Medicaids Evolving Role in Health Coverage

1
Medicaids Evolving Role in Health
Coverage Alice Burton, Director AcademyHealth
National Governors Association Health Policy
Advisors Meeting September 9, 2004
2
Presentation outline

• Pressure for reform and redesign
• Medicaids changing role in health coverage
• New groups covered by Medicaid
• Private sector partnerships
• Benefits and cost-sharing

3
Total State Medicaid Spending as a Percentage of
Total State Spending, FY93 - FY03
Source National Association of State Budget
Officers
4
Only a few ways to control budget

• Enrollment eligibility cuts, premiums, changes
  to enrollment process
• Utilization benefit cuts, limits on services,
  co-payments, shifting to lower cost services
• Provider reimbursement limited ability to cut

5
Medicaid cushions recent growth in the uninsured
Health Insurance Coverage, individuals under
65 Source CPS March 2003 Supplements 1997-2002
6
Regardless of perspective likely challenge

• Growing enrollment in Medicaid, growing cost
• Growing uninsured despite expansions in public
  coverage

7
New options for Medicaid coverage

• SCHIP (1997)
• 1115 waivers and HIFA (2001)
• Breast and Cervical Cancer (2000)
• 50 states (including DC)
• Ticket to Work Working individuals with
  disabilities (2001 Medicaid expansion)
• 32 states, some states with no income limit

8
States with expanded coverage for parents through
Medicaid
AK
WA
ME
MT
ND
MN
OR
VT
NH
ID
WI
SD
NY
MA
MI
CT
WY
RI
IA
PA
NE
NJ
NV
OH
IN
MD
IL
DE

UT
WV
CO
KS
VA
CA
MO
KY
NC

TN
AZ
OK
NM
AR
SC
0 49 FPL 50 - 99 FPL 100
199 FPL 200 FPL no new
enrollment or capped enrollment
MS
AL
GA
LA
TX
FL
Program not implemented
HI
9
States that cover childless adults through
Medicaid
AK
WA
ME
MT
ND
MN
OR
VT
NH
ID
WI
MA
SD
NY
MI
CT
WY
RI
IA
PA
NE
NJ
NV
OH
IN
MD
IL
DE
UT
WV
CO
KS
VA
CA
MO
KY
NC

TN
AZ
OK
NM
AR
SC
no coverage under 100 FPL 100
199 FPL 200 FPL and greater no new
enrollment or capped enrollment
MS
AL
GA
LA
TX
FL
Program not implemented
HI
10
Illinois covers parents

• Sept. 02 HIFA Expanded coverage to parents of
  Medicaid and SCHIP (phases in expansion)
• KidCare Rebate Premium assistance available to
  children 133 - 185 FPL - Informed consumer
  choice model
• July 03 expansion
• Children from 185 to 200 FPL
• Parents of Medicaid and SCHIP children with
  incomes from 49 to 90 (Goal is to raise to
  185)
• FY 2005 expansion to cover an additional 56,000
  working adults to 133 FPL

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Arizona covers parents childless adults

• December 2001 HIFA waiver allowed state to use
  unspent SCHIP funds to cover the following
  expansion groups in phases
• Phase 1 childless adults to 100 FPL
• Phase 2 parents of Medicaid/SCHIP children
  between 100 and 200 FPL
• Studied feasibility of ESI pilot program
  determined not feasible
• Strengthening Arizona Health Care Group to
  address crowd-out

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Private sector partnerships

• Sustained interest by states because programs
  meet a broad set of policy and political goals
• Currently operating premium assistance models pay
  the employees contribution for qualifying
  employer sponsored insurance when it is
  cost-effective
• 14 states, just over 50,000 enrolled out of over
  50 million enrolled in Medicaid and SCHIP
• Newer models create a new product, targeting
  working uninsured
• Target either employer or employees

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What problem are you trying to solve?

• Different problem requires different solution
• Problem Coverage offered by employer but not
  taken up by worker
• Solution Subsidize employee premium
• -or-
• Problem Employer doesnt offer coverage at all
• Solution Create affordable product targeting
  employers and workers

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A small portion of workers decline employer
sponsored insurance
SOURCE Kaiser Comissionon Medicaid and
Uninsured, Key Facts, December 2003
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Making new private insurance options more
affordable Arkansas HIFA proposal

• January 2003 HIFA proposal
• Employers that previously (gt12 mo) were not
  offering coverage may insure workers through new
  program
• 100 worker participation requirement
• Safety-net benefits insurance package
• For workers with incomes below 200 FPL,
  participating employer fees paid to the state
  qualify as federal match

16
Making new private insurance options more
affordable New Mexicos HIFA

• Goal is to help small employers provide insurance
  to low-income workers
• Expand coverage to individuals under 200 FPL
• Must have been uninsured gt6 mo
• New product (300/month)
• Employer share 75, may not have provided
  insurance gt12 mo
• Employee share 25, individuals without
  participating employer pay employee and employer
  share
• Medicaid share 200 (36 state funds)
• Coverage similar to basic commercial plan

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New approaches to benefits

• Fewer benefits for higher income groups
• Primary care programs
• Pharmacy Plus Rx only benefits

18
One states example of redesigning Medicaid
benefits for new populations
Medicaid SCHIP Benefits
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)
Increased Benefits
Expansion Benefits
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
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
No Annual Maximum
100,000 Annual Maximum
Some limits on services offered
Service limits based on medical necessity
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Utahs Primary Care Network

• 1115 waiver expands coverage to parents
  childless adults to 150 FPL
• Some reductions in benefits Medicaid
• Reductions in speech, dental, PT, transportation
  and psych services
• Primary care benefit package for expanded
  population
• Office visits - DME
• Immunizations - Basic dental
• Emergency/Urgent care - Hearing and vision
  screening (no glasses)
• Lab/X-ray - Rx (4 per month)
• Donated care - 10 million hospital care,
  outpatient specialty care, health education
  services, referral to Rx assistance programs

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New approaches to premiums

• Greater use of premium and buy-in to public
  programs
• 26 states collect premiums under SCHIP

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New approaches to premiums

• New experience with collecting premiums
• Few states have studied impact
• Higher income group (gt150) approx 20 dont
  take up coverage when asked to pay premium
• About ½ end up with other insurance
• For very low income groups impact of premium is
  much greater
• About ¾ remain uninsured
• Administrative process has a big impact on
  enrollment

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State Coverage Initiatives (SCI)

• An Initiative of The Robert Wood Johnson
  Foundation
• Direct technical assistance to states
• Onsite technical assistance
• Meetings for state officials
• Web site http//statecoverage.net
• Publications
• Grant funding