. 2015 - 2017 • Innovation Waivers • Beginning 2015, states may consider developing proposals to waive portions of the ACA beginning in 2017. • “Innovation Waivers” must cover at least as many people as under the ACA and provide coverage that is at least as comprehensive and affordable, at no extra cost to the federal government. • States that receive waivers may finance their reforms with federal funding that otherwise would have been provided for premium tax credits, cost-sharing reduction and small business tax credits

27. 2015 House Budget • Continuing enhanced PCP rates • Restore Dental coverage for adults • Restore coverage of Therapies • Physical Therapy • Occupational Therapy • Speech Therapy • Asthma Education and Home Environment Assessments

28. MEDICAID EXPANSION AND REFORM BACKGROUND • Key points • Eligibility for Medicaid • Cost for expansion • Savings to the state budget • Additional revenue • Summary of budget impact

29. KEY POINTS • Provide access to affordable health insurance to 313,000 Missourians. • Save state general revenue to invest in other priorities. • Net positive impact, even with full cost of expansion built in. • Positive impact on the economy from additional health care.

30. CURRENT ELIGIBILITY FY 2013 ACTUAL MEDICAID CASELOAD (879,000) • Children – 535,000 • Person with Disabilities – 163,000 • Parents – 79,000 • Seniors – 75,000 • Pregnant Women – 27,000

31. EXPANDED ELIGIBILITY • Missourians with incomes up to 138% of the federal poverty level ($32,913 for a family of four; $16,105 for an individual) • Non-elderly and not Medicare eligible • Two eligibility categories • Medically frail (provided with necessary wrap around services) ( for cost estimate, grouped by frail, ADA, and CPS) • Healthy adults

32. DONUT HOLE • Without expansion, Missourians with income from 19% to 100% of the federal poverty limit face a “donut hole.” • For a family of four, annual income from $4,532 to $23,850. For an individual, $2,217 to $11,670. • They make too much money to qualify for the existing Medicaid Program, but too little money to qualify for subsidized health insurance through the Exchange. • About 200,000 uninsured Missourians are in that donut hole.

33. COST -- STATE SHARE • No state cost for calendar years 2014, 2015 & 2016 • State share then phases up to 10% - January 2017 – 5% (half year for FY 2017) - January 2018 – 6% - January 2019 – 7% - January 2020 – 10%

34. COST SUMMARY

35. SAVINGS – TRANSFER POPULATIONS • Current Medicaid Populations under 138% FPL • Pregnant women (get coverage before pregnant) • Ticket to Work • Breast/cervical cancer • Spend down • People with disabilities (non-Medicare) • CHIP (affordability) • Women’s health services • Increased Pharmacy Assessment

36. SAVINGS – TRANSFER POPULATIONS • Current State Only Populations under 138% FPL • Blind Pension • Corrections • Dept of Mental Health Clients

37. GENERAL REVENUE SAVINGS SUMMARY

38. ADDITIONAL REVENUE

39. BUDGET SUMMARY • State costs for new eligibles $0 until FY 2017 • Lose 100% federal match for every day we wait • Full phase in of state share at 10% in FY 2021 • Savings for existing populations begin immediately • Lose savings for every month that we wait • Additional revenue estimate conservative – no multiplier

40. EXPANDING AND REFORMING MEDICAID GENERAL REVENUE BUDGET SUMMARY

41. CONCLUSION • Provide access to affordable health care insurance to 313,000 Missourians. • Save state general revenue to invest in other priorities. • Net positive impact, with full cost of expansion built in. • Other considerations - indirect budget implications: • Improved access to care, • Better health outcomes, and • Improved job retention when healthy.

42. Per Member Per Month Costs Melek et al Milliman Inc, 2013

43. MH/SU costs in NY State’s Medicaid Program

44. What is a Health Home? Not just a Medicaid Benefit Not just a Program or a Team A System and Organizational Transformation

45. Health Care Home Strategy • Case management coordination and facilitation of healthcare • Primary Care Nurse Care Managers • Disease management for persons with complex chronic medical conditions, SMI, or both • Behavioral Health management and behavior modification as related to chronic disease management for persons with Medical Illness • Preventive healthcare screening and monitoring by MH providers • Integrated Primary Care and Behavioral Healthcare

46. Health Home Strategy • Health technology is utilized to support the service system. • “Care Coordination” is best provided by a local community-based provider. • MH Community Support Workers who are most familiar with the consumer provide care coordination at the local level. • Primary Care Nurse Care Managers working within each Health Home provide system support. • Behavioral Health Consultants in each Primary Care Health Home • Statewide coordination and training support the network of Health Homes.

47. Treatment as Usual Health Homes What is Different about Health Homes? • Individual Practitioner • Episodic Care • Focus on Presenting Problem • Referral to meet other Needs • Managed Care • Manages access to care • Does not change clinical practice • Integrated Primary/Behavioral Health Care Team • Continuous Care • Comprehensive Care Management • Coordinates care across the healthcare system • Data driven population management • Transforms clinical practice • Emphasizes healthy lifestyles and self-management of chronic health problems

48. Primary Care Health Homes CMHC Healthcare Homes Health HomeTarget Populations • Patients with Diabetes • At risk for cardiovascular disease and a BMI > 25 • Patients who have two of the following • COPD/Asthma • Diabetes (also as single condition) • Cardiovascular Disease • BMI>25 • Developmental Disabilities • Use Tobacco • Individuals with a serious mental illness; or with other behavioral health problems who also have • Diabetes • COPD/Asthma • Cardiovascular Disease • BMI>25 • Developmental Disabilities • Use Tobacco

49. Primary Care Health Homes CMHC Healthcare Homes Missouri’s Health Homes • Providers • 18 FQHCs • 67 Clinics • 6 Hospitals • 22 Clinics • 14 Rural Health Clinics • Enrollment • 15,526 adults • 428 children • 15,954 total • Providers • 28 CMHCs • 120 Clinics/Outreach Offices • Enrollment • 16,611 adults • 2,387 children • 18,998 total

50. Health Home Team • Nurse Care Managers (1FTE/250pts) • Care Coordinators (1FTE/500pts) • Health Home Director • Behavioral Health Consultants (primary care) • Primary Care Physician Consultant (behavioral health) • Learning Collaborative training • Next day notification of Hospital Admissions