Presentation on theme: "Virginia: Legislative Update"— Presentation transcript:
1 Virginia: Legislative Update Brent Rawlings and Keith HareVHHA and VHCAMarch 11, 2015
2 Outline for Today’s Discussion IntroductionsOverview of VHHA and VHCAWho we areFocus of state legislative activitiesOverview of Political EnvironmentReview of 2015 General AssemblyKey legislation tracked by VHHA and VHCAVHHA and VHCA state budget prioritiesStudies (Medicaid, COPN, and Provider Tax)State Health Reform InitiativesWhy reform is neededMedicaid reform objectivesMedicaid ExpansionQ&ALast year the General Assembly came up short in agreeing to a plan to close the coverage gap in VirginiaVirginia can still develop and implement a program to draw down 100% federal funding through FY 2016Should be done in a fiscally responsible manner that promotes value, improves access to preventive services, elevates quality, and further reduces costsVHHA supports the Governor’s budget language and his continuing efforts to extend coverage to more than 200,000 low-income working VirginiansWe stand ready to work with all sides to find an innovative, bipartisan and fiscally prudent path forwardA Virginia solution will provide dividends to the Commonwealth, its economy and its health care system
4 VHHA at a Glance“The Virginia Hospital & Healthcare Association is an alliance of 110 hospitals and 36 health delivery systems that develops and advocates for sound health care policy in the Commonwealth. Its vision is to achieve excellence in both health care and health.”Trade association of hospitals and health systemsAdvocacyPolicyPatient safety and quality improvementHealth care data and informationTop tier performance and health care value/population healthEmergency preparedness
5 VHHA at a GlanceVirginia’s hospitals and health systems contributed $34.8 billion to the economy and directly and indirectly supported 913,636 jobs in The health care industry as a whole directly employs 444,298 professionals, while hospitals alone employ 123,508 Virginians. Hospitals and health systems are among the top five employers in 60% of cities and counties in Virginia, among top three employers in 45% of cities and counties. For every $1 dollar spent by a Virginia hospital, $1.61 is spent in other parts of the economy. Virginia hospitals accounted for $200 million in state and local taxes in The total value of community support provided by Virginia’s hospitals and health systems exceeded $2.6 billion in Virginia hospitals provided over $600 million in charity care in Virginia hospitals are implementing evidence-based best practices to improve quality of care by reducing central line-associated blood stream infections, preventable readmissions and early elective deliveries, saving millions of dollars in the process.
6 VHHA Focus of State Legislative Activities “Closing the Coverage Gap”Medicaid ExpansionEnrollment in ExchangesBudget and fiscal priorities dominateMedicaid payments to hospitals have not kept pace with inflationSignificant Medicare payment cuts under ACA and SequestrationFocus on rural healthMore than half of rural hospitals had negative operating margins in 2012Rural hospitals one of top 5 employers in 82% of rural Virginia communitiesHealthcare workforceSupporting existing and incentivizing more health professional graduate trainingProvider Assessments?Certificate of Public Need (COPN) Reform?Last year the General Assembly came up short in agreeing to a plan to close the coverage gap in VirginiaVirginia can still develop and implement a program to draw down 100% federal funding through FY 2016Should be done in a fiscally responsible manner that promotes value, improves access to preventive services, elevates quality, and further reduces costsVHHA supports the Governor’s budget language and his continuing efforts to extend coverage to more than 200,000 low-income working VirginiansWe stand ready to work with all sides to find an innovative, bipartisan and fiscally prudent path forwardA Virginia solution will provide dividends to the Commonwealth, its economy and its health care system
7 VHCA - Virginia’s Nursing Facilities Virginia’s 286 nursing facilities employ over 36,000 people and care for over 28,000 residents every day.Nursing facilities often are among the largest employers in many Virginia towns and communities and have an annual statewide payroll of approximately $1.5 billionOverall, all long term care facilities, of which nursing facilities represent a vital component, along with their suppliers represent about 2% of Virginia’s economyLong term care providers provide additional economic support through their significant role as taxpayers at the local, state and federal levels
8 VHCA - ChallengesBy 2030 Virginia will have 1.8 million citizens age 65 or olderCitizens age 65 and older will make up 19 percent of the total populationAverage life expectancy is almost 80 years old compared to 70 years in the 1960sLife expectancy will continue to rise with advances in medical technology and healthier lifestylesThe public and private sector will need to work together to meet the growing demands of an aging population
9 VHCA - ChallengesVHCA members are caring for residents with more complex medical needs than in the pastResidents in Virginia’s nursing facilities have some of the most complex medical needs in the United States due to strict eligibility criteriaThe average age of a nursing home resident in Virginia almost 80 years oldReimbursement rates from Medicare and Medicaid are not keeping pace with the cost of providing care
11 Political Environment With 2015 being an election year for all 140 members of the General Assembly, the political environment remains challenging on many frontsHigh turnover in last five years in General AssemblyKey retirements of knowledgeable health care leaders since 2010The Commonwealth’s budgetary challenges continue to play a large role in what the Governor and General Assembly do and do not doRepublicans likely to maintain strong majority in House, but majority control of Senate uncertain heading into elections
12 Virginia’s Political Environment General Assembly is losing over 150 years of experience with the retirements of Senators Colgan, Stosch, Watkins and PullerSince 2010, there have been 57 new members elected to the House of Delegates and 14 new members elected to the SenateIf you go back to 2008 they are 63 new members of the House and 21 new members of the Senate.That is a combined turnover rates of 58% in 8 years.*Source: Virginia Free
13 Review of 2015 General Assembly: VHHA Key Legislation
14 VHHA Key Legislation No movement on Medicaid Expansion Recognition that substantive movement on this issue in 2015 was unlikelyVirginia can still develop and implement a program to draw down 100% federal funding through FY 2016Should be done in fiscally responsible manner that promotes value, improves access to preventive services, elevates quality, and further reduces costsGovernor’s introduced budget authorized Medicaid Expansion, but eliminated from House and Senate budgetHB 2212 (Hope) Healthy Transitions Program (tabled)HB 1830 (Plum) State Plan Eligibility (tabled)
15 VHHA Key Legislation COPN HB 2030 (Byron) - remove certain projects to obtain medical equipment with a minimum value below $1 million from COPN requirements (tabled)HB 2177 (Orrock) - remove capital expenditures, bed additions, additional operating rooms, NICUs and open heart surgery from the requirement to obtain a COPN and eliminate regional health planning agency for Northern VirginiaSubsequently amended to only remove capital expendituresSB 1283 (Martin) – Senate companion bill to HB 2177Subsequently amended to conform to HB 2177 as amendedSB 1415 (Dance) - remove capital expenditures from the requirement to obtain a COPN (incorporated into SB 1283)
16 VHHA Key Legislation COPN (cont.) VHHA supports a comprehensive, system-wide approach to any efforts to reform the COPN law that takes into account the effects of any changes on charity care, patient safety and quality of care, access to essential health care services, and other critical aspects of our health care delivery systemProcedural reforms and improvements are necessary and appropriate, but piecemeal deregulation of COPN that fails to address the principles above may not yield a better system for VirginiansHB 2177 (Orrock) and SB 1283 (Martin) (as amended) presented a compromise that allows Virginia hospitals and health systems to work with the General Assembly and the Secretary to undertake a comprehensive review of the COPN process and avoid piecemeal deregulation
17 VHHA Key Legislation Behavioral Health SB 1265 (Deeds) and HB 2118 (Cline) clarify definition of “real time” for psych bed registry (when there is a change or if no change, at least daily)SB 773 and SB 779 (McWaters) and HB 1717 (LeMunyon) modify law governing inpatient psychiatric admission of objecting minors between the ages of 14 and 18SB 1114 (Barker) – Provides that a TDO for medical testing, observation and treatment may be issued for a person who is also the subject of an ECO as a way to reconcile the 8-hour limit on an ECO with a hospital’s EMTALA obligationsSB 1410 (Deeds) – establishes new requirement for the CSB employees who conduct evaluations of persons held under ECOs
18 VHHA Key Legislation Workers Compensation Drug Prior Authorization HB 1820 (Farrell) initially directed the Workers’ Compensation Commission to develop a prevailing community rate fee schedule based upon representative charges for services on an annual basis, subject to a cap on growth tied to CPIFinal bill simply authorizes the Commission to establish “communities” for purposes of determining a prevailing community rate and directs the Commission to study possible data sources for determining charges to be used in developing prevailing community rate fee schedule and to report back to the House and Senate Commerce and Labor Committees by December 15, 2015.Drug Prior AuthorizationHB 1942 (Habeeb)/SB 1262 (Newman)Requires provider contracts with insurers to include specific provisions for practices pertaining to prior authorization of drugs
19 VHHA Key Legislation“CARE (Caregiver Advise, Record, Enable) Act” BillsHB 1413 (Filler-Corn)/SB 851 (Favola)Requires hospitals to follow specified procedures to identify and educate “caregivers” who will be providing post-discharge care for patientsPart of AARP national initiativeObservation Status BillsHB 1509 (Sullivan)/HB 1561 (Rust)/SB 750 (Black/Barker)/ SB 857 (Ebbin)Requires hospitals to give observation patients notice of their status and the potential for higher patient costs, hospital, post-discharge skilled nursing and pharmaceutical services
20 VHHA Key Legislation “Right to Try” Laws Stillbirth Policies Permits prescribing of experimental drugs for terminally ill patientsHB 1750 (Ransone)/SB 732 (Stanley)Part of national initiative (Goldwater Institute)Stillbirth PoliciesSB 1197 (Norment) requires hospitals with obstetrical services to have a policy for managing stillbirths and incorporates into existing reporting requirements for congenital birth anomalies the reporting of stillbirthsTelemedicineHB 2063 (Kilgore)/SB 1227 (McWaters) amends definition of “telemedicine” and authorizes prescription of Schedule VI drugs via telemedicineSB 718 (Stanley) establishes a 3-year telemedicine pilot program to reduce ED visits for low-acuity services (left in Appropriations)
21 Review of 2015 General Assembly: VHCA Key Legislation
22 VHCA Legislation of Interest - PASSED Criminal History Check for Nurse Licensure - SB1018 (Dance)Establishes state and federal criminal history background check requirements for applicants for licensure as a practical nurse or registered nurse beginning January 1, 2016Hospice - HB1738 (Hodges)The bill requires every hospice licensed by the Department of Health or exempt from licensure to notify every pharmacy that dispensed drugs to a hospice patient for the purpose of pain management of the patient's death within 48 hoursMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
23 VHCA Legislation of Interest - FAILED Staffing Standards - HB1396 (Leftwich)Was tabled by the House Committee on Health, Welfare & Institutions. The bill had a large fiscal impact to the Medicaid program in future yearsWould have required the Boards of Health and Social Services to set staffing standards for nursing facilities and assisted living facilitiesCNA Training Hours Increase - HB1583 (Watts)Would have increased the minimum duration of education programs to prepare nurse aides for certification from 120 to 200 hours was also tabled in the House Committee on Health, Welfare & Institutions.Concern was expressed that the cost of training would increase and be burdensome on potential CNAs who paid for their own training and for facilities that provided the training free for potential CNAsMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
24 VHCA Legislation of Interest - FAILED Punitive Damages Cap - HB2360 (Toscano)Would have changed the punitive damages cap, including for medical malpractice, from $350,000 to $750,000Paid Sick Leave - HB2008 (Kory) and HB2387 (Sickles)Would have required private employers to give to each full-time employee paid sick days, to be accrued at a prescribed scheduleMinimum Wage BillsSeveral minimum wage bills were introduced, but all were tabledMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
25 Review of 2015 General Assembly: VHHA Budget Issues
26 VHHA Budget Priorities Support Governor’s introduced budget authorizing Medicaid expansionRecognizing that hospitals have not received inflation updates to Medicaid payment in recent years, focused on additional funding in critical areas of needRural Health AmendmentItem 301 #8s (Carrico) directed DMAS to pay costs for Medicaid services provided by Virginia's 37 rural hospitalsCost approx. $10 million GF ($20 total)Health Care Workforce/GME AmendmentItem 301 #12s (Howell) and #22s (Watkins) directed DMAS to rebase Medicaid GME payments (which haven’t been updated in 15 years) to strengthen current programs and support further growth in residencies with incentive fund program in FY17Cost $6.5 million GF (yielding $13 million in support) in FY16Provider Assessment AmendmentItem 278#1s (Watkins) directed the Secretary of HHR to develop a process to study and design a mutually beneficial program that meets certain criteriaReport and implementation plan to the Governor and General Assembly for FY16 if such criteria are met
27 VHHA Analysis of Budget Results Medicaid Expansion / Closing the Coverage GapEliminates Governors’ language authorizing Medicaid expansionHealthy Virginia PlanRetains coverage for medical services included in Governor’s Access Plan (GAP).Reduces income eligibility criteria for severely mentally ill from 100 percent of the federal poverty level (FPL) to 60 percent FPL, but includes “grandfather” provisions for individuals covered under original 100 percent FPL criteria.Estimates number of individuals to be covered at 21,600.Healthcare Workforce and Rural Health ItemsNeither body included VHHA’s proposed amendments for additional funds to address rural health or GME payment improvementsSenate recommends study of the GME issues, but not included in final bill
28 VHHA Analysis of Budget Results Provider AssessmentDirects Secretary of HHR to develop a plan with options for a hospital provider assessment program and report back to the General Assembly by November 1, 2015Eliminates provision that sought to redirect “at least 20 percent” of potential assessment away from supporting supplemental provider paymentsAdds language incorporating the VHHA suggested design proposal with additional provisions directing that the plan consider the other related proposals that were offered COPNAdds evaluation of COPN process by a work group convened by the Secretary of HHR, using language equivalent to that included in HB2177/SB1283Safety Net ServicesAdds $3.1 million to support for free clinics in fiscal year (FY) 2016 (moving General Fund support from $1.7 million to $4.8 million)Adds $1 million to support community health centers in FY16 (from $1.8 million to $2.8 million)Other ItemsAdds $2.2 million General Fund to avoid a cut to non-emergency professional emergency department claims
29 Review of 2015 General Assembly: VHCA Budget Issues
30 What Happened in Last Year’s Budget Nursing facilities were poised to receive an additional $123 million (total funds) over the course of the bienniumAnd THEN, the floor dropped of the Commonwealth’s BudgetThe discussion became one of holding onto as much of the “gains” for nursing facilities as possible through a full court press with legislators and other policy-makers.It meant re-emphasizing the importance of the rebasing and inflationary adjustments in order to support the change in payment methodology and our challenges for facilities as they transitioned to managed care under CCCIt also meant reminding them of the previous savings ($150 million, since 2009) extracted from nursing facility paymentsMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
31 What Happened in Last Year’s Budget (continued) VHCA protected full rebasing and inflationary adjustments for SFY 2015However, the Budget as passed last year removed the inflation adjustment for SFY 2016, meaning Medicaid nursing facility rates would essentially be level funded from to 2016The Budget also accelerated the scheduled reduction in capital reimbursement (Fair Rental Value) under the new payment methodologyThis represented a reduction in Medicaid funding of approximately $14 million for 2015 and 2016 combinedMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
32 What Happened in Last Year’s Budget (continued) The Bottom LineLast Session, we held onto $81.4 million (total funds) in new money to Medicaid nursing facility providers despite a very significant revenue shortfall in the CommonwealthThis represented two-thirds of the previously anticipated increase and importantly, 85 percent of the anticipated 2015 increase to nursing facilities which was viewed as vital in implementing both Commonwealth Coordinated Care (CCC) and Price-Based ratesMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
33 This Year’s BudgetThe General Assembly closed the revenue gap that had arisen last Spring, however the gap had widened by the FallThus, we entered this year’s Budget cycle with two main goals:Hold onto the gains made last year as they carry through to 2016 in terms of base fundingSeek restoration of inflation for 2016 in the event revenue became availableMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
34 This Year’s Budget (continued) Several factors were working against our two goals:Sequestration was significant due to Virginia’s reliance on the defense industry (and our general reliance of federal government spending)The Governor and General Assembly tapped Virginia’s “Rainy Day Fund” in order to balance the budget.Items, such as State employee and teacher raises had been eliminated to achieve savings last year; these were priorities for funding should revenue become available.NFs had been largely spared in 2015, so becoming a priority in front of programs that had been cut was an uphill battleMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
35 This Year’s Budget (continued) On Thursday, February 26th, the General Assembly passed their budget amendmentsVHCA was successful in avoiding additional reductions to reimbursement for Medicaid services by nursing facilitiesHowever, the revenue situation had not improved to the point of restoration of 2016 inflation.Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
37 Studies: Medicaid Reform SJR268/HR637 directs the Joint Legislative Audit and Review Commission (JLARC) to conduct a study of MedicaidLook at eligibility screening processes and fraud and abuseLook at appropriateness and cost-effectiveness of servicesLook at evidence-based practices and strategies used successfully in other statesReport is due November 30, 2016House bill initially called for a comprehensive financial audit of DMAS while the Senate version was limited to a study of long term careConference bill narrowed the House version to include a more limited review of the program focusing on areas not previously auditedRelevant to ongoing debate over Medicaid Expansion
38 Studies: Provider Assessment The Secretary of Health and Human Resources shall conduct an analysis and develop a plan with options for a hospital provider assessment program, including a review of other issues deemed necessary, for consideration by the General Assembly in the 2016 Session, that: (i) complies with applicable federal law and regulations; (ii) is designed to operate in a fashion that is mutually beneficial to the Commonwealth and affected health care organizations; (iii) addresses health system challenges in meeting the needs of the uninsured and preserving access to essential health care services (e.g. trauma programs, obstetrical care) throughout the Commonwealth; (iv) supports the indigent care and graduate medical education costs at hospitals in the Commonwealth; (iv) advances reforms that are consistent with the goals of improved health care access, lower overall costs and better health for Virginians; and (v) takes into account the extent to which it provides equity in the assessment and funding distribution to affected health care organizations. In the development of this program, the Secretary’s office shall be assisted by the Department of Medical Assistance Services, the Virginia Center for Healthcare Innovation, the Virginia Hospital and Healthcare Association and other affected stakeholders.
39 Studies: Provider Assessment Provider assessment is a mechanism by which the state can raise revenues needed to fund the state Medicaid program and obtain a federal matchA growing interest in provider assessments among the Governor, the General Assembly, and our members has made this a policy priority for VHHAVirginia is one of 8 states without a hospital assessment or tax program (TX and Louisiana are listed as not having hospitals taxes, but they have local authority or inter-governmental transfer programs which are functionally equivalent)
41 Studies: Provider Assessment CMS requires that such assessments be broad-based, uniformly applied and, after any resulting payment increases back to affected providers, that there be winners and losers (42 CFR )Experience in other states shows that assessment programs, if implemented, should have clear parameters that specify who is taxed, how it is assessed, and how the proceeds will be usedThe current federal limitation on provider taxes is 6 percent of net patient revenue of taxed entities.
42 Studies: Provider Assessment Complex issue, with both political and technical judgments to makePROs CONsFederal parameters and tests must be satisfiedProtections against diversion for other funding priorities is keyCreates state share to leverage additional Medicaid reimbursementEnhances relationship with Medicaid agencyEnhances base rates under expansionCan help address inequities within current reimbursement structureMitigation may occur naturally within systems or facilitated by the associationAssessment programs must be redistributive and therefore not all hospitals will gain, or gain equallyAssessment programs don’t usually go away and therefore providers become permanent source of financingNot unusual to have administrative fee paid to the stateLimited direct payments under managed care
43 Studies: COPNSB1283/HB2177 and budget direct the Secretary of HHR to convene a workgroup of stakeholders to review the current COPN processWork group to develop specific recommendations for changes to the COPN process to address any problems or challenges identified, which shall include recommendations for changes to the process to be introduced during the 2016 Session of the General AssemblyThe Secretary shall report on the recommendations developed by the work group by December 1, 2015
44 Studies: COPNIn 2000, the General Assembly directed the Joint Commission on Health Care (JCHC) to develop a plan for phasing out the COPN program (SB 337 – 2000)After comprehensive study, a VHHA-supported plan for responsible deregulation was developed and submitted to the 2001 General Assembly (HB 2155/SB1084 – 2001).Each phase associated with improvements in access to care for low-income uninsured, Medicaid payment improvements, and funding for graduate medical educationWhile broadly endorsed, the state’s fiscal difficulties precluded the plan’s adoption
45 Studies: COPNEfforts to change COPN law are cyclical in nature occurring every five years or soLast significant changes made in 2009 (HB1598 – Hamilton)Streamlining and reducing the criteria for determining need from twenty down to eight criteriaTransitioning the review process for psychiatric beds to a Request for Application processExpediting the review process for certain capital projectsOther changes to COPN process
46 Studies: COPN 36 states and the District of Columbia have a CON law Virginia ranks 24th out of 36 states and the District of Columbia based upon the number of different types of facilities and services regulated by certificate of needTied with Alaska at 19 different typesThe highest number of types is 30 and the lowest is 1, with an average of 1516 states have eliminated or drastically curtailed their CON lawsEleven (11) of those states repealed their CON laws after 1983 and before 1990Only states to repeal after 1990 and North Dakota and PennsylvaniaPennsylvania experience suggests that deregulation could, at least initially, result in a decrease in general hospitals and an increase in ASCs and imaging centers
47 Studies: COPNCOPN law allows Commissioner to attach charity care condition to COPN approvalAbout 2/3 of COPNs have charity care conditions with an average of 3.3% of gross revenuesIn FY 2011 $856,950,546 was reported as provided in meeting the obligations of COPN conditions plus $15,528,163 of in-kind and cash donations to safety net providersHealth care is not a “free market”Hospitals required to treat patients who need immediate medical attention regardless of ability to payLargest payors – Medicare and Medicaid set payment amounts below cost for health care servicesNo incentive to provide certain specialized, low-profit or money-losing, but essential health care services
48 State Health Reform Initiatives: Why reform is needed
49 Health Care Reforms - Why they matter Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
50 Health Care Reforms - Why they matter Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
51 Health Care Reforms - Why they matter Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
52 Health Care Reforms - Why they matter Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
53 Health Care Reforms – Why they matter Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
54 Health Care Reforms – Why they matter Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
55 State Health Reform Initiatives: Medicaid Reform
56 Health Care Reforms – DMAS Specific Dual Eligible Demonstration Pilot – Commonwealth Coordinated Care ProgramReduce Medicaid Fraud and Increase Administrative Efficiencies ( Recovery Audit Contract, Fraud, Waste and Abuse Contract, MFCU Program and PERM Rate Review)Inclusion of children enrolled in foster care in managed care
57 Health Care Reforms – DMAS Specific eHHR efforts to overhaul Virginia’s Medicaid and Social Service enrollment systemsImprove Veterans Access to ServicesBehavioral Health tightening of standards, service limits, provider qualifications and licensure requirementsGovernor’s Access Plan (GAP)
58 Commonwealth Coordinated Care One system to coordinate care for Medicare and Medicaid enrolleesHigh-quality, person-centered care for the Dual Eligible that is focused on their needs and preferencesAll the same benefits currently available under Medicaid and MedicareSingle program with built-in Care Coordination for primary, preventive, acute, behavioral, and long- term services and supportsPromotes improved transitions between acute and long-term facilities
59 Commonwealth Coordinated Care - Eligibility Medicare-Medicaid Enrollees (entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, with full Medicaid benefits)Participants in the Elderly or Disabled with Consumer Direction WaiverResidents of nursing facilitiesLive in designated regions (Northern VA, Tidewater, Richmond/Central, Western/Charlottesville, and Roanoke)
60 Commonwealth Coordinated Care - Duals Receive both full benefit Medicare and Medicaid coverage58.8% age 65 or older41.2% under age 65Often have multiple, complex health care needsMedicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
61 Commonwealth Coordinated Care - Participation Blue Circles / Diagonals : Opt-in Only Red Circle/Gray: No ParticipationEverywhere Else: Auto-Enrollment
62 Commonwealth Coordinated Care - Enrollment Enrollment has been less than expectedFor nursing facilities, 40.9% of the eligible population has been enrolled (not including Northern Virginia); 42.6 percent have opted-outPrimary Care Physician “mis-assignment” has lead to Opt-OutsService denials / authorization delays lead to Opt-OutsEnrollee identification has been difficultCCC has increased the administrative complexity, adding significant administrative burden on nursing facility staff at the expense of other administrative functions
63 Commonwealth Coordinated Care - Nursing Facility Enrollment RegionOriginal EstimateRevised EstimateActual EnrollmentDifference (Revised to Actual)% UptakeCentral/Richmond4,4302,9991,263(1,736)42.1%Northern1,9351,355172(1,183)12.7%Tidewater3,0312,3481,045(1,303)44.5%Western/C’ville1,4771,026438(588)42.7%Roanoke2,8331,998680(1,318)34.0%TOTAL13,7069,7263,769(5,702)37.0%
64 Commonwealth Coordinated Care - Enrollment Trends
65 Governor's Access Plan (GAP) In early January, the Governor launched the Governor’s Access Plan (GAP)The three key goals of the GAP plan were are to:Improve access to care for uninsured Virginians with significant behavioral health needsImprove physical and behavioral health outcomesServe as a bridge to closing the insurance coverage gap for uninsured Virginians with serious mental illness
66 Governor's Access Plan (GAP) EligibilityScreened and meet the criteria for GAP SMIUninsured and age 21 through 64 years oldResident of VirginiaHousehold income that is 60 percent of the (FPL)Not otherwise eligible for any state or federal full benefits program including: Medicaid, FAMIS, Medicare, or TriCareNot residing in a long term care facility, mental health facility, long-stay hospital or penal institution
67 State Health Reform Initiatives: Medicaid Expansion
68 Short History of the Affordable Care Act “Obamacare”Reduce the UninsuredReform Insurance PracticesReduce CostsExpand Access to Affordable Health Care CoverageExpand Medicaid eligibility to 133% of FPLImplement ExchangesPay or PlayEmployer MandateIndividual MandateSupreme Court makes Medicaid expansion optional
69 Coverage Options before the Affordable Care Act MedicaidMedicare65+IndividualMarketUNINSUREDEmployer Sponsored Insurance65+19-64Children
70 Coverage Options under the Affordable Care Act MedicaidMedicaidExpansionMedicare65+Health Insurance MarketplaceEmployer Sponsored Insurance65+19-64Children
72 ACA "Coverage Gap" in States Not Expanding Medicaid
73 ACA "Coverage Gap" in States Not Expanding Medicaid Below poverty(≤ $11,940 individual / $23,550 for a family of four)Most are working or live in working families(60% in a family with one worker, 54% are working themselves)Source: Kaiser Family Foundation, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (October 2013)
75 ACA "Coverage Gap" in States Not Expanding Medicaid 29 states and DC have taken action to close the coverage gap through Medicaid expansion or alternative plans approved by CMS.PA, IN, and NH recently expanded under alternative plan. UT has also recently adopted plans to move forward. TN close to approving alternative plan, but ultimately failed to get votes needed.In total 30 states and DC are oriented in some way towards a solution to closing the coverage gap.
76 Profile of Virginia’s Uninsured Are nonelderly adults 19 to 64 years of age89%Are 19 to 34 years of age41%Live in families with income below 200% FPL71%Live in families with income below 100% FPL43%Live in working families with at least one full or part-time worker70%Live in working families with at least one full-time worker47%Source: Profile of Virginia’s Uninsured, 2011, The Urban Institute, prepared for the Virginia Health Care Foundation, October 2013.Of uninsured adults are U.S. Citizens78%Of Virginians in rural areas are uninsured compared to 15% statewide25%
77 Profile of Virginia’s Uninsured Source: The Virginia Atlas of Community Health
78 To Expand or Not to Expand? Proponents Argue:400,000 Virginians are without access to affordable health careFailure to act threatens the financial stability of hospitals in our communitiesThe status quo is crippling businesses in VirginiaOpponents Argue:Medicaid is the fastest growing segment of the budgetNeed to reform broken system firstFederal government cannot continue to fund growth in entitlement programs
79 2014 Action on Medicaid Expansion GovernorSenateHouseBudget included Medicaid Expansion under 2-year pilotBudget included Marketplace VirginiaAudit and ReformNo Coverage Gap ProvisionDecouple Medicaid Expansion from Budget
80 Budget ShowdownA deal in Senate to include a path forward for closing the coverage gap, but . . .Black or Bust: Senate conservatives rebelBlack/Stanley amendment: no funds for Medicaid expansion without legislative approval
81 Budget Showdown Governor vetoes Stanley amendment Override requires 2/3 vote of both chambersSpeaker rules veto of Stanley amendment out-of-order“Clean” budget passedGovernor vows to move ahead with efforts to close the coverage gap
82 McAuliffe Plan – A Healthy Virginia 10-step incremental approachGovernor’s Access Plan – limited benefit to 20,000 with serious mental illnessImprove care coordinationSpur enrollment to Medicaid, FAMIS, and MarketplaceDental benefits to pregnant momsNew websiteNot a comprehensive approach to closing the coverage gap, but makes meaningful strides in right direction
83 Special Session Debate over Medicaid Expansion “Fair and honest” debate over Medicaid ExpansionVirginia Health Care Independence Act (Rust)Alternative to traditional Medicaid ExpansionBlock grant-like approachFailed on 3rd ReadingOther Medicaid reform bills proposed,but not debated
84 Key Message: Find a Path Forward Virginia knows better than WashingtonPro-business, common sense solutionWe are already paying for this – return the dollarsA lot of smart people working together should be able to find a path forward for Virginia
85 Brent Rawlings – firstname.lastname@example.org Keith Hare email@example.com Q&ABrent Rawlings –Keith Hare