CMS Pre limina ry Re c o mme nda tio ns July 26, 2019 CMS is c - - PowerPoint PPT Presentation

HB 19- 1004: Sta te Option for He a lth Ca re

CMS’ Pre limina ry Re c o mme nda tio ns

July 26, 2019

CMS is c ommitte d to finding solutions

• He lpe d inc ub a te SB 06-208’ s Blue Rib b o n

Co mmissio n fo r He a lth Ca re Re fo rm

• Suppo rte d a nd/ o r he lpe d pa ss:
• 208 Co mmissio n re po rt
• CI

VHC

• Me dic a id e xpa nsio n
• He a lth insura nc e e xc ha ng e
• Co st Co mmissio n
• HB 19-1004

CMS is c ommitte d to finding solutions

• Suppo rt a pub lic o ptio n tha t inc re a se s c o mpe titio n

in he a lth insura nc e ma rke ts; re duc e s insura nc e pre miums; fa c ilita te s q ua lity impro ve me nt a nd a dministra tive simplific a tio n; a nd inspire s physic ia n ne two rk pa rtic ipa tio n.

CMS’ Goal

• I

nc re a se c o mpe titio n in the multi-pa ye r syste m utilizing c urre nt c o mme rc ia l pa ye rs

• F

und pub lic o ptio n thro ug h re duc tio n o f wa ste a nd ta xe s o n g o o ds kno wn to da ma g e he a lth

• Sta nda rdize b e ne fit pa c ka g e utilizing va lue -b a se d insura nc e de sig n

princ iple s a c ro ss a ll c a rrie rs se lling in the individua l a nd sma ll g ro up ma rke t

• Sta nda rdize fo rmula rie s, pro vide r c o ntra c ting , prio r a utho riza tio n, utiliza tio n &

c la ims ma na g e me nt, g uide line s, a nd c o st & q ua lity me tric s a c ro ss c a rrie rs

• Be ne fits o ffe re d o n E

xc ha ng e with sub sidie s to b e de te rmine d b y a ffo rda b ility c rite ria a c ro ss inc o me le ve ls

Harne ss inno vative strate g ie s to re duc e c o sts b y inc e ntivizing e ffic ie nt c are de live ry, hig h-value se rvic e s, stre amline d administratio n, and he althy b e havio rs

Ove r vie w

• T
• g a in the b e ne fit o f inc re a se d c o mpe titio n, the

pub lic o ptio n sho uld b e o ffe re d sta te wide

• Offe r in the individua l a nd sma ll g ro up ma rke ts

thro ug h the E xc ha ng e

• I

nspire a nd inc e ntivize physic ia n pa rtic ipa tio n thro ug h a de q ua te re imb urse me nt a nd re duc tio ns in a dministra tive b urde n in o rde r to e nsure a c c e ss

E ligibility & Ac c e ss

• I

nc re a se fa ir ma rke t c o mpe titio n to impro ve a ffo rda b ility fo r c urre ntly insure d, uninsure d, a nd unde rinsure d po pula tio ns

• Affo rda b ility c rite ria sho uld a pply to pre miums, de duc tib le s, a nd c o st-

sha ring

• Re duc e c o sts b y ide ntifying , c a pturing , re turning , a nd re inve sting sa ving s:

– Stro ng suppo rt fo r prima ry c a re , b e ha vio ra l/ me nta l he a lth, a nd a ll

c o mpo ne nts o f the me dic a l ne ig hb o rho o d

– Re duc e pric e

• Ne g o tia te d a lte rna tive pa yme nt stra te g ie s to re duc e unwa rra nte d

va ria tio ns in pric ing a nd e nc o ura g e pa rtic ipa tio n

– Re duc e wa ste

• Ove ruse , unde ruse , misuse o f re so urc e s (da ta re vie w a nd o ve rsig ht)
• Administra tive simplific a tio n: sta nda rdize fo rmula rie s, pro vide r c o ntra c ting ,

prio r a utho riza tio n, utiliza tio n & c la ims ma na g e me nt, g uide line s, c o st & q ua lity me tric s a c ro ss c a rrie rs

– I

nc e ntivize pa tie nts’ he a lthy b e ha vio rs, a dva nc e c a re pla nning

– I

nc re a se tra nspa re nc y a nd use o f c o st a nd q ua lity da ta

Affor dability

• Prima ry insura nc e risk is b o rn b y c a rrie rs
• Risk fo r q ua lity a nd e ffic ie nc y o f c a re de live ry ma y

b e b o rn b y pro vide rs if ide ntifie d a c c ura te ly a nd imple me nte d fa irly

• T

a x g o o ds kno wn to da ma g e he a lth (e .g . to b a c c o , a lc o ho l, c a nna b is pro duc ts, sug a ry b e ve ra g e s)

Risk Be ar e r , F inanc ing

• Sta nda rd (a c ro ss pa ye rs)
• Va lue -b a se d insura nc e de sig n

– De c re a se d o r no c o st-sha ring fo r de fine d hig h-va lue

se rvic e s

• e .g . pre ve ntio n, prima ry c a re , me nta l he a lth, pre na ta l c a re ,

c hro nic dise a se ma na g e me nt, immuniza tio ns, e tc .

– I

nc re a se d c o st sha ring fo r lo w-va lue se rvic e s (e xpe nsive a nd o ve rutilize d)

– Othe r se rvic e s c o ve re d pe r c urre nt sta nda rds Be ne fits

Amy Goodman, JD, MBE

Se nio r Dire c to r o f Po lic y a my_g o o dma n@ c ms.o rg

Dave Downs, MD, F ACP

Cha ir, Wo rk Gro up o n He a lth Ca re Co sts & Qua lity da ve do wns1@ me .c o m