SoonerCare and National Health Care Reform

Oklahoma Health Care Authority Board Retreat

August 26, 2010

Chad Shearer

Senior Program Officer

Center for Health Care Strategies

CHCS Mission

To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care.• Our Priorities

► Improving Quality and Reducing Racial and Ethnic Disparities► Integrating Care for People with Complex and Special Needs► Building Medicaid Leadership and Capacity

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Medicaid’s Challenges and Opportunities

60 million People in the United States with Medicaid coverage.

$380 billion Projected Medicaid spending for FY 2009.

1 millionMedicaid beneficiaries resulting from a 1% increase in unemployment; enrollment increased by 5.4% in FY2009 and is projected to increase by 6.6% in FY2010.

16 - 20 million Additional Medicaid/CHIP beneficiaries by 2019 due to health reform.

41% Births in the United States covered by Medicaid.

28% Children in the United States covered by Medicaid.

27% Percentage of total mental health costs financed by Medicaid.

41% Total long-term care costs financed by Medicaid.

5% Medicaid beneficiaries accounting for 57% of total Medicaid spending.

8.8 millionPeople who are dually eligible for Medicare and Medicaid; roughly 18% of Medicaid beneficiaries. 3

National Health Reform Impacts & Opportunities

• Major Medicaid expansion► Transition Medicaid from welfare program to

insurance program► Complicated Medicaid interface with health insurance

exchanges

• Exciting grant and demonstration opportunities

• Substantial health insurance reforms

• Vast implementation challenges may require enhanced state capacity

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Health Reform Facts - Coverage

• Currently insured retain employer coverage• Estimated 25 million Americans covered through

new health insurance exchanges (subsidized to 400% FPL)

• Estimated 16-20 million Americans covered through Medicaid expansion (available to everyone up to 133% FPL)

• Tax penalties for individuals failing to obtain coverage (with some exceptions)

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Health Reform Facts - Financing

• Demonstrations to test financing and delivery system reforms focusing on:

► Medical/Health Homes► Bundled payments around episodes of care► Accountable care organizations

• New entities will focus on financing issues► Center for Medicare and Medicaid Innovation► Federal Coordinated Health Care Office (duals)► Medicaid and CHIP Payment and Access Commission► Medicare Independent Payment Advisory Board

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Health Reform Facts - Quality

• New quality measures for adults that apply to the Medicaid expansion population

• Expanded quality data collection and reporting (extends to all payers and plans)

• Focus on community based approaches (e.g., health teams and community based prevention)

• Connecting HIT efforts to delivery system quality improvement initiatives

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Health Reform Facts - Timeline

• 2010 ► Medicaid maintenance of effort► State option for Medicaid expansion► High risk pool► Insurance regulations

• December 31, 2012► States must notify HHS of exchange intentions

• January 1, 2014► Medicaid expansion and exchange/subsidies begin► Additional heath insurance regulations take effect

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Reform and SoonerCare - Coverage

• Estimated 350,000 – 470,000 new SoonerCare members due to expansion

• SoonerCare enrollment and eligibility systems must interact seamlessly with the exchange

• Many adults in expansion population will have chronic conditions and pent up demand (workforce and access to care concerns)

• Basic health plan option for state to cover up to 200% FPL and receive federal subsidies

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Reform and SoonerCare - Financing

• 100% FMAP for expansion population (decreasing to 90% in 2020 and beyond)

• 100% FMAP to increase primary care provider payments in 2013-2014

• Enhanced FMAP for long-term services and supports

• Enhanced FMAP for covering preventative and immunization services

• Eliminates FMAP for preventable health care acquired conditions

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Reform and SoonerCare - Quality• Health homes for enrollees with chronic conditions

(planning grants and 90% FMAP for 2 years)

• Demonstrations for bundled payments and ACOs

• Community health teams to support medical homes

• Medication management for chronic disease

• Grants to provide incentives to Medicaid beneficiaries to participate in programs to prevent chronic disease

• Awards for co-locating primary and specialty care in community based mental health settings

• Center for Medicare and Medicaid Innovation pilots to test payment and system reforms

• Federal Coordinated Health Care Office for dual eligibles

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Challenges

• Budget – increasing expenditures and decreasing revenues

• Staffing – Lots of new work• Systems/Infrastructure – Eligibility and

enrollment, MMIS enhancements• Exchange and Medicaid – Interaction will be

difficult and CMS guidance has been lacking• Grants and demonstrations – Require

substantial resources for application and program management

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Reform Resources• CMS

► https://www.cms.gov/Center/healthreform.asp

• Health Reform GPS ► http://www.healthreformgps.org/

• Kaiser Family Foundation ► http://healthreform.kff.org/

• National Academy for State Health Policy ► http://nashp.org/health-reform

• National Governors Association► Health Reform Implementation Resource Center

• AcademyHealth – State Coverage Initiatives► http://www.statecoverage.org/health-reform-resources

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Visit CHCS.org to …• Download practical resources to improve the quality and

cost-effectiveness of Medicaid services.

• Subscribe to CHCS eMail Updates to learn about new programs and resources.

• Learn about cutting-edge efforts to improve care for Medicaid’s highest-need, highest-cost beneficiaries.

www.chcs.org

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Contact information• Chad Shearer, Senior Program Officer

Center for Health Care Strategies

cshearer@chcs.org