MASSHEALTH: THE BASICS PREPARED BY CENTER FOR HEALTH LAW AND ECOMICS UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL Webinar: May 29, 2014
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING WEBINAR OVERVIEW MassHealth: The Basics, April 2014 Update Eligibility, enrollment and spending in MassHealth PRESENTERS Kate Nordahl, Massachusetts Medicaid Policy Institute Center for Health Law and Economics, University of Massachusetts Medical School: Robert Seifert Kate Russell Carol Gyurina 1
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING FUNDAMENTALS OF MASSHEALTH MASSACHUSETTS 1115 WAIVER MassHealth is Medicaid (Title XIX of the Social Security Act) and the State Children s Health Insurance Program (CHIP, Title XXI) Federally- and state-funded and state-administered 1.4 million members; increasing under the ACA Includes benefits not covered by other insurance Supports workers access to private insurance Section 1115 Research and Demonstration Waiver ( MassHealth ) since 1997 Expanded eligibility for higher incomes and broader categories; subsidies in Commonwealth Care Programmatic innovations such as CommonHealth, payment reforms and delivery system transformation Supplemental financial support for safety net providers Vehicle for reform 5-year renewal request pending (effective 7/1/2014) 2
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH ELIGIBILITY UNDER THE ACA 400% 300% 200% ELIGIBLE FOR CHILDREN TAX CREDITS FOR QUALIFIED ADULTS AGES 21 THROUGH 64 HEALTH PLAN 300% 250% 200% 150% 150% 133% 133% 100% 100% FPL* 0 1-18 19-20 AGE IN YEARS DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 FORMER FOSTER CARE YOUTH UP TO AGE 26 FPL* ALL OTHER** MEDICALLY FRAIL ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD HIV POSITIVE DISABLED INDIVIDUALS RECEIVING SERVICES FROM DMH PARENTS OF CHILDREN < 19 PREGNANT ALL AGES INDIVIDUALS WITH BREAST OR CERVICAL CANCER HCBS WAIVER GROUP MassHealth Standard MassHealth CommonHealth Connector Care/Qualified Health Plan (QHP) MassHealth CarePlus MassHealth Family Assistance *FPL = income as percent of federal poverty level ** Includes members previously eligible for Commonwealth Care and for MassHealth Basic and Essential. 3
300% 200% 185% 150% 133% 100% 86% INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CHILDREN 400% 300% 200% 150% 133% 100% ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN % of FPL* 300% 0 1-5 6-14 15-17 18 PREGNANT DISABLED FPL* ADULTS UNDER 65 0 1-18 19-20 DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 FORMER FOSTER CARE YOUTH UP TO AGE 26 ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN 200% 185% 150% 133% 100% 86% PREGNANT DISABLED HIV POSITIVE WORK FOR QUALIFIED EMPLOYER (INSURANCE PARTNERSHIP) ALL OTHER WORK FOR LONG-TERM QUALIFIED UNEMPLOYED EMPLOYER (INSURANCE PARTNERSHIP) ALL OTHER ALL OTHER** MEDICALLY FRAIL ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD HIV POSITIVE DISABLED INDIVIDUALS RECEIVING SERVICES PARENTS OF CHILDREN < 19 PREGNANT ALL AGES INDIVIDUALS WITH BREAST OR CERVICAL CANCER FROM DMH HCBS WAIVER GROUP
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH ELIGIBILITY UNDER THE ACA 400% 300% 200% ELIGIBLE FOR CHILDREN TAX CREDITS FOR QUALIFIED ADULTS AGES 21 THROUGH 64 HEALTH PLAN 300% 250% 200% 150% 150% 133% 133% 100% 100% FPL* 0 1-18 19-20 AGE IN YEARS DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 FORMER FOSTER CARE YOUTH UP TO AGE 26 FPL* ALL OTHER** MEDICALLY FRAIL ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD HIV POSITIVE DISABLED INDIVIDUALS RECEIVING SERVICES FROM DMH PARENTS OF CHILDREN < 19 PREGNANT ALL AGES INDIVIDUALS WITH BREAST OR CERVICAL CANCER HCBS WAIVER GROUP MassHealth Standard MassHealth CommonHealth Connector Care/Qualified Health Plan (QHP) MassHealth CarePlus MassHealth Family Assistance *FPL = income as percent of federal poverty level ** Includes members previously eligible for Commonwealth Care and for MassHealth Basic and Essential. 5
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH IS IMPORTANT TO MANY POPULATION GROUPS PERCENT OF SELECT MASSACHUSETTS POPULATIONS COVERED BY MASSHEALTH, 2012 All non-elderly adults 19% Non-elderly adults earning > 100% FPL and <300% FPL 36% Non-elderly adults earning <100%FPL 51% All children 40% Children in families earning > 100% FPL and <300% FPL 49% Children in families earning <100%FPL 72% Births (child born in last 12 months) 33% Medicare beneficiaries 27% People with disabilities (require assistance with self-care) 58% Nursing home residents 63% 0% 20% 40% 60% 80% SOURCES: Author s calculations using the 2012 American Community Survey (ACS). Nursing home data from Kaiser State Health Facts (C. Harrington, H. Carrillo, M. Dowdell, P. Tang, and B. Blank. Table 6, "Nursing, Facilities, Staffing, Residents, and Facility Deficiencies, 2005 Through 2010," Department of Social and Behavioral Sciences, University of California, San Francisco, accessed January 2012). Data for all children and all elderly adults calculated from Census 2012 population data projections and MassHealth Snapshot report, 2013 monthly average. 6
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH COVERS CHILDREN, ADULTS & SENIORS, AND OFTEN SUPPLEMENTS OTHER INSURANCE PERCENT OF TOTAL MASSHEALTH ENROLLMENT, DECEMBER 2013 Seniors in Nursing Facilities 24,476 Seniors in Community 102,466 Other 22,709 2% 2% 7% 18% Adults with Disabilities 245,129 9% LT Unemployed Adults 128,721 Non-Disabled Children 527,623 38% 23% Non-Disabled Adults 316,270 2% Children with Disabilities 31,726 SOURCE: MassHealth, December 2013 Snapshot Report. 7
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING GROWING MASSHEALTH ENROLLMENT HAS ACCOMPANIED THE DECLINE IN THE NUMBER OF UNINSURED TRENDS IN MASSHEALTH ENROLLMENT AND UNINSURED, 1995-2011 (THOUSANDS) 1,600 1,400 MassHealth 1,200 1,000 800 600 400 Uninsured 200 0 1995 1998 2000 2002 2004 2006 2007 2008 2009 2010 2011 2012 2013 SOURCES: MassHealth figures are from the Office of Medicaid and are monthly averages, except 1998-2002 which are as of June 30. Uninsured numbers for 1998-2011 from the Division of Health Care Finance and Policy, from a survey in that year, and for 2012 from the Center for Health Information and Analysis, from ACS data. 1995 Uninsured numbers from Blendon et al., Massachusetts Residents Without Health Insurance, 1995, Harvard School of Public Health. 8
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MORE THAN THREE IN FIVE MASSHEALTH MEMBERS ARE ENROLLED IN MANAGED CARE MASSHEALTH ENROLLMENT BY PAYER TYPE, DECEMBER 2013 FFS & Premium Assistance 463,474 33% 37% MCO 522,311 PCC PLAN 382,795 27% 2% SCO 30,540 As of May, 13,274 individuals have enrolled in One Care, a new MassHealth program. SOURCE: MassHealth, December 2013 Snapshot Report; EOHHS May 2014 One Care Enrollment Report 9
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MANAGED CARE PROGRAM Managed Care Organizations (MCO) Primary Care Clinician Plan (PCC) POPULATIONS SERVED Children and adults under 65 Children and adults under 65 COVERED SERVICES Medical and Behavioral Health services covered by a capitated payment to health plans. Long-term support services (LTSS) and dental benefits not included in MCO benefit but available through MassHealth Fee-For-Service Behavioral Health services covered by capitated payment to behavioral health plan. Medical services, which are not capitated, are managed by a primary care clinician. Dental and LTSS benefits are available through MassHealth Fee-for-Service Some primary care clinicians receive capitated payments as part of the Primary Care Payment Reform Initiative (PCPRI) One Care Ages 21-64 Eligible for MassHealth and Medicare Full spectrum of services covered by capitated payment to one health plan (includes medical, LTSS, Dental, & Behavioral Health) Senior Care Options (SCO) 65 + Eligible for MassHealth and Medicare Full spectrum of services covered by capitated payment to one health plan (includes medical, LTSS, Dental, & Behavioral Health) 10
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MCOs SERVE A LESS MEDICALLY COMPLEX POPULATION THAN THE PCC PLAN MASSHEALTH MCO AND PCC PLAN ENROLLMENT BY POPULATION TYPE, DECEMBER 2013 600,000 Total: 522,311 500,000 11% 400,000 27% Total: 382,795 Basic Essential Adults 17% Non-Disabled Adults 300,000 200,000 8% 19% 15% Disabled Adults Non-Disabled Children Disabled Children 52% 100,000 45% 0 3% 3% MCO TYPE OF MANAGED CARE PCC TE: Chart shows enrollment for members under age 65. SOURCE: MassHealth, December 2013 Snapshot Report. 11
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MINAL MASSHEALTH SPENDING HAS GROWN BY MORE THAN HALF SINCE 2005; WHEN ADJUSTED FOR MEDICAL INFLATION SPENDING HAS GROWN ON AVERAGE 2% ANNUALLY MASSHEALTH SPENDING, SFY 2005-2013 (BILLIONS OF DOLLARS) $10 $9.8 $9 $8.8 $9.1 $9.3 Current Dollars $8.1 $8 $7 $6 $6.3 $6.3 $6.8 $6.5 $7.0 $6.4 $7.7 $6.7 $6.7 $7.0 $7.1 $7.2 Inflation-adjusted Dollars $7.3 $5 2005 2006 2007 2008 2009 2010 2011 2012 2013 STATE FISCAL YEAR SOURCE: MassHealth Budget Office. Inflation adjustment uses the Medical Consumer Price Index for the Boston area, from the Bureau of Labor Statistics. 12
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING ENROLLMENT HAS DRIVEN GROWTH IN MASSHEALTH SPENDING IN RECENT YEARS GROWTH IN MASSHEALTH TOTAL SPENDING, ENROLLMENT AND PER MEMBER PER MONTH (PMPM) COSTS (YEAR 2005 = 100) 155 150 145 Total Spending 140 135 Enrollment 130 125 120 115 110 105 $PMPM 100 95 2005 2006 2007 2008 2009 2010 2011 2012 SOURCES: EOHHS (total spending and enrollment) and authors calculations. 13
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH SPENDING PER ENROLLEE IS HIGHER FOR SENIORS AND THE DISABLED MASSHEALTH PAYMENTS PER ENROLLEE PER YEAR, FY 2013 $- $5,000 $10,000 $15,000 $20,000 $25,000 Seniors $21,613 Adults with Disabilities $12,633 Children with Disabilities $14,617 Adults $3,959 Children $3,590 Total $7,072 SOURCES: Calculations based on total spending form the MassHealth Budget Office, and average membership for July 2012 June 2013 from the MassHealth Snapshot Report. 14
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH SPENDING IS IMPORTANT TO MANY TYPES OF PROVIDERS MASSHEALTH REVENUE AS A PERCENTAGE OF PROVIDERS TOTAL PATIENT REVENUES 60% 50% 49% 51% 45% 40% 30% 27% 20% 14% 10% 0% Hospitals Nursing Homes Community Health Centers Long-term Services and Supports Pre-natal Care SOURCES: Center for Health Information and Analysis, 403 Cost Reports (Acute Hospitals, data from FY2012); Massachusetts Senior Care Association (Nursing Homes data from CY 2012); Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System Report (CHCs data from Federal FY 2012); Securing the Future: Report of the Massachusetts Long-Term Care Financing Advisory Committee, November 2010 (LTSS data from Calendar Year 2005); Mass. DPH, Massachusetts Births 2010 (Pre-natal Care data from Calendar Year 2010), March 2013. 15
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MASSHEALTH SPENDING BY SERVICE TYPE FOR STATE FISCAL YEAR 2013 TOTAL MASSHEALTH SPENDING FY2013 = $9.8B Other $534M Physician $331M 5% Dental $245M 3% 3% Pharmacy $512M 5% Hospital Outpatient $585M 6% 32% Managed Care Capitation Payments $3.2B Hospital Inpatient $740M 8% Community LTC Supports $1.4B 15% 8% SCO/PACE Capitation Payments $774M 15% Nursing Homes $1.4B TE: Other includes Transportation, community health centers, and smaller amounts of spending on rest homes, vision care, EI/Chapter 766, hearing care, group practice organization, family planning clinics, renal dialysis clinics, ambulatory surgery center, eye glasses, DME/Oxygen, imaging/radiation centers, certified independent labs, psychologists, mental health clinics, psychiatric day treatment, substance abuse services, and Medicare crossover payments. SOURCE: MassHealth Budget Office. 16
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MOST MASSHEALTH DOLLARS ARE SPENT ON SERVICES FOR A MIRITY OF MEMBERS DISTRIBUTION OF MASSHEALTH ENROLLMENT AND SPENDING BY POPULATION GROUP 100% 90% 80% 9% 20% 27% Seniors 70% 60% 50% 34% 36% Adults and Children with Disabilities 40% Non-Disabled Adults 30% 18% 20% 10% 38% 19% Non-Disabled Children 0% Enrollment Spending SOURCES: MassHealth Budget Unit, SFY 2013 data. 17
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING FEDERAL AND STATE SPENDING ON MASSHEALTH W REPRESENTS 30 PERCENT OF THE STATE BUDGET MASSHEALTH AS A PROPORTION OF ALL STATE SPENDING (BILLIONS OF DOLLARS) $35 $30 $27.8 $28.9 $28.9 $29.6 $30.3 Other state spending MassHealth-covered services $32.5 $31.3 $25 $23.5 $25.4 $20 $15 $17.2 $18.6 $20.8 $21.2 $20.8 $20.9 $21.2 $21.9 $22.7 $10 $5 $6.3 $6.8 $7.0 $7.7 $8.1 $8.8 $9.1 $9.3 $9.8 27% 27% 25% 27% 28% 30% 30% 30% 30% $0 2005 2006 2007 2008 2009 2010 2011 2012 2013 STATE FISCAL YEAR SOURCES: EOHHS (MassHealth data); Office of the Comptroller, Statutory Basis Financial Reports (other state spending). 18
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING MEDICAID IS THE MAIN SOURCE OF FEDERAL REVENUES TO MASSACHUSETTS MASSHEALTH AS A PROPORTION OF ALL FEDERAL REVENUES (MILLIONS OF DOLLARS) $10,000 Non-Medicaid federal revenue Medicaid/CHIP federal revenue $9,000 $8,000 $7,000 $945 $928 $925 $943 $1,005 $6,000 $858 $971 $5,000 $856 $824 $871 $4,000 $3,000 $2,000 $4,733 $4,546 $4,783 $5,388 $5,372 $7,698 $7,963 $8,413 $6,825 $7,210 $1,000 $0 85% 85% 85% 86% 85% 89% 90% 90% 88% 88% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 SOURCE: Massachusetts Budget and Policy Center 19
INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING Massachusetts Medicaid Policy Institute Blue Cross Blue Shield of Massachusetts Foundation Kate Nordahl Katharine.Nordahl@bcbsma.com Center for Health Law and Economics University of Massachusetts Medical School Robert Seifert Robert.Seifert@umassmed.edu Carol Gyurina Carol.Gyurina@umassmed.edu Kate Russell Kate.Russell@umassmed.edu Download the complete MassHealth: The Basics chart pack at http://bluecrossmafoundation.org/publication /updated-masshealth-basics-facts-trends-and-national-context 20