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Healthcare Payment Systems & Policy: Medicaid & CHIP Kimberly Davis Policy Advisor for Policy Development Medicaid/CHIP Division.

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Presentation on theme: "Healthcare Payment Systems & Policy: Medicaid & CHIP Kimberly Davis Policy Advisor for Policy Development Medicaid/CHIP Division."— Presentation transcript:

1 Healthcare Payment Systems & Policy: Medicaid & CHIP Kimberly Davis Policy Advisor for Policy Development Medicaid/CHIP Division

2 2 Overview Medicaid & CHIP Background Benefits Eligibility & Enrollment Costs & Financing Delivery Models Texas Specifics Current HHSC Initiatives

3 Medicaid & CHIP: Overview

4 4 Medicaid: What is it? Provides medical coverage to eligible individuals primarily: Low-income families Non-disabled children Related caretakers of dependent children Pregnant women People age 65 and older People with disabilities Entitlement program = no enrollment limitation

5 5 Medicaid: What is it? Federal / State Program Funded jointly by state and federal governments Administered by states Subject to federal law and regulation: – Requires coverage of certain populations and services – Allows states to cover additional populations and services

6 6 Federal level Centers for Medicare & Medicaid Services (CMS) Within the U.S. Department of Health and Human Services:  Kathleen Sebelius – Secretary of Health and Human Services  Cindy Mann – Director, Center for Medicaid and State Operations Texas level Administered by single state agency – HHSC Billy Millwee – Texas State Medicaid Director  Single point of contact with federal government  Establishes Medicaid Policy  Administers state plan or agreement with the federal government  Administers Medical Care Advisory Committee (MCAC) mandated by federal Medicaid law Medicaid: Who runs it?

7 7 Medicaid in the Federal Budget, Federal Fiscal Year 2009

8 8 Medicaid State Plans: State & Federal Program State Plans = agreements with federal government on: Eligibility Services Program administration Financial administration Other program requirements State Plan Amendments (SPA) = requests to CMS to change: Optional services provided, or Manner benefits are offered.

9 9 Medicaid Waivers: State & Federal Program Waivers = state request to CMS for permission to deviate from certain requirements, often to: Provide services beyond those in state plan. Limit geographical areas. Limit free choice of providers. Implement innovative new service delivery and management models. Common Types of Medicaid Waivers 1115 Waiver – Research and Demonstration – Test policy innovations likely to further Medicaid program objectives. 1915(b) Waiver – Freedom of Choice – Allow states to implement managed care delivery systems or otherwise limit individuals' choice of provider under Medicaid (i.e. STAR+PLUS). 1915(c) Waiver – Home and Community-Based Services – Waive Medicaid provisions to deliver long-term care services and supports in community settings as an alternative to institutional settings.

10 10 CHIP: What is It? Children’s Health Insurance Program (CHIP) Medical coverage for uninsured children up to age 19. Joint state-federal program, either: – Extension of state Medicaid program – Separate program Federal funding – Limited to block grant amounts allocated to each state. Not entitlement program, so states can: – Determine age and income eligibility. – Cap enrollment. – Limit service benefits (as approved by HHS).

11 11 Medicaid Benefits: Acute and Long-Term Care Acute Care Physician, inpatient, outpatient, pharmacy, behavioral health, lab, X-ray services Health care for children and pregnant women for episodic health care needs. Long-Term Services and Supports Chronic health conditions requiring ongoing medical care & often social support. Includes care:  In facilities, e.g. nursing homes  For behavioral health conditions Distinction based on: Cognitive and medical condition Need for assistance with activities of daily living Degree to which a disability is chronic Nature of services provided Setting in which services are provided

12 12 Medicaid Benefits: Mandatory vs. Optional Mandatory Inpatient hospital services Outpatient hospital services Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services Nursing facility services Home health services Physician services Rural health clinic services Federally qualified health center services Laboratory and X-ray services Family planning services Nurse midwife services Certified pediatric and family nurse practitioner services Freestanding birth center services (when licensed or otherwise recognized by the state) Transportation to medical care Smoking cessation for pregnant women

13 13 Medicaid Benefits: Mandatory vs. Optional Optional Prescription drugs Clinic services Physical therapy Occupational therapy Speech, hearing and language disorder services Respiratory care services Other diagnostic, screening, preventive and rehabilitative services Podiatry services Optometry services Dental services Dentures Prosthetics Eyeglasses Chiropractic services Other practitioner services Private duty nursing services Other services approved by HHS Secretary

14 14 CHIP: Benefits Inpatient hospital services Outpatient hospital & ambulatory services Lab & X-ray Surgical & medical physician / physician extender services (including immunizations & well-baby / well-child exams) Emergency services Prescription drugs Behavioral health & substance abuse benefits Physical / speech / occupational therapy Home health Transplants Durable medical equipment Dental services Hospice care services Skilled nursing facilities Vision (eye exams / eyeglasses) Chiropractic services Tobacco cessation

15 15 CHIP: Benefits Perinatal benefits = limited, basic prenatal care including: Prenatal & postpartum visits  First 28 weeks of pregnancy: 1 visit every 4 weeks  28 to 36 weeks of pregnancy: 1 visit every 2-3 weeks  36 weeks to delivery: 1 visit per week Delivery  Hospital facility charges  Professional services charges Other  Pharmacy (based on CHIP formulary)  Prenatal vitamins  Limited laboratory testing No cost-sharing requirements  2 postpartum visits  Additional visits if medically necessary – Assessments – Planning services – Education and counseling

16 16 Income and Federal Poverty Levels Federal Poverty Level (FPL) Compared to family’s income level. Basis for Medicaid financial eligibility. Intended to identify the minimum amount of income a family would need to meet certain, very basic, family needs. Indicate annual income levels by family size and are updated each year by the U.S. Department of Health and Human Services.

17 17 Federal Poverty Income Levels, 2011 U.S. Department of Health and Human Services poverty guidelines based on annual income SOURCE: Federal Register, Vol. 76, No. 13, January 20, 2011, pp At 100% of poverty, for families larger than 8, add $3,820 for each additional person. Family Size100% FPL 1 10, , , , , , , ,630

18 18 Medicare and Medicaid Eligibility Medicare Federally funded Federally administered Eligibility People age 65+ People with disabilities People with end stage renal disease Medicaid Jointly funded by federal and state government Administered by state Eligibility Low-income individuals Pays for most long-term care services & supports

19 19 Medicaid & Medicare: Dual Eligibles Dual eligibles Individuals who are aged or disabled (Medicare eligible) AND Limited income (eligible for some Medicaid coverage) Full Dual Eligibles Entitled to Medicaid benefits that Medicare does not cover. Include low-income individuals who are aged or disabled in community, waiver programs, nursing homes, and state schools. Other Dual Eligibles Eligible only for Medicaid payments for Medicare premiums, deductibles, and coinsurance for Medicare services. Not entitled to Medicaid services. Include several categories of eligibility; incomes generally up to 135% of FPL.

20 20 CHIP Eligibility CHIP covers children in families who: Have too much income or too many assets to qualify for Medicaid. Cannot afford to buy private insurance. Generally are below 200% of the FPL. States can design their CHIP program as: Medicaid expansion (7 states, D.C. and 5 territories) Separate from Medicaid (17 states) Combination of the two approaches (26 states)

21 Medicaid & CHIP: Texas Specifics

22 22 Texas Medicaid: Organization

23 23 Texas Medicaid: Optional Benefits The state may choose to provide some, all, or no optional services specified under federal law. Optional services provided in Texas include: Prescription drugs Physical therapy Occupational therapy Targeted case management Some rehabilitation services Certified Registered Nurse Anesthesiologists Eyeglasses/contact lenses Hearing aids Services provided by podiatrists Certain mental health provider types

24 24 Texas Medicaid: Pharmacy Benefits HHSC Vendor Drug Program performs most pharmacy services functions, including policy and program oversight, formulary management, and pharmacy customer services. Texas contracts with private companies for: Pharmacy claims processing Prior authorization services Administration of drug rebate program Texas contracts with pharmacies to provide Medicaid clients with pharmacy benefits. Over 4,200 licensed Texas pharmacies are under contract. Beginning March 2012, managed care organizations (MCOs) will be responsible for providing pharmacy benefits to their members

25 25 Texas Medicaid Women’s Health Program (WHP): Benefits Annual family planning exam & Pap smear Follow-up visit, if related to contraceptive method Counseling on specific methods & use of contraception Female sterilization Follow-up visits related to sterilization Sexually Transmitted Infection (STI) Screenings Certain screenings related to family planning: – Pregnancy test – Rubella antibody test – Routine urinalysis – Urine culture – Complete blood count (CBC) – Hemoglobin and hematocrit tests – Blood typing – Blood glucose screening – Lipid panel – Thyroid stimulating hormone test

26 26 Texas Medicaid Women’s Health Program (WHP): Benefits Services not covered through WHP: Mammography - screens for breast cancer are limited to a clinical breast exam. Treatment for any conditions diagnosed during a WHP visit. Visit for pregnancy test only. Visit for STI test or treatment only. Follow-up after an abnormal Pap test. Counseling on and provision of emergency contraceptives. Referrals made for medical problems to providers that perform elective abortions. Other visits that cannot be appropriately billed with one of WHP- allowable diagnosis codes.

27 27 Texas CHIP: Benefits Inpatient general acute & rehabilitation hospital services Surgical services Transplants Skilled nursing facilities Outpatient hospital, comprehensive outpatient rehabilitation hospital, clinic & ambulatory health care center services Physician/physician extender professional services (including well- child exams & preventive health services) Laboratory & radiological services Durable medical equipment, prosthetic devices, & disposable medical supplies Home & community-based health services Nursing care services Inpatient mental health services Tobacco cessation Outpatient mental health services Inpatient & residential substance use treatment Outpatient substance use treatment Rehabilitation and habilitation services Hospice care services Emergency services Emergency medical transportation Care coordination Case management Prescription drugs Dental services Vision Chiropractic services

28 28 Texas CHIP Perinatal Program Provides prenatal & post-partum care to pregnant women ineligible for Medicaid due to: income (whose income 186%-200% FPL), or immigration status (with income below 200% FPL). Upon delivery, CHIP Perinatal newborns in families: With incomes at or below 185% FPL: – are deemed to Medicaid – receive 12 months of continuous Medicaid coverage With incomes above 185% FPL up to 200% FPL: – remain in CHIP Perinatal Program – receive CHIP benefits for the remainder of the 12-month coverage period Members receiving CHIP Perinatal benefits are exempt from: 90-day waiting period, asset test & all cost-sharing, including enrollment fees & co-pays

29 29 Medicaid Benefits: Compared to Private Employer-Sponsored Coverage

30 30 Texas Medicaid: Eligibility Medicaid serves: Low-income families Non-disabled children Related caretakers of dependent children Pregnant women People age 65 and older People with disabilities Texas Medicaid does not currently serve: Non-disabled, childless adults

31 31 Texas Medicaid Eligibility: Percent of FPL June 2010

32 32 Texas Medicaid Women’s Health Program (WHP): Eligibility WHP Eligibility Criteria: Ages 18 – 44. U.S. citizens & qualified immigrants. Reside in Texas. Not eligible for full Medicaid benefits, CHIP, or Medicare. Not pregnant. Not sterilized, infertile, or unable to get pregnant due to medical reasons. No private health insurance coverage covering family planning services. – Exception if filing a claim would cause physical, emotional, or other harm from a spouse, parent, or other person. Countable household income at or below 185% FPL.

33 33 Texas CHIP: Eligibility General eligibility Uninsured children under age 19. – CHIP Perinatal serves unborn children meeting eligibility requirements. Gross income up to 200% FPL. U.S. citizens or legal permanent residents. Not eligible for Medicaid. Families with net incomes above 150% FPL must meet assets criteria: Assets below $10,000. One vehicle is exempt up to $18,000; additional vehicles are exempt up to $7,500. Eligibility is determined for a 12-month period; income verification at 6 th month for families at 185% FPL and above CHIP Perinatal eligibility is determined for a 12-month period

34 34 Texas Medicaid: Enrollment The Texas Medicaid program has grown considerably in recent years. Texas Medicaid now serves over 3.4 million people out of a total population of about 25 million (as compared to 2.8 million in 2006). Persons who are aged, blind or disabled represent: – 25% of Texas Medicaid recipients. – 58% of Texas Medicaid costs. – They often have complex medical conditions, needing both Acute care (e.g. hospitalization, outpatient services, and laboratory), and Long term services and supports (LTSS) provided in the home or community (e.g. assistance with daily living, skilled nursing, and therapy services).

35 35 Texas Medicaid: Historical Enrollment History of Medicaid Eligibility: Caseload September August 2010

36 36 Texas Medicaid: Enrollment by Age, State Fiscal Year 2009

37 37 Texas Medicaid: Enrollment & Spending June 2011, 3.3 million people received Medicaid.  Over 2.3 million are children.  Over 700,000 are individuals who are aged, blind, or disabled. Texas Medicaid beneficiaries & expenditures, state fiscal year 2009

38 38 Texas Medicaid: State Budget Medicaid spending FY $44.9 billion from all fund sources $18.8 billion from General Revenue (GR), GR- Dedicated, and Tobacco Settlement Receipts 75% of all appropriations for HHS

39 39 Federal Spending State Spending $16.1 B $8.6B Texas Medicaid: Historical Spending

40 40 Texas CHIP: Enrollment & Spending How many children in Texas are enrolled CHIP? Caseload for June 2011: 539,137 children How much is spent on CHIP? Total state fiscal year 2010 budgeted* for CHIP – $815.6 million from all fund sources – $270.2 million from GR *Based on FY 2010 Operating Budget. Includes all traditional CHIP costs: client service costs for federally funded children, legal immigrants, school employee children, and vendor drugs; administrative and operating expenses.

41 41 Texas CHIP: Average Monthly Enrollment, State Fiscal Year

42 42 Texas CHIP: Enrollment by Age, State Fiscal Year 2010

43 43 Texas CHIP Perinatal Program: Enrollment, State Fiscal Year

44 44 Texas Medicaid: FMAP Federal Medical Assistance Percentages (FMAP) Portion of total Medicaid costs paid by the federal government. Texas FMAP for federal fiscal year 2012: – Of each dollar spent on Medicaid services in Texas, the federal government pays approximately 58 cents. Based on average state per capita income compared to the U.S. average. Small changes in the FMAP could result in significant loss or gain of federal funds.

45 45 Texas Medicaid: DSH Payment Medicaid Disproportionate Share Hospital (DSH) Program Source of reimbursement to state-operated and non-state (local) Texas hospitals that treat indigent patients. Federal law requires that state Medicaid programs make special payments to hospitals that serve a disproportionately large number of Medicaid and low-income patients. Not tied to specific services for Medicaid-eligible patients, unlike other Medicaid payments. Total funds to all DSH hospitals in state fiscal year 2009: $1.615 billion State DSH Hospitals: $339 million Non-state DSH Hospitals: $1.276 billion

46 46 Texas Medicaid: UPL Payment Upper Payment Limit (UPL) Financing mechanism used by states to provide supplemental payments to hospitals or other providers. Federal regulations allow states to pay providers up to what Medicare would have paid, or the amount the hospital charges for services. States may use local funds transferred to the state to fund the supplemental payments. HHSC currently makes UPL payments to: 4 state-owned hospitals 11 non-state large urban public hospitals 100 non-state owned rural public hospitals 7 children’s hospitals 11 state university physician group practices unknown number of privately-owned hospitals in Private Hospital UPL program

47 47 Texas CHIP: EFMAP Enhanced Federal Medical Assistance Percentages (EFMAP) Portion of total CHIP costs paid by the federal government. Generally higher than Medicaid  In 2012, the federal government pays 70.89% of CHIP medical care expenditures  Compared to 58.42% of Medicaid medical care expenditures.

48 48 Texas CHIP: Historical Spending, State Fiscal Year

49 49 Texas CHIP: Cost Sharing CHIP annual enrollment fee: $0 for families with net income less than 150% FPL $35 for families between % FPL $50 for families between % FPL Families are required to pay the enrollment fee upon enrollment or renewal of CHIP.

50 50 Texas CHIP: Cost Sharing Families enrolled in CHIP are responsible for co-payments for certain plan benefits. At or below 100% FPL 101% to 150% FPL 151% to 185% FPL 186% to 200% FPL Preventative Health Care and Shots Office Visit Non-Emergency Room Use Generic Prescription Name-brand Prescription Inpatient Hospital Care Outpatient Hospital Care $0 $3 $0 $3 $10 $0 $5 $0 $5 $25 $0 $7 $50 $5 $20 $50 $0 $10 $50 $5 $20 $100 $0

51 51 Texas Medicaid Women’s Health Program (WHP): Savings In 2008, WHP saved: $63 million (all funds) due to reduction in expected births. $42.4 million (all funds) after paying program costs. State share of reduced Medicaid costs totaled:  approximately $23.5 million (GR)  net state share of savings after paying WHP expenditures totaled approximately $21.4 million (GR)

52 52 Medicaid Delivery Models: Managed Care vs. FFS Managed Care Programs in Texas STAR – provides acute care services to children, pregnant women, and families. STAR+PLUS – provides acute and long-term services and supports to individuals with disabilities and elderly people. NorthSTAR – provides behavioral health services to individuals in a multi-county area in and around Dallas. STAR Health – provides a comprehensive managed care program for children in foster care. Fee-for-Service (FFS)/Traditional Medicaid A few eligibility categories remain in FFS. Individuals in FFS can choose any provider. FFS does not offer the management or utilization controls that managed care provides.

53 53 Provider Reimbursement: Managed Care vs. FFS Payment and processes vary by delivery model Managed Care: – HHSC pays MCOs a capitated rate. – MCOs pay providers reimbursement rates established by contracts with the providers. – Providers send claims (bills for services) to the MCO for payment. FFS: – HHSC establishes FFS methodologies to pay providers. – Claims are sent to state for payment.

54 54 Texas CHIP: Delivery Systems CHIP Service Delivery Models include: MCO: A type of health care plan that arranges for or provides benefits to covered clients – The state pays the CHIP MCOs on a capitation basis: a set dollar amount PMPM to cover the health care costs of clients. – Client selects an MCO and a Primary Care Provider (PCP) – PCP authorizes services within the network – Providers are paid reimbursement rates established by the MCO Exclusive Provider Organization: A health plan that arranges for or provides benefits to covered persons through a network of exclusive providers – Limited to services provided to client in network, except for emergencies. Dental Maintenance Organization for dental services

55 Medicaid & CHIP: New Initiatives

56 56 Budget-Related Outcomes of the 82 nd Texas Legislature Summary of Medicaid Funding for FY $40.6 billion in All Funds ($17.1 billion in GR). Assumes expansion of managed care, anticipated to result in a net savings of $385.7 million GR and increases in insurance premium tax revenue collections. Funding levels continue provider rate reductions implemented during the biennium, including an 8% hospital rate reduction. Cost containment initiatives totaling $1.8 billion in GR funds, including $450 million assumed in Rider 61.

57 57 Budget-Related Outcomes of the 82 nd Texas Legislature Statewide Standard Dollar Amount (SDA) Converted hospital reimbursement from a hospital-specific, cost-based reimbursement to a statewide base SDA effective September 1, HHSC worked closely with hospital industry to develop the statewide SDA. Add-on adjustments for hospital wages, medication education, and trauma centers to recognize high-cost services and geographic variations. Hold Harmless: HHSC authorized to use up to $20 million in GR ($48.1 million all funds) to mitigate losses to hospitals that are disproportionately impacted. Funding available up to September 1, 2012.

58 58 Budget-Related Outcomes of the 82 nd Texas Legislature Medicare Equalization Past Texas Medicare-Medicaid Policy – Part A - State limits Medicare coinsurance and deductible payments to no more than the Medicaid rate for the same service. – Part B - State makes Medicare coinsurance and deductible payments. Total payment for service may exceed Medicaid rate. As of January 2012 – The General Appropriations Act directs HHSC to align payment policies for Medicare Part A and B cost sharing.

59 59 Initiatives from the 82 nd Texas Legislature Managed Care Expansion September 1, 2011 – Expanded existing STAR and STAR+PLUS service areas to contiguous counties. March 1, 2012 – Expand STAR to new service areas. – Expand STAR+PLUS to new service areas. – Replace TX Primary Care Case Management Program (PCCM) with a capitated MCO program. – Carve the pharmacy benefit into the services delivered by the Medicaid and CHIP MCOs. – Develop statewide Medicaid dental MCOs.

60 60 Initiatives from the 82 nd Texas Legislature Reduce inappropriate utilization of Emergency Departments (ED) by Medicaid recipients ED hospital rates – As of September 1, 2011, HHSC applied a 40% reduction to facility charges for non-emergent services delivered in an ED setting to recipients of Medicaid FFS Medicaid cost-sharing – Encourage personal accountability and appropriate use of health care services. – Cost-sharing includes non-emergency services through a hospital ED. – HHSC is researching options for implementation. – Target implementation date is December Develop incentives though MCOs for providers to: – Offer evening and weekend hours, and – Educate recipients about appropriate Emergency Department utilization.

61 61 Initiatives from the 82 nd Texas Legislature Quality Initiatives Shift to paying for outcomes and quality instead of volume. – Quality-based payments for hospitals and managed care. – Policy changes Example: Ending Medicaid payments for elective deliveries prior to 39 weeks. S.B. 7 established: – Quality-Based Payment Advisory Committee – Texas Institute of Health Care Quality and Efficiency

62 62 Healthcare Transformation 1115 Waiver Texas Health Care Transformation and Quality Improvement Program 1115 Waiver includes: Managed care expansion – Expands Medicaid managed care services statewide. – Includes legislatively mandated pharmacy carve-in and dental managed care. Hospital financing component – Preserves hospital funding under a new methodology. – Creates Regional Healthcare Partnerships (RHPs).

63 63 Healthcare Transformation 1115 Waiver Under the waiver, trended historic UPL funds and additional new funds are distributed to hospitals through two pools: Uncompensated Care Pool – Costs of care provided to individuals who have no third party coverage for the services provided by hospitals or other providers (beginning in first year). Delivery System Reform Incentive Payments – Support coordinated care and quality improvements through RHPs to transform care delivery systems (beginning in later waiver years).

64 64 Healthcare Transformation 1115 Waiver Pool

65 65 Healthcare Transformation 1115 Waiver RHPs: Will form around hospitals currently receiving UPL payments. Will develop plans to address local delivery system concerns with a focus on improved access, quality, cost-effectiveness, and coordination. Must provide opportunities for public input in plan development and review. Should encourage broad engagement of local stakeholders in RHPs.

66 66 Chronic Conditions Waiver S.B. 1, 82 nd Legislature, First Called Session, 2011 If feasible and cost-effective, HHSC may apply for a waiver to more efficiently leverage use of state and local funds. Would provide benefits to individuals eligible to receive services through the county for chronic health conditions. Requires broad-based input from interested persons. Must use intergovernmental transfers to maximize federal Medicaid matching funds.

67 67 Affordable Care Act: Medicaid Expansion Medicaid eligibility expands to include individuals under age 65 with incomes up to 133% FPL Includes income deduction of 5 percentage points, creating effective eligibility level of 138% FPL. In 2014, Texas will experience 1.8 million increase in caseload. New client populations in Texas include: Parents and caretakers at % of FPL Childless adults up to 133% FPL Emergency Medicaid in expansion populations Children in foster care through age 25 Federal government bears full cost of coverage for new eligibles for first 3 years of mandatory expansion.

68 68 Current & Estimated Future Medicaid/CHIP Eligibility Levels Current Medicaid 185% FPL CHIP 200% FPL CHIP 200% FPL CHIP 200% FPL CHIP 200% FPL Current Medicaid 185% FPL Current Medicaid 133% FPL Current Medicaid 100% FPL Current Medicaid 74% FPL 14% FPL NEW Medicaid (Currently CHIP) 133% FPL NEW Medicaid 133% FPL NEW Medicaid 133% FPL Current Medicaid 185% FPL Current Medicaid 225% FPL 133%

69 69 Affordable Care Act: Eligibility Changes State Health Benefit Exchange (HBE) The law requires each state to have a HBE. If a state chooses not to operate a HBE, the federal government will operate an HBE for the state. Texas has not yet decided whether or not it will operate an HBE. Medicaid, CHIP, and the HBE must interface. Applications through the HBE must be “deemed” to Medicaid and CHIP with no additional required action by the applicant.

70 70 Affordable Care Act: Medicaid Benchmark Benefit Federal law allows for a Medicaid benchmark benefit that: Will be provided to the new Medicaid adult expansion population in 2014, May be different from the regular Medicaid benefit package, Must include essential health benefits (EHB), as defined by federal Department of Health and Human Services (HHS). In December 2011, HHS released initial guidance on EHB. Additional guidance specific to Medicaid is forthcoming. HHSC is reviewing the guidance and researching options for Texas while awaiting additional guidance. Texas will seek stakeholder input while developing the benchmark benefit.

71 71 Texas Health Care Coverage: Post ACA Implementation CHIP 200% FPL CHIP 200% FPL CHIP Current Medicaid 185% FPL Current Medicaid 133% FPL Current Medicaid 100% FPL Current Medicaid 185% FPL Current Medicaid 74% FPL 14% FPL NEW Medicaid 133% FPL NEW Medicaid 133% FPL NEW Medicaid 133% Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Unsubsidized – In or Out of Exchange Unsubsidized – In or Out of Exchange Unsubsidized – In or Out of Exchange Unsubsidized – In or Out of Exchange Unsubsidized – In or Out of Exchange Unsubsidized – In or Out of Exchange Estimated Medicaid/CHIP 5.6 million Estimated Insured & Subsidized in Exchange 1.9 million Estimated Insured but not Subsidized (In or Out of Exchange) 15.5 million Estimate of Ongoing Uninsured 2.3 million % of Federal Poverty Level

72 72 Current State Challenges Redesign of existing programs Strengthening and transforming the health care infrastructure. Streamlining Medicaid and CHIP eligibility determinations and coordinating with the HBE. Effectively redesigning existing state and local programs currently serving the population. Building adequate workforce to serve newly insured populations. Uncertainties Pending federal guidance for many provisions, which complicates states ability to implement. Long term fiscal planning as federal participation levels decrease over time. Estimating the ongoing needs of the undocumented and remaining uninsured populations.

73 73 Additional Resources Medicaid Managed Care Initiatives Approved Healthcare Transformation 1115 waiver HHSC News Releases Texas Medicaid Pink Book


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