STATE OF WASHINGTON HEALTH CARE AUTHORITY 626 8th Avenue, SE P.O. Box Olympia, Washington

Transcription

1 March 5, 2013 STATE OF WASHINGTON HEALTH CARE AUTHORITY 626 8th Avenue, SE P.O. Bx Olympia, Washingtn Dear Health Plans: As yu knw, changes in family incme can result in switching between health cverage ptins and the split f family members acrss different health cverage and health plans. These issues are mre cmmnly called churn and whle-family cverage, and they intrduce majr inefficiencies in the delivery f health care where access t family prviders is ften disrupted. The Health Care Authrity (HCA) has been especially cncerned at the ptential fr increased churn and whlefamily cverage discntinuity when the expansin f Medicaid and start-up f subsidized cverage in the Exchange begin in The enclsed dcument prvides an verview f the Apple Health Plus slutin we intend t implement fr cverage beginning January 1, It is an apprach develped ver the past nine mnths, with extensive input frm Medicaid and cmmercial health plans, legislative staff and ther stakehlders. Over the next three mnths the HCA will be develping a prcess t slicit Exchange Qualified Health Plans fr participatin as "Limited Medicaid Plans" that will ffer a relatively seamless apprach fr sustaining cverage and prvider netwrk cnnectins when family members with Exchange cverage becme eligible fr Medicaid. Apple Health Plus is grunded in the frmer state spnsred Basic Health Plus prgram that histrically ffered a seamless system fr crdinating eligibility and benefits fr Basic Health and Medicaid enrllees. Fr further details n the implementatin f Apple Health Plus, please cntact Prestn Cdy, Divisin Directr by telephne at phne r via at prestn.cdy@hca.wa.gv. Sincerely, MaryAnne Lindeblad Medicaid Directr Enclsure cc: Prestn Cdy, Assistant Directr, Divisin f Health Care Services Nathan Jhnsn, Assistant Directr, Divisin f Health Care Plicy

2 Apple Health Plus in 2014 Backgrund: In early 2012, the Health Care Authrity (HCA) and Health Benefit Exchange (Exchange) held jint and individual discussins with Medicaid and cmmercial health plans n the issues f churn and whle-family cverage. HCA cntracted with the Institute fr Health Plicy Slutins (IHPS) t quantify the issues, craft a prblem statement, and generate plicy ptins fr further cnsideratin. Tgether, HCA and IHPS engaged in a significant utreach effrt, thrugh in-persn meetings and cnference calls with health plans, legislative staff and thers. This apprach was designed t gather different views n the scpe f the prblem and ptins that culd address churn and whle-family cverage discntinuity. Optins discussed included the ptential fr limited participatin f: (a) Medicaid health plans in the Exchange; and (b) Exchange Qualified Health Plans (QHPs) in Medicaid. The main gal was t prevent disruptin f cverage, severing f critical prvider cnnectins, and mixed-family cverage, as family circumstances change. In cncept, the ptins identified are nt withut precedent. In 1993, the Washingtn State Legislature established the Basic Health Plan (BH) as a permanent prgram and directed the HCA and the Department f Scial and Health Services (DSHS) t create a seamless system t crdinate eligibility and benefit cverage fr families with enrllees in BH and Medicaid (knwn as Healthy Optins). This culminated in the creatin f Basic Health Plus (BH Plus) t crdinate cverage fr children and pregnant wmen served by the Maternity Benefits Prgram. This became especially imprtant in 1994 when Medicaid cverage fr children expanded t 200% f the Federal Pverty Level (FPL). Fr much f the BH histry, health plans perating in Healthy Optins have nt been the same as thse serving BH. BH Plus ensured the State s bjective f seamless, whle-family cverage, by allwing sme BH health plans t participate in Healthy Optins n a limited basis fr children whse parents were cvered thrugh BH. On February 11, 2013, the Exchange published a list f 13 health plans that are interested in participating as a QHP in 2014, including three f the five currently cntracted Medicaid health plans. These 13 health plans must successfully cmplete further steps befre their participatin in the Exchange is assured. Hwever, their expressed interest prvides an early indicatin f the ptential Exchange marketplace and cnfirms that cnversatins arund churn and whle-family cverage are likely t cntinue. The Prblem: Whle-Family Cverage Discntinuity: Mixed cverage ptins may frce family members int different plan and prvider netwrks. In 2014, parents with incme belw 138% 1 f the FPL will be able t secure Medicaid cverage thrugh the same health plan as their children. Hwever, parents with incmes between % f the FPL will ptentially face mixed cverage they will be 1 Under the ACA, the 133% f the FPL incme limit is effectively 138% f the FPL because f a 5% acrss-the-bard incme disregard. Apple Health Plus - March 2013 Page 2

3 cvered by a subsidized QHP in the Exchange while their children are cvered in Medicaid r CHIP 2. In additin, many wmen wh becme pregnant while cvered in the Exchange may be Medicaideligible during pregnancy 3 but they will revert back t Exchange cverage afterwards while their newbrn child(ren) remains cvered in Medicaid r CHIP. Mixed cverage fr a family can create cnfusin and barriers t accessing health care fr the entire family. Sme families may prefer having mixed cverage but, wherever pssible, they shuld have an ptin t cntinue their cverage and care withut having t change prvider netwrks when their family circumstances change. Churn: Mvement between the Exchange and Medicaid. IHPS analysis suggests that a cnsiderable number f adults will mve frm Exchange t Medicaid cverage (and vice versa) each year because f changes in family incme 4. Withut a streamlined apprach, many f these adults may be frced ff their Exchange QHP int a different Medicaid health plan, resulting in prblems fr themselves, their families, health plans, and the HCA. These prblems include: Discntinuity f prvider relatinships, which leads t incnsistent, lwer quality f health care and increases csts, e.g., due t duplicatin f diagnstic tests and the need t crdinate r renew treatment plans. Frequent turnver in enrllment, which increases administrative expenses fr health plans and Medicaid. Undermining f incentives fr health plans and prviders t invest in lnger-term health imprvements, because enrllment turnver means health plans cannt expect t benefit frm such investments. Thus, effrts t imprve the verall cst-effectiveness f the health care system will suffer. The ptential fr individuals whse incme and eligibility status changes t have t satisfy a deductible mre than nce during a plan year. Frequent enrllee switching amng health plans, which will make it difficult fr the State t enfrce benefit limits and will cmprmise Medicaid s effrts t measure and cmpare quality acrss cntracted health plans ver time. The Apple Health Plus Slutin fr 2014: T limit the impact f changes in family incme n cntinuity f cverage and care, the HCA intends t permit health plans participating as QHPs in the Exchange t als participate in the Medicaid managed care delivery system n a limited basis. This ptin allws health plans t serve Exchange nexus ppulatins individuals wh churn between the Exchange and Medicaid cverage, and families with mixed Exchange/Medicaid/CHIP cverage. Health plans electing this ptin as a "Limited Medicaid Plan" wuld be able t cver: Medicaid r CHIP-eligible children f parents enrlled in a QHP. Medicaid r CHIP-eligible children wuld be permitted t enrll in, and remain cvered under, the Apple Health Plus Medicaid plan fr the full duratin f their 12-mnth cntinuus eligibility perid, regardless f their parent s nging cverage status. Wmen enrlled in a QHP wh becme Medicaid-eligible due t pregnancy. Wmen receiving subsidized cverage thrugh a QHP in the Exchange wh becme pregnant and have incme that places them belw 185% f the Federal Pverty Level, wuld have the ptin f staying with the same 2 Children under age 19 living in families whse incme is up t 300% f the FPL, can receive cverage thrugh the Apple Health fr Kids prgram. 3 Pregnant wmen are eligible fr Medicaid cverage if their incme is up t 185% f the FPL their unbrn child(ren) are included in the determinatin f family size. 4 Apple Health Plus - March 2013 Page 3

4 plan and prviders thrugh Apple Health Plus. Pregnant wmen 5 wuld receive full Medicaid cverage (with n cst sharing) fr the duratin f their Medicaid eligibility. Fllwing cmpletin f Medicaid cverage fr the pregnancy and pst-partum perid, the mther (and father where he t was impacted) wuld be able t chse t maintain cverage thrugh the same Exchange QHP mving frward. The newbrn child(ren) wuld remain eligible fr nging Medicaid/CHIP cverage with the same health plan. QHP enrllees wh becme Medicaid eligible due t incme fluctuatins. Exchange enrllees wh becme Medicaid eligible as a result f incme changes wuld als have access t this seamless Apple Health Plus cverage ptin until the fllwing pen enrllment perid. Additinal Details: Additinal terms and cnditins wuld apply t Apple Health Plus: A participating health plan wuld ffer a QHP in the Exchange and wuld als need status t ffer an Apple Health Plus prduct. The prcess t btain this status wuld be separate frm existing Medicaid managed care prcurement activities. Existing Medicaid managed care cntracting requirements wuld need t be met by health plans participating in Apple Health Plus. T the extent pssible, there wuld be alignment between Exchange/Medicaid eligibility and enrllment perids fr children and adults, t effectively preserve cntinuus eligibility prtectins fr children. The same prvider netwrk wuld need t be available t Exchange and Medicaid ppulatins served by Apple Health Plus. Enrllees receiving Medicaid cverage thrugh Apple Health Plus wuld have Medicaid benefits and prtectins; participating health plans wuld be paid Medicaid rates. Apple Health Plus wuld perate as a "bridge prgram until a mre cmprehensive and streamlined fix fr churn and whle-family cverage culd be develped, r until the health insurance market reaches a level f alignment that makes such an ptin unnecessary. Operatinal Limitatins and Parameters fr an Innvative Interim Slutin: T implement the Apple Health Plus slutin with the start-up f the Exchange and Medicaid expansin, an administratively innvative apprach wuld be necessary given the cmpressed timeline fr systems develpment and testing. Apple Health Plus eligible clients wuld be aut-assigned t ne f the cntracted Medicaid health plans, cnsistent with the existing (2012) Medicaid prcess. Versin 1.0 f the Exchange (i.e., the system t be implemented Octber 2013) wuld be unable t systematically verride Medicaid autassignment. Hwever, eligible clients wuld have the ptin f selecting a Limited Medicaid Plan fllwing their initial assignment. HCA staff wuld have access t QHP enrllment infrmatin and wuld be able t verify individual level eligibility fr the Apple Health Plus cntinuity r whle-family cverage ptin. 5 Where the family incme drps belw 138% f the FPL as a result f the pregnancy, the father might als becme eligible fr Medicaid cverage as a member f the new Medicaid expansin adult grup. Apple Health Plus - March 2013 Page 4

5 The Exchange wuld generate a regular reprt fr health plans participating in Apple Heath Plus, identifying adults with Medicaid-eligible dependents and thse with incme r husehld changes that impact their advanced premium tax credit eligibility. Implementatin f Apple Health Plus by January 1, 2014: An estimated timeline fr key milestnes t implement Apple Health Plus fr cverage beginning January 1, 2014 is as fllws: Milestnes Request fr Applicatins (RFA) July 22, 2013 Date RFA Submissin Deadline August 19, 2013 Evaluatin and Scring Perid August 20 August 26, 2013 Annunce Apparently Successful Vendr (ASV) September 3, 2013 Final Vendrs Annunced September 17, 2013 Cntract Effective Date January 1, 2014 Apple Health Plus begins January 1, 2014 Apple Health Plus - March 2013 Page 5