UNIVERSAL ACCESS TO CARE WORK GROUP 2018 1 LPRO : L EGISLATIVE P - - PowerPoint PPT Presentation

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UNIVERSAL ACCESS TO CARE WORK GROUP 2018 1 LPRO : L EGISLATIVE P - - PowerPoint PPT Presentation

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September 20, 2018 LPRO : L EGISLATIVE P OLICY AND R ESEARCH O FFICE UNIVERSAL ACCESS TO CARE WORK GROUP 2018 1 LPRO : L EGISLATIVE P OLICY AND R ESEARCH O FFICE AGENDA Welcome, Opening Remarks

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UNIVERSAL ACCESS TO CARE WORK GROUP 2018

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

September 20, 2018

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AGENDA

Welcome, Opening Remarks ……………………..…………………………………………….8:00—8:05am Representative Salinas, Chair, Work Group Public Comment…………………………………………………………………………………….8:05—8:20am Representative Salinas, Chair Medicaid Buy-in: Policy Priorities and Approaches…………….............................8:20—8:50am Tim Sweeney, OHA; Jesse O’Brien, DCBS; Oliver Droppers, LPRO Discussion: Medicaid Buy-in, Oregon Considerations………............................8:50—10:00am Representative Salinas, Chair Premium Assistance – Project Access NOW.…………………………………………...10:00—10:40am Janet Hamilton, Project Access NOW Work Group – Next Steps (Oct. & Nov. Meetings) ………………………………….10:40—11:00am Representative Salinas, Chair, Work Group Adjourn……………………………………………………………………………………………………….11:00 am

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Today’s Objectives

  • Consider Medicaid buy-in option in Oregon; preliminary design

considerations (cont. from August 23rd meeting)

  • Identify and confirm preferred list of policy goals
  • Review and discuss straw proposals – *disc

scussi ssion purpose ses o s only*

  • Learn about a premium assistance program operated by Project

Access NOW

  • Review next steps, discuss work group product and priorities for

remaining meetings (Oct.-Dec.)

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  • 2. What problems are the work group

being task to solve in Oregon?

  • Policy pathway to universal coverage
  • Better care, more people, less money
  • Access issues (rural/urban, income disparities)
  • Affordability
  • Address unmet health care needs
  • Address cost drivers; administrative burden, system

complexity, & financial accountability

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LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

* Information from the April 19th workgroup meeting

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Member Observations - August

Learned about approaches to Medicaid Buy-in: 1) marketplace option to compete with commercial carriers 2) provide coverage for target population(s) with certain eligibility 3) public option to minimize churn Members raised the following issues and questions: (1) smoothing coverage transitions between OHP/Marketplace plans (2) increasing competition on the Marketplace (3) establishing provider reimbursement rates (4) scalability – pilot vs. statewide (5) transition from fee-for-service to value-based payment models (6) provider participation (7) voluntary vs. mandatory approach (8) coverage of behavioral health services LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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Medicaid Buy-in Design Considerations

1. What is the overall policy goal? Is it to increase coverage? Improve affordability? Increase competition by creating another marketplace option? Leverage delivery system reform through Oregon’s Medicaid program? 2. How many individuals would gain new coverage or shift existing coverage? What is the target population? What’s the income level? Exclude individuals eligible for employer-based coverage? 3. Would the buy-in program be administered as an extension of the ACA Medicaid program (low-income individuals and families), or as a stand alone program? Managed care or fee-for-service? 4. What benefits would be covered? OHP benefits or 10 essential health benefits? Long-term services, adult dental benefits, non-emergency transportation LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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Medicaid Buy-in Design Considerations (cont.)

5. What is the appropriate level of out-of-pocket costs? How would cost sharing be structured: co-pays, premiums, deductibles? Similar to Marketplace, Medicaid, in between, other? 6. How would premiums be set and corresponding premium assistance determined? Would premiums be set by the state (similar to Medicaid), or would rates be developed by carriers in the marketplace? Would certain populations pay no premiums? 7. Provider reimbursement? Medicaid level, commercial, or in between (e.g., Medicare fee-for-service)? Potential cost savings to the program based on differences between market coverage and the buy-in program? 8. What federal dollars would be available? How much federal funding would be available, if any, and what percentage of program costs can federal spending support? LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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Medicaid Buy-in Design Considerations

Considerations outlined by OHA and DCBS

Population – available to all or parameters to population Access and competition within the insurance market Affordability – offer subsidies based on marketplace standards, premium assistance Market alignment Risk pool – in Medicaid risk pool versus separate from Medicaid Financing LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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Less Affordable More Affordable

Medicaid Buy-in: Key Factors Influencing Affordability and Costs for Coverage

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Coverage Affordability Premiums, Deductibles, and Co-pays Level of Benefits Provider Reimbursement Availability of Federal/State Funds

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Medicaid Buy-in Design Proposals

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Proposal A Improve Access a ss and Affordability: Contract with CCOs to provide consumers outside of Medicaid eligibility to purchase insurance product with similar design consideration to CCO plans. Expand affordable coverage in Oregon

  • Reduce monthly premiums, or
  • Reduce out-of-pocket costs, or
  • Enhance benefits or value for given

premium Proposal B Increase se Access a ss and Competition: CCOs offer commercial insurance product on Marketplace in counties with limited carriers (fewer than two carriers). Stabilize/Strengthen Individual Market

  • Carrier of last resort
  • More plans on the marketplace
  • Increased plan offerings

(potentially)

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Medicaid Buy-in Design Proposals

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Proposal C Strengthen A Alignment Betwe ween Medicaid and M Marketplace: ensure the same provider networks are offered in Medicaid and Marketplace; enhance care continuity. Streamline transitions for consumers between Medicaid and commercial coverage

  • CCOs offer plans on the Marketplace

(individual market)

  • CCOs offer plans to small group market
  • Accountability and quality (Triple Aim)

Proposal D Spread c d coordi dinated c d care m mode del: establish quality reporting and incentive structures modeled after those in Medicaid and CCOs for QHP offerings in Marketplace. Spread Oregon’s Health Care Transformation (coordinated care model)

  • CCO-type plans on the marketplace

(individual market)

  • CCO-like financial incentives on the

marketplace (individual market)

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Medicaid Buy-in Design Proposals

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Proposal E HYBRID OF PROPOSALS A-D Entirely DIFFERENT proposals (E-G)

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Medicaid Buy-in Design Considerations

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Delivery Model

Managed care or fee-for-service

Marketplace, Stand Alone, other On or off the Marketplace Target population(s)

Determine eligibly by income (FPL), ineligibility for federal coverage, other categories

Benefit Coverage

More or less generous coverage of benefits

Cost-Sharing

More or less consumer out-of-pocket costs including monthly premiums, deductibles, and co-pays for services

Provider Reimbursement

Level of provider reimbursement

Scalability and Financial Model

Pilot or statewide

Federal and State Considerations

Identify federal waiver authorities and impact to current coverage environment

Feasibility and Implementation Considerations

Risk pools, provider and/or carrier participation

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Medicaid Buy-in Design Considerations

1. What is the overall policy goal? Is it to increase coverage? Improve affordability? Increase competition by creating another marketplace option? Leverage delivery system reform through Oregon’s Medicaid program? 2. How many individuals would gain new coverage or shift existing coverage? What is the target population? What’s the income level? Exclude individuals eligible for employer-based coverage? 3. Would the buy-in program be administered as an extension of the ACA Medicaid program (low-income individuals and families), or as a stand alone program? Managed care or fee-for-service? 4. What benefits would be covered? OHP benefits or 10 essential health benefits? Long-term services, adult dental benefits, non-emergency transportation LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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Medicaid Buy-in Design Considerations (cont.)

5. What is the appropriate level of out-of-pocket costs? How would cost sharing be structured: co-pays, premiums, deductibles? Similar to Marketplace, Medicaid, in between, other? 6. How would premiums be setting and corresponding premium assistance determined? Would premiums be set by the state (similar to Medicaid), or would rates be developed by carriers in the marketplace? Would certain populations pay not premiums? 7. Provider reimbursement? Medicaid level, commercial, or in between (e.g., Medicare fee-for-service)? Potential cost savings to the program based differences between market coverage and the buy-in program? 8. What federal dollars would be available? How much federal funding would be available, if any, and what percentage of program costs can federal spending support? LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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Premium Assistance

September 20, 2018

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Project Access NOW & Premium Assistance

  • Project Access NOW
  • Started in 2007
  • Health based non-profit with multiple programs
  • Ensuring access to care, services, and resources for those most in need
  • Premium Assistance
  • Financial assistance program
  • Started in January 2014
  • Project Access NOW and Oregon Health Leadership Council
  • Funded by Hospital Systems Network
  • Kaiser Permanente, Providence Health and Services, Adventist Health, Tuality Healthcare,

Legacy Health, OHSU

  • Part of Outreach, Enrollment and Access program
  • Serves low-income Portland Metro tri-county residents
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Program Benefits

  • Monthly premium payment
  • Reduced out-of-pocket costs*
  • Pharmacy co-pay assistance
  • Navigation of health care and Marketplace
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Eligibility Requirements

  • Under 300% FPL
  • Resident of Clackamas, Multnomah, or Washington County
  • Enrolled in Qualified Health Plan (QHP) through Marketplace
  • Silver-level with Kaiser, Moda, PacificSource, or Providence
  • Eligible for tax credit
  • Not eligible for other “affordable” qualified health insurance
  • Use full tax credit
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Pros and Cons

  • Not an overhaul of the current system
  • Filling in the cracks
  • Helps clients who would otherwise not have access to affordable coverage
  • Does not address systemic barriers
  • Eliminates some, but not all, barriers to using coverage
  • State-based Marketplace
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Capitalizing on Existing Resources

  • Tax credits (APTCs) and cost-sharing reductions (CSRs)
  • Hospital Charity Care & Community Benefit
  • Hospital Systems Network funding
  • Bill write-offs
  • Relationships with insurance carriers
  • Referrals from community partners
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Current Challenges

  • Relationships with insurance carriers
  • Processes for third-party payments
  • Single contact at insurance carrier billing offices
  • Helping clients understand and utilize their insurance and PA
  • Providers’ differing policies
  • Client navigation and follow up
  • Rate changes
  • Changes in eligibility and transitioning clients
  • Ineligible populations
  • Tax credit reconciliation
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Potential Challenges

  • Funding
  • Hospital and provider policies
  • Processes for third-party payments
  • Enrollment assisters and outreach in local areas
  • Client navigation and follow up
  • Establishing relationships with insurance carriers and providers
  • Plan availability in rural areas
  • Barriers to care
  • High-risk clients
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Similar Programs

  • COFA Premium Assistance
  • Health Insurance Premium Program - American Kidney Fund
  • Ryan White HIV/ AIDS Program
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Next Steps – October and November

October 18th :

  • Revisit Medicaid buy-in in Oregon based on today’s discussion
  • Explore the concept of an individual mandate
  • Compile and review list of policies as basis for report on

incremental options for Oregon November 15th:

  • Review and revise the draft report

December 20th

  • TBD

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Proposal Outline for Member Consideration

  • A. Craft a preamble about the inefficient and fragmented coverage and delivery system in

Oregon including remaining coverage and affordability gaps for individuals and families

  • B. Summarize main topics, presentations, and key considerations identified and discussed by

the work group with a focus on:

  • Incremental state-level policy changes to make it easier for under and uninsured to

access services and coverage options in Oregon (per May 2018 workplan)

  • C. Develop a consensus around 4-5 proposals (possibly more) the work group collectively

agrees merit further investigation by the Legislative Assembly.

  • Poll members for additional ideas in the next 30 days.
  • D. Communicate to the Legislative Assembly that the work of the Work Group is unfinished

(e.g. deeper discussion post 2019 legislative session)

  • E. Draft and approve a comprehensive report that identifies barriers to and incremental steps

for moving Oregon towards creating a financially sustainable, universal, and affordable health care system (per Dec. 2017 charter)

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