Maximizing coverage and
access to care under PPACA
State Coverage Initiatives Program
August 4, 2010
Stan Dorn
The Urban Institute
Sdorn@urban.org 202.261.5561
Overview
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Maximizing enrollment and retention of
eligible individuals
Improving affordability and continuity of
coverage and care above Medicaid
income levels
Increasing Medicaid beneficiaries’ access
to care
But first: a quick review
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Medicaid to 138% FPL
 MAGI
 Rules for newly eligible adults
o Definition: would not have qualified under state rules as of 12/1/09
o Highly enhanced FMAP
o “Benchmark benefits”
 Standard FMAP for other adults
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Subsidies in the exchange up to 400% FPL
 OOP cost-sharing subsidies to 250% FPL – higher AV
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Integrated eligibility system for Medicaid and exchange
Individual mandate raises the stakes on enrollment
Caveat: much hinges on how CMS interprets the law
Part I
Maximizing enrollment
and retention of eligible
individuals
The need for public education
and application assistance
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The Massachusetts story
 Major public education effort
 Application assistance
o “Virtual gateway”
o CBO contracts
o Provider incentives
o > ½ of all successful applications came from CBOs and
providers
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Other states have facilitated enrollment – CA,
NY, WI, etc.
Behavioral economics
Public education and application
assistance under PPACA
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Responsibility of exchange
 Patient navigators
 Call centers
 Federal funding through 12/31/14
Partner with local philanthropy
Hospital-based presumptive eligibility
Follow MA precedent in terms of safety net
providers?
 Must be done carefully, to avoid deterring access to care
Limit application forms to
questions relevant to eligibility
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Need to distinguish the newly eligible from others
 Claim enhanced FMAP
 Provide benchmark benefits
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Requires information irrelevant to eligibility
 Parents
o Assets
o Deprivation
 Childless adults and empty nesters
o Disability
o Pregnancy
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Solutions
 To claim FMAP, use sampling
 Provide standard Medicaid benefits as “Secretary-approved”
benchmark coverage, Social Security Act Section 1937(b)(1)(D)
Asking for help without
completing a traditional form
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Eligibility is determined based on data when an
individual applies “by requesting a determination of
eligibility and authorizing disclosure of … information
[described in Social Security Act Sections 1137, 453(i),
and 1942(a)] … to applicable State health coverage
subsidy programs for purposes of determining and
establishing eligibility.” PPACA Section
1413(c)(2)(B)(ii)(II)
Precedents
 EITC amount
 CA income tax
 Medicare Parts B and D – automatic, without request
Requirements
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Consumer must
 Request for disclosure
 Provide SSNs needed for data-matching
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State and exchange must gather data
 1137 – IEVS, SAVE
 453(i) – National Directory of New Hires
 1902(a) – public benefit programs, new hires data,
state tax records, Medicaid TPL data showing private
coverage, vital statistics records in any state
Basing eligibility on receipt of
other benefits
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Express Lane Eligibility remains an option for
children
New SSA Section 902(e)(13)(D)(i)(I) says
that MAGI does not apply to people “who are
eligible for medical assistance … as a result
of eligibility for, or receipt of, other Federal or
State aid or assistance” [in addition to SSI]
Implies that states can base Medicaid
income-eligibility on receipt of other benefits
 Logical if other program’s eligibility is far below
138% FPL
Basing eligibility on income data
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Subsidies in exchange
 Based on prior-year tax data
 Chance to supplement at application
 Year-end reconciliation
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Medicaid
 Initial determination based on income at time
application is processed
 Post-application changes? Not clear, under PPACA
 What happens if application submitted to exchange?
Suppose states cannot base
Medicaid eligibility on data
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Pay stubs required or self-attestation
Consequences for consumer
 Two-tier system obstructing participation
 Successful programs have used data-driven eligibility
o Massachusetts enrollment
o Louisiana renewal
o Medicare subsidies for Parts B and D
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Consequences for states
 Administrative costs higher
 Caseload costs lower
 Higher likelihood of PERM liability
Possible approach
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If prior-year tax data show Medicaid eligibility, consumer
automatically receives Medicaid
 If after a certain point in the calendar year, could supplement
with more recent data (new hires, quarterly earnings)
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If prior-year tax data show ineligible for Medicaid,
receive an opportunity to apply for Medicaid using
traditional procedures, including pay stubs, etc.
 In the meantime, subsidies in the exchange
 Precedent: ELE
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Legal support
 “Less restrictive methodology”
 PPACA requires Medicaid, CHIP, and the exchange “to the
maximum extent practicable, to determine … eligibility on the
basis of reliable, third party data.” Section 1413(c)(3)(A)(ii)
Integrated eligibility determination
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Basic model
 Exchange, Medicaid, and CHIP compile a data warehouse for
each applicant
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States need better eligibility IT
 Will CMS develop modules?
 Will CMS makes grants to states under PPACA Section 1561?
Revisit the denial of MMIS FMAP to eligibility systems?
 Can administrative funding for the exchange help with Medicaid?
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Exchange can contract with Medicaid to determine
eligibility for subsidies in exchange
 Massachusetts model
 Must meet HHS “requirements ensuring reduced administrative
costs, eligibility errors, and disruptions in coverage.”
1413(d)(2)(A)
o Single, statewide office, as in Massachusetts?
Part II
Improving affordability and
continuity of coverage above
Medicaid eligibility levels
Concerns about affordability in
the exchange
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Subsidy levels lower than any state program
covering this income level
Example: single adult at 160% FPL
 $1,444 in monthly pre-tax income in 2009
 PPACA requires $64 in monthly premiums
 Coverage could include
o $25-30 office visit copays
o Prescription drug copays between $10 and $40
 Contrast: most CHIP programs impose no charges or
nominal charges at this income level
Basic health program (BHP)
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Covered individuals
 Income at or below 200% FPL
 Ineligible for Medicaid or CHIP because of
o Income; or
o Legalization of immigration status during the past 5 years.
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State
 Contracts with health plans to provide coverage at least as generous as
in the exchange
 Receives 95% of what the federal government would have spent in
subsidies
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State could use BHP to provide Medicaid look-alike coverage
 Federal dollars roughly 50% higher than Medicaid average for adults
 Could use excess to raise reimbursement, improve access
 Makes it easier to end optional Medicaid coverage above 138% FPL
Another approach
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State can supplement subsidies in the
exchange
 Can apply above BHP income levels or
instead of BHP
 Could limit to high-value plans implementing
delivery system reforms
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Trade-off: state general fund cost
 Can limit subsidies to the lowest-income
households, not all the way to 400% FPL
Continuity
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Income changes could shift people
between Medicaid and the exchange
 Involuntary changes of plan and provider
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State policy options
 Include Medicaid MCOs in the exchange
o When income changes, so do premiums and OOP
costs, but not the health plan or provider
 Massachusetts model
Part III
Increasing access to care
for Medicaid
beneficiaries
PPACA
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Raises reimbursement to Medicare levels,
but…
 Only for evaluation and management services
 Only for primary care providers
o Not for mental health, dentistry, specialists
 100% FMAP ends after 2013 and 2014
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Provides other infrastructure funding
 $11 billion for community health centers
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MACPAC
Alternatives to raising rates
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Streamline Medicaid claims processing
Increase permitted scope of practice for
non-physicians
 Especially for Medicaid, potentially for other
payors to address workforce shortages
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Rural tele-health
Incentives to take Medicaid patients
 Link to other coverage
Conclusion
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No matter what, PPACA is likely to
dramatically increase coverage and
access to care
The amount of that increase will depend,
in significant part, on state policy
decisions