1. Vermonts Global Commitment Waiver Prepared by Vermonts Legislative Joint Fiscal Office Used as background material at Families USAs Health Action Conference Sheila Reed, Vermont Childrens Forum January 26, 2006

2. V e r m o n t Legislative Joint Fiscal Office Introduction to Global Commitment Steve Kappel, JFO January 10, 2005

3. V e r m o n t Vermont Legislature Current Financial Situation

4. V e r m o n t Legislative Joint Fiscal Office Global Commitment - History December 2004 – Initial presentation by OVHA January 2005 – Governors Saving Medicaid February 2005 – Global Commitment concept paper. April 2005 – final proposal to federal government September 2005 – approval by federal government September 2005 – provisional approval by Joint Fiscal Committee, based on recommendation from Health Access Oversight Committee October 1 – Global Commitment implemented December 2005 – final JFC approval

5. V e r m o n t Legislative Joint Fiscal Office Key Concepts OVHA to become a public Managed Care Organization (MCO) –Must comply with federal regulations for MCOs AHS to pay OVHA a fixed premium –Based on historical spending –Certified by actuary (within a range) Premium to include ALL Medicaid spending except Long Term Care waiver, some administrative costs, DSH, SCHIP

6. V e r m o n t Legislative Joint Fiscal Office Key Concepts (cont.) OVHA will contract with other departments to provide or pay for some services. –Contracts will be based on existing programs and expertise Changes to benefits received by mandatory beneficiaries (including optional services) will require an amendment to the waiver.

7. V e r m o n t Legislative Joint Fiscal Office Key Concepts (cont.) There is new flexibility in determining benefits for optional and expansion (previous waiver) populations Changes in benefits that change spending by less than 5% can be made without federal approval. Possibility of changing methods for payment from fee-for-service. Waiver of federal laws could result in changes to the ways benefits are structured & provided.

8. V e r m o n t Legislative Joint Fiscal Office How the MCO is Funded

9. V e r m o n t Legislative Joint Fiscal Office How the Premium is Established Based on: –Historical Vermont spending –Vermont and national trends –Specified administrative allowance –Need for reserves

10. V e r m o n t Legislative Joint Fiscal Office Financial Overview

11. V e r m o n t Legislative Joint Fiscal Office Financial Opportunity According to the Terms and Conditions of the waiver, any premium revenue that remains after making payments for the existing Medicaid program can be used for a variety of health-related purposes. These funds have been referred to as savings

12. V e r m o n t Legislative Joint Fiscal Office Savings May Be Used to: Reduce the rate of uninsured and underinsured Increase access to quality health care for the uninsured, underinsured, and Medicaid beneficiaries Fund public health programs that improve outcome and quality of life for Medicaid beneficiaries Support public-private partnerships in health care.

13. V e r m o n t Legislative Joint Fiscal Office Global Commitment - Example Current system –Total Program$1,000 –Federal Share $600 –State Share(40%) $400 –Chronic Care (100%) $40 –Total State Spending $440

14. V e r m o n t Legislative Joint Fiscal Office Global Commitment – Example Under Global Commitment –Premium $1,040 (actuary / appropriation) Includes Chronic Care Initiative –Federal Share $624 –State Share $416 –State saves $24 (spent $440 before) –This is the source of the $135 to $165 million in savings.

15. V e r m o n t Legislative Joint Fiscal Office Other Policy Implications Additional funds can be used for supplementing programs such as Chronic Care Initiative, for reducing the Medicaid shortfall, or some combination of the two. However, the amount available to do this is limited. At best, Global Commitment is a partial solution to the Medicaid shortfall. MCO regulations v. Vermont rules – substantive changes currently undetermined.

16. V e r m o n t Legislative Joint Fiscal Office Other Policy Implications Premium structure will change the appropriations process, because money will flow to OVHA and then to other departments. MCO structure will necessitate interdepartmental agreements – could be status quo, could result in change. Waiver of specific federal laws allows some changes to eligibility calculations, premium amounts & retroactive eligibility – unclear if OVHA will proceed at this time on these changes.

17. V e r m o n t Legislative Joint Fiscal Office

18. V e r m o n t Legislative Joint Fiscal Office

19. V e r m o n t Legislative Joint Fiscal Office Global Commitment - Risks Space between the actual costs and the premium may be smaller than anticipated. –This can occur if a sufficiently high premium can not be justified or if spending growth is faster than expected. The first is a particular concern in the later years of the waiver. The budget neutrality cap may be exceeded. Documentation of waiver details is not as complete as many waivers –JFC conditioned approval on complete documentation.

20. V e r m o n t Legislative Joint Fiscal Office Global Commitment – Finances

21. V e r m o n t Legislative Joint Fiscal Office The End Many documents are available at: http://www.leg.state.vt.us/JFO/default.htm http://www.ovha.state.vt.us/globalhome.cfm