Affordable Care Act:
Overview of Impacts on Medicaid
Marni Bussell
SIM Project Director, DHS
Lindsay Buechel
Communications Manager, IME
Introduction
• The Patient Protection and Affordable Care Act (ACA), also known
as “Health Care Reform”, was signed into law on March 23, 2010.
o
The law is complex and requires a significant amount of time and effort to
plan and implement during the last 2 and coming year(s).
• There continues to be strong public policy debate on the law
o
o
Supreme Court Decision
Strong efforts to repeal or change the law in Congress.
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Affordable Care Act (ACA)
• Key provisions take effect January 1, 2014
o
o
Creation of Health Benefits Exchange/Health Insurance Marketplace
 Exchange is a “marketplace” to allow consumers to compare plan benefits
and price, provide consumer assistance, facilitate plan enrollment.
 Mandate for individuals to have insurance coverage; penalties for large
employers who don’t offer insurance
Option for Medicaid expansion to 133% of the Federal Poverty Level (FPL)
2013 133% FPL:
 Household of 1: $15,282
 Household of 4: $31,322
• Other provisions with various implementation dates
o Mandatory Iowa Medicaid Enterprise (IME) operational changes to ensure ACA
compliance
o Optional opportunities to improve or re-balance health care programs
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State Innovation Model Grant
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The problem
Chronic disease drives costs
Chronic Care Within Medicaid
100%
23%
80%
60%
29%
80%
40%
20%
48%
15%
5%
0%
Members
Top 5%
Costs
Next 15%
Bottom 80%
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Top 5% High Cost/High Risk Members*
Accounted for:
• 90% of hospital readmissions within 30 days
• 75% of total inpatient cost
• Have an average of 4.2 conditions, 5 physicians, and 5.6
prescribers
• 50% of prescription drug cost
• 42% of the members in the top 5% in 2010, were also in
the top 5% in 2009
*Excludes Long Term Care, IowaCare, Dual Eligibles, and maternity
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Why change?
• Health care delivery system is fragmented
• Reimbursement methods reward volume not
value
• Cost of health care is unaffordable and
unsustainable for citizens and taxpayers
• We need to increase quality/outcomes & lower
cost
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What is Medicaid’s role in
Delivery Reform?
• Medicaid relies on the same health care system as all
others to deliver care to our covered members
• Medicaid uses very similar payment and contracting
methods
• Whatever is driving the rest of the health care system is
also driving Medicaid
• Medicaid is a significant payor - 2nd largest payor, covers
23% of Iowans
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Iowa Health and Wellness
Plan Background
The Iowa Health and Wellness Plan
was enacted to provide comprehensive
health coverage for low-income adults
• Begins January 1, 2014
• Iowans age 19 - 64
• Income up to and including 133% of the Federal Poverty Level (FPL)
• New, comprehensive program will replace the IowaCare program,
ending December 31, 2013
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Iowa Health and Wellness Plan
• The Iowa Health and Wellness Plan must receive
approval from the federal government
• DHS is working to obtain approval
• Some program details may still change as we work
with federal officials
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One Plan, Two Options
Iowa Wellness Plan
• For adults age 19 - 64
• Income up to and including 100% of the Federal
Poverty Level
Marketplace Choice Plan
• For adults age 19 - 64
• Income 101% to no more than 133% of the Federal
Poverty Level
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Iowa Wellness Plan: 0-100% FPL
Family of
one
$11,490
Individuals up
to
100% FPL
Family of
two
$15,510
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Patient Manager (PM) Benefits
Payment
Performance
Fee for Service or Encounter
Based Fee
Claim submission
Administrative Fee $4.00
Per Member-Per Month
Wellness Exam Incentive $10.00
Per Member Annually if Threshold
Achieved
Up to $4.00 Wellness Plan Medical
Home Value Index Score (VIS)
Bonus
Per Member Quarterly if Quality Target
Achieved
Iowa Wellness Plan: 0-100% FPL
Program innovations include:
• Ensure coordination of care for members through
‘medical homes’
• Ensure health care providers are accountable for
achieving high quality and cost effective care that
is focused on the patient
Program innovations will continue to be developed
through a statewide planning process related to
the State Innovation Model* grant
*Go to http://www.ime.state.ia.us/state-innovation-models.html for more information
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ACO Option
• Medicaid may contract with Accountable
Care Organizations
• ACO can earn the wellness exam and
medical home bonus for attributed
population
• By Year 3: the Wellness ACO option will
likely be replaced with the SIM initiative to
develop a state-wide, full Medicaid ACO
program.
State Innovation Model (SIM)
• Grants available to Governors
from the Centers for Medicare
and Medicaid Innovation
• 2 tracks: Design (Iowa) or
testing
• Provides funding for
developing State Health Care
Innovation Plan
• Iowa’s Plan will be complete
by January
• Will apply for Testing funds
2013 Design:
State Health Care
Innovation Plan
2014 Testing:
Application for funds /
authority to test
2016? Implementation
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State Health Care
Innovation Plan
“Vision”
•Patient-focused
•Accountability
• Aligned Quality Strategies
•Economically Sustainable
•Workforce
Vision: Transform Iowa’s
health care economy so that
it is affordable and
accessible for families,
employers, and the state,
and achieves higher quality
and better outcomes for
patients.
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Iowa State
Innovation Model
Plans
• Strategy 1: Implement a multi-payer
ACO* methodology across Iowa’s
primary health care payers
Improve value and align
payment models
• Strategy 2: Expand on the multi-payer
ACO methodology to address integration
of long term care services and supports
and behavioral health services
 Valued based payment
reform
 Organized, coordinated
delivery systems
 Build on developing health
homes / medical homes
 Align payors to provide
‘critical mass’ to support
needed investments in
change
• Strategy 3: Population health, health
promotion, member incentives
* ‘Accountable Care Organizations’ are a
reimbursement method that incents accountability for
outcomes and lowers costs
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Goals of Iowa Wellness Plan
• Begins to implement SIM Strategy 1 and 3
in the Wellness Plan
– Implements medical homes and ACOs
– Health Incentives for members to engage in
Healthy Behaviors
•
•
•
2/13/2012
Based on local access to care
Focus on health and improved outcomes
Emphasis on care coordination
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Iowa Wellness Plan Reforms
• Iowa will pay incentives to physicians and ACOs
for achieving quality metrics consistent with
Wellmark metrics
• No claims history so starting with incentives and
will move to shared savings for ACOs
• Provides starting point to begin and learn, and
will eventually be merged under larger Medicaid
SIM designs
2/13/2012
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Iowa Wellness Plan: 0-100% FPL
Out of Pocket Costs:
• No copayments except for using the emergency room
when it is not an emergency
• No monthly contributions during the first year (2014)*
• No contributions for those with income below 50% FPL*
• Costs cannot exceed 5% of income
*Monthly contributions subject to CMS approval
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Iowa Wellness Plan: 0-100%
FPL
Monthly contributions* waived
beginning in 2015 if the member
completes wellness activities
First year (2014) members
need to complete health risk
assessment and wellness
exam (annual physical)
• 2015 and beyond will also
other wellness activities
*Monthly contributions subject to CMS approval
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Marketplace Choice Plan: 101-133% FPL
Family of
one
$11,491$15,282
Family of
two
$15,511$20,628
Individuals
101% FPL
up to
133% FPL
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Marketplace Choice Plan: 101-133% FPL
Members select a certain commercial health
plan available on the Health Insurance
Marketplace
Medicaid pays the premiums to the commercial
health plan on behalf of the member –
often referred to as “premium assistance”
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Marketplace Choice Plan: 101-133% FPL
Innovation: Purchasing private
coverage
Allows individuals to stay
enrolled in their current plan
if their income changes
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Application Process
Federal Health
Insurance
Marketplace
www.HealthCare.gov
DHS website
www.dhs.state.ia.us
DHS Contact Center
1-855-889-7985
APPLICATION
PROCESS
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Iowa Health & Wellness
Builds PCP Capacity &
Entry Point for New
Population
SIM Development
Phase I: H&W Population
Stronger Primary
Care (PCP/MH)
Incentivizes
Medical Home
Concepts,
Prepares for ACO
models
Phase II: Full
Medicaid ,
Statewide ACO
Regions
Stronger Care
Management
(Health Home
(Chronic
Condition & SPMI
& BIPP)
Stronger Home
and Community
Based Services
(through BIPP)
Sustainability
through SIM
Development,
and Multiplayer
Alignment
Phase III: Fully
Defined LTC and
Behavioral health
Accountability
Future State:
Current State:
Mostly FFS
Unmanaged
Care
Silos of Care
Delivery
Limited Access
Volume Based
Purchasing
Value Based
Purchasing
Clear Accountability
Integrated Care
Delivery
Alignment in
Measures and
Analytics
Data are timely and
Secure
Stronger Mental
Health System
(Through
Redesign Efforts)
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Stakeholder Process
• Workgroups met June – September, 2013
•
•
•
•
Metrics and Contracting
Member Engagement
Long Term Care Integration
Behavioral Health Integration
• Two Consumer Focused Workgroups (October)
• Recommendations to Steering Committee,
October 30, 2013
• Review and seek guidance from Legislative
Subcommittee in November 2013
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SIM Organizing Principles
for Transformation
• Dedicated and
consistent leadership
• Collaboration and
open communication
• Clarity in
accountability
• Transparency in Data
• Alignment in measure
and analytics
Areas of Recommendation Across all
Workgroups:
•
•
•
•
•
•
•
•
Care Coordination/Community focus
Communication/Technology
Regulatory
Financing
Measures/data Transparency
Provider Supports
Patient Supports
Access/Benefits
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IowaCare Transition
IowaCare Transition
• IowaCare will end on December 31, 2013
• Current members will continue to have
same access to services until the program
ends
o Continue to seek care at medical home
IowaCare Transition
• Current members will not be cancelled
unless:
o Premiums are not paid
o Get other health insurance
o Turn 65
o Move out of the state
IowaCare Transition
• DHS re-evaluated the decision that all
IowaCare members will have to go
through the full application process and
will:
o Centrally verify the income of all IowaCare
members
o `Administratively transfer` qualifying
members into the Iowa Health and
Wellness Plan
IowaCare Transition
• DHS must verify income in order to
`administratively transfer`
• Members who cannot be verified or
whose income exceeds the Iowa Health
and Wellness Plan limits will be instructed
to proceed to the full application process
IowaCare Transition
•
•
•
The verification/transfer process will take place by the
end of October
Members whose verified income indicates eligibility for
Iowa Health and Wellness will receive confirmation of
eligibility and will proceed to enrollment for physician
selection, or qualified health plan selection
Members whose income cannot be verified or cannot be
transferred, or have income too high for the program will
receive an additional letter instructing them to proceed
to HealthCare.gov
IowaCare Transition
• Iowa Medicaid will:
o Send letters to each IowaCare member
before October 1 notifying them of this
change in the verification/transfer process
o Coordinate with medical homes on outreach
o Reach out to members multiple times to make
sure they are aware of transition
Questions?
Marni Bussell
SIM Project Director
Iowa Medicaid Enterprise
mbussel@dhs.state.ia.us
515-256-4659
Lindsay Buechel
Communications Manager
Iowa Medicaid Enterprise
lbueche@dhs.state.ia.us
515-974-3009
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