The ACA & Medicaid Expansion: Update
Washington State Nurses’ Association
February 24, 2014
MaryAnne Lindeblad, Medicaid Director, Health Care Authority
Today’s Topics
Affordable Care Act & Medicaid Expansion
Overview
Medicaid Enrollment - Estimates & Actual
Personal Stories
What’s Next for Medicaid?
2
ACA & Medicaid Expansion Overview
3
Washington’s Goals

Streamline administrative processes to capitalize on
opportunities

Leverage new federal financing opportunities to ensure the
Medicaid expansion is sustainable

Maximize use of technology to create consumer-friendly
application/enrollment/renewal experience

Maximize continuity of coverage & care as individuals
move between subsidized coverage options

Reform the WASHINGTON WAY—comply with, or seek
waiver from, specific ACA requirements related to coverage
and eligibility, as needs are identified
4
Key ACA Impacts on Medicaid

“New Eligibles” - Medicaid expansion to 138% of the FPL for
adults under age 65 not receiving Medicare*
– Modified Adjusted Gross Income (MAGI) methodology defines how income is counted,
and how household composition and family size are determined
– MAGI will determine eligibility for children, pregnant women, parents and all adults in
the new adult category. No resource/asset limits.

Washington’s new Medicaid adult group includes:
– Childless adults with incomes below 138% of the FPL
– Parents with incomes between ~54% and 138% of the FPL (based on MAGI)

Current Medicaid eligibility standards still apply to aged,
blind, disabled, SSI, and foster children
– ACA does not impact these groups
• The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard – for more
details see: http://www.hca.wa.gov/hcr/me/documents/ME2014_Changes_Comparison_Fact_Sheet.pdf
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ACA: New Coverage Continuum
*138%
**193%
** 312%
400%
% Federal Poverty Level
0%
100%
200%
300%
400%
Apple Health (Adult Medicaid)
Coverage)
Apple Health (Pregnancy Medicaid)
Apple Health for Kids (Medicaid/CHIP)
*
Premium Tax Credits & Cost-Sharing Reductions for Qualified Health
Plans
Qualified Health Plans
* The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard
** Based on a conversion of previous program eligibility standards converted to new MAGI income standards
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2014 FPL Levels
Federal Poverty Level
Annual Income:
Individual
Annual Income Level:
Family of 3
100%
$11,670
$19,790
133%
$15,521
$26,321
138%
$16,105
$27,310
200%
$23,340
$39,580
300%
$35,010
$59,370
400%
$46,680
$79,160
Source: http://aspe.hhs.gov/poverty/13poverty.cfm http://www.gpo.gov/fdsys/pkg/FR-2014-01-22/pdf/2014-01303.pdf
(released 2-7-2014)
Per HHS directive, after inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family sizes.
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Adult Medicaid Benefits as of Jan 1, 2014
Affordable Care Act – Alternative Benefit Plan for new
Medicaid adult group
 10 essential health benefits
 Mental health and substance abuse parity
 Non-emergency medical transportation
 Early Periodic Screening, Diagnosis & Treatment for
adults age 18-19
 SBIRT
 Shingles vaccination for adults 60+
2013-15 Budget – Benefit enhancements
 Adult benefits standardized except habilitative services
benefit only applies to new Medicaid adult group
 Dental services restored for all adults
 Naturopaths covered for all adults
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Essential Health Benefits
1.
2.
3.
4.
5.
Ambulatory services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use
disorder services, including
behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative
services and devices
8. Laboratory services
9. Preventive and wellness services
and chronic disease management
10. Pediatric services, including oral
and vision care
New WA Medicaid Brand Name
Capitalizing on the success of “Apple Health for
Kids” five years ago, Washington’s Medicaid
program will be known as Apple Health. The new
name is being phased in slowly, to avoid confusion
and give clients and providers time to adjust.
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This is the
first page
started.
Single
Door
toto get
Find
Coverage – Began Oct 2013
Medicaid Enrollment – Estimates & Actual
11
Estimated Medicaid Adults: 2014-2016
Financial models assume New Eligibles and Welcome Mat caseloads will ramp up over time.
NEW ELIGIBLES
250,000
223,500
(new adult group eligible for
Medicaid as a result of the ACA)
100% federal financing 2014-2016
200,000
184,000
WELCOME MAT
150,000
120,000
100,000
76,500
63,000
50,000
43,000
(adults and children who would
have been eligible for Medicaid
based on standards before the
ACA implementation, but they
never enrolled at that time.
Welcome mat specifically reflects
caseload growth resulting from
ACA implementation that is
beyond historical growth
averages.
50% federal financing
2014
2015
2016
Based on: Buettgens, et al. The ACA Medicaid Expansion in Washington. The Urban Institute.
12
February 19, 2014 Enrollment Snapshot
Regular updates
available at:
http://www.hca.wa.gov
/Pages/index.aspx
Individuals being converted, re-determined, or renewed under the MAGI standard – they
are not considered “new” to Medicaid.
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Progress Toward April 1, 2014 Medicaid Expansion Enrollment Target
Nearly Half Newly Eligible Adults Under Age 35
29%
Enrolled October 1, 2013 – December 31, 2013 for coverage beginning January 1, 2014
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Gender Breakdown by Age for Newly Eligible Adults
20,000
18,000
16,000
14,000
12,000
10,000
29%
MALE
FEMALE
8,000
6,000
4,000
2,000
0
<25
26-35
36-50
51-64
Enrolled October 1, 2013 – December 31, 2013 for coverage beginning January 1, 2014
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2014 Coverage Continuum through
Insurance Affordability Programs (IAP)
Medicaid Standard
CHIP
Medicaid Standard
Family Planning Extension
Medicaid Alternative Benefit Plan
Take Charge Family Planning
CHIP
Breast & Cervical Cancer Treatment
QHP with Subsidy
ADATSA
QHP without Subsidy
Basic Health Program
Medical Care Services Program
Presumptive SSI (aka DL-X)
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Benefits generally aligned
Programs eliminated or minimal state-only funded
program remains for targeted small groups.
Previous Medicaid Programs Streamlined
Unexpected Challenges

Over 40 State Plan Amendments required for:






MAGI-based income changes to all Medicaid groups
MAGI eligibility group definitions
Enhanced federal match claim
General Medicaid requirements
Alternative benefit requirements for new adults (in process)
Waiver amendments required to:



Implement MAGI-based eligibility Oct 1, 2013 (using Exchange portal)
Meet federal requirements for income changes based on MAGI
Transfer adults into New Adult category (100% FMAP) where prior programs
eliminated

Estate recovery rules revised for new adult group

Processing of Medicaid renewals delayed

Individuals notified of action needed to sustain coverage have not all
responded
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Personal Stories
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Washington State Success Stories
Laura
Mother of one working part-time and going to college to
become a teacher
Health compromised 22 years ago making insurance necessary,
expensive, and difficult to find—before the ACA
Cost of her premium and deductible constantly increased until it
was unaffordable
Learned she qualified for Washington Apple Health while visiting
the HealthPlanFinder
So happy to get coverage, posted her experience on Facebook
Laura’s friends are signing up for Apple Health
Photo Source: clipart.com
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Washington State Success Stories
Adam
Homeless single adult
Unemployed; no resources
Heard about Apple Health through “grapevine” and tried
unsuccessfully to apply online
Contacted HCA and reached a receptionist, who connected him
with a Medicaid eligibility worker
Medicaid eligibility worker resolved the issues blocking his
application
Adam was enrolled in Apple Health by the end of that day
Photo Source: clipart.com
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WashingtonState
State Success
Stories
Washington
Success
Stories
Tom
Young adult, previously uninsured
Sporadically employed; no resources
Heard about Apple Health while in the hospital (multiple times
during Fall 2013 for which his hospital care cost $250,000 )
Applied the day he was released from hospital for coverage
beginning January 1, 2014
From Tom: “Wow – if only I’d had Apple Health in November!”
Photo Source: clipart.com
22
Washington State Success Stories
Bill
Works under contract as a caterer
Had insurance, but could no longer afford it
At age 61, made a decision to go without health insurance
until he qualified for Medicare at age 65
One of the first to sign up for Washington Apple Health
Fully covered as of January 1, 2014
From Bill: “It will give me peace of mind, definitely more
peace of mind. …That is one anxiety I don’t have to worry
about now.
Photo Source: clipart.com
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What’s next for Medicaid?
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Further Outreach Planned
•
•
•
•
•
•
•
•
•
•
Spanish language radio PSAs (Seattle, Skagit, Clark, Yakima counties)
Coordinate JCAs staff—especially rural areas
Commission on Hispanic Affairs collaboration to work on cultural bridges
Coordinate with Dept. of Agriculture in rural areas
Regular Apple Health news mailings (county ministerial associations & school
districts)
Editorial board visits
Mailings to clients with other services (e.g. food stamp recipients)
Distribution of Apple Health posters in English and Spanish in Yakima Valley
Posters to food banks in selected areas and possible “bill stuffers”
WA Apple Health Speakers Bureau
25
Medicaid Plan Selection - 2015
Ability for Modified Adjusted Gross Income (MAGI) clients to select
Medicaid Managed Care Organization (MCO) of their choice
 HealthPlanFinder (HPF) will store and display available MCOs
 Major system changes required to support:
 Real-time MCO selection (ProviderOne)
 HPF online system interface with ProviderOne for eligibility data transmission
 Real time eligibility interface with ProviderOne (DSHS Automated Client
Eligibility System/Eligibility Service - ACES/ES)
 Cost based on Rough Order Magnitude (ROM) estimates from HPF and
ProviderOne vendors:
 HFP enhancements/changes: $3 million (90/10 federal match)
 ProviderOne enhancements/changes: $900,000 (90/10 federal match)
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State Health Care Innovation Plan
The Plan’s Core Objectives
Ensure a healthier Washington
Pay for value and outcomes
instead of volume of services
Empower communities to improve
health and better link with health
delivery
Integrate physical and behavioral
health to address the needs of the
whole person
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State Health Care Innovation Plan
What’s In the Plan?
Seven Building Blocks:
Quality and price transparency
Person and family engagement
Regionalize transformation
Create Accountable Collaboratives for Health
(ACHs)
Leverage and align state data
Practice transformation support
Workforce capacity and flexibility
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State Health Care Innovation Plan
What’s In the Plan?
Three Strategies:
Drive value-based purchasing across the community,
starting with the State as “first mover”
Build healthy communities and people through
prevention and early mitigation of disease throughout the
life course
Improve chronic illness care through better integration of
care and social supports, particularly for individuals with
physical and behavioral health co-morbidities
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HCA & Other Contacts
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HCA Contact Information
 Dorothy Teeter, Director
dorothy.teeter@hca.wa.gov l 360-725-1523
 MaryAnne Lindeblad, Medicaid Director
maryanne.lindeblad@hca.wa.gov l 360-725-1863
 Nathan Johnson, Policy, Planning & Performance Director
nathan.johnson@hca.wa.gov l 360-725-1880
 Dan Lessler, MD, Chief Medical Officer
daniel.lessler@hca.wa.gov l 360-725-1612
 Dennis Martin, Legislative Affairs
dennis.martin@hca.wa.gov l 360-725-9808
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