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Vermont Health Care Reform Susan W. Besio, Ph.D. Director of Health Care Reform Implementation Vermont Agency of Administration July, 2007.

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Presentation on theme: "Vermont Health Care Reform Susan W. Besio, Ph.D. Director of Health Care Reform Implementation Vermont Agency of Administration July, 2007."— Presentation transcript:

1 Vermont Health Care Reform Susan W. Besio, Ph.D. Director of Health Care Reform Implementation Vermont Agency of Administration July, 2007

2 2 Vermont Context  Population: 623,000  19 U.S. cities are larger than Vermont  Ranked 11th for proportion of population insured 1 1 US Census 2005 revised

3 3 Vermont Context  Ranked the 2nd healthiest state overall in 2005 and Highest percentage (86.4%) of women enter prenatal care in 1st trimester Lowest percentage (7.4%) of children living in poverty 4 th lowest re: prevalence of obesity (20.2%) Decrease in prevalence of smoking from 30.7% to 19.3% since 1990 Lowest rate of motor vehicle deaths Lowest premature death rate (years of potential life lost before age 75)  Vermont is considered an “aging state,” where the older population is growing faster than the younger population Vermont has approximately 78,000 (12.6%) residents age 65 or older. By the year 2030, 25% of Vermont’s population will be age 65 and older 1 United Health Foundation

4 4 Vermont Context – Health Care Costs  Growing cost of health care is unsustainable Annual expenditures of $3.5 billion 15.2% of Vermont’s gross state product Vermont’s per capita costs still less than national average, but spending growth rates have been higher than national average for last 6 years Health Care Expenditures(2005) Vermont U.S. Total (billions)$3.5$2,016 Per capita$5,636$6,682 Annual Change ( )7.2%7.4% Average Annual Change ( )7.9%7.0% Share of Gross State/Domestic Product15.2%16.2%  Over 60,000 Vermonters are uninsured, and the number is growing  An estimated 50% of Vermonters with chronic conditions account for 70% of health care spending, but only 55% get the right care at the right time

5 5 Vermont Context – The Insured  Private Health Insurance 59.4% (370,000) have private insurance as primary coverage –91% receive employer-sponsored insurance –5% purchase their own coverage in the individual market –Remaining covered by higher education, COBRA, etc.  Medicaid: 14.5% (90,350) have Medicaid as primary coverage –Traditional Medicaid – up to 125% FPL –Dr. Dynasaur – Children in households up to 300% FPL (34% of Vermont’s children) –Vermont Health Access Plan (VHAP) – Adults up to 150% FPL and caretakers of dependent children up to 185% FPL Largest Insurer in Vermont (9,000 Enrolled Providers)  Medicare: 14.5% (90,100)  Military Insurance: 1.7% (10,500)

6 6 Vermont Data (2005) – The Insured 91.2% of Vermonters, 95.1% of Vermont children Private Insurance  61.5% (382,239) of insured have private insurance - A decline of 2.1% since 2000 (63.6%) % (347,435) have employer-sponsored insurance  4.9 % (18,658) purchase their own coverage in the individual market  Enrollees decreased by 47% from 2002 to 2005  Another 4.2% covered by higher education, COBRA, etc.

7 7 Vermont Data (2005) – The Insured 91.2% of Vermonters, 95.1% of Vermont children Medicaid / VHAP / Dr. Dynasaur  19.1% (118,388) of insured are enrolled in Medicaid programs - An increase of 0.6% since 2000 (18.5%) - 22% (26,442) are employed adults % (90,352) are enrolled in a Medicaid program as primary coverage  41% (58,000) of Vermont children under age 18 are enrolled in Dr. Dynasaur - 86% of these (50,000) rely exclusively on Medicaid  Largest Insurer in Vermont (9,000 Enrolled Providers)

8 8 Vermont Context – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children An 1.4% increase in the rate of uninsured since 2000 (8.4%) 51% are eligible for Medicaid programs but not enrolled 79% of uninsured children; 49% of uninsured adults (18 – 64) 87% are interested in enrolling; 57% believe they are not eligible 27% have household income between % and 300% FPL and are not eligible for a Medicaid program but cannot afford private insurance

9 9 Vermont Data 2005 – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children  69% have been without insurance for more than a year  77% reported cost as the main reason for being uninsured  30% of uninsured children and 40% of uninsured adults did not see a health care professional in past year  45% of uninsured children did not see a physician for routine care (compared to 7% of insured children)  Much more likely to go to ER or urgent care (8.6% vs.7%)  25% of uninsured adults reported not seeking needed medical care due to cost

10 10 Vermont Context – The Uninsured  9.8% - A 1.4% increase in the rate of uninsured since 2000 (8.4%)  Uninsured Adults (18 to 64) –13.4% of adults (N = 53,708) Young: 38% are between ages18 -24; over 25% between Male: 60% are male Educated: 50% have high school /GED; 21% have up to college degree; 18% have college degree or more Employed: 81% are employed –60% work full-time –30% work for employers that provide health insurance benefits  Uninsured Children (0 to17) – 4.9% of all children (N = 6,942) Adolescents: 60% of uninsured children are between ages Male: Over 60% of uninsured children ages 0 to 17 are male Uninsured Families: 70% of adults with uninsured children are also uninsured

11 11 Vermont Context – The Uninsured  51% are eligible for Medicaid programs but not enrolled 79% of uninsured children; 49% of uninsured adults (18 – 64) 87% are interested in enrolling; 57% believe they are not eligible  27% have household income between % and 300% FPL and are not eligible for a Medicaid program but would be eligible for new Premium Assistance 1 person: $15,315 - $30,630 2 person: $20,535 - $41,070 4 person: $30,975 - $61,950  69% have been without insurance for more than a year  77% reported cost as the main reason for being uninsured  45% of uninsured children did not see a physician for routine care (compared to 7% of insured children)  Much more likely to go to ER or urgent care for medical care (8.6% vs.7%)  25% of uninsured adults reported not seeking needed medical care due to cost

12 12 What the Data Tell Us  Many of the uninsured are people who cannot afford coverage  We have very specific demographic data about the uninsured  51% of uninsured are eligible for Medicaid programs; 87% are interested; over half think they are not eligible  Catamount Health must be affordable  We need to provide premium assistance to people to enroll in Catamount Health or ESI  Outreach will be designed for and targeted to specific groups  We will re-tool our outreach and enrollment processes to enroll more people

13 13 Vermont’s Response  2006 Legislation Health Care Affordability Acts (Acts 190, 191) Common Sense Initiatives (Appropriations Bill) Sorry Works! (Act 142) Safe Staffing and Quality Patient Care (Act 153)  2007 Legislation Corrections and Clarifications to the Health Care Affordability Acts of 2006 (Act 70) An Act relating to Ensuring Success in Health Care Reform (Act 71)  Joint Legislative Commission on Health Care Reform  Administration Director of Health Care Reform Implementation

14 14 Health Care Reform Goals Increase AccessImprove Quality Contain Costs

15 15 Goal: Increase Access to Affordable Health Care Coverage Enhance Private Insurance Coverage Catamount Health Plan for the Uninsured Non-Group Market Reform Promotion of Employer-Sponsored Insurance Local Health Care Coverage Planning Grant Potential Individual Insurance Mandate Improve Outreach to Uninsured Medicaid Enrollment Study Comprehensive Marketing, Outreach Single Enrollment Web-site number Assist with Affordability Premium Assistance (ESI, Catamount) Reduction in VHAP Premiums

16 16 Goal: Improve Quality of Care Chronic Care Management Expand Blueprint Statewide OVHA Chronic Care Management Program State Employee Health Plan ESI Premium Assistance plan approval, cost-sharing Catamount Health coverage, cost-sharing Care Coordination Payment Reforms Increase Provider Access to Patient Information Health Information Technology Electronic Medical Records Master Provider Index Multi-payer Database Promote Quality Improvement Consumer Health Care Price & Quality System Adverse Events Monitoring System Hospital-acquired Infections Data Safe Staffing Reporting SorryWorks! Advanced Directives Increase Provider Availability Loan Repayment Program Loan Forgiveness Program FQHC Look-alike Funding Uncompensated Care Pool Promote Wellness Immunizations CHAMPPS Grants Catamount Health Coverage, cost-sharing Healthy Lifestyles Insurance Discounts AHS Inventory of Health and Wellness Programs

17 17 Goal: Contain Costs Increase Access to Coverage and Care  Decrease Uncompensated Care  Lower Premium Costs Decrease Cost Shift Increase Medicaid Provider Rates Cost Shift Task Force Standardize Policy for Hospital Uncompensated Care and Bad Debt Hospital Cost Shift Reporting Reforms Improve Quality of Health Care  Appropriate Care, Better Information  Lower Costs Simplify Administration Common Claims and Procedures Uniform Provider Credentialing

18 18 Insurance Coverage

19 19 Why is Coverage Important?  Un-reimbursed care increases private insurance premiums  Makes insurance less affordable Fewer people are covered Benefits are decreased and/or people choose non-comprehensive plans to make plans affordable  People with comprehensive insurance coverage are more likely to participate in preventive care  Increases quality of life  Decreases cost of health care overall

20 20 Catamount Health  A non-group insurance product for uninsured Vermont residents  Offered as a preferred provider organization plan by two private insurers, beginning October 1, 2007  Is required to be a comprehensive insurance package covering: Primary care Preventative care Acute episodic care Chronic care Hospital services Pharmaceutical coverage  Individuals may choose which insurer they would like to use.

21 21 Catamount Health LEGISLATIVELY-MANDATED COST-SHARING Deductibles: In-Network:Out-of-Network: $250/individual $500/individual $500/family $1,000/family Co-Payment: $10/office visit Prescription Drugs:No deductible Co ‑ payments: $10 generic drugs $30 drugs on preferred drug list $50 non-preferred drugs Preventive Care & Chronic Care*: $0 Not subject to deductible, co-insurance, co-payments Out-of-Pocket Maximum: In-Network:Out-of-Network: (excluding Premium) $800/individual $1,500/individual $1,600/family $3,000/family * For people enrolled in Chronic Care Management Program

22 22 Catamount Health  PROVIDER REIMBURSEMENT Health Care Professionals: Medicare +10% in 2006, increasing as per Medicare reimbursement methodology Hospitals: Cost +10%, increasing as per Medicare economic index  OVERSIGHT Insurers go through the usual rate-setting process at the Department of Banking, Insurance, Securities and Health Care Administration (BISHCA) Emergency Board will suspend enrollment in Catamount Health premium assistance if there is not enough money Commission on Health Care Reform to review Catamount Health Plan by October 1, 2009 for cost effectiveness  may trigger a self- insured plan if current structure is not cost effective

23 23 Catamount Health Costs  The cost will depend on individual / household income Cost for Individual Coverage with Premium Assistance: Individual Income by federal poverty level Monthly premium cost * (1 person/annual in 2007) Below 200% FPL ($20,420) $ % ($20,421 – 22,973)$ % ($22,974 – 25,525)$ % ($25,526 – 28,077)$ % ($28,078 – 30,630)$ * Cost for two-person coverage will be double these amounts Estimated Full Cost for Individuals/Households over 300% FPL: Single$ 390 / month Two Person$ 780 / month Family$1,750 / month

24 24 Catamount Health Eligibility  You can purchase Catamount Health if you are an uninsured Vermont resident, are 18+, and are not eligible for an Employer-Sponsored Insurance (ESI) plan *. Uninsured means: You have insurance which only covers hospital care OR doctor’s visits (but not both) You have not had private insurance for the past 12 months You had VHAP or Medicaid but became ineligible for those programs You had private insurance but lost it because you: Lost your job Got divorced No longer have COBRA coverage Had insurance through someone else who died Are no longer a dependent on your parent’s insurance Graduated, took a leave of absence, or finished college or university and got your insurance through school

25 25 Catamount Health Eligibility  You can purchase Catamount Health even if you are eligible for an Employer-Sponsored Insurance (ESI) plan IF you have an income under 300% FPL, AND Your ESI plan is not approved by the state as comprehensive and affordable (with state assistance) OR It is more cost effective to the state to provide premium assistance for you to enroll in a Catamount Health plan than providing premium assistance for you to enroll in your ESI OR It is more cost effective to the state to provide premium assistance for you to enroll in your ESI than providing premium assistance for you to enroll in Catamount Health, but you must wait until the next open enrollment period for your ESI (at which point you must switch to your ESI to receive premium assistance)

26 26 Key Dates  CATAMOUNT HEALTH September 8, 2006Rules filed with Secretary of State October 7, 2006Carriers submitted Letters of Intent (BCBS-VT, MVP, CDPHP) Mid-March, 2007Carriers file forms and rates October 1, 2007Catamount Health Insurance available to uninsured Vermonters October 1, 2009 Legislative review re: cost effectiveness; may trigger a self-insured plan

27 27 Premium Assistance  Catamount Health Vermonters who qualify for Catamount Health with income less than or equal to 300% of Federal Poverty Level (FPL) ($29,500 for one person) may receive premium assistance from the state  Employer-Sponsored Insurance (ESI) Uninsured Vermonters with income less than or equal to 300% FPL may apply for ESI premium assistance ESI plans must offer comprehensive benefits and be affordable in order for the individual to receive premium assistance  Affordable = maximum individual in-network deductible of $500  Comprehensive = covers physician, inpatient care, outpatient, prescription drugs, emergency room, ambulance, mental health, substance abuse, medical equipment/supplies, and maternity care  Employers do not have to contribute to the plan for it to qualify

28 28 Premium Assistance Cost Effectiveness Test  VHAP Applicants (under % FPL) If providing premium assistance to the individual to enroll in their ESI plan is more cost-effective to the state than enrollment in VHAP, the applicant will be required to enroll in their ESI plan to get state assistance.  Catamount Health Applicants (at or under 300% FPL) If providing premium assistance to the individual to enroll in their ESI plan is more cost-effective to the state than providing premium assistance for the Catamount Health Plan, the applicant will only receive state assistance to enroll in their ESI plan.

29 29 How will Premium Assistance be Paid?  Catamount Health Premium Assistance Beneficiary will pay his or her share to state State will pay total premium to carrier  ESI Premium Assistance Employee will pay total premium to employer through payroll deduction State will pay employee prospectively for premium assistance Employers will not have to modify payroll or accounting systems Employers may have to provide information on the plan’s cost to the employee to assist with enrollment in the premium assistance program

30 30 Key Dates: PREMIUM ASSISTANCE FOR ESI / CATAMOUNT September, 2006Waiver Amendment Request submitted to CMS for approval of premium assistance programs November, 2006Report to Legislative Committees on fiscal implications (estimated costs and savings) April, 2007Draft Rules for Premium Assistance Eligibility Determination July, 2007Finalize Rules for Premium Assistance Eligibility Determination October 1, 2007Premium Assistance enrollment for ESI and Catamount to eligible Vermonters

31 31 OVERVIEW OF VERMONT EDUCATION, OUTREACH AND ENROLLMENT STRATEGY Goal: To develop and implement a comprehensive, integrated and aggressive education, outreach and enrollment strategy:  across a continuum of solutions for the uninsured, including Medicaid, VHAP, Dr Dynasaur and Catamount Health Plans  using a unified multi-stakeholder campaign,  with specialized interventions for specific uninsured populations, and  targeted at multiple stakeholders (health care providers, community-based providers, grass-roots organizations, advocate organizations, state employees, employers)

32 32 Outreach and Enrollment  Integrated Medicaid, Catamount Outreach and Enrollment Strategies Aggressive Marketing and Education Campaign in Late Summer, Fall 2007 Using state and local staff, partners and volunteers number New web-site  Possible Re-branding  Re-tooling of Existing Application and Enrollment Processes

33 33 Key Elements  Broad-based Outreach and Enrollment Steering Committee: to guide and inform outreach and enrollment efforts (see attached membership list)  Health Care Marketing Firm to Develop: A broad-based, compelling message that conveys to all Vermonters why it is important to have health insurance coverage; Promotion of all available insurance products and subsidies, including private market options. Coordination of the broad message with education, outreach and enrollment activities that are nuanced to address targeted populations, including  1) specific uninsured sub-populations (using the 2005 Vermont Family Health Insurance Survey data), and  2) partners who can assist with the coverage efforts (e.g., employers, health care providers, human services providers and other community organizations, schools, the faith community). Use of health literacy research, such as that produced by the Harvard School of Public Health, to inform our effort

34 34 Key Elements, continued  Revisions to Current Enrollment Tools: The above must be coupled with the tools needed for effective screening and enrollment, including shifting FROM Current relatively passive approach: Examples:  using brochures,  number,  paper applications and  office-based staff TO Pro-active and consumer-friendly approach: Examples:  all of above, plus  one-to-one and community-based outreach,  user-friendly web-based screening tools,  simplified application forms,  ability to track application status and change in eligibility over time to prevent program drop-out, etc.  Outreach and Enrollment Coordinator to facilitate the implementation and interface between all of the above activities.

35 35 Revisions for Medicaid/VHAP/Dr. Dynasaur Eligibility Determination and Enrollment  Explore streamlining Medicaid/VHAP/Dr Dynasaur application form  Pro-actively assist with eligibility screening and applications (complete forms for people at key junctures)  Actively engage AHS employees and partners (providers, regional partnerships, clergy, accountants, others to help people complete eligibility screening tool and / or application  Add a contract/grant provision to state contracts/grants that have natural connections to the target populations  Change VHAP coverage date to be the date of application receipt  Move from 6 month to 12 month VHAP renewals  Solicit feedback from individuals about the enrollment and renewal processes to inform additional refinements

36 36 Revisions for Medicaid/VHAP/Dr. Dynasaur Eligibility Determination and Enrollment  Create the Vermont Health Care Portal - an on-line system to access information and enrollment processes for all Vermont health care programs, designed to: streamline the application and eligibility process, and reduce the burden of program rules; interface in real time with other systems to verify information needed to grant eligibility and to disseminate notification of coverage; utilize the health information exchange being created by VITL in a way that improves the sharing of health care data; quickly incorporate changes in eligibility rules; reduce the need for paper by managing applications, notifications and billing electronically whenever possible; and enable caseworkers to be more focused on personally serving Vermonters because they need less time for data entry, managing paperwork, and getting accurate, timely results from the enrollment system.

37 37 Vermont Health Care Portal, continued (This proposal is still under discussion and may be altered as more detailed information evolves about implementation issues – e.g., technical challenges, timelines, cost)  Phase 1 (by August 2007): Web-based simple screening tool Links to information about Vermont’s healthcare programs and application processes Down-loadable pdf version of the application form that can be completed and mailed or faxed Automated contact form that the individual can submit to request a follow-up phone call  Phase 2 (by October 2008): Phase 1 plus: On-line application that can be submitted electronically Expanded links to educational health-related materials and sites  Phase 3 (by June 2010): On-line application and renewal processes linked to back-end eligibility/enrollment/renewal system From any place with internet access, an individual will be able to:  read and download current information about health care programs;  complete an anonymous self-screening to determine if they may be eligible for assistance;  fill out and submit an automated application or recertification that connects with the processing system;  chat immediately with a caseworker to get answers to questions, help completing the application and an explanation of remaining requirements;  submit verification, and receive notification letters and reminders, electronically;  check the status of their case and gather the details of their benefit package;  pay their premiums and select their providers; and,  review information about the services and costs paid by Vermont health care programs for their household. This project will be a component of the vision for the “Medicaid enterprise’ which also entails replacement of the Medicaid Management Information System (MMIS)

38 38 Other Initiatives to Enhance Private Insurance Coverage  Non-Group Market Reform  Promotion of Employer-Sponsored Insurance  Local Health Care Coverage Planning Grant

39 39 CHRONIC CARE MANAGEMENT

40 40 Blueprint for Health  State’s Plan for Better Management and Prevention of Chronic Illnesses across All Payers and Providers  Vision: Vermont will have a standardized statewide system of care that improves the lives of individuals with and at risk for chronic conditions.  To achieve this vision, the Blueprint is: Statewide system reform based on the Chronic Care Model A public-private collaborative Recognizes the central role of the patient and community Designed around “Core System Competencies” rather than disease programs Is the state’s mandated standard for chronic care management across all payers and providers

41 41 Public Policy Public Health Health Systems Community Health Provider Team Patients and Families Policies Infrastructure Financing Resources Advocacy Regulation Info. Systems System Policy Quality Care Service Development Reimbursement Financing Continuity Coordination Info. Systems Built Environment Programs and Services Health Awareness Healthy Options Info. Systems Practice Standards Info. Systems Decision Support Office Systems Coaching/Support Health Knowledge Self-Management Skill and Practice Supportive Home Environment Info. Systems Blueprint for Health Model Healthier Vermonters

42 42 Examples of Blueprint Components Public Policy  Blueprint legislation and funding  Executive Director at Governor’s Office level  Integration of health disparities/minority health  Internal coordination—Chronic Disease Community  Blueprint physical activity opportunities  Walking maps, walking programs Self-Management  Healthier Living Workshop—All conditions  Over 40 statewide; 500+ enrolled  +60% reduction in MD and ED visits post at one year Information Systems  Practice based disease registries  EMRs Health Care Practice  Consensus treatment standards—Diabetes and Asthma  Physician coordination—dedicated medical director  6 Communities (HSAs); 200 primary care practices Health Systems  Insurance company collaboration  Required payment reform in 2 pilots in 2008

43 43 Other Chronic Care Strategies To Be Aligned with the Blueprint  Medicaid Chronic Care Management Program  State Employee Health Benefit Programs  State-approved Employer-Sponsored Insurance (ESI) Plans for Premium Assistance  Catamount Health Plans

44 44 Medicaid Chronic Care Management Program (CCMP)  Establish a Chronic Care Management Program (CCMP) for the Medicaid and VHAP populations  Contract with external vendors for two components: Program intervention Monitoring, evaluation and payment

45 45 CCMP Interventions  Identify Medicaid enrollees with one or more chronic conditions (using claims data)  Conduct health risk assessments (HRAs) for all beneficiaries identified  Stratify the population into high, middle, low risk groups  Conduct evidence-based care management interventions for each risk group (intensity varies by group)  Coordinate CCMP activities with: Care coordination program (coordinating the care needs of the 1-2% most complex Medicaid enrollees) Blueprint for Health Choices for Care 1115 Waiver (Long-term Care Waiver)

46 46 Blueprint Alignment Topics Across Chronic Care Programs  Coordination of care across the multiple programs working with the same providers and patients  Agreement on best practices for all chronic diseases  Use of a consistent health risk assessment  Referrals to patient self-management resources  Coordination of IT initiatives to improve access and support clinical decision making  Use of consistent metrics for provider feedback, profiling and measurement  Changing and aligning payer fee structures to provide incentive to reward quality (e.g., pay-for performance, payment reforms)

47 47 Blueprint Impact on Health Care Costs  It will not SAVE money – but it will reduce the rise in cost of care  We do expect to reduce the cost per case for chronic illness by: reducing hospitalizations reducing complications reducing specialist visits  So why doesn’t that save money? Because when we take better care of chronic illness we prolong productive life Because more people are developing chronic illness, especially with the obesity epidemic That means more people in Vermont with chronic illness More cases at less cost per case still means more total health care cost for the population

48 48 Health Information Technology  VITL = Statewide Regional Health Information Organization (RHIO) State Health Information Technology Plan Medication History Pilot Project  Implemented at 2 Hospital Emergency Rooms in April, 2007  Chronic Care Information System (Disease Registry) First community site (Mt. Ascutney) for diabetes will be implemented in December, 2007  Electronic Health Records supported statewide  Master Provider Index, Multi-payer Database

49 49 PREVENTION

50 50 CHAMPPS (Coordinated Healthy Activity, Motivation and Prevention Programs)  Competitive multi-year grants to communities starting July 1, 2007  Projects must be: Comprehensive approaches to promote healthy behavior and disease prevention  Across the community  Across the lifespan Consistent with the Blueprint and community goals Goal and outcome driven Based on effective strategies Able to provide data for evaluating and monitoring progress

51 51 Healthy Lifestyles Insurance Discounts  Permits BISHCA regulations to allow carriers to establish rewards, premium discounts, rebates, or waive/modify cost-sharing in return for member’s adherence to programs of health promotion and disease  Allows discounts of up to 15% of premium for compliance with health promotion program  Limits total deviation from community rate to 30% (including these discounts) in the individual and small group insurance markets  Rules developed in Fall, 2007  Also allowed in Catamount Health plans

52 52 Other Prevention Initiatives  Agency of Human Services inventory of state wellness initiatives and funding  Clinically recommended immunizations provided to all Vermonters at no cost January 15, Report on Methods to Ensure Universal Access to Immunizations  Catamount Health Plan: waiver of cost-sharing for prevention

53 53 Quality Improvement Initiatives  Consumer Health Care Price & Quality System  Hospital Adverse Events Monitoring System  Hospital-acquired Infections Data  Hospital Safe Staffing Reporting  SorryWorks!  Advanced Directives Registry, Forms and Stickers

54 54 Administrative Simplification  Common Claims and Procedures Maximization of the electronic claims process to support accurate and timely payment of claims  Standardizing ID cards Simplification of Explanation of Benefits and patient bills Pre-authorization comparisons for commonality and variation Improving the efficiency of claims adjudication through common policies that determine how a claim may be adjudicated Simplification of Workers Compensation claims processing Credentialing standardization for provider application and billing eligibility  Uniform Provider Credentialing Form Council for Affordable Quality Healthcare (CAQH) form will be used by hospitals and insurers for provider credentialing

55 55 Strategies to Address Cost Shift  Medicaid Rate Increases for Primary Care Providers, Hospitals and Dentists (January 1, 2007)  Cost Shift Task Force  Hospital Cost Shift Reporting Reforms  Standardized Policy for Hospital Uncompensated Care and Bad Debt

56 56 Financing of Reforms  Based on the principle that everybody is covered and everybody pays: Catamount Health Plan: individuals pay sliding scale premiums based on income Employers pay an assessment based on number of uncovered employees Increases in tobacco taxes VHAP savings due to Employer-Sponsored Insurance (ESI) enrollment Cost avoidance due to better chronic care management Matching federal dollars via Global Commitment 1115 waiver

57 57 Employer Contribution  Assessment for “uncovered FTEs” Employers without a plan that pays some part of the cost of insurance of its workers must pay the health care assessment on all employees. Employers who offer coverage * must pay the assessment on: Workers who are ineligible to participate in the plan New amendment: If the employer offers insurance to all full time employees, they do not have to pay the assessment on seasonal or part-time employees who have coverage from another source (unless it is Medicaid or VHAP). Workers who refuse the employer’s coverage and do not have coverage from some other source.  Assessment does NOT enroll employees in Catamount Health! * Employers plan must include hospital and physician coverage to qualify

58 58 Employer Contribution  Employee = any individual 18 years or older on employer’s unemployment insurance filing Based on the unemployment insurance definition of employee; excludes the following:  Workers on small farms  Full time college students working at the college in a program designed to provide financial assistance  Elected officials  Emergency volunteers such as volunteer fire fighters  Licensed insurance and real estate sales  Foreigners temporarily in Vermont on cultural exchange (J-1) visas  Foreigners in Vermont on temporary foreign agricultural (H-2A) visa  $365 / year Fee per Uninsured FTE (2007) Assessed quarterly - $91.25 / FTE / Qtr FTE = number of employee hours worked during a calendar quarter divided by 520 (based on 40 hour work week maximum) Exempts 8 FTEs in 2007 & 2008; 6 FTEs in 2009; 4 FTEs thereafter  Annual Fee indexed to Catamount Health premium increases *

59 59 Key Dates  EMPLOYER CONTRIBUTION September, 2006Draft Rules Distributed for Public Comment December 13, 2006Final Rules Approved January 15, 2007 Report on Inclusion of Seasonal Employees April 1, 2007Assessment Implemented (to be paid at end of 4th Quarter – June 30, 2007)

60 60 Reform Oversight  Joint Legislative Commission on Health Care Reform Monthly meetings  Reports on Reform Progress Five-year plan for Health Care Reform Implementation, including recommendations for administration or legislation (December 1, 2006) Annual Administration Reports on Reform Progress (January 15) Multiple Reports on Enrollment, Costs  Universal Coverage/Individual Mandate If Vermont has less than 96% of the population insured in 2010, the Health Care Reform Commission must submit a plan to increase health care coverage to ensure universal access, including individual mandates

61 61 Opportunities for Transferability  Make health care affordable and accessible to uninsured  Manage and coordinate chronic care for all  Health Information Technology infrastructure  Administration Simplification  Build on Employer-Sponsored Insurance (ESI)  Outreach to Medicaid eligible uninsured  Reduce cost shift by: Insuring the currently uninsured and reimbursing at 110% of cost Providing better chronic care Increasing Medicaid reimbursement  Finding common ground: building broad based coalitions

62 62 Vermont Health Care Reform Web-site

63 63 For more information about enrollment Member Services:


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