Medicaid and CCO Update. Presented by Kelly Knivila OSB Health Law Section October 2017

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1 Medicaid and CCO Update Presented by Kelly Knivila OSB Health Law Section October 2017

2 WHAT WE WILL COVER Federal Medicaid Update Oregon Medicaid Update Some facts, some news, some new laws 2

3 Federal Medicaid Update

4 FEDERAL SOME FACTS Medicaid is joint federal/state program of health insurance for low income Americans Federal share = 50% to 75% Total Medicaid spending = $553B Medicaid = over half of all federal revenue going to states 1 in 5 Americans are covered by Medicaid Largest payer of long-term care services for seniors and people with disabilities 32 states have implemented Medicaid expansion 4

5 FEDERAL SOME NEWS 5

6 FEDERAL SOME NEWS Affordable Care Act Expanded Medicaid to 138% of poverty level (state option) with increased federal match for expansion population (90% in 2020) Better Care Reconciliation Act proposal Phase out additional federal match by 2024 Convert federal Medicaid spending to per capita Limit growth of federal spending using medical CPI Optional state block grant No Medicaid for Planned Parenthood 6

7 FEDERAL SOME NEWS Graham-Cassidy proposal Repeal Medicaid expansion authority and funding by 2020 Convert federal Medicaid spending to per capita Limit growth of federal spending using medical CPI Optional state block grant State option to require work as a condition of Medicaid eligibility (non-elderly, non-disabled) No Medicaid for Planned Parenthood for one year 7

8 FEDERAL SOME NEWS Tom Price, Obamacare Critic, Is Trump s Choice for Health Secretary NYT 11/28/16 Trump Picks Seema Verma To Run Medicare And Medicaid NPR 11/29/16 Seema Verma s Austere Vision for Medicaid The Atlantic 2/17/2017 8

9 FEDERAL SOME NEWS On first day in office, new Medicaid chief urges states to charge premiums, prod recipients to get jobs Washington Post 3/15/17 CMS letter to state governors encourages waivers [E]mpower [low income Americans] with skills and employment Able-bodied work requirements, lifetime limit on benefits Help working-age, non-disabled adults prepare for private coverage by aligning Medicaid with commercial plans Premium payments, ER co-pays, penalties for failing to renew 9

10 FEDERAL SOME NEWS CMS says it will change direction of CMMI, wants providers to have greater flexibility in payment model design HealthcareITNews 9/20/17 Price Resigns From Trump Cabinet Amid Private Jet Investigations NPR 9/29/17 After Tom Price resigns over travel flap, Indiana s Seema Verma on list of possible replacements Des Moines Register 9/30/17 10

11 FEDERAL SOME NEW LAWS Institution for Mental Disease Exclusion MCO Exception went into effect July 2016 Permits states to pay MCOs for treatment in IMDs Up to 15 calendar days/month Not for Substance Use Disorder 11

12 FEDERAL SOME NEW LAWS Mental Health Parity applies to Medicaid plans Mental Health Parity and Addiction Equity Act (MHPAEA) (2008) for group health plans Medicaid Final Rules apply MHPAEA to Medicaid and CHIP programs (2016) 42 CFR et seq. CMS issued guidance toolkit (January 2017) States required to document compliance by October

13 Oregon Medicaid Update

14 OREGON SOME FACTS $8.6B in Medicaid spending FY % = federal share of spending (more for expansion population) 67% of federal funds received by Oregon are Medicaid funds 10% of state general fund spending in Oregon is for Medicaid Medicaid is 50% of long term care spending in Oregon Medicaid expansion ($2.7B in additional federal $) 14

15 OREGON SOME NEWS Oregon Spending Millions On Ineligible Medicaid Recipients, Secretary Of State Warns OPB 5/17/17 Oregon Secretary of State Dennis Richardson slammed for inaccurate Medicaid audit alert USA Today, 5/23/17 Oregon removes nearly 55,000 people from Medicaid after they failed eligibility checks Oregonian, 8/31/17 15

16 OREGON SOME NEWS FamilyCare accuses state of trying to put it out of business Oregonian, 2/2/17 FamilyCare Sues Oregon Health Authority Over Reimbursement Rates Again OPB 2/28/17 State sought to plant negative stories about nonprofit, Portland Tribune 8/8/17 OHA director Lynne Saxton resigns in wake of FamilyCare PR controversy PBJ, 8/8/17 Brown taps DCBS director Allen as OHA s new acting director PBJ 8/16/17 16

17 OREGON SOME NEW LAWS CCO Bill to Convert all CCOs to Non-Profits Dies (HB 2122). Concerns motivating the law: Lack of transparency of finances Profits should be used to improve health Citizen boards not really in charge Keeping control local SB 934 passed By 2023, CCOs must spend 12% of budget on primary care (excluding drugs, vision, dental) Similar requirement for commercial/state plans 17

18 OREGON SOME NEW LAWS HB 2675 passed Mandates that CCO s community advisory council adopt a plan and strategy for integrating physical, behavioral and oral health care services HB 2882 passed Requires CCOs to have a DCO representative on governing board HB 2398 passed Prohibits health care provider from billing or soliciting payment from a Medicaid recipient, except co-pays 18

19 OREGON SOME NEW LAWS SB 419 passed Task force to study feasibility of all-payer hospital rate-setting process (Maryland) HB 2391 passed Health insurance and managed care assessment (aka tax) ($670M) 1.5% tax on Medicaid plans, PEBB, commercial insurers Hospital Provider Tax increases by 0.7% Funds generated used for Medicaid and Oregon Reinsurance Programs 19

20 OREGON SOME NEW LAWS IMD Exclusion Exception New Rule: OAR (10) permits CCO to cover service in IMD consistent with new federal rule Meet requirements for in lieu of services: medically appropriate, cost effective alternative to a covered service Member cannot be required to use Offered CCOs optional contract amendments to permit but no rate increase 20

21 OREGON SOME NEW LAWS Mental Health Parity applies to CCOs in Oregon OHA provided training to CCOs (April 2017) CCOs required to perform mental health parity analysis and submit to OHA (May 2017) Identify MH/SUD benefits Map to 4 benefit classifications (inpatient, outpatient, emergency, prescription drugs) Evaluate quantitative and non-quantitative treatment limits Compare to medical/surgical limits 21

22 OREGON A NEW WAIVER New five year 1115 demonstration wavier ( ) Expedited approval process Maintains core components CCOs providing integrated physical, behavioral and oral health care Payment innovation and sustainable rate of growth Evidence-based benefits (Prioritized List) Continues hospital transformation performance program 22

23 OREGON A NEW WAIVER New Flexibility to Transform the Health System Permits CCOs to be paid financial incentives to offset costs of non-traditional services that improve health Permits new performance incentive payments to PCPs Tribal Uncompensated Care Program transitioned to be a Medicaid benefit Easier enrollment in CCOs for dual eligibles (Medicare/Medicaid) 23

24 Questions? Presented by Kelly Knivila OSB Health Law Section October 2017