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  1. Rates Part 2

  2. Managed Care: Elements • Enrollment • Benefits • Usage • Cost sharing (co-pays) • Access • Quality • Accountability Part 2

  3. …with “Carve Outs” • Dental • Medications • Transport • Behavioral health Part 2

  4. ACA’s Medicaid Expansion &NJ’s Comprehensive Waiver Part 2

  5. Affordable Care Act …bringing the biggest change in Medicaid since it began. Part 2

  6. The Bill... Part 2

  7. 3 Years Later: 2/3rds Don’t Know!(Gold, 2013) Part 2

  8. ACA: Goals(Tate, 2012) • Increase access • Control costs • Add benefits & protections • Address many smaller issues Part 2

  9. ACA: 3 Legged Strategy • Insurance reform • Individual mandate • Exchanges + subsidies • Subsidies for those at 100% -400% of FPL • Medicaid expansion • For adults < 138% of FPL Part 2

  10. Federal Poverty Level (FPL) 2014 Federal Poverty Limit (FPL) Family of 1: $11,670 x 133% = $15,521 Family of 4: $23,850 x 133% = $31,721 Part 2

  11. Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured) Part 2

  12. Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured) Part 2

  13. Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012)) Part 2

  14. Out-of-Pocket Premiums… Part 2

  15. ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012) “New Eligibles”: FMAP = 100%  90% “Old Eligibles”: FMAP = 50% Part 2

  16. ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012) Change in Coverage in NJ under ACA (ages 0-64) Part 2

  17. Premiums: NJ  19%, US  41%, (Roy, 2013) Part 2

  18. Rate Ratios(Zuckerman et al., 2009) Part 2

  19. Rate Ratios(Zuckerman et al., 2009) US 0.72 WY 1.43 AK 1.40 DE 1.00 PA 0.73 CA 0.56 NY 0.43 NJ 0.37 Part 2

  20. Rate Ratios(Zuckerman et al., 2009) US 0.72 WY 1.43 AK 1.40 DE 1.00 PA 0.73 CA 0.56 NY 0.43 NJ 0.37 50th! Part 2

  21. Provider Supply = f(Rate Ratio) (Decker, 2012) % doctors accepting Part 2

  22. Rate Ratios After ACA But… • For PCPs only • Family practitioners • Internists • Pediatricians • = 1.00! • Only for 2013, 2014 • Also for managed care Part 2

  23. Innovation: Medicaid ACO • “Accountable Care Organization” Part 2

  24. How? Get “Waivers” • Why? • Eligibility changes • Service benefit additions • Payment criteria changes • Waivers for…? • Medicaid ACOs • Define scope • Define new roles • Build capacity • Include high-cost groups • Multi-payer alliances • Payment models • Measurements Part 2

  25. NJ’s Comprehensive Waiver Getting it all together Part 2

  26. NJ Medicaid • “Division of Medical Assistance and Health Services” • $11 billion (federal and state) • 500 people • Director: Valerie Harr • (“NJ FamilyCare”) Part 2

  27. Medicaid: The State Plan • Required by Section 1902(a) (30)(A) • 71 elements • Rates • Methodology • Comment periods Part 2

  28. Waivers by Type(Centers for Medicare & Medicaid, 2013) • Section 1115 • Research and demonstration • Section 1915(b) • Managed Care • Section 1915(c) • Home and Community Based • Concurrent 1915(b) & (c) …for more “flexibility” Part 2

  29. 1115: NJ “demonstrations” (new) • Health homes • 2010: NJ Public Law 2012, Chapter 74  3 year Medicaid Medical Home demonstration project  Section 2703 of ACA • Accountable Care Organizations (ACO) • 2011: NJ Public law 2011, Chapter 114  Medicaid Accountable Care Organization demonstration project. Part 2

  30. 1915(b): Mandatory Managed Care (Howell, Palmer & Adams, 2012) Keep… Add… • Mandated services • Choice of plans • “Actuarially sound” rates • …“Risk-based” payments LOSE… Part 2

  31. Managed Care: NJ’s 4 HMOs Part 2

  32. NJ Waivers: Previously (Centers for Medicare & Medicaid, 2013) • Section 1115 • Research and demonstration • Section 1915(b) • Managed Care (Mandatory) • Section 1915(c) • Home and Community Based • Concurrent 1915(b) & (c) • Childless adults • Family coverage (SCHIP) • ACOs • NJ Care 2000+ • NJ Family Care • BH ASO • Global Options (LT care) • Renewal Waiver • Community Resources • Community Care Alternatives Part 2

  33. NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013) • Section 1115 • Research and demonstration • Section 1915(b) • Managed Care (Mandatory) • Section 1915(c) • Home and Community Based • Concurrent 1915(b) & (c) • Childless adults • Family coverage (SCHIP) • Accountable Care (ACO) • NJ Care 2000+ • NJ Family Care • Behavioral Health (ASO) • Global Options (LT care) • Renewal Waiver • Community Resources • Community Care Alternatives Part 2

  34. NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013) • Section 1115 • Research and demonstration • Section 1915(b) • Managed Care (Mandatory) • Section 1915(c) • Home and Community Based • Concurrent 1915(b) & (c) • Childless adults • Family coverage (SCHIP) • Accountable Care (ACO) • NJ Care 2000+ • NJ Family Care • Behavioral Health (ASO) • Global Options (LT care) • Renewal Waiver • Community Resources • Community Care Alternatives Part 2

  35. NJ Waivers: Now (Centers for Medicare & Medicaid, 2013) • Section 1115 • Research and demonstration • Section 1915(b) • Managed Care (Mandatory) • Section 1915(c) • Home and Community Based • Concurrent 1915(b) & (c) One Comprehensive Waiver Part 2

  36. BH Managed Care ASO • One already exists! • In DCF: “CSOC” • 40,000 kids • Phase in risk-based over 5 years Administrative Services Organization Part 2

  37. 10 Challenges for Consumers Part 2

  38. 1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010) Part 2

  39. 1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010) “Benchmark” coverage under ACA Part 2

  40. 1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010) “Benchmark” coverage under ACA Excludable for newbies under ACA Part 2

  41. 2. Providers: Enough? Part 2

  42. 2. Providers: Rate Ratios(Zuckerman et al., 2009) US 0.72 WY 1.43 AK 1.40 DE 1.00 PA 0.73 CA 0.56 NY 0.43 NJ 0.37 50th! Part 2

  43. 2. Providers: Supply = f(Rate Ratio) (Decker, 2012) % doctors accepting Part 2

  44. 2. Providers: “Rate Bump” For…?(Kaiser Commission on Medicaid and the Uninsured, 2012a) • 100%! • …for PCPs and those they supervise… • …even in managed care… • …even for dual eligibles. • Result: 10-24% increase in accepting PCPs? BUT: • Not for specialists (e.g., psychiatrists) • Only for 2013 and 2014 • Extend? Measurement will be key… = 100% Part 2

  45. 3. Exchanges: FPL Overlap?(Blahous, 2013) • Overlap! • Medicaid: < 138% FPL. • Exchanges: > 100% FPL. • Partial expansion? All > 100% to exchanges, where no state funding needed… • HHS: 100% FMAP if states do partial? NO! Part 2

  46. 3. Exchanges: FPL Overlap?(Blahous, 2013) • Overlap! • Medicaid: < 138% FPL. • Exchanges: > 100% FPL. • Partial expansion? All > 100% to exchanges, where no state funding needed… • HHS: 100% FMAP if states do partial? NO! Part 2

  47. 3. Exchanges: FPL Overlap?(Blahous, 2013) • Overlap! • Medicaid: < 138% FPL. • Exchanges: > 100% FPL. • Partial expansion? All > 100% to exchanges, where no state funding needed?… • NO! HHS: no 100% FMAP if states do partial Part 2

  48. 4. Transitions: Coverage Churn?(Ingram, McMahon & Guerra, 2012) • Medicaid  Exchanges: 35% of all adults below 200% FPL • Exchanges  Medicaid: 28 million p.a.? Wages Part 2

  49. 5. “Woodwork” Effect?(Castro, 2013; Alaigh, 2002) New eligibles vs. old eligibles not enrolled FMAP = 100% 234,000 total eligibles Part 2

  50. 6. Measures: Of What? • HEDIS: measure behavioral health? • Healthcare Effectiveness Data and Information Set • System metrics, not consumer metrics Part 2