the "healthy ohio" medicaid waiver: disrupting health care coverage and increasing cost
TRANSCRIPT
The “Healthy Ohio” Medicaid Waiver
Disrupting Health Care Coverage and Increasing Cost
a statewide coalition of over 475 organizations and thousands of individual advocates
Advocates for Ohio’s Future is…
Ohio should be a great place for ALL Ohioans to live and work.
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Nita CarterProject Director
Universal Health Care Action Network of Ohio (UHCAN)
Tara BrittonPublic Policy Fellow
The Center for Community Solutions
Webinar Presenters
Healthy Ohio 1115 Waiver New Medicaid Waiver Proposal Will Disrupt Coverage and Increase
Costs
Tara BrittonPublic Policy Fellow
The Center for Community Solutions
Agenda • Background on Medicaid program• What is an 1115 waiver?• Healthy Ohio 1115 waiver proposal• What have been the experiences in other
states?• Policy questions and advocacy strategies
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Medicaid • Medicaid is a joint federal-state health insurance
program for low-income people. About 2.9 million Ohioans, or 25 percent of the state’s population, are enrolled in Medicaid.
• Currently, Medicaid enrollees do not pay a monthly premium for insurance, but they do make co-payments for some services.
• The state contracts with managed care organizations (MCOs) to handle payments to medical providers. In this arrangement, the state pays a set amount per month for each person enrolled, to the MCO to enroll Medicaid-eligible people and pay for their care.
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Medicaid Extension• Prior to 2014, in Ohio, low-income
childless adults, and parents above 90% of the federal poverty level, were not covered by Medicaid
• In January, 2014 these groups became eligible for coverage up to 138% FPL when Medicaid was extended under the Affordable Care Act (ACA).
• Over 650,000 people are now covered through the extension.
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Healthy Ohio Waiver in H.B. 64Who Has to Enroll?
• The 2016-2017 state budget bill requires the Ohio Department of Medicaid (ODM) to apply to the federal government for permission to change, or “waive,” fundamental Medicaid rules.
• The waiver would require ALL non-disabled adults on Medicaid who currently qualify based on income to pay premiums into a modified health savings account (HSA). This would apply to over 1 million adult Ohioans who are currently enrolled in Medicaid, and is not limited just to the expansion population.
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Healthy Ohio: Who Has to Enroll?
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37% of Medicaid Population will be Required to Enroll in Healthy Ohio
Source: Ohio Department of Medicaid, ODM Eligible Clients, November 2015
CFC- Kids and CHIP; 1104254; 37%
Healthy OH En-rollees- Medicaid
Extension; 649803; 22%
Healthy OH En-rollees- CFC Adults;
456514; 15%
Aged, Blind, Disabled; 371304; 13%
Other Categories, 228546, 8%
Limited Benefit; 138689; 5%
What is an 1115 Waiver and How Does it Work?• “Section 1115 of the Social Security Act gives the Secretary of
Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid program.”
• A waiver application must first be written by ODM and submitted to the Center for Medicare and Medicaid Services (CMS).
• There is a 30-day state public comment period prior to submission to CMS. This includes a period for written comments and two public hearings on the waiver.
• After ODM submits the waiver to CMS, and CMS deems the application complete, there is a 30-day federal public comment period.
7Source: CMS. Section 1115 Demonstrations, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/1115/section-1115-demonstrations.html
Healthy Ohio 1115 Waiver Proposal-
The Details
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Healthy Ohio- Premiums• Charged to all non-disabled adults in Medicaid (no medically frail exemptions)
• Premiums are equal to the lesser of 2% of annual family income or $99/year, made in monthly installments. Deposited into modified-health savings account (HSA), known as Buckeye Account
• Requires waiving federal law that prohibits charging premiums to individuals with incomes below 150% FPL
• Third party organizations can help with premiums
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Healthy Ohio- Lockout Period• If a participant goes 60 days without paying a
premium, he/she is “locked out” (disenrolled from the program without access to fee-for-service or regular managed care)
• Lock-out continues until back premiums are paid.
• Failure to submit documentation to recertify for the program within 60 days of receiving a notice will also result in being locked out of Medicaid
• Pregnant women are not locked out of Medicaid for failure to pay (lock-out can occur after delivery)
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Healthy Ohio- Buckeye Account• After participant makes initial contribution, ODM
is required to make a deposit of $1,000 into each Buckeye account
• The ODM portion of the Buckeye Account is spent toward medical expenses before Medicaid managed care plans cover any services. The participant’s premium contributions are spent on co-payments for services.
• A debit swipe card system will be created to track spending from each portion of the account. This system must signal MCOs to pay providers when the card balance reaches zero.
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Healthy Ohio- Buckeye Account• There is a point system attached to each
Buckeye account and participants can earn points for certain activities and meeting goals. One point is equal to $1.
• Points are awarded for: • setting up electronic funds transfers to pay
monthly premiums (20 points), • achieving health goals (up to 200 points),
and • satisfying health benchmarks (up to 100
points) 12
Healthy Ohio- Limits to Coverage• Institutes a cap on yearly and lifetime
expenses. The bill includes a provision that would implement a $300,000 annual payout limit and a $1 million lifetime payout limit.
• If a person exceeds these limits, he/she would be transferred to coverage through the Medicaid fee-for-service or managed care system.
• The bill does not require coverage for all of the Essential Health Benefits, as required by the Affordable Care Act.
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Questions?You can ask a question by typing into the chat bar.
Unmute by pressing *6 on your phone or using the microphone button on the top center of your screen.
What happened in other states as a
result of premiums/cost-
sharing?
Premiums Led to Declines in enrollment in Other States• Oregon increased premiums for adults in
its Medicaid program under 100% of FPL and after the premium increase, enrollment dropped by 77% (80,000 people), and the biggest drop in enrollment was among enrollees with the lowest income.
14Wright et al. (2005; 2010), Health Affairs; Dague (2014) JHE
Premiums Led to Declines in enrollment in Other States• Wisconsin’s experience shows that the
implementation of monthly premiums resulted in a decline in program enrollment. Premiums were applied to adults starting at 150% of FPL and children at 200% of FPL, so even at higher income ranges than Ohio is proposing, program enrollees were more likely to exit the program
14Wright et al. (2005; 2010), Health Affairs; Dague (2014) JHE
Costs Associated with Administering Cost-Sharing in Medicaid
• Arkansas recently eliminated the imposition of health savings accounts and cost‐sharing requirements on participants below 100% of the FPL due to high administrative costs.
15Sources: Arkansas Advocates for Children and Youth, February 6, 2015
Costs Associated with Administering Cost-Sharing in Medicaid
• Virginia implemented a $15 monthly premium for each child enrolled in Medicaid with family income between 150% and 200% of the FPL. VA ended the program when it found that 4,000 children were going to be disenrolled due to premium non-payment and that the state was spending $1.39 on administration for every $1 in premiums collected.
15Sources: Georgetown University Health Policy Institute, Center for Children and Families
What has been approved in other
states?
Elements allowed in waivers to extend
Medicaid • Premiums for Individuals above 100% FPL• Disenrollment into basic Medicaid for
failure to pay premiums (for enrollees 100% FPL or below); or remain in the program, but debt owed to state for missed premiums
• Copays and premiums up to 5% of income
• Referrals to work programs • Incentives for preventive care or
healthier lifestyles 16
Approved Waivers in Other States
Indiana- Healthy Indiana requires premiums from adult Medicaid recipients.
• Healthy Ohio is similar to this plan; 6-mo lockout.
• Waiver extension approved and was used to extend Medicaid under ACA.
• Adults under 100% FPL who are dis-enrolled for failure to pay premiums fall into basic Medicaid plan with fewer benefits.
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Pending Waivers in Other States
Arizona- Expanded its Medicaid program to childless adults up to 138% FPL under the ACA. Recently submitted a waiver application to CMS to change coverage for expansion population. The waiver proposes:• Five-year lifetime limit• Work requirement • Charge monthly premiums of 2% of
income or $25, whichever is less, on all adults in the Medicaid expansion category, 0-138% FPL
• Establish healthy behavior incentives and co-pays for missed appointments and inappropriate ER use. 20
Implications for policy objectives• Interrupting treatment of chronic disease,
provision of preventive care, and mental health and substance abuse treatment, among other important services
• Will Healthy Ohio increase the cost of care and not just administration?
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Questions?You can ask a question by typing into the chat bar.
Unmute by pressing *6 on your phone or using the microphone button on the top center of your screen.
Participating in Public Comment Periods for Ohio’s Healthy Ohio Waiver
Presented By:
Nita Carter, Project Director, UHCAN Ohio
UHCAN Ohio is a statewide, nonprofit organization working to build the voice of consumers to achieve quality, affordable health care for all Ohioans.
What You Need to Know About Ohio's Medicaid Waiver34
Ohio Medicaid: Current vs. Waiver
What You Need to Know About Ohio's Medicaid Waiver35
Healthy Ohio Poses Key Implementation Questions:
• Program Costs-to implement and administer the system
• Potential Enrollment Decline
• Patient Education
• Transitions
What You Need to Know About Ohio's Medicaid Waiver36
Process for Submitting the Waiver• Ohio Department of Medicaid(ODM) drafts the waiver
• ODM submits the waiver to Federal Centers for Medicaid and Medicare(CMS)
• CMS has the final say on whether the Waiver is approved as submitted, approved with modifications, not approved.
• There are 2 opportunities for public comments in the process, state-level public comment period and Federal/CMS level public comment period.
What You Need to Know About Ohio's Medicaid Waiver37
State Public Comment Period
Prior to submission to CMS there will be a state-level public comment period which will include:
1. an opportunity to submit comments on the wavier2. 2 Public Hearings in separate locations
The state comment period will last for 30 days.
The state will be responsible for compiling and providing comments received during the state’s comment period to CMS along with the Waiver Proposal.
What You Need to Know About Ohio's Medicaid Waiver38
Federal Public Comment Period:
• Once the Waiver and comments are submitted to CMS this begins the federal comment period.
• CMS Comment period last for 30 days.• While the comments are submitted from the state level process it is
important to send comments directly to CMS during the federal comment period.
• After the close of the CMS comment period CMS then begins the review process to make a decision on the waiver.
• Once Decision is final they will announce their decision.
What You Need to Know About Ohio's Medicaid Waiver39
Importance of the Public Comment Periods
• These public comment periods are an opportunity for the public to provide feedback to the state and CMS on the proposed waiver.
• It is important that those who would be negatively affected by the waiver weigh in and be heard. This could result in the waiver being denied or amended.
• It is important to have people whom this change will affect participating in the public comment periods as well as organizations who work with Medicaid populations.
• CMS reviews all comments submitted at the state level and those submitted to them and weighs comments in their decision-making process.
What You Need to Know About Ohio's Medicaid Waiver40
Ways to Get Involved in the Public Comment Periods:As an individual you can:• sign on to comments developed by UHCAN Ohio.• You can tell your story how this change can impact you or those you
know and love. • You can tell your story on how Medicaid has helped you or those you
know or work with.• You can testify at public hearings at the state level.• Meet with your federal Congress person to share your concerns
about the waiver
What You Need to Know About Ohio's Medicaid Waiver41
How to Get Involved in Public Comment Periods Continued:As an organization you can:
• Sign on to draft comments• Draft your own comments• Get the information out to those you work with• Help identify people who can participate in public hearings
and tell their stories.• Meet with you federal Congress person.
What You Need to Know About Ohio's Medicaid Waiver42
UHCAN can help you get involved
• UHCAN Ohio will have draft comments, templates to help you draft your comments and sign-on letters.
• UHCAN Ohio is collecting stories to use at public hearings and to send to the Ohio Department of Medicaid and CMS. If you are interested or have someone who wants to share their story you can call UHCAN Ohio.
• UHCAN Ohio will have information on our web-site when the public comment periods begin and end and when public hearings will be held.
• See the Medicaid Waiver Action Center on our website: uhcanohio.org/HealthyOhioMedicaidWaiver
What You Need to Know About Ohio's Medicaid Waiver43
How We Use Stories
• Share them with the Media to tell the story of how Medicaid is working and how premiums and other provision would impact Medicaid recipients.
• Share them with CMS and the Ohio Department of Medicaid during the public comment periods.
• Share them at public hearings.
What You Need to Know About Ohio's Medicaid Waiver44
For More Next Steps:
• You’ll receive a follow-up email from this webinar
• Visit UHCAN Ohio’s Medicaid Waiver Action Center
• Sign up for UHCAN Ohio’s email alerts
What You Need to Know About Ohio's Medicaid Waiver45
Tell us how you’ll get involved
• Please respond to the survey after the webinar to let us know if you plan to be participate in the public comment periods and how.
• What assistance do you need from UHCAN Ohio to help you in your advocacy?
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Questions?
Unmute by pressing *6 or using the microphone button on the top center of your screen.
You can also ask a question by typing into the chat bar.
Next Steps for Medicaid Advocacy• Answer the survey question after this webinar.
• You’ll receive a follow-up email from this webinar
• Visit UHCAN Ohio’s Medicaid Waiver Action Center
• Sign up for UHCAN Ohio’s email alerts
Thank you for joining us today!
Please wait while you are directed to the survey.