Medicaid Advisory Committee February 22, 2017 WEBINAR MEETING - - PowerPoint PPT Presentation

Medicaid Advisory Committee

February 22, 2017 WEBINAR MEETING

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9:00 Welcome and Introductions Laura Etherton, Co-chair 9:15 Federal Health Policy Update David Simnitt, OHA 9:45 Section 1115 Waiver 2017-2022 Veronica Guerra, OHA 10:15 Legislative Preview/Update Brian Nieubuurt, OHA 10:45 Public Comment All 10:55 Closing Laura Etherton, Co-chair

Welcome, Overview & Introduction

Emerging Federal Health Policy Changes: Understanding proposals and assessing impacts on Oregon’s Health System Transformation

David Simnitt, Director of Health Policy, OHA

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Overview

• Overview & Update on OHA & DCBS Efforts to Analyze and Assess

Changing Federal Landscape

• Update on Congressional Actions and Potential for ACA Changes in

Current Congressional Session

– Budget Reconciliation process and ACA repeal

• Key Themes of ACA Alternative Plans Offered in Recent Years
• Broad Highlights of 5 High Profile ACA Alternative Proposals

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Congressional Time for Repealing and/or

Replacing ACA Keeps Changing

• Congressional Work Throughout 2017, into 2018
• Scope of Repeal / Replace Getting Less Clear

– Full repeal before replacement bill becoming less likely – Targeted repeal proposals emerging – Medicaid “reform” part of emerging House plan

• Uncertain prospects in US Senate
• Challenges Facing Congress:

– Fully repealing entire bill requires 60 votes in US Senate – Congressional leaders & administration have not agreed upon replacement proposal

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Budget Reconciliation – Multi-Step Process Now Underway

• First step: House & Senate enacted a budget resolution

– The resolution itself DOES NOT repeal ACA; provides framework to repeal parts of ACA through process requiring only 51 votes in Senate

• Reconciliation bill starting in the House

– Limited to budgetary items & may not be able to repeal some policy & regulatory provisions of the ACA – House bill may include block grants / other Medicaid caps – Final bill dependent on Senate rules & parliamentary decisions

• Parts of ACA replacement may be included in reconciliation bill,

but many could NOT be enacted through this process

– Provisions not able to go through reconciliation process require 60 votes in the U.S. Senate

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Notable Elements of many (not all) Replacement Proposals

• Eliminate individual and employer mandates (& penalties)
• “Consumer driven” plan designs

– Higher deductibles (less generous actuarial value) paired with tax- advantaged health savings accounts.

• Eliminates federal exchanges & linking federal tax credit

subsidies to Qualified Health Plans as defined by the ACA

– Smaller tax credits – Age-adjusted instead of income-based

• Grants to states to help operate / establish high risk pools
• Cross-state sales of health insurance
• Eliminates ACA’s taxes on medical devices & “Cadillac” health

plans

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Elements of Reform: Consumer Protections

• Many plans keep:

– Guaranteed renewal, eliminating lifetime/annual benefit caps,

maintaining dependent coverage up to age 26 and eliminating pre- existing condition exclusions and medical underwriting

• Many plans eliminate/revise guaranteed issue

requirements to apply only for consumers who maintain continuous coverage for 12-24 months

– Individuals without continuous coverage could be charged more

• Eliminating Essential Health Benefits Requirements

– Some shift responsibilities to states while others weaken state authority in name of “cross-state sales” of health insurance

• Shift towards high-deductible plans w/ Health Savings

Accounts

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Elements of Reform: Medicaid

• Many ACA Alternative Reduce Federal Medicaid Spend

Through New Approaches & Shift Costs to States

• Block Grants

– Eliminates matching-rate structure of Medicaid – Sets total funding levels for states – uncertainty around baseline

– Annual growth set by fed. govt., designed to reduce fed spending – States able to set eligibility & covered services, but responsible for all spending in excess of federal block grant

• Per-capita Caps / Capped Allotments

– Caps federal funding on per-enrollee basis

– Set federal allotment for enrollees based on their eligibility category

– Greater state flexibility to determine Medicaid service package, but

funding still tied to specific eligibility categories limits state flexibility regarding eligibility

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Medicaid Reform Considerations

• Congressional Disagreement RE: ACA’s Expansion

– 31 expansion states want to protect $ (many with R Gov/Sen) – Non-expansion states want new funding added to baseline – Status of ACA’s CHIP funding bump is unclear?

• Federal Caps Affect States Differently

– States already taking steps to reduce spending growth (Oregon) could be disadvantaged – States with higher Medicaid spending could disproportionately benefit from caps & federal flexibility – Ultimate impact on Oregon will depend on details not yet available – especially regarding expansion funding

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Prominent ACA Alternatives - Summarized

Ryan Price Hatch Cassidy/ Collins

• A. Roy

Mandates Repeal Repeal Repeal State option Repeal Medicaid

Block Grant / per-capita Cap Repeal Expansion Per-Capita Cap State opt: ACA

• r HSA-based

Move to Exchanges, LTSS to States

X-State Sales

Yes Yes Yes No No

Tax Credits?

Age-Based Age-Based Age-Based ACA cont OR HSA-based Income & Age

HSAs

Higher Contributions Higher Contributions Higher Contributions Roth HSA (post-tax, pay 4 premiums) Subsidized

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Common Challenges / Opportunities

• Reduced federal Medicaid investment shifts costs to states
• Cross-state sales of health insurance takes away states ability

to regulate their own insurance market

• Reduced federal regulatory oversight shifts regulatory

authority back to Oregon

• “State Flexibility” may be good for Oregon given state’s

historical focus on innovative health policy

• Executive branch changes - waivers, etc

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Questions?

Oregon’s Waiver: 1115 Demonstration Renewal with the Centers for Medicare & Medicaid Services

Veronica Guerra, Policy Analyst, OHA

Agenda

• Waiver overview and goals
• Targeted changes under renewal
• Next steps

Oregon’s Medicaid 1115 Demonstration Waiver Renewal

• Expedited approval: preserves Oregon’s Medicaid system,

continues Oregon’s Health System Transformation (HST) momentum, and provides continuity for CCOs

• Approval period: five year contract with the federal

government from January 12, 2017 through June 30, 2022

• Federal investment: Oregon will continue to receive federal

match to cover the Medicaid population

Waiver Goals

• 1. Build on transformation with focus on integration of physical,

behavioral, and oral health care through a performance driven system

• 2. More deeply address social determinants of health and health

equity with the goal of improving population health and health

• utcomes
• 3. Commit to ongoing sustainable rate of growth, advance the

use of value-based payments, and promote increased investments in health related services

• 4. Continue to expand the coordinated care model

Continuing the Success of the Oregon Health Plan

• The waiver renewal preserves OHP’s core tenets:

– Integrated physical, behavioral, and oral health care – Provide services to OHP members through CCOs – Advance the coordinated care model – Pay for value rather than volume of services – Continue to hold down costs to a sustainable rate of growth – Offer evidence-based benefits through the state’s prioritized list of services

Waiver Renewal Targeted Changes

• Oregon received additional flexibility to:

– Continue the Hospital Transformation Performance Program (HTPP) – Promote increased investments in health related and flexible services – Promote primary care and pay for value – Expand access to coordinated care – Advance Tribal Health Programs

Hospital Transformation Performance Program Extension

• The waiver provides flexibility to:

– Extend the current HTPP program through June 30, 2018 – Redesign the program upon expiration of the one-year approval

Increased Investments in Health-Related Services

• The waiver renewal:

– Provides definitions: in lieu of services and health related services (flexible services + community benefit initiatives) – Provides clarity on how non-traditional services that improve health are accounted for in global budgets – CCOs encouraged to invest in health related services that improve quality and outcomes – CCOs that reduce costs through use of these services can receive financial incentives to offset those cost reductions

Promote Primary Care and Pay for Value

• The waiver provides flexibility to:

– Require CCOs to enter into value-based payment (VBP) arrangements with network of providers

• OHA will work with CCOs and stakeholders to develop a

framework to advance the use of VBPs

– Offer new performance incentive payments to Patient Centered Primary Care Homes (PCPCH) and Comprehensive Primary Care Plus (CPC+) providers that reflect provider performance in these programs

Expand Access to Coordinated Care

• The waiver provides flexibility to:

– Auto-enroll (with opt-out option) individuals dually eligible for both Medicaid and Medicare into CCOs – Begin phased in implementation on January 1, 2018

• OHA will work closely with DHS to ensure alignment and

coordination as we prepare for implementation

• Members will be enrolled in the same CCO as their D-SNP and

Medicare Advantage program

Advancing Tribal Health Programs

• The waiver provides flexibility to:

– Transition the Tribal Uncompensated Care Program (UCCP) to become a Medicaid benefit, making the program easier to manage for tribe – Establish minimum requirements for CCOs to collaborate and communicate with tribes and Indian Health Care Providers – Develop a Model Medicaid and CHIP Managed Care Addendum for Indian Health Care Providers

Questions?

For more information, visit:

http://www.oregon.gov/oha/hpa/Medicaid-1115-Waiver/Pages/Waiver-Renewal.aspx

Photos: Oregon State Archives

Legislative Session Update

Brian Nieubuurt, OHA

Key 2017 Medicaid Legislation Bill # Summary House Bill 2122 (Senate Bill 273) Modifies requirements for coordinated care organizations in 2018 and 2023. Beginning in 2023, requires coordinated care

• rganizations to be community-based nonprofit organizations, to have membership of governing body that reflects local

control and to distribute at least 80 percent of payments to providers using alternative payment methodologies. Creates Community Escrow Fund in State Treasury to hold coordinated care organization restricted reserves. Requires Oregon Health Policy Board to adopt minimum criteria for continuation of contracts with coordinated care organization. Requires coordinated care organizations seeking to contract with Oregon Health Authority in 2018 to present plan for moving toward 2023 requirements and to explain steps taken to innovate health care delivery. House Bill 2391 Requires Oregon Health Authority to submit blueprint for basic health plan to Centers for Medicare and Medicaid Services by December 31, 2017 House Bill 2580 Exempts foster children and homeless youth from requirement to enroll in coordinated care organization in order to receive medical assistance. House Bill 2451 Establishes medical assistance eligibility for individuals under age 26 who have aged out of foster care in Oregon or another state House Bill 2726 (Senate Bill 558) Requires Oregon Health Authority to convene work group to advise and assist in implementing targeted outreach and marketing for Health Care for All Oregon Children program. Permits all children residing in Oregon and meeting financial eligibility requirements to enroll in program. Requires authority, in collaboration with Department of Consumer and Business Services if necessary, to seek necessary federal approval or waiver of federal requirements to secure federal financial participation in costs of outreach and marketing and in expansion of eligibility for program. Senate Bill 233 Requires Oregon Health Authority to make publicly available specified information regarding administration of medical assistance and payments to coordinated care organizations. Specifies criteria and procedures for establishment of global

• budgets. Provides review by Department of Consumer and Business Services of global budget established by authority.

Requires department to implement procedures for reviewing de novo global budget determination appealed to department by coordinated care organization. Senate Bill 234 Requires Oregon Health Authority to renew coordinated care organization contract for another five-year term if specified conditions are met. Senate Bill 236 Limits discretion of Oregon Health Authority with respect to contracts with and rules concerning coordinated care

• rganizations and imposes new requirements. Imposes requirements on authority for rulemaking and collaborating with

coordinated care organizations. Imposes additional responsibilities on Oregon Health Policy Board in oversight of authority, Health Evidence Review Commission and Office for Oregon Health Policy and Research. Requires Department of Consumer and Business Services to certify global budget before budget may take effect.

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Public Comment