Eastern Medicaid Pharmacy Administrators Association October 21, - - PowerPoint PPT Presentation

Eastern Medicaid Pharmacy Administrators Association

October 21, 2014

Heather Howard Lecturer in Public Affairs, Princeton University Director, RWJF State Health Reform Assistance Network heatherh@princeton.edu

Overview

• Current Status of ACA Implementation
• Impact of ACA
• Issues to Watch

Medicaid Expansion Status

Medicaid Expansion – Current status

• 28 states (including DC) expanding Medicaid
• 5 states expanding Medicaid using an alternative to

traditional expansion.

• States see opportunity (and leverage) to innovate using

waivers

• Several considering expansion
• Indiana in negotiations with CMS
• TN and UT preparing plans
• Impact of elections?

Medicaid Expansion: Alternative Approaches

• Arkansas “private option” providing QHP premium

assistance to newly eligible adults up to 138% FPL

• Michigan expansion – creation of health savings accounts,

consumer healthy behavior incentives, premiums and copays, and four year “limit”

• Pennsylvania alternative recently approved; includes

premiums, but no job search requirement as previously proposed

Medicaid Expansion Challenges

• How has expansion decision played out in states?
• State analysis of impact
• Role of stakeholders
• Politics trumps policy in many states
• Enrollment
• Problems interfacing with healthcare.gov
• Expansion enrollments still beat state estimates
• “Woodwork effect” even in states that didn’t expand
• Provider capacity

Impact of expansion – Distribution of the uninsured

Type of Health Insurance Marketplace

Enrollment numbers

• Exchange enrollment this year
• Enrollment through August: 7.3 million
• Original CBO projection for all of 2014: 7 million
• Medicaid enrollment
• Approximately 8 million additional individual Medicaid

enrollments since October 2013

• States with expanded Medicaid programs experienced 20 percent

enrollment growth, compared to 5 percent growth in states that did not expand Medicaid

• Projections for 2015
• CBO projects cumulative enrollment of 13 million in the

exchanges

• CBO projects additional cumulative Medicaid/CHIP enrollment to

reach 11 million in 2015

Early Victories and Challenges

• 47% of all exchange enrollees nationally, and 52% of those

age 18‐34, enrolled the last month of the initial OEP

• 80% avoided bronze plans
• FFM enrollment grew rapidly once healthcare.gov fixed
• Some FFM states putting substantial barriers in the way of

federally funded consumer assisters

• Some SBM state IT systems still not up to par
• Vendors unable to deliver
• States didn’t use systems integrator
• Medicaid and exchanges not sufficiently coordinated

Early Observations – Systems Builds

• Importance of systems integrator
• The vendor matters
• Focus on core functionality – avoid scope

creep

• Integration with Medicaid is key
• Focus on consumer experience
• Clear lines of accountability, both internally

and in vendor contracts

Maslow’s Hierarchy of Needs

Exchange Hierarchy of Goals

Enhance Quality of Care, Strengthen Delivery Systems and Improve Population Health

Restrain Premium Trend and other Costs Near Universal Coverage Financially Self‐Sustaining, Enhanced Consumer Experience and Decision Support Tools Accurate and Timely Functionality, Good Customer Service

Self ‐ Actualization Esteem Belonging Security Physiological

What’s changed for OEP2

• Renewals
• Shorter enrollment period – Nov. 15 to Feb. 15
• Different shopping experience
• More carriers in many states
• Premium changes
• Impact on subsidies
• Increased penalty for not carrying insurance
• First year of tax forms (1095s)
• Year of experience
• Impact on Medicaid?

Renewals

• CMS has provided states with great flexibility in the

Medicaid renewal (a.k.a. redetermination) process

• States can delay renewals
• States can use new data sources to process renewals
• Marketplace renewals may present challenges for

Medicaid

• Auto‐renewal in FFM states may put a person into a Marketplace

plan when they should have been Medicaid

• Persons that renew on the Marketplace may be found eligible for

Medicaid (perhaps with retroactivity) while they are still enrolled in their QHP

• Medicaid should remain payer of last resort
• Renewal process will strain consumer assistance and eligibility

functions

Issues to Watch

• IT Challenges
• State Medicaid and Federal Exchange connections
• November 2014 election
• New Medicaid expansion states / Federal

Flexibility

• Churn
• Health insurance literacy and utilization
• Ongoing debates on specialty pharmaceuticals

Heather Howard Director, RWJF State Health Reform Assistance Network Lecturer in Public Affairs, Princeton University Woodrow Wilson School of Public and International Affairs (609) 258‐9709 heatherh@princeton.edu