NEW MEXICO STATE COVERAGE INITIATIVE New Mexico Human Services Department June, 2004 Carolyn Ingram, Director Medical Assistance Division

2 Objectives for today’s discussion New Mexico SCI Program Background Design of the program Issues regarding SCI Discussion New Mexico Human Services Department

3  To address New Mexico’s high rate of uninsured and low rate of employer sponsored health care  To offer affordable health care coverage to low-income working adults through an employer-based system The Goal of New Mexico’s State Coverage Initiative is to help reduce the number of uninsured GOALS:

4 New Mexico Human Services Department  The program in New Mexico was granted by CMS through a federal HIFA (Health Insurance Flexibility and Accountability) waiver  Development has occurred by using two grants from the Robert Wood Johnson Foundation  Under the waiver, granted in August 2002, New Mexico intends to partially fund the program using funds from the State Children’s Health Insurance Program (SCHIP) at an 82 percent match rate The flexibility to create SCI was granted through a HIFA waiver

5 New Mexico Human Services Department  SCI will be open to individuals who have not been insured for at least six months and to employers who have not provided insurance to their employees in the last twelve months  There will be no pre-existing condition limitations  Early estimates expect 40,000 working individuals to be covered (these numbers may change based on benefit design and cost) ELIGIBILITY: SCI was designed to target employees without insurance

6 New Mexico Human Services Department The proposed SCI benefit package is similar to a basic commercial plan BENEFITS INCLUDE: Hospital—inpatient/outpatient Emergent and urgent care Primary care/Specialty care Women’s health services Preventive health services Inpatient physical rehabilitation and skilled nursing facility Home health services/home intravenous services Ambulance services Durable medical equipment Supplies, Orthotic Appliances & Prosthetic Devices Pharmacy OT/PT/ST Lab/diagnostics/X-ray Behavioral health/ substance abuse Reconstructive surgery Diabetes treatment * $100,000 annual limit

7 New Mexico Human Services Department  Some stakeholders expressed concerns about the benefit package and costs sharing of the program  Both aspects are being revisited in light of current budget issues and further stakeholder input  Design is being updated to reflect more accurate cost data representing the benefit package & cost sharing design  Benefit changes could affect costs  Significant changes to the program will have to be approved by the federal government Benefit package and service costs have been evaluated

The SCI benefit package is designed differently than Medicaid program Some limits on services offered Service limits based on medical necessity Inpatient & Outpatient Services Physician & Specialty Services Prescription Drugs OT, PT, ST DME & Supplies (prosthetics & orthotics) Lab & X-ray Emergent & Urgent Care Home Health Mental Health & Substance Abuse $100,000 Annual Maximum SCI Benefits No Annual Maximum Inpatient Services & Outpatient Services Physician & Specialty Services Prescription Drugs OT, PT, ST, DME & Supplies ( prosthetics & orthotics ) Lab & X-ray Emergent & Urgent Care Home Health Mental Health & Substance Abuse (limits for adults) Medicaid & SCHIP Benefits Increased Benefits Podiatry Dental Optometry & Eyeglasses Long Term Care - ICFMR/Nursing Home/Pre-PACE Personal Care & Home Nursing for Children EPSDT & Early Intervention & Nutrition Targeted Case Management Hospice Transportation & Lodging

9 Cost sharing provisions for SCI, SCHIP and Medicaid will be different Currently no cost sharing requirements HSD is developing cost sharing provisions Legislation required cost sharing for ER and pharmacy Regular Medicaid Kids 184% FPL Adults differ Regular Medicaid Kids 184% FPL Adults differ SCI Adults 200% FPL SCI Physician Services $5.00 Pharmacy - $2.00 Outpatient - $5.00 Inpatient - $25.00 ER - $15.00 Missed Appointment $5.00 *Native American’s exempt The Comparison of Cost Sharing Requirements Co-pays for services based on sliding scale with out-of- pocket maximum Employers pay about $75/person/month Employees pay based on family income from about $0-$35.00/month Costs may change with more analysis SCHIP* Kids 185% - 235% FPL SCHIP* New Mexico Human Services Department

10 New Mexico Human Services Department Avg. cost per member per month (pmpm) =$300* Less: Premium Sharing Employer$ 75 Employee$ 25 Net Cost$200 Federal 82%$164 State Share$ 36  Costs were originally estimated to be $15.3 million with $2.7 million in State funds * PM/PM provided only as an example not as actual cost Financing will be shared between public and private sources FINANCING EXAMPLE:

11 New Mexico is working with Counties on possible financing structures

12 New Mexico Human Services Department  Program is being redesigned to address implementation issues  Concepts are being reviewed/redesigned to incorporate a new integrated approach between divisions within HSD and information systems for the State  Financial resources to make information system enhancements are being reviewed The administration of the program is being redesigned Administration activities to be reviewed include: Enrollment & Tracking Information System Features Funding Administration activities to be reviewed include: Enrollment & Tracking Information System Features Funding

13 New Mexico Human Services Department Funding:  It was originally determined that unspent SCHIP funds would be used to fund this program with some type of State share or other source of matching funds  This concept has been reviewed in terms of steps taken at the congressional level and the federal dollars available as well as the appropriate funding sources for the required match  HSD is holding conversations with UNM and Association of Counties concerning potential matching funds The source of matching funds needs to be identified

14 New Mexico Human Services Department  Listening to stakeholders  Designing administrative infrastructure  Planning for implementation with in the larger Medicaid System Redesign and the State’s health care agenda  Reanalyzing costs and determining funding sources How HSD is proceeding?