Massachusetts Health Care Reform and Adult Members with Disabilities

Annette Shea, MEd and Jay Himmelstein MD, MPH

University of Massachusetts Medical School Center for Health Policy and Research

Disability and Employment Policy Research GroupNovember 9, 2009

Agenda

• Overview of Massachusetts Health Care Reform

• MassHealth and “CommonHealth”: The Massachusetts Medicaid Buy-In program

• Health Reform and Medicaid - Lessons learned

• Implications for PWD and Medicaid Buy-in programs

• Discussion

Massachusetts Health Care Reform of 2006: Key Elements

• Created “Connector Authority” – Board and Insurance Exchange• MassHealth (Medicaid) Expansion - Expansion of financial rules for non-

disabled categories• New insurance options for legal residents who are not eligible for other

public or employer-sponsored health insurance: – Completely subsidized, comprehensive health insurance to adults

earning up to 150% of the federal poverty level (FPL).– Commonwealth Care – subsidized insurance for those less than

300% FPL – Commonwealth Choice – offered through Connector Authority,

links individuals over 300% of FPL with health insurance • Reforms to the commercial market• Individual Mandate• Employer “fair share” assessment for those with 11+ full-time equivalent

employees.

The Massachusetts Health Connector

• An independent state agency which helps Massachusetts individuals and employers get more affordable health insurance coverage.– Provides low or no-cost health insurance to qualified residents

(Commonwealth Care). – Works with insurance companies to create new health

insurance choices for individuals and employers (Commonwealth Choice).

• The Connector Board also granted authority to make key decisions with regard to Minimal Creditable Coverage (MCC), affordability, waivers to individual mandate, and other aspects of health reform implementation

Massachusetts Health Reform: Three Years Later

• Status – Estimate of over 400,000 newly insured– Rate of un-insurance in MA estimated at 3%, compared to

the national average of 15.5%– 99,000 more MassHealth members– 160,000 Commonwealth Care members

• Challenges– Costs are somewhat higher than expected– Keeping insurance costs affordable will require substantial

changes– Impact of National Health Reform?

5

MassHealth (Medicaid) and MA Health Reform

• MassHealth - The Massachusetts Medicaid Program– Administered under an 1115 Waiver Authority– More than 1.2 million residents enrolled– 200,000 members with disabilities age 19-64

• MassHealth and Health Reform: – Centralized enrollment process: Use of the state’s Medicaid

(MA21) eligibility system to process application for subsidized health programs.

– Use of the state’s Medicaid (MA21) eligibility system to process applications with built-in logic to enroll applicants in the “richest” benefit category of assistance.

– Applicants with disabilities continue to have same access to established MassHealth plans for members with disabilities.

– Applicants with disabilities not eligible for MassHealth, without comparable coverage, i.e. Medicare, have access to Commonwealth Care and Commonwealth Choice.

The Massachusetts Medicaid Program: CommonHealth

• CommonHealth is the Massachusetts Medicaid Buy-In Benefit Plan.

• CommonHealth was created a state program as part of the Dukakis Universal Health Care Act of 1988.

• CommonHealth included under State 1115 Waiver as of 1997.

• Currently, more than 20,000 Medicaid Buy-In enrollees in 3 subgroups: – 12,000 CommonHealth Working Adults age 19+– 5000 CommonHealth Non-Working Adults age 19-64– 3000 CommonHealth Children <19

• Note: the CommonHealth Working Adults program (“Buy-in”) requires 40 hours work/month and has no income limit or asset test.

The Massachusetts Medicaid Program: Plans for People with Disabilities

Eligibility Criteria MassHealth Standard CommonHealthWorking

CommonHealthNon-Working

Age 19 - 64 19 or older 19 - 64

Financial criteria (household income: member and spousal income where applicable)

At or below 133% Federal poverty level

Above 133% federal poverty level

Above 133% federal poverty level

Work Status Could be working Working 40 hours or more each month

Not working or working less than 40 hours each month

Disability Determined by Social Security (SSA) or MassHealth

Determined by SSA or MassHealth

Determined by SSA or MassHealth

Needs Test None None One time spend down will apply

Premium None Based on family size & monthly household income

Based on family size & monthly household income

Asset Test None None None

Redetermination Annually Annually Annually

Massachusetts Health Care Reform Access for People with Disabilities

• Massachusetts took specific measures to ensure ongoing access to programs for people with disabilities.

– Single application for MassHealth and subsidized plans– Centralized eligibility and enrollment process– No change for MassHealth members with disabilities

• Members with disabilities continue to have access to MassHealth plans which offer community long-term care services not provided by private insurers or Medicare.

– Access can include enrollment in multiple plans with MassHealth as wrap coverage.

Massachusetts Health Care ReformImpact on People with Disabilities

• Some adult applicants with disabilities age 19-64, may be enrolled in either Commonwealth Care or Commonwealth Choice plans if:– Their household income exceeds the MassHealth

Standard threshold of 133% FPL, and– They are not working 40 hour or more each month, and– They do not have access to comparable coverage like

Medicare or private insurance.

• Commonwealth Care and Commonwealth Choice plans do not offer community long term care services like personal care attendant services.

Factors Contributing to Success inMassachusetts

• Massachusetts had an established Medicaid program for people with disabilities, age 19-64, with a 133% FPL financial eligibility.

• The CommonHealth Working (MBI) has work requirement, an income related premium but no income limits or asset test.

• Massachusetts negotiated with CMS to ensure existing Medicaid programs for people with disabilities would remain intact.

• Focus on outreach and centralized enrollment systems provided increased access to information for applicants and members. – Same application and state’s Medicaid (MA21) eligibility

system used to process applications for subsidized health programs.

• Multiple mechanisms for program enrollment– Standard application available on web– Use of Virtual gateway by providers and community groups

Health Care Reform: Implications for People with Disabilities and Medicaid Buy-Ins

• The impact of the state and national health reform will vary dependent upon each state’s existing Medicaid and MBI programs.

• Emphasis on outreach and centralized enrollment systems can facilitate access to information for applicants and relatively smooth transition for members.

• Non-Medicaid “Insurance Exchange” products may need to take on cost and care needs of people with disabilities.

Questions?

Annette Shea, MEd Senior Project Director for Medicaid Disability and

Employment InitiativesAnnette.Shea@umassmed.edu

508-856-2654

Jay Himmelstein MD, MPHProfessor, Family Medicine and Community Health

Director, Massachusetts Medicaid Infrastructure and Comprehensive Employment Opportunities Grant

Jay.Himmelstein@umassmed.edu508-856-5763