Financing Shared Services between State Medicaid Programs, State-Based Marketplaces, and Human Service Programs
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1 Financing Shared Services between State Medicaid Programs, State-Based Marketplaces, and Human Service Programs Tricia Leddy, Senior Fellow Chris Heiss, Senior Program Officer This presentation is supported by the Robert Wood Johnson Foundation s State Health Reform Assistance Network
2 Agenda 1. Cost Allocation: A Continued Opportunity for Medicaid Marketplace Partnership 2. Reviewing the Process for Establishing Cost Allocation 3. State Examples and Discussion 2
3 A Medicaid Partnership Benefits State-Based Marketplaces & Human Service Programs Shared services can help provide: Seamless continuum of health insurance/access to health insurance programs Seamless application process for health insurance and other support programs Improved customer service Integrated, online application technology Ongoing federal financial support States can adjust their partnerships/relationships as systems evolve and change. 3
4 Understanding Your Partner s Key Priorities and Concerns is Critical Examples of Marketplace priorities Increase and maintain enrollment Provide excellent customer service Secure financial viability Examples of State Medicaid program priorities Enroll the right people at the right time in the right program Provide excellent customer service Be good stewards of State General Funds Avoid adverse audit findings 4
5 Establishing a Cost-Allocation Workgroup for Eligibility and Related Services Workgroup representation State Medicaid program State Marketplace Budget officials? Human Service agencies? Who convenes, manages or owns the process? Medicaid Program Governor s Office One department or super-agency, or multiple departments? Staffing Levels and Progress Reports At what level are final decisions made? How are timelines dictated? 5
6 Agenda 1. Cost Allocation: A Continued Opportunity for Medicaid Marketplace Partnership 2. Reviewing the Process for Establishing Cost Allocation 3. State Examples and Discussion 6
7 CMS Take on Cost Allocation with Marketplaces in those cases where Exchanges share services and functionalities with Medicaid and the Children s Health Insurance Program (CHIP), those programs must also pay their share. Using a common set of systems and services for certain activities has the potential to reduce all programs administrative costs over the long run, and deliver better results for consumers... Supplemental Guidance on Cost Allocation for Exchange and Medicaid Information Technology (IT) Systems Questions and Answers. Centers for Medicare & Medicaid Services, October 5, Available at: 7
8 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CMS 8
9 Potential Medicaid/Marketplace Shared Services Determining whether applicants for advanced premium tax credits (APTCs) or cost-sharing reductions (CSRs) are Medicaid eligible Technology systems and support Customer service related to application and eligibility Consumer education and outreach Staff training Data collection, analysis, and reporting Other administrative functions 9
10 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CMS 10
11 Opportunities for Medicaid Federal Match 90 percent for the design, development, and implementation (DDI) of new or improved Medicaid eligibility determination systems 75 percent for ongoing maintenance and operation (M&O) 75 percent for customer service, including call center activities and eligibility worker activities related to Medicaid application, eligibility determination, and renewal, using new or improved eligibility systems 50 percent for other shared administrative services 11
12 States Must Meet Certain Conditions to Receive Enhanced Federal Matching Rates Examples Accepting the new single streamlined application to make MAGI-based eligibility determinations Coordinating with the SBM or the federally facilitated marketplace (FFM) 12
13 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CMS 13
14 CMS Generally Does Not Specify HOW Costs Must be Allocated CMS is responsible for ensuring that state Medicaid programs follow OMB s A-87 principles when sharing services or functions with other government programs or entities States propose ways to fairly split combined costs between Medicaid and other program(s) through an established approval process 14
15 CMS-Approved Methodologies Fall into Two Categories Methods that measure level of effort, such as: Number of applications processed by the shared technology system for each program; Number of phone calls to the contact center; or Random moment time studies for shared government staff. Methods that allocate costs by program use, such as: Number of applicants in a given period for each program; or Number of enrollees in each program at a point in time. 15
16 Examples of CMS-Approved Cost Allocation Methodologies By actual program populations (MA, MD, RI) By predicted future program populations (NV) Based on the proportion of program population which will use each system function (MN) By which program uses each system function (CA, MA) By function point analysis based on lines of code to split technology DDI costs; by population for Maintenance & Operations (RI) SOURCE: 16
17 Factors to Consider When Testing Cost Allocation Methodologies Accessibility and availability of data To support periodic validation of actual allocations Comparison of the financial impact of each methodology on federal revenue Different methodologies can yield very different results, and may be different for each service or activity being cost allocated Likelihood of CMS approval of the cost allocation method Using previously approved methodologies States continue to develop and submit new methodologies for approval 17
18 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CMS 18
19 Suggestions for Finding the Most Favorable Methodology Look at methods used in other states Develop a variety of methods to fully consider Narrow by discarding any for which there is no data available to validate the methodology Do calculations to see which method is more financially favorable 19
20 Example: Choosing a Cost Allocation Methodology for Submission to CMS 20
21 Example: CMS-Approved Cost Allocation Methodologies in Rhode Island DDI for technology: Based on lines of code 64% Exchange; 36% Medicaid M&O for technology and contact center: Initially based on projected enrollment 75% Medicaid/25% Exchange Current updated allocation based on actual enrollment: 86% Medicaid/14% Exchange When Human Service programs join in 2016: Exchange and Medicaid share will be lower 21
22 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CMS 22
23 States Can Use Marketplace Premium Assessments to Finance State Share State-based Marketplaces are typically reliant on a premium assessment applied to Marketplace enrollees and/or more broadly to enrollees across the individual and/or small group market Because these assessments are broad-based assessments, not solely focused on Medicaid, they may be used as Medicaid state match 23
24 Inter-Governmental Transfers (IGTs) of Premium Assessment Revenue is Allowed IGTs NOT allowed: CMS does not allow transfers of funds from providers ( Provider Donations or Taxes ) when the providers will directly benefit as a result of the transfer in terms of increased payments by Medicaid CMS does not allow transfers which impact the Upper Payment Limit CMS does not allow transfers of funds to Medicaid from sources that are not allowed to be used for state match None of these concerns impact transfers of allowable funds from a state Exchange to a state Medicaid program 24
25 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CM 25
26 High-Level Process for Establishing Medicaid/Marketplace Cost Allocation 1. Develop a list of shared services to be cost allocated 2. Determine federal match rate for each service 3. Identify and test potential cost allocation methodologies 4. Decide on a method for allocating costs between Medicaid and the Marketplace 5. Identify potential financing sources for state match 6. Finalize financing and any funds transfer decisions 7. Discuss the state s shared services and cost allocation methodology with CMS 8. Write an Interagency Agreement 9. Submit formal request to CMS 26
27 Submitting a Formal Request to CMS Two potential processes: 1. Cost Allocation Plan Proposals to share program costs which will be claimed by Medicaid at 50% match May be reviewed by the CMS Regional Office Example: Random Moment Time Studies for Interagency Government Staff 2. Implementation Advanced Planning Document (IAPD) Proposals to share program costs that will be claimed at an enhanced match rate (75%, 90%) CMS has an IAPD Template Review and decision by CMS Central Office 27
28 Agenda 1. Cost Allocation: A Continued Opportunity for Medicaid Marketplace Partnership 2. Reviewing the Process for Establishing Cost Allocation 3. State Examples and Discussion 28
29 State Reactors Kim Eisen Eligibility and Enrollment Project Manager, Colorado Department of Health Care Policy and Financing Deb Florio Administrator, Center for Child and Family Health, Rhode Island Executive Office of Health and Human Services 29
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