Presentation on theme: "Modernizing Idaho Medicaid Value-Based Reform Prevention/Wellness/Responsibility August 4, 2006 SCI Summer Workshop Kate VandenBroek, Sr. Project Mgr.,"— Presentation transcript:
Modernizing Idaho Medicaid Value-Based Reform Prevention/Wellness/Responsibility August 4, 2006 SCI Summer Workshop Kate VandenBroek, Sr. Project Mgr., Idaho Medicaid
Idaho Medicaid, Pre-Reform Fiscally unsustainable, crowding out other state budgets. Program administration focus vs. outcomes focus. Eligibility categories do not describe health needs of populations. Eligibility structure results in cost controls without regard to health needs. One size fits all benefits.
Modernization “Filters” for Decision Making Is the change holistic? Does the change foster simplicity? Does the change promote fairness? Does the change create value?
Approach to Modernization Simplify eligibility to match identified needs. Establish policy goals relevant to specific populations. Modify benefits to meet identified needs and promote policy goals. Alter delivery systems to efficiently and effectively meet needs and policy goals. Match quality and performance improvement to population served.
Idaho Medicaid Simplification Act Provides framework and policy goals for Idaho Medicaid reform. Three distinct health need categories: Low-income children and working-age adults Individuals with disabilities or special health needs Dually eligible for Medicaid & Medicare (Elder Plan) Three distinct benefit packages: Medicaid Basic Plan Medicaid Enhanced Plan Medicare-Medicaid Coordinated Benefits
Health Need Categories Low-Income Children and Working-Age Adults Individuals with Disabilities or Special Health Needs TANF-related families Poverty-Related Pregnant Women Poverty-Related Children CHIP Children Adults & children with disabilities Individuals who need Long term care Foster Children Special Health Need HRA
New Benefit Plans BASICENHANCED Major Medical Mental Health Dental Vision Transportation Primary Care Case Management All Basic Benefits, plus: Extensive Mental Health Benefits Developmental Disability Services Long-Term Care Services Targeted Case Management
Coordinated Plan Proposed Integration of Medicare Part D Excluded Drugs. Ongoing Collaboration with Medicare Advantage Plans. Medicare AdvantageMedicaid Integrated Medicare FFS BenefitsNon-Medicare Benefits Benefits – NOWBenefits- FUTURE Part D Drugs Hospital Physician, Lab & X-Ray DME Nursing Facility* Home Health Other * Limited to only 100 Day Benefit Period. Vision/Eyeglasses Hearing Services Basic Dental Health & Wellness Excluded Drugs PCCM/TCM Incontinence Supplies Other Dental PHA Benefits LTC- Nursing Home, Personal Care, Community- Based Services Idaho Medicaid Will Now Pay Premiums/Cost-Sharing for Full Duals Enrolled in Medicare Advantage
Also: Preventive Health Assistance (PHA) benefits Originally “Personal Health Accounts” PHA type #1: Behavior PHA Supports weight management and tobacco cessation. Targets adults with high or low BMI or who want to quit tobacco. Initial loading of points; more points with participation. PHA type #2: Wellness PHA Helps pay delinquent premiums and purchase goods/services to support activity/wellness. Targets children eligible for premiums (above 133% FPL). Points loaded if immunizations and well child checks are current.
Idaho Reform Timeline 10/29/05. Governor Presents Concept to HHS Secretary 11/18/05. Modernizing Idaho Medicaid Concept Summary published 1/26/06. Governor Presents Proposal to HHS Medicaid Commission 2/13/06. Idaho Medicaid Simplification Act Introduced 3/31/06. Governor Signs Idaho Medicaid Reform Legislation April 24, HIFA Waiver Submitted for CHIP changes 10/27/05. S Introduced in Senate 11/7/05. H.R Introduced in House 11/3/05. S Passed Senate; with amendments (52-47) 11/18/05. H.R Passed in House ( ) 2/8/06. President Signs S.1932, Deficit Reduction Act of 2005 Idaho Shifts to DRA. DRA
Technical Submissions Section 1115 Demonstration Waiver ApplicationSubmitted 4/24/06 Basic Benchmark Benefit Package for Low-Income Children and Working-Age Adults SPA Submitted 4/26/06 Enhanced Benchmark Benefit Package for Individuals with Disabilities (includes Elders) SPA Submitted 4/26/06 Multi-State Drug Purchasing Pool (to offset new premium payments through PHAs) SPA Submitted 4/26/06 Removal of Asset Test for Low-Income ChildrenSPA Submitted 4/26/06 Non-Emergency Transportation Brokerage SPA Submitted 4/26/06 Long-Term Care Partnership Program SPA Submitted 4/27/06 Asset Transfer Restrictions SPA Submitted 4/28/06 Healthy Schools InitiativeXXI Submitted 4/26/06 Coordinated Benchmark Benefit Package for Elders (Dual Eligibles) SPA Submitted 5/05/06 Medicare Enrollment as a Condition of Medicaid EligibilitySPA Submitted 5/05/06 Simplified Eligibility (all children below 133% FPL to Title XIX)SPA Submitted 5/05/06 Simplified Eligibility (only children above 133% FPL in Title XXI)XXI Submitted 5/05/06 Premiums above 133% “ “ “ Submitted 5/05/06 Expanded Premium Assistance OptionHIFA 1115Submitted 5/08/06 Approved by CMS New DRA Provisions
Outstanding Issues Modify (scale back) “standard” Medicaid Caregiver support benefits Premium assistance expansion Targeted co-payments Prescription Drugs Inappropriate ER Use Inappropriate Ambulance Use Missed Appointments Health information technology grants for primary care providers Incorporating existing waivers