Upload
janel-potter
View
214
Download
0
Embed Size (px)
Citation preview
Expanding publicly subsidized coverage for low income adults
Maximizing use of Existing systems and infrastructure Public-private partnerships Federal funding
2
Focus on low income uninsured
About 60% of Michigan’s uninsured population –
654,000 people* -- have incomes below 200% of the Federal Poverty level (FPL)
Non-elderly Uninsured in Michigan by Income (Percentage of Federal Poverty Level
Under 100%
100 - 149%
150 - 199%
200% +
* Rough numbers from 2005 CPS – need multi-year average
3
A Brief Summary of the Model
Increase access to federally subsidized coverage for low income families persons with disabilities, and young adults (<21)
Makes scarce local and safety net resources available for those not able to be covered under federal programs
Reduce red tape and develop new opportunities for private contribution toward coverage for the uninsured to promote continuity of care (“pay in” option)
4
Use existing public –private partnerships, systems and infrastructure
Public agencies determine eligibility and coverage, process some fee-for-service claims
Private, managed care health plans deliver most services to individuals with full coverage
Private pharmacy manager handles fee-for-service prescription claims
5
Maximize federally-funded coverage
Federal Medicaid match
Federal government pays for more than half (56.59%) of of costs
$1.00 in state funds buys $2.30 of medical care
Three strategies
1. Phased in expansion of coverage
2. Phased in reduction in out of pocket cost (deductibles or spend-downs) for those not fully covered
3. Allow “pay in” by those not fully covered
9
Cover low-income parenting adults in families with Healthy Kids- or MIChild-covered children (“the working poor”)
Strategy #1: Coverage expansions
Cover low-income persons with disabilities at the same income levels as parenting adults
Cover low-income young adults (19- and 20-year olds) until they are 21 & more likely to have access to employer-based coverage
13
Effects of expansion on the uninsured – starting point:
Non-elderly Uninsured in Michigan by Income (Percentage of Federal Poverty Level
Under 100%
100 - 149%
150 - 199%
200% +
Rough numbers from 2005 CPS – need multi-year average
14
Phase 1
Phase 1: Non-elderly Uninsured in Michigan by Income (Percentage of FPL)
Rough numbers from 2005 CPS – need multi-year average
Parents & Young Adults up to 100% of FPL
15
Phase 2
Phase 2: Non-elderly Uninsured in Michigan by Income (Percentage of FPL)
Rough numbers from 2005 CPS – need multi-year average
Parents, Adults with Disabilities, & Young Adults up to 150% of FPL
16
Phase 3
Phase 3: Non-elderly Uninsured by Income Level (Percentage of FPL)
Rough numbers from 2005 CPS – need multi-year average
Parents, Adults with Disabilities, & Young Adults up to 200% of FPL
17
Strategy #2: Phased in reduction in out of pocket cost for those not fully covered
Expand coverage under Medicaid with a Deductible (formerly known as “Spend-down” Medicaid)
periodic coverage for individuals with income in excess of the limit for full coverage
monthly deductible equals budgeted monthly income minus a “protected income level” (based on family size)
coverage begins only after verification that the monthly deductible is met
18
Monthly Spend-down/Deductible = Budgeted Income - Protected Income Level
Example:
Single person with a disability and $850 per month budgeted income
Protected income level for an individual = $375
Monthly Deductible = $475
19
The “spend-down problem”
Protected income levels are much lower than income limits for full coverage
Doesn’t provide coverage until medical expenses have driven the enrollees deep into poverty
100% of Federal Poverty Level
20
The fix: increase income disregards for the medically needy
Federal law limits the amount of the Protected Income Level, based on historic family cash assistance levels
Income disregards may be used to reduce “budgeted” income by the difference between the income limit for full coverage and the Protected Income Level
Has the same effect as raising the PIL
21
Phase-in: Increase disregards as the income limit for full coverage is increased
Phase #1: Deductibles only require “spend down” to 100% of federal poverty level
Phase #2: Deductibles require “spend down” to 150% of federal poverty level
Phase #3: Deductibles require “spend down” to 200% of federal poverty level
22
Strategy #3: Allow purchase of coverage with premiums equal to monthly deductible
Problems with Deductible (Spend-down) system:
No continuity of coverage – Medicaid is approved only for certain days of the month
Providers can’t bill Medicaid until weeks or months later - after DHS workers process paperwork submitted by recipient
Recipients cannot be enrolled in managed care plans
23
Strategy #3 (cont’d) “Pay-in” Option
Build on the existing MIChild system for processing premiums
Employers could pay premiums for low income employees
Reduces red tape and paperwork for enrollees and DHS
Allows for managed care enrollment Gives providers certainty re payment source Provides continuity of care
25
Number of people covered
Strategy #1 (Expansion of full coverage) Phase 1: 60,000* parenting adults and 11,000 young adults with
income below 100% of FPL Phase 2: 45,000* parenting adults, 3,400 young adults, and 9,000
adults with disabilities with income below 150% of FPL Phase 3: 53,000* parenting adults, 4,600 young adults, and 10,000
adults with disabilities with income below 150% of FPL
TOTAL decrease in the number of uninsured: 196,000 adults
Strategy #2 (Reduced Deductibles) - ???
Strategy #3 (Pay in Option) Coverage for ???000 adults
*Rough numbers from 2005 CPS – need multi-year average
26
Portability and continuity of coverage
Full portability: individuals remain covered as long as income is within limits (or deductible/pay-in is met) and non-financial criteria are met (age, parenting, disability)
Wrap-around coverage when employer-based coverage or Medicare becomes available
Good continuity of care, subject to health plans’ geographic limits, and limits due to shortage of fee-for-service providers when
managed care is unavailable (e.g. private insurance or Medicare is primary, rural areas)
27
Benefits
Physician visits Specialists Labs and diagnostic
testing Prescription drugs and
supplies Inpatient and outpatient
hospital care Home help services Nursing homes*
Current comprehensive benefits package available to Medicaid recipients
Mental healthDurable medical equipmentVisionHearingPhysical and occupational therapyDentalPodiatryChiropractic
* Most current nursing home residents with incomes below 200% of FPL are already receiving Medicaid
28
Quality of care & effects on the delivery system
Quality under current programs varies and needs improvement overall
Shortage of fee-for-service providers and participating health plan providers in many areas (especially specialists and rural areas) due to low reimbursements
Increasing enrollment and creating a larger pool may increase the number of health plans willing to provide coverage in smaller, more rural counties
30
Resource and Budgetary Cost
Increased spending on a broad range of medical goods & services
State administrative costs More enrollees (applications), more providers
(claims) Modification and expansion of existing premium
collection system, to administer the buy in option
Need for increased payment rates to assure that coverage = access
31
Resource and Budgetary Savings
Lower cost, early intervention prevents or reduces spending on higher cost care when health conditions progress or deteriorate, including expensive hospital-based treatment
Reduced mortality and disability
Increased productivity and reduced absenteeism for employed enrollees
Continuity of care & use of managed care plans reduced costs
Increased bargaining power with pharmaceutical companies due to larger pool of enrollees
Reduced administrative costs at DHS, through buy-in option
32
Cost Containment
Features that promote cost containment:
Managed care
Disease management
Bargaining power of a large purchaser
Features that hinder cost containment:
Entitlement – number of enrollees will grow during economic slumps
Federal law prohibits some types of limits on services
33
Implementation & Administration:
Uses existing infrastructure and systems Existing eligibility and enrollment system through DHS/MSA
Existing health plan choice/enrollment system through private contractors
Existing health delivery system through managed care health plans (with fee-for-service for auxiliary services and services for those with deductibles or other primary insurance); community mental health system
35
Access to coverage and subsidies
Provides equity within families (i.e. expands coverage to parents of children who currently are eligible)
Increases equity among many adult populations (i.e. expands coverage to parents & young adults at same income levels as disabled/elderly who currently are covered)
Does not provide equity for childless adults with no total & permanent disability
36
Financing of costs
Increased public responsibility for subsidizing care to those with low incomes
Requires a tax-based mechanism for financing
Equity/fairness would depend on the specific taxes/funding mechanisms chosen
Potential to achieve greater equity and fairness reducing the burden on those with commercial
insurance to pay for the uninsured taxing employers who do not cover their low-wage
workers
38
Consumer choice of providers and health plans
Choice of health plans, where available Current shortage in UP and some LP counties Increased enrollment may attract more plans
Choice of providers within plans (limited)
Choice of providers with fee-for-service (limited)
Higher reimbursement needed to attract more providers
39
Provider autonomy
Same autonomy as private insurance (must accept the reimbursement allowed by health plan for enrollees in managed care or state, for fee-for-service enrollees)
Limits on clinical autonomy as in other managed care arrangements
40
Government compulsion or regulation
Regulated to a higher degree than private insurance
Same as in current Medicare, Medicaid
No compulsory enrollment
42
Adopt some strategies/phases and not others, to save on costs
EXPANSIONS - greatest beneficial impact on the very lowest income groups*
ADJUSTING DEDUCTIBLES - greatest beneficial impact on slightly higher, but still low-income groups*
BUY-IN OPTION - greatest beneficial impact on continuity of care and access for slightly higher, but still low-income groups* who have some degree of coverage – much less likely to be helpful if deductibles are not adjusted
* Excluding the childless adults who cannot be covered with federal Medicaid dollars
43
Allow buy-in for higher income individuals
Allow uninsured individuals and employers of uninsured individuals who cannot afford private insurance rates to purchase coverage at the lower per capita Medicaid rate
Require that individuals be within a certain range of the Medicaid income eligibility limits