Health Care Reform and DRA 2005 Implementation Update

Transcription

1 Health Care Reform and DRA 2005 Implementation Update May 24, 2006 Stephanie Anthony Deputy Medicaid Director

2 Health Care Reform Overview Signed by Governor Romney on April 12, 2006 (passed by General Court on April 4, 2006) Provides access to affordable health insurance coverage to all Massachusetts residents -Modernizes health insurance laws -Removes barriers to purchasing health insurance -Redirects existing government assistance for uncompensated care to health insurance premium subsidies (from institutions to individuals) -Expands MassHealth eligibility and benefits -Increases transparency in health care costs and quality -Requires individual responsibility -Requires employer responsibility Builds upon MassHealth 1115 Waiver extension approved by CMS on January 26,

3 Key Elements of Health Care Reform Create a culture of insurance through expectation of Individual Responsibility Create affordable insurance products through various Insurance Market Reforms Facilitate the offer and purchase of affordable health insurance products through the Commonwealth Health Insurance Connector Authority Provide subsidies for affordable products to low-income individuals through the Commonwealth Care Health Insurance Program Eliminate cost-shifting by reforming the UCP and creating the Health Safety Net Office and Trust Fund Increase transparency in quality and costs through Health Care Quality and Cost Council and Medicaid Pay-for-Performance 3

4 Health Care Reform Implementation Update Statewide Consolidated HCR Implementation Team led by Secretary Murphy -Multiple state agencies involved, including DOR, DOI, DOL, Connector, DHCFP, GIC, DPH -HCR Implementation Plan to Legislature by June 12 (Section 132) MassHealth HCR Implementation Team led by Robin Callahan -Core Team members with various subgroups, primarily focusing on eligibility and benefit expansions -Executive Policy Group for consulting and decision-making -Includes Communications Subgroup (Outreach and Education) -LOTS of work to do at MassHealth for MassHealth changes and potentially for Commonwealth Care Health Insurance Program CMS approval of waiver submission provisions needed ASAP Technical corrections bill to be filed Finalize veto/override process: two vetoes outstanding 4

5 1115 Waiver Amendment Submission (May 1, 2006) Expands MassHealth via SCHIP to children with income from 200% FPL to 300% FPL (July 1, 2006) Restores optional services cut in 2002 and adds dental to Essential (July 1, 2006); introduces plan for two-year smoking cessation pilot program (July 1, 2006); creates Wellness Program tied to reduced cost-sharing if wellness goals met (will not be ready by July 1, 2006) Increases enrollment caps for adults in MassHealth Family Assistance/HIV; CommonHealth; and Essential programs (March 9 and July 1, 2006) Expands IP to employees with income from 200% FPL to 300% FPL; enhances crowd-out provisions; limits premium assistance to that in CWC program (October 1, 2006); and prohibits self-employed from getting employer subsidy (July 1, 2007) Withdraws pending disability eligibility criteria waiver amendment as such changes are prohibited by the Act 5

6 SCHIP Expansion Expands MassHealth via SCHIP state plan amendment to children with income from 200% FPL to 300% FPL, effective July 1, 2006 CMS approval of SCHIP SPA necessary (favorably received by CMS) FY 2007 enrollment estimate is ~16,000 (9,300 CMSP converters and 7,000 previously uninsured) -Advance notice to 6,600 households of CMSP children identified as eligible for Family Assistance Expansion for Children (FAEC) -Mailing begins May 25 staggered over 5 days -Automatic redeterminations for all of these children by July 7 8 Will receive approval letter from MassHealth as a result Premiums % FPL = $20 per child; $60 family maximum % FPL = $28 per child; $84 family maximum -Consistent with existing MassHealth premiums and for comprehensive benefits 6

7 SCHIP Expansion (2) Introduction of crowd-out provisions (i.e., must be uninsured for a minimum of six months prior to application) -Encouraged by CMS -Align policy with IP reform and Commonwealth Care Program -Challenging to implement new concept in MassHealth, but we are doing -Applies prospectively to those who apply on or after July 1, If have ESI within previous six months, will be subject to six-month waiting period, from the date of loss of coverage, before being eligible for FAEC -Six exceptions from waiting period 8 Special or serious health care needs of child 8 Prior coverage involuntarily terminated 8 Parent died in the previous six months 8 Prior coverage lost due to domestic violence 8 Prior coverage lost due to becoming self-employed 8 Existing coverage s lifetime benefits reduced substantially within previous six months 7

8 Restoration of Optional Benefits Restores federally optional benefits for adults to what was provided on January 1, 2002, effective July 1, Dental, eyeglasses, chiropractor, orthotics, prosthetics, Level IIIB detox, inpatient administrative necessary days for non-behavioral health stays Adds dental benefit to MassHealth Essential Includes smoking cessation pilot benefit Directs creation of MassHealth Wellness Program tied to reduced cost-sharing if wellness goals met (not ready by July 1) Member notices, including all benefit changes, in draft and will be mailed to ~650,000 members starting in late-june to mid-july Working on systems changes, provider bulletins, regulation changes, etc. Provider capacity issues? Dental? Eyeglasses? Detox? 8

9 Enrollment Cap Increases Family Assistance/HIV Adults (770 to 1,300) effective March 9, 2006 CommonHealth Adults (13,000 to 15,600) effective March 9, 2006 Essential (44,000 to 60,000) effective July 1,

10 Insurance Partnership Reforms Beginning to work on IP changes next (after July 1 changes) Expansion of IP to individuals with income from 200% FPL to 300% FPL, effective October 1, 2006 (includes crowd-out provisions) -Still in discussions with CMS Eliminate employer subsidy for self-employed (not until July 1, 2007) Many questions to work through regarding interaction and alignment between IP and CWC Trainings for BEIs, guides for small employers, CPU/MEC training 10

11 Outstanding Issues with CMS on 1115 Submission Approval of requested items in waiver submission -SCHIP SPA for expansion -Insurance Partnership reforms -Enrollment cap increases - Safety Net Care Pool financing -Waiver budget neutrality -Hold: Wellness program development -Note: benefit expansions are in Medicaid state plan, but impact waiver budget neutrality Ongoing discussions with CMS regarding each item Working actively together at Central and Regional levels for timely approval 11

12 Commonwealth Care Health Insurance Program Administered by the Commonwealth Health Insurance Connector Authority Private insurance-based premium assistance program for uninsured individuals at or below 300% FPL and not eligible for MassHealth or Medicare Specialized program for individuals below 100% FPL (required benefits and limited cost-sharing) Crowd-out provisions (e.g., employer must not have provided coverage for which employee is eligible in previous 6 months and for which employer paid more than 20% of premium for family coverage or 33% of premium for individual coverage) Affordable products (~$300 per month with no deductibles) offered by private plans: MMCOs for first three years if meet enrollment benchmarks CWC premium assistance is eligible for FFP from the Safety Net Care Pool created by the 1115 Waiver extension Enrollment can be capped if funds in CWC Trust Fund are insufficient Comprehensive outreach and education campaign 12

13 MassHealth and Commonwealth Care CWC administered by Connector, but in consultation with MassHealth -MassHealth stands ready to support processes where necessary, but it is not a MassHealth program Stepping stone from MassHealth to CWC to unsubsidized affordable private insurance -So, need to align policies and cost sharing incentives MMCOs plan to be ready to offer CWC products by October 1, More similar to private affordable products than MassHealth but with subsidized cost sharing benefits TBD -Totally monthly premiums - TBD -MMCO enrollment and assignment process - TBD Issues and policy around families with members in both MassHealth and CWC - TBD Interaction with UCP - TBD Virtual Gateway changes - TBD 13

14 Outreach and Education SFY 2006 outreach grants ($500K in FY06 budget matched by $250K from BCBS) -Partnership with BCBS -22+ grantees (generally $16K or $10K grants) -Training on VG and success in increasing MH enrollment SFY 2007 outreach grants ($3M in HCR) -May use any time in FY Will use in broader context of HCR and CWC -Some logical dates: July 1, 2006, October 1, 2006, and/or March 1, Role of advocates and community-based organizations: crucial as in last cycle Communications workgroup: focus on communication with external groups, including provider associations and advocates; focus on necessary MassHealth trainings (Maximus and MECs) 14

15 DRA - Mandatory provisions Payment for prescription drugs [Sec ] Reform of asset transfer rules [Sec ] Enhancing third-party identification and payment [Sec. 6035] Enforcement of documentation requirements [Sec. 6036] Reforms of case management and targeted case management [Sec. 6052] Employee education about false claims recovery [Sec. 6032] Medicaid Integrity Program [Sec. 6034] Managed care organization provider tax reform [Sec. 6051] 15

16 DRA - Asset transfer rules Asset Transfer Rules [Effective for transfers made on/after 2/8/06] -Look-back period lengthened from 36 to 60 months -Start date of penalty period for improper transfer changed from month of transfer, to later of month of transfer or date eligibility for Medicaid LTC would have been established but for the penalty period -Requires hardship waivers (MA has one); facility can file hardship waiver with consent of individual or personal representative Treatment of Annuities [Effective for annuities purchased on/after 2/8/06] -Purchase of annuities treated as transfer for less than fair market value unless State named as remainder beneficiary Disqualification for LTC assistance for individuals with home equity in excess of $750,000 [Effective for individuals determined eligible based on application filed on or after 1/1/06] MassHealth regulations in final draft; filing scheduled for mid-june; effective 2/8/06 16

17 DRA - Documentation requirements Effective July 1, 2006 (for eligibility determinations and redeterminations), individuals declaring to be a citizen or national of the U.S. must present satisfactory documentary evidence of citizenship or nationality Satisfactory documentary evidence includes: -Any of following documents: U.S. passport; Certificate of Naturalization; Certificate of U.S. Citizenship; Valid state-issued driver s license or other identity document IF state requires proof of citizenship before issuance of such, or obtains and verifies validity of a SSN from the applicant; or such other document specified by Secretary through regulation that provides proof of U.S. citizenship or nationality and personal identity -One document from EACH of the following two lists: 8 Birth certificate; Certification of birth abroad; U.S. citizen identification card; Report of birth abroad of a U.S. citizen; other specified by Secretary 8 Any identity document described in Immigration and Nationality Act; other specified by Secretary 17

18 DRA - Documentation requirements (2) Medicaid eligible individuals with SSI or Medicare do not need to document citizenship or nationality with MassHealth (but states need to do match with SSA and Medicare to verify eligibility) -CMS considering similar process for TANF, IV-E populations and other federal programs State Medicaid Letter with further clarification and guidance is forthcoming, but we cannot wait Secretary shall establish an outreach program to educate individuals likely to be affected -CMS punted to state with regular FMAP uproar SWM budget provision(s) regarding the State helping to pay for the costs of obtaining documentation 18

19 DRA Documentation requirements (3) MassHealth working closely with DTA to have them electronically send citizenship/alien verification status for their caseload, including Food Stamp applicants. -This will capture about 500,000 MassHealth members -Information already shared for EAEDC population. MassHealth also using SDX file from SSA (position 578) to verify citizenship for SSI recipients Updating MA-21 Qualified Alien/Citizen (QAC) event to record verification of citizenship status Updating MA-21 verification notices to request verification of citizenship and identity for members not known to DTA and SSA data sources. When new cases are added to MA-21, eligibility determination held until MA-21 electronically checks a verified QAC file -If member already known to the file, MA-21 will change the QAC indicator to verified and record source of information Beginning to draft regulations 19

20 Optional provisions Medicaid flexibility Alternative premiums and cost sharing, including enforceability of premiums and cost sharing [Sec. 6041] Cost sharing for prescription drugs [Sec. 6042] Cost sharing for non-emergency care furnished in an emergency department [Sec. 6043] Benchmark benefit packages [Sec. 6044] 20

21 Optional provisions seniors and disabled Expansion of Long-term Care Partnership Program [Sec. 6021] Family Opportunity Act [Sec ] Money Follows the Person Rebalancing Demonstration [Sec. 6071] Expanded access to HCBS for the elderly and disabled [Sec. 6086] Self-directed personal assistance services (Cash and counseling) [Sec. 6087] 21

22 Optional provisions other Medicaid Transformation Grants [Sec. 6081] Health Opportunity Accounts [Sec. 6082] Option to establish non-emergency medical transportation brokerage program [Sec. 6083] 22

23 Questions? Contact information: Stephanie Anthony Deputy Medicaid Director Office of Medicaid 23