1. Federal Financial Support for State Health Reform Implementation Edwin Park Center on Budget and Policy Priorities From Vision to Reality: State Strategies for Health Reform Implementation November 10, 2010

2. States bear primary or significant responsibility for all of the major coverage elements. Establishing new health insurance exchanges. Instituting health insurance market reforms. Helping administer the premium credits and cost-sharing reductions, and the individual and employer responsibility requirements. Expanding Medicaid. Coordinating enrollment of eligible individuals into public programs and premium credits and cost-sharing subsidies. State Role in Implementing New Coverage Pathways

3. By 2014, states must establish new marketplaces for individuals and small businesses. Federal minimum requirements for exchanges. Significant flexibility on how states can design their exchanges. Only source of coverage eligible for premium credits and cost-sharing reductions for individuals/families and for small business tax credits. Existing individual and small group markets remain in place. Determine eligibility for premium credits and cost-sharing reductions. Coordinate eligibility with Medicaid and CHIP. Health Insurance Exchanges

4. HHS is providing grants to states for any activities (including planning activities) related to establishing an Exchange. Uncapped, mandatory $, with discretion on total $, state amounts, requirements and renewals left to HHS Secretary. First $1 million grants were awarded at end of September. Next round of general grants to be awarded in early 2011. Further grants will likely be tied to states meeting certain federal requirements and benchmarks. Exchange Planning and Establishment Grants

5. Use of planning and establishment grants to fund special grants to develop innovative IT systems for exchanges. 2 year grants for up to 5 states (or 5 state consortia). Applications due by December 22, 2010 and to be awarded by February 15, 2011. States must commit to establish an exchange. Resulting model systems to be available for other states to adopt. Cannot be used solely for Medicaid or CHIP eligibility systems. Exchange IT Systems Grants

6. By 2014, states are required to expand their Medicaid programs to all non-elderly individuals up to 133% of the poverty line. Significant change in eligibility for adults, particularly childless adults. Gains for people with disabilities, including those in 2-yr. waiting period. No assets test. Changes in how income is counted. Medicaid Expansion

7. Federal Government Picks Up Nearly All Costs of Expansion

8. Modest Increase in State Costs

9. That is because Medicaid matching rate (FMAP) will be significantly higher for newly eligible population than the regular FMAP (on average, 57%). 2014-2016: 100% 2017: 95% 2018: 94% 2019: 93% 2020 and after: 90% Higher Medicaid Matching Rates for Expansions

10. Regular matching rate for current eligibles who newly enroll. Exceptions include: Childless adults in early expansion states. Children switched from CHIP to Medicaid. Costs of temporary increase in primary care physician payment rates. Matching Rates for Current Eligibles

11. Regular administrative matching rate for Medicaid implementation costs generally. New proposed regulation would provide higher federal support for improvements to Medicaid eligibility systems. Estimated $2.2 billion through 2015. Same higher match now available for claims processing (MMIS). 90% for improvements through end of 2015 and 75% for ongoing operation and costs permanently. States must meet certain conditions and must perform cost allocation. Proposed Higher Match for Systems Improvements

12. Affordable Care Act provides additional sources of funding to help support health reform implementation and other health improvements. Examples: $250 million in rate review grants through 2014. First round awarded. $300 million in development of Medicaid quality measures for adults. $100 million in Medicaid prevention and wellness grants. Funding to experiment with health care delivery system reforms in Medicaid including bundled payments, global payments for safety net hospital systems, and pediatric accountable care organizations. Other Sources of Federal Funding for States