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

UNIVERSAL ACCESS TO CARE WORK GROUP 2018

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

October 18, 2018

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AGENDA

Welcome, Opening Remarks ……………………..……………………………………………..8:00—8:05am

• Representative Salinas, Chair, Work Group

Rhode Island Market Stability Workgroup – Shared Responsibility………………8:05—9:00am

• Zachary Sherman, Director, HealthSource, Rhode Island

Work Group Discussion – Shared Responsibility…….…………………………………..9:00—9:20am

• Representative Salinas, Chair, Work Group

Medicaid Buy-in: Oregon Policy Goals and Approaches………………………........9:20—10:00am

• Tim Sweeney & Zachary Goldman, OHA

Jesse O’Brien, DCBS, Oliver Droppers, LPRO Work Group Proposals – Review and Refinement…….………………………………10:15—10:45am

• Representative Salinas, Chair, Work Group

Public Comment …………………………………………………………………………….....10:45—11:00am Adjourn……………………………………………………………………………………………………....11:00 am

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Today’s Objectives

➢Learn about Rhode Island’s Shared Responsibility Proposal ➢Consider Medicaid Buy-in options A-C

• Discuss member feedback and program proposals
• Clarify and potentially refine proposals
• Summarize key considerations for policy makers

➢ Review and discuss preliminary list of policy concepts and topics identified by work group

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THE RHODE ISLAND PRESPECTIVE:

A PRESENTATION TO THE OREGON UNIVERSAL ACCESS TO CARE WORKGROUP

By HealthSource RI Director Zach Sherman

AGENDA

• The Rhode Island Market Stability Workgroup
• Why a state Shared Responsibility Payment?
• Anticipated Shared Responsibility Payment revenue impact
• Q&A

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RHODE ISLAND MARKET STABILITY WORKGROUP CHARGE

Goal: Identify and propose sensible, state-based policy options for Rhode Island that will be in service to those Principles. Membership: A diverse group of stakeholders including all Rhode Island payers, providers, hospital and medical societies, legislators, consumer advocates, nonprofit leaders and brokers.

Guiding Principles:

• 1. Sustain a balanced risk

pool;

• 2. Maintain a market that is

attractive to carriers, consumers and providers; and

• 3. Protect coverage gains

achieved under the Affordable Care Act.

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WORKGROUP RECOMMENDATIONS

Near-term recommendations:

• To secure a 1332 waiver under the ACA to implement a

reinsurance program

• Garner state authority to regulate Short-Term Limited

Duration (STLD) and other limited benefit health plans

• Implement a state-based shared responsibility

requirement Further work remains, including:

• Action to determine how to fund a state reinsurance

program and how to best design and implement a shared responsibility requirement

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REASONS TO CONSIDER A STATE SHARED RESPONSIBILITY PROVISION

A state-level Shared Responsibility Payment would:

• Incentivize people to get and stay insured
• Help stabilize the risk pool, protect against adverse

selection

• Generate revenue for affordability programs
• Provide data on the uninsured, create outreach
• pportunities

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The Shared Responsibility Payment, as currently structured could generate ~$10.6 M in 2020.

ANTICIPATED SHARED RESPONSIBILITY PAYMENT REVENUE

$4.3 $8.6 $10.6

2014 2015 2016

Amount is Larger of: $95/person or 1% of income $325/person or 2% of income $695/person or 2.5% of income # RI returns with penalty 23,540 21,320 16,320 % of RI returns 4.5% 4.0% 3.1%

RI Shared Responsibility Payment Revenue ($M)

Note: Assumes enrollment/uninsured rate stays at current levels.

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11.6% 7.4% 5.7% 4.3% 4.6%

2013 2014 2015 2016 2017

Rhode Island Uninsured Rate

Sources: U.S. Census; Rhode Island Market Stability Workgroup (10/16/18); Faulkner Consulting Group

QUESTIONS?

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Have questions? Email me at Zachary.Sherman@exchange.ri.gov or visit www.HealthSourceRI.com/market-stability- workgroup

STATE-BASED INSURANCE MANDATES: OREGON CONSIDERATIONS

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Data Considerations and Informational Needs - Discussion

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Source: Oregon Health Insurance Survey 2017 – Summary and Results

State-Based Insurance Mandates

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Oregon

State-Based Insurance Mandates

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On average, the state mandates would reduce marketplace premiums by 11.8 percent if all states adopted the ACA’s federal individual mandate structure.

Work Group Discussion: State-Based Insurance Mandates

• 1. Initial reactions to Rhode Island’s state-based shared

responsibility proposal?

• 2. What is your overall impression of state-based insurance

mandates?

3. What questions do you have about a state-based insurance mandate in Oregon?

• Additional information or analysis to further explore this concept in

Oregon?

• Penalties and enforcement?

4. Initial thoughts on potential advantages or disadvantages around an ACA-like state-based insurance mandate in Oregon?

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MEDICAID BUY-IN: OREGON CONSIDERATIONS

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Medicaid Buy-in Oregon Design Considerations

• Staff requested non-legislative members respond to a set of questions

about their perspectives on Medicaid Buy-in

• Members had two weeks to review and submit responses
• Eight of the 12 non-legislative members submitted responses
• Staff compiled and summarized member responses
• Member feedback used to revise initial proposal ‘A,’ (September 20th

proposals)

• Result: three different buy-in options for a Medicaid Buy-in program
• ffered off the Marketplace without pursuit of a federal 1332 waiver (see

Table 1, pgs. 8-9).

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Medicaid Buy-in Design Proposals

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Proposal A Improve Access 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 Access 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)

Medicaid Buy-in Design Proposals

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Proposal C Strengthen Alignment Between Medicaid and 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 coordinated care model: 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)

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

Medicaid Buy-in Oregon Design Considerations

• 1. Policy Goal: Medicaid Buy-in potentially moves Oregon closer to

the goal of bringing more Oregonians into a coverage program.

• 2. Target Population(s): individuals who do not qualify for Medicaid
• r federal subsidies on the Marketplace.
• 3. Program Administration: CCOs enroll and administer the

program, manage member premiums and provider reimbursement and networks.

• 4. Benefits: Oregon Health Plan (OHP) for adults including dental

and vision.

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Medicaid Buy-in Oregon Design Considerations

• 5. Out-of-pocket Costs: no deductibles or co-pays at the point of care

with members paying a portion, or all the monthly premiums for coverage.

• 6. Enrollee Premiums: premiums based on Medicaid per-member, per-

month rates paid to CCOs (e.g., ACA adult population with regional adjustments).

• 7. Provider Reimbursement: rates in Medicaid utilizing existing

payment models by CCOs with the goal of deploying value-based payment methodologies.

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Data Considerations and Informational Needs - Discussion

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Source: Oregon Health Insurance Survey 2017 – Summary and Results

Comparative PMPM – Illustrative Purposes ONLY

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2018 Payment Rate: ACA Monthly PMPM Annual Premium Oregon Health Plan (*no cost-sharing in OHP) (2018) $ 503 $6,031

1) Rates summarized above are weighted using calendar year 2017 enrollment (using the paid COA) and average maternity cases 2) Rates above do not include the Hospital Reimbursement Adjustment or "pass-through" to hospitals 3) Rates above do not include the 1.5% MCO tax

• Benefit package differences between Medicaid and commercial insurance
• Provider reimbursement rate differences between CCOs and commercial carriers
• Profit/administrative cost differences between CCOs and commercial carriers
• Population differences (risks factors, socioeconomic factors, and other differences between

ACA Medicaid expansion population and marketplace enrollees)

• Utilization differences (primary care utilization vs. specialty care, behavioral health

utilization, etc.)

• Financial barriers to care / incentives for patients in commercial coverage
• Other barriers to access to care in Medicaid population (time, transportation barriers in

spite of NEMT benefit, etc)

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Comparative PMPM – Illustrative Purposes ONLY

Monthly PMPM Annual Premium Individual Market (2017) 1 Premiums $390 $4,680 Total Cost: Premium + Cost- Sharing $550 $6,600

Estimated Total Cost for Premiums with no Cost-Sharing 3

$594--$632 $7,128-$7,584

1. Rates are estimated based on 2017 PMPMs for the individual commercial market 2. “Total cost with cost-sharing” includes estimated consumer out-of-pocket spending on covered services. 3. $0 or no cost-sharing is expected to increase utilization which is estimated to increase average costs by 8-15% 4. Individual market estimates with cost-sharing are based on an average actuarial value of approximately 70%, compared to Medicaid which is 100% AV.

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Monthly PMPM Annual Premium Oregon Health Plan (*no cost-sharing in OHP) (2018) $ 503 $6,031 Individual Market (2017)

Premiums

$390 $4,680

Total Cost: Premium + Cost- Sharing

$550 $6,600 Estimated Total Cost for Premiums with no Cost-Sharing 3 $594--$632 $7,128-$7,584

Comparative PMPM – Illustrative Purposes ONLY

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Medicaid Buy-in Program Offered Off Exchange to provide consumers not eligible for federal and state health coverage to purchase directly an insurance product administered by CCOs.

Overview

Option A: Targeted Buy-in Option B: Targeted Buy-in Option C: Broad Buy-in Limited Medicaid Buy-in

• ption targeted to individuals

not eligible for Medicaid or federal marketplace subsidies based on geographic region, age, or health status. Limited Medicaid Buy-in

• ption targeted for individuals

unable to obtain affordable coverage in the individual and small group markets. Offer Medicaid Buy-in program

• ff the exchange and allow

anyone to participate (more Public Option).

Policy Goals

• Expand coverage to finite

set of groups currently uninsured (e.g., fill in the gaps)

• Improve affordable access

to quality care

• Avoid creating new

products to compete with plans on Marketplace

• Administrative

simplification by leveraging existing insurance design,

• rganizations, providers

networks and payment models available in Medicaid

• Reduce the number of

uninsured by creating a new coverage option for specified set of groups currently uninsured (e.g., fill in the gaps)

• Allow potentially healthier

individuals purchase coverage; improve risk pool

• Improve affordable access

to quality care

• Address family-glitch in

Oregon

• Expand coverage by

promoting enrollment into plans by potentially creating an affordable coverage option

• Pay for value and quality

using value-based payment model(s)

• Potentially creates a

pathway to universal coverage by building on key elements of Oregon’s coordinated care model

Medicaid Buy-in Oregon Design Considerations

• 1. Policy Goal: changes, clarifications, other?
• 2. Target Population(s): changes, clarifications, other?
• 3. Program Administration: changes, clarifications, other?
• 4. Benefits: changes, clarifications, other?

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Medicaid Buy-in Oregon Design Considerations

• 5. Out-of-pocket Costs: changes, clarifications, other?
• 6. Enrollee Premiums: changes, clarifications, other?
• 7. Provider Reimbursement: changes, clarifications, other?

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UNIVERSAL ACCESS TO CARE WORK GROUP

REPORT—TOPICS AND MEMBER PRIORITIES

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Potential List of Topics for Report

• A. Identify incremental state-level policy changes to make it easier for

individuals to access and maintain coverage, whether through their employer or through existing or new publicly funded programs.

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• Premium Assistance Program
• Enrollment Assistance and

Outreach

• Consumer Coverage Simplification
• Administrative Billing

Simplification

• Plan Uniformity
• Primary Care Trust Fund to

Support Universal Primary Care

• Shared Responsibility Mandate
• Medicaid Buy-in
• Pharmaceutical Costs
• Price Transparency
• Public Opinion

Potential List of Topics for Report (cont.)

• B. Describe potential changes to employer-sponsored coverage and

commercial plans, including the extent to which existing coverage mechanisms are compatible with a universal coverage system. Determine what mechanisms, if any, are needed to minimize disruption to the current health care system.

• 1. Expansion of the coordinated care model: expand the state’s

reform model beyond Medicaid and coordinated care

• rganizations (CCOs) to all commercial health carriers and health

plans offered in Oregon based on the six key elements

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Potential List of Topics for Report (cont.)

• C. Explore whether new governance models are needed to achieve

universal access, including major components and functions of any such model. Information below is largely drawn from international perspectives on universal coverage models that provide comprehensive, affordable, high-quality health care coverage for all residents.

• 1. Simplify and standardize consumer cost-sharing
• 2. Ownership models
• 3. Provider reimbursement
• 4. Propose new governance models for a state-based coverage system

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Potential List of Topics for Report (cont.)

• D. Explore long-term sustainable funding sources to raise sufficient

revenue to finance universal health access, including local, state, and federal funding. (RAND 2017 Study)

• 1. Single payer (RAND Study): use public financing to provide

privately delivered health care for all Oregon residents,

• 2. Health Care Ingenuity Plan: create a public financing pool for

coverage in commercial health plans for all Oregon residents

• 3. Public Option: establish a state-run public plan that would

compete with private Marketplace plans

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Potential List of Topics for Report (cont.)

• E. Investigate the federal waivers and permissions that would be

required for Oregon to maximize federal funding for the provision

• f health care services.

1. House Resolution (HR) 6097—State-based Universal Health Care Act: expands the current Affordable Care Act (ACA) section 1332 waiver to include waivers from multiple federal laws currently preventing state- based universal care.

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Potential List of Topics for Report (cont.)

• Anything missing from the list (Jan. thru Oct. discussions)?
• What are critical issues, considerations, or key messages

members want shared with legislators about universal access to care in Oregon?

• Additional information staff should provide in advance of the
• Nov. 15 meeting?
• Process questions?

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Next Steps

Review draft report in advance of Nov. 15 meeting TBD: offline exercise, survey, or homework for members? Finalize report at Nov. 15 meeting Submit final report to the House Committee on Health Care no later than

• Nov. 30th

December Legislative Days (Dec. 12-14th): present comprehensive report that identifies barriers to and incremental steps for moving Oregon towards creating a financially sustainable, universal, and affordable health care system (December 2017 charter) LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

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