health care reform & medicaid - - heops shot of dc medicaid before health care reform medicaid...
TRANSCRIPT
Health Care Reform & Medicaid
Lessons Learned from an Early Expansion State
Washington, DCA Case Study
Department of Health Care FinanceOctober 2014
Washington DC
Agenda
� Snap shot of DC Medicaid before Health Care Reform
� Medicaid Expansion
� Drill down into the Childless Adult Population
� Impact on Eligibility and Costs
� Implementation Challenges
– Coordinating Eligibility Policy with the State-based Marketplace
– Integrating eligibility into a streamlined, automated system
– Lessons Learned
� Where do we go from here?
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Early Efforts to Cover the Uninsured
• DC awarded 1115 Waiver to Enhance Medicaid Access to Low Income HIV-Infected Individuals on November 1, 2004
• Goals• Increase access to early therapy for people with HIV infection
• Enhance access to full range of Medicaid benefits
• Coverage extended to individuals with HIV+ diagnosis with incomes below 100% FPL.
• Key to cost neutrality was capped enrollment and securing additional discounts on HIV drugs through the Federal Supply Schedule
• DC Health Care Alliance – locally funded program to individuals up to 200% FPL who are not eligible for Medicaid
Department of Health Care FinanceApril 2013
Washington DC
Medicaid Expansion
�DC received SPA approval to expand Medicaid coverage to Childless Adults up to 133% FPL, effective July 1, 2010.
�DC received 1115 waiver approval to expand Medicaid coverage to Childless Adults between 133% and 200% FPL, effective November 1, 2010.
�Expansion allowed DC to shift Alliance members into Medicaid.
DC Snapshot 2010
2010
Population 601,767
Medicaid MCO Enrollment
141,182
Medicaid FFS Enrollment
65,394
Alliance Enrollment 24,135
Program Costs $1.8 billion
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DC Medicaid Eligibility Thresholds Pre-ACA Compared to VA and MD (1 of 2)
Effective
1/1/2014
ACA
mandates
coverage of
all of these
groups at
133% FPL
Comparison of D.C. Eligibility Groups and Income Thresholds to VA & MD (2
of 2)
These Eligibility Policies Produced A Spike In The District’s Medicaid Enrollment Levels
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Annualized Growth In Medicaid Enrollment Rates, 2003-2013
Medicaid Expansion
Sources and Notes: Excludes ineligible individuals (individuals who failed to recertify due to lack of follow-up, moving out of the District, excess income,or passed away), the Alliance, and immigrant children. The large jump in 2010-2011 is due to the implementation of childless adulteligibility expansion. Data for 2000-2009 data was extracted by ACS from tape back-ups in January, 2010. Data from2010-present are from enrollment reports
Large Portions Of The Medicaid-Eligible Population In The District Of Columbia Are Enrolled In The Program
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94%
97%
ChildrenTotal Adults
92%
Medicaid Health Insurance Coverage Rate For Eligible DC Residents
Note: Data reported are from the 2009 American Community Survey using the Integrated Public Use Microdata Survey. The total coverage rate is a DHCF calculated average of the rates reported for adults and children. The District of Columbia expanded Medicaid eligibility in 2010 and aeseparate 2011 survey reveals a 94 percent Medicaid participation rate for children
The Combination Of Medicaid Expansion And The District’s Comprehensive Benefit Package Are
Contributing Factors To Increases In The Cost For The Medicaid Program
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Source: FY08-FY11 totals extracted from Cognos by fiscal year (October, 1 through September, 30), using variable Clm Hdr Tot Pd Amt (totalprovider reimbursement for claim). Includes fee-for-service paid claims only, including adjustments to claims, and excludes claims with Alliance Line of Business or Immigrant Children's group program code. Only includes claims adjudicated through MMIS; excludesexpenditures paid outside of MMIS (e.g. pharmacy rebates, Medicare Premiums).
Expansion PopulationHIV/AIDS Prevalence
FY 2011
Department of Health Care FinanceApril 2013
Washington DC
Legacy Population
Up to 133% FPL(SPA)
Between 133% and 200% FPL(waiver)
Monthly Members
37,197 31,689 2,503
Memberswith HIV/AIDS
664 968 146
Proportion HIV/AIDS
1.8% 3.1% 5.8%
Males only (1.1%) (3.7%) (8.9%)
Pharmacy Costs
Department of Health Care FinanceApril 2013
Washington DC
July 10 January11
July 11
Legacy MCO
$24 $25 $24
774/775 $27 $65 $78
Top 3 Drugs Total Spend
PMPM Cost
Legacy MCO $1,856,638 $ 3.22
774/775 $2,924,484 $21.06
Response
• HIV Drug Carve Out.
• Uses DOH Pharmaceutical Warehouse and Pharmacy Network and DOD pricing
• New Rate Cell for Waiver Population.
• Waiver population will be moved to SPA.
• Implementing at Health Homes.
• Working on HIV/AIDS coordinated interventions.
• Seeking grant funds to drill down into high cost, high utilizers.
• Taking hard look at care coordination.
Department of Health Care FinanceApril 2013
Washington DC
Integrating Eligibility
Department of Health Care FinanceWashington DC
Low Uninsured Rate at Implementation
� Due to:
– High Medicaid penetration
– Presence of Federal government and high rates of employer-sponsored coverage
� In 2012, approximately 6% of DC residents were uninsured.*
*Source: US Census Bureau, American Community Survey, 2012
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Who are the Insured in DC?
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Creation of State-based Marketplace
� DC Council enacted the DC HBX, March 3, 2012.
� Established quasi-independent authority with an independent board.
� Medicaid, Department of Human Services and Department of Health are ex-officio members.
� Members of Congress and their staff must obtain health insurance coverage through the DC HBX.
� Given small individual market, focus of DC HBX is on securing small business market.
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Commitment to Integrated Eligibility
� Pre-existing Mayor’s order directed integrated eligibility for health and human services programs.
� DC took full advantage of the relaxation of cost allocation rules and availability of Establishment Grant funds and enhanced Medicaid reimbursement to plan for fully integrated health and human services eligibility portal.
� First APD approved December 30, 2011.
� Contract for Integration Vender executed January 22, 2013.
� Vendor was responsible for implementing a stack of commercial, off the shelf software products (COTS) to meet the business needs of the principal agencies, DHS, DHCF and DCHBX.
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DC Developed Detailed Project Plans
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The project plan called for three releases:
Release I – Includes all functionality required to operate the District’s HBX and integrate Medicaid and HBX eligibility.
Release II – Remaining Medicaid, Alliance and other Human Services Programs (TANF, SNAP, LIHEAP, POWER and other public benefits programs)
Release III – Other local programs (Burial Assistance, Strong Families Program, Family Violence Prevention, Refugee Resettlement, etc).
Despite Significant Challenges and Delays, DCAS (know by consumers as DC
Healthlink) Launched On October 1, 2013
� To meet federally mandated times, Release I went live on October 1 despite numerous defects and system glitches.
� Unlike other States, the District avoided project implosion by aggressively managing the defects and deploying SWAT teams to perform manual workarounds.
� Nevertheless, even today Release I remains incomplete. System defects remain and needed functionality for Medicaid and DCHBX has been delayed or de-scoped.
� Release II has been significantly delayed and is now scheduled to deploy in May, 2016.
� A new, ACA-mandated process for conducting Medicaid renewals (called “passive renewals”) was originally planned to begin in April 2014. It has been postponed to December, 2014.
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Challenges
� COTS products failed to deliver expected functionality.
� Systems are characterized by high degree of customized code.
� MAGI rules for Medicaid and the Exchange are the same, except when they are different. Vendors lacked appreciation of those differences and consequences to the programs.
� Given high rates of insurance, HBX and Medicaid are focused on very different markets and at times, have had very different priorities.
� Press of work did not permit planning or sufficient attention to governance model.
� Impacts of churn have largely been postponed due to deferral of renewals – this will change! 21
Opportunities
� Despite defects and differences, an integrated, functioning eligibility is emerging.
� Early testing suggests that even with defects, automated eligibility is more accurate than eligibility determinations in the legacy system.
� Automating functionality for non-MAGI programs including long-term care will greatly enhance and streamline current business processes and support a NWD system for seniors and people with disabilities.
� With longer implementation timeline, opportunity exists to greatly enhance user experience through citizens’ portal and for enrolling in a Medicaid health plan.
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DC Snapshot 2010-2014
2010 2014
Population 601,767 651,000
Medicaid MCO Enrollment
141,182 171,064
Medicaid FFS Enrollment
65,394 66,871
Total Medicaid Enrollment
206,576 237,935
AllianceEnrollment
24,135 14,917
Program Costs $1.8 billion $2.7 billion
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Questions?
Claudia Schlosberg, J.D.
Acting Senior Deputy/Medicaid Director
DC Health Care Finance Administration
441 4th Street Street, N.W.
Washington, D.C. 20001
202-442-9075
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