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EDPMA Solutions Summit XVI April 28, 2013 Laura Tobler, National Conference of State Legislatures,

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Presentation on theme: "EDPMA Solutions Summit XVI April 28, 2013 Laura Tobler, National Conference of State Legislatures,"— Presentation transcript:

1 EDPMA Solutions Summit XVI April 28, 2013 Laura Tobler, National Conference of State Legislatures,,

2 Presentation Highlights Health Insurance Exchanges Essential Health Benefits Medicaid expansion Interoperability with exchanges Churning Medicaid Cost Containment State progress on HIT State budgets

3 Exchanges: Where States Stand Source: 2013 NCSL Research and NCSL Health Reform: State Legislative Tracking Database.

4 Legislatures Continue Addressing Exchanges in 2013 200 Bills in 45 States in 2013 215 Bills in 45 States in 2011 224 Bills in 42 States in 2012 Source: 2013 NCSL Research and NCSL Health Reform: State Legislative Tracking Database: 2013 NCSL Research Health Reform: State Legislative Tracking Database

5 17 States Introduce Legislation to Establish a State Exchange in 2013 Enacted Idaho* Minnesota* New Mexico* Pending Arkansas Arizona Iowa Illinois Maine Ohio Oklahoma Pennsylvania Rhode Island Texas Wisconsin Failed Georgia Kentucky Virginia *Authorized state-based exchange, blueprint and intent to establish state exchange was submitted to HHS in 2012 by governor, state health dept. or insurance commissioner.

6 Navigators 16 states Prohibiting 10 states Details 8 states Funding 10 states Partnership 4 states Exchange/ Medicaid 3 states Study 4 states 2013 State Legislation Related to Exchanges



9 Medicaid Matters The Expansion Innovations Cost Containment Medicaid is a top Issue in 2013

10 10 Optional Medicaid Expansion The ACA expands Medicaid to adults aged 19‒64 with incomes at or below 138% FPL States will receive 100% FMAP rates for the newly eligible population from 2014 through 2016 FMAP rates decline gradually, reaching 90 percent in 2020. Supreme Court did not change the Medicaid provision, but effectively allows states to opt out.

11 Median Medicaid/CHIP Eligibility Thresholds, January 2012 SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012. Minimum Medicaid Eligibility under Health Reform - 133% FPL ($25,390 for a family of 3 in 2012)

12 Medicaid Expansion, Bills So Far Bills To Expand AR, CA, CO, IL, MN, MS, MO, MT, ND, OK, PA, SC, SD, TN, TX, UT, VA, WA and WY Bills to Urge Gov. To Expand AL, AK, GA, HI, MI, NJ, PA and SC Bills To Reject Expansion IL, MS, NC, NH, SC, SD, TN and WY Bills To Require Legislative Approval For Expansion KY Other Types of Expansion Related Bills AR, CO, GA, HI, IA, TX, IN, IA, IL, MT, MO, MD, ME, MI, OR, TX and UT.

13 Medicaid Expansion Activity

14 CMS answers 14 Is there a deadline for expanding Medicaid?Can states “partially” expand Medicaid?Once expanded, can states rollback?Will there be flexibility in cost sharing and benefit packages.Options on adopting MAGI NO YES

15 Premium Assistance Exists for current Medicaid beneficiaries (employer-based) Must be cost effective and provide wrap- around services HHS will consider approving a limited number of premium assistance demonstrations.

16 More CMS Answers: Will require 1115 demonstration waiver Must provide choice: at least 2 QHPs Wrap around benefits Only for the new Medicaid adult group Encourage states to target adults 110 to 133 % FPL Will consider new factors for cost effectiveness Premium Assistance

17 Remaining Questions How many “wood work” people will enroll? What will happen to disproportionate share hospital (DSH) payments? What are the medical needs and costs for the newly enrolled? What about provider capacity? Other costs to the state?

18 Health Insurance Exchange (State, Federal, Partner) MedicaidCHIP Seamless Eligibility Determination Interoperability: Exchanges and Medicaid

19 Examples of 2011/12 Enacted Laws 2012: New Mexico adopted HM 18, requesting the New Mexico Office of Health Care Reform and the Human Services Department to implement an integrated enrollment system for Medicaid, any health insurance exchange and basic health program coverage. 2011: North Dakota enacted HB 1475. The act provides funds to the Information Technology Department for additional positions in regard to updating the eligibility system. Study Commissions/ Ex. Branch Actions In 2011 South Carolina Governor Nikki Haley signed Executive Order 2011-09 establishing the South Carolina Health Exchange Planning Committee. The committee divided into subcommittees and provided recommendations, the Information Technology Subcommittee Report was completed in November 2011. In May 2011 the New York State Health Foundation funded a report titled, “Preparing New York’s Information Technology Infrastructure for Health Reform: A Gap Analysis” to assist with informing future decisions regarding creating a “no wrong door” process. States Address Interoperability

20 Income Eligibility MedicaidCHIP Exchange (subsidies) Family income or job status changes will change coverage plans. Medicaid and Exchange Churning

21 Possible state policies to address churn Integrating Exchange and Medicaid plans Basic Health Program (delayed until 2015) 12-month continuous eligibility Employer Sponsored Insurance premium assistance Exchange plan portability Source: The Urban Institute, Churning Under the ACA and State Policy Options for Mitigation,” June 2012.

22 Medicaid Cost Containment  Address overall health care costs: prevention and payment reforms  Move toward managed care  Reduce fraud and abuse  Reforms that focus on high-cost patients  Innovations to improve the value of Medicaid " Do the right thing at the right time, at the right place and to the right body part" "Controlling costs is all about incentives — for employers, for consumers, for health-care providers, and for insurers.” Yevgeniy Feyman, National Review

23 42 M 74.2 %


25 Medicaid Managed Long Term Services and Supports (MLTSS) MLTSS has grown significantly.600,000 enrolled in 2012, up from 68,000 in 2004.15 states up from 7 in 2004. Of the 15 states, 11 are statewide or in multiple counties.

26 26 Notes: 1. Does not include PACE programs. 2. Three States (Minnesota, New York, and Wisconsin) operate two MLTSS programs each. States with MLTSS Programs, 2004 and 2012 Source: Presentation by Susan Reinhard, AARP, NCSL’s Fall Forum, 12/5/12

27 27 States Planning to Implement New MLTSS Programs by January 2014 Note: We included States that have public plans for new MLTSS programs that include: a public planning document, request for information, request for proposals; proposal to CMS or waiver application to CMS. Submitting a letter of intent to CMS for the Medicare-Medicaid Financial Alignment Demonstration was not by itself sufficient to be included here. Source: Presentation by Susan Reinhard, AARP, NCSL’s Fall Forum, 12/5/12

28 Fraud Fighters Medicaid Program Integrity Unit Identify and prevent fraud Conduct audits Refer suspected fraud to MFCU CMS Center for Program Integrity Medicaid Fraud Control Unit Investigate, prosecute provider fraud & patient abuse

29 State Strategies to Improve Program Integrity Comply with PPACA California SB 1529 (2012) Maine SB 539 (2012) Establish an Independen t Office AZ, FL, IL, KS, MI, NJ, NY, TX, UT Michigan SB 18 (introduced 2013) Explore Potential of Technology Illinois SB 2840 (2012) Washington HB 2571 (2012) Improve Collaboration Oklahoma SB 1386 (2012) Increase Reporting Requirement Colorado SB 12-060 (2012)

30 Some States Are Focusing on High Cost Patients -Dually Eligible People -Medical Homes and Care Coordination for People with Certain Diseases -Hot-spotting -Moving long-term care patients into managed care and home and community-based services

31 31  Approximately nine million "duals" (eligible for Medicare and Medicaid).  Among the poorest and sickest Medicare and Medicaid enrollees.  Account for disproportionate spending—16 percent of Medicare beneficiaries but 27 percent of spending; 15 percent of Medicaid enrollees but 38 percent of spending.  23 states are moving forward with proposals to participate in the CMS Medicare-Medicaid Coordination Office’s Financial Alignment Initiative for dually eligible people. When a state meets the standards and conditions for the Financial Alignment Demonstration, CMS and the state develop a memorandum of understanding; four states have MOU: Illinois, Massachusetts, Ohio and Washington. Focus on Dually Eligible People


33 State Innovation Models Awards State Innovation Model Testing Awards: AR, MA, ME, MN, OR, VT

34 In January 2013, about HALF of state legislators were freshmen or sophomores! 34

35 State Budget Overview Better state fiscal conditions – Few budget gaps – Revenues continue to improve – Year-end balances are rising Performance uneven & state budgets remain vulnerable. – Federal deficit reduction actions. – Spending pressures. – Sluggish economy recovery. – Deep holes.

36 Cumulative State Budget Gaps: FY 2002-FY 2014 Source: NCSL survey of state legislative fiscal offices, various years.

37 NCSL Resources Health Reform home page: State legislation database: Health Reform State Action newsletter: Health Reform two-page briefs: Cost Containment Briefs:

38 2013 Questions?

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