Nancy Atkins, R.N., M.S.N., N.P.-B.C.

CommissionerWest Virginia Bureau for Medical Services

Enroll WV: The Changing Face of Medicaid

ACA Medicaid Reforms• Eligibility Group Changes.• Streamline financial eligibility determination process through the use

of the modified adjusted gross income (MAGI) and electronic data sources.

• “No wrong door” approach to applying for health insurance coverage through the Marketplace (formerly Exchange).

• Increase access to Medicaid by expanding eligibility coverage to 138% of the federal poverty level.

• Promoting individual responsibility by requiring most individuals to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. Certain individuals will be able to obtain a waiver of this requirement. Effective January 1, 2014

Medicaid Eligibility Group Changes

• West Virginia Medicaid currently serves: • Pregnant Women• Children• Very Low Income Families• Aged/Blind/Disabled• Medically Needy Populations

• The Affordable Care Act (ACA) will add two new groups:• Adults between 19 and 65• Former Foster Children

• The ACA will also consolidate many other groups under larger umbrella groups

• Notably this occurs for Pregnant Women and Children under 19

WV Medicaid Expansion

• On May 2, 2013, Governor Earl Ray Tomblin announced that WV Medicaid would expand its coverage to individuals aged 19 to 64 making up to 138% of the Federal Poverty Level (FPL).

Family Size

201317% FPL

2013138% FPL

1 $1,778 $15,8562 $2,412 $21,4033 $3,036 $26,9514 $3,744 $32,499

WV Medicaid Expansion Plans

• Managed care (Mountain Health Trust) will be expanded to include behavioral health, personal care, pediatric dentistry and Non-Emergency Medical Transportation.

• Newly eligible (expansion) individuals will be enrolled into managed care.

• Current Medicaid members enrolled in managed care will receive all of their services through managed care.

Benefits of Managed Care

• Providing full benefits through managed care:• Is proven to control cost and create a predictable

budget for the State• Results in better coordination of services to improve

outcomes• Drives quality through accreditation and contractual

monitoring

Benefits of Managed Care

• The expanded use of managed care, particularly related to substance abuse and behavioral health, can aid in reducing the State’s substance abuse problem and creating other cost savings, freeing up resources that may be repurposed for the State’s expanded population Medicaid match.

Personal Responsibility• West Virginia will adopt strategies promoting personal

responsibility.• West Virginia will continue to explore premium assistance

and other innovative strategies to reduce cost and improve quality.

• Co-pays will be developed by the State that will:• Create sliding cost sharing scale, adjusted by consumer

income• Alleviate some cost burden from state revenue• Curb inappropriate utilization, controlling cost• Encourage personal responsibility• Create larger degree of parity with private market

What Expansion Means to WV

• Medicaid expansion will provide insurance coverage to more than 90,000 West Virginians.

• Combined with other Affordable Care Act mandates, the number of uninsured West Virginians will drop from 246,000 to 76,000 by 2016.

• Creates financial security for working families that experience medical hardships.

• Ends the disincentive to current Medicaid enrollees from working. Impoverished families can work to the middle class and no longer fear losing insurance coverage.

What Expansion Means to WV

• Cost of care will be covered by 100% federal funds for first three years, capturing the majority of pent-up demand, with $1.267 billion federal dollars at a cost of only $15 million in state administrative match dollars.

• When match rate is fully applied in 2020, Feds will pay 90% of every $1 spent on the expanded population for cost of care.

• Expansion results in $5.2 billion in federal funds entering the state economy from FY 2014 to FY 2023.

Next Steps

• The Bureau for Medical Services will prepare State Plan Amendments to provide the following:• Expanding the Medicaid population• Expanding the use of managed care• Developing co-pays for Medicaid

• The plan will be submitted by July 2013, with open enrollment beginning October 1, 2013.

• Coverage will begin on January 1, 2014.

Next Steps

• Although better situated than most states, West Virginia must work with its institutions of higher learning to address any shortages in health care providers given the pent-up demand that will be released with expansion and exchanges.

• DHHR and BMS will work closely with the Governor and Legislative leadership to determine continued funding options for the expansion.

Thank You

Nancy V. Atkins, RN, MSN, NP-BCCommissioner

WV Bureau for Medical Services304-356-4849

MedicaidCommissioner@wv.govwww.dhhr.wv.gov/bms