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






Enrollment
Benefits
Usage
Cost sharing (co-pays)
Access
Quality
Accountability
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
Dental

Medications

Transport

Behavioral health
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…bringing the biggest change in Medicaid since it began.
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
Increase access

Control costs

Add benefits & protections

Address many smaller issues
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Insurance reform
1.

2.
Individual mandate
Exchanges + subsidies
 Subsidies for those at 100% -400% of FPL
3.
Medicaid expansion
 For adults < 138% of FPL
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2014 Federal Poverty Limit (FPL)
Family of 1:
Family of 4:
$11,670
$23,850
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x 133% = $15,521
x 133% = $31,721
10
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“New Eligibles”:
FMAP = 100%  90%
“Old Eligibles”:
FMAP = 50%
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Change in Coverage in NJ under ACA (ages 0-64)
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17
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑥=
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒
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18
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑥=
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒
Part 2
US
0.72
WY
AK
DE
PA
CA
NY
1.43
1.40
1.00
0.73
0.56
0.43
NJ
0.37
19
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑥=
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒
Part 2
US
0.72
WY
AK
DE
PA
CA
NY
1.43
1.40
1.00
0.73
0.56
0.43
NJ
0.37
20
% doctors accepting
𝑥=
Part 2
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒
21

=
1.00!
But…

For PCPs only

Only for 2013, 2014

Also for managed care
 Family practitioners
 Internists
 Pediatricians
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
“Accountable Care Organization”
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
Why?

 Eligibility changes
 Service benefit additions
 Payment criteria
changes
Waivers for…?
 Medicaid ACOs
▪
▪
▪
▪
▪
Define scope
Define new roles
Build capacity
Include high-cost groups
Multi-payer alliances
 Payment models
 Measurements
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Getting it all together
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
“Division of Medical Assistance and Health Services”

$11 billion (federal and state)

500 people

Director: Valerie Harr

(“NJ FamilyCare”)
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
Required by Section 1902(a) (30)(A)

71 elements
 Rates
 Methodology
 Comment periods
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
Section 1115
 Research and
…for more “flexibility”
demonstration

Section 1915(b)
 Managed Care

Section 1915(c)
 Home and Community
Based

Concurrent 1915(b) & (c)
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
Health homes
 2010: NJ Public Law 2012, Chapter 74  3 year
Medicaid Medical Home demonstration project 
Section 2703 of ACA

Accountable Care Organizations (ACO)
 2011: NJ Public law 2011, Chapter 114  Medicaid
Accountable Care Organization demonstration
project.
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ADD…
KEEP…

Mandated services

Choice of plans

“Actuarially sound” rates
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
…“Risk-based” payments
LOSE…
30
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31

Section 1115
1.
2.
Childless adults
Family coverage (SCHIP)
demonstration

ACOs
Section 1915(b)
3.
4.
NJ Care 2000+
NJ Family Care
BH ASO
 Research and

 Managed Care (Mandatory)

Section 1915(c)
 Home and Community
Based

Concurrent 1915(b) & (c)
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
5.
6.
7.
8.
Global Options (LT care)
Renewal Waiver
Community Resources
Community Care Alternatives
32

Section 1115
 Research and
demonstration

Section 1915(b)
 Managed Care (Mandatory)

Section 1915(c)
 Home and Community
Based

1.
2.

Childless adults
Family coverage (SCHIP)
Accountable Care (ACO)
3.
4.
NJ Care 2000+
NJ Family Care
Behavioral Health (ASO)

5.
6.
7.
8.
Concurrent 1915(b) & (c)
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Global Options (LT care)
Renewal Waiver
Community Resources
Community Care Alternatives
33

Section 1115
 Research and
demonstration

Section 1915(b)
 Managed Care (Mandatory)

Section 1915(c)
 Home and Community
Based
1.
2.

Childless adults
Family coverage (SCHIP)
Accountable Care (ACO)
3.
4.
NJ Care 2000+
NJ Family Care
Behavioral Health (ASO)

5.
6.
7.
8.

Concurrent 1915(b) & (c)
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Global Options (LT care)
Renewal Waiver
Community Resources
Community Care Alternatives
34

Section 1115
 Research and
demonstration

Section 1915(b)
 Managed Care (Mandatory)

Section 1915(c)
One
Comprehensive
Waiver
 Home and Community
Based

Concurrent 1915(b) & (c)
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Administrative Services Organization

One already exists!
 In DCF: “CSOC”
 40,000 kids

Phase in risk-based
over 5 years
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“Benchmark”
coverage
under ACA
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“Benchmark”
coverage
under ACA
Excludable
for newbies
under ACA
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41
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑥=
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒
Part 2
US
0.72
WY
AK
DE
PA
CA
NY
1.43
1.40
1.00
0.73
0.56
0.43
NJ
0.37
42
% doctors accepting
𝑥=
Part 2
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒
43

100%!
 …for PCPs and those they supervise…
 …even in managed care…
𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒
𝑥
=
 …even for dual eligibles.
𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒 𝑟𝑎𝑡𝑒

= 100%
Result: 10-24% increase in accepting PCPs?
BUT:

Not for specialists (e.g., psychiatrists)

Only for 2013 and 2014
 Extend? Measurement will be key…
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
Overlap!
 Medicaid: < 138% FPL.
 Exchanges: > 100% FPL.

Partial expansion? All > 100% to exchanges,
where no state funding needed…

HHS: 100% FMAP if states do partial? NO!
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
Overlap!
 Medicaid: < 138% FPL.
 Exchanges: > 100% FPL.

Partial expansion? All > 100% to exchanges,
where no state funding needed…

HHS: 100% FMAP if states do partial? NO!
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
Overlap!
 Medicaid: < 138% FPL.
 Exchanges: > 100% FPL.

Partial expansion? All > 100% to exchanges,
where no state funding needed?…

NO! HHS: no 100% FMAP if states do partial
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

Medicaid  Exchanges:
35% of all adults below
200% FPL
Exchanges  Medicaid:
28 million p.a.?
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Wages
48
New eligibles vs.
old eligibles not enrolled
FMAP
= 100%
234,000
total eligibles
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
HEDIS: measure behavioral health?
 Healthcare Effectiveness Data and Information Set
 System metrics, not consumer metrics
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
Publicity hurdles
 150 different languages in NJ
 Cultural differences

Application hurdles
 Multipage application
 Documentation of income and residency

Tracking hurdles
 ACA does not apply to incomes < IRS tax filing threshold
($9,350 for singles, $18,700 for joint)
 = 50% of eligible uninsureds
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South Carolina’s IT Enterprise Strategy Map
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
ASO: July 1, 2014!
 “Managed care”, but…
 Fee for service

“Live”: January 1!
 Medicaid Expansion
 Exchanges
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
Reporting

Documentation

Audits

Clawbacks

Penalties
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
Reduced fees

Increased costs

New investments
 EMR
 Compliance
 Training
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Access
Availability
Quality
Cost
Innovation
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  
Enrolled
To be enrolled
Not enrolled
Access
Availability
Quality
Cost
Innovation
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
To the System

To Providers

To PsyR services

(To Insurance…)
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
Of basic care

Of specialty care

Of emergency care

Of evidence-based practices
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
Provider





What level?
What training?
What experience?
What supervision?
Process
 Simpler?
 Smoother?
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
Co-pays

Deductibles

Premiums

(Work incentives?)
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
Practices

Medications

Technology

Management
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  
Access
Availability
Quality
Cost
Innovation
Part 2
Enrolled
To be enrolled
Not enrolled















67
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References
Alzer, A., Currie, J., & Moretti, E. (2007). Does Medicaid managed care hurth health? Evidence
from Medicaid mothers. The Review of Economics and Statistics, 89(3).
Averill, Patricia M., Ruiz, Pedro, Small, David R., Guynn, Robert W., & Tcheremissine, Oleg.
(2003). Outcome assessment of the Medicaid managed care program in Harris County
(Houston). Psychiatric Quarterly, 74(2), 103-114.
Bigelow, Douglas A., McFarland, Bentson H., McCamant, Lynn E., Deck, Dennis D., & Gabriel,
Roy M. (2004). Effect of Managed Care on Access to Mental Health Services Among
Medicaid Enrollees Receiving Substance Treatment. Psychiatric Services, 55(7), 775779.
Cook, Judith A., Heflinger, Craig Anne, Hoven, Christina W., Kelleher, Kelly J., Mulkern,
Virginia, Paulson, Robert I., . . . Kim, Jong-Bae. (2004). A Multi-site Study of Medicaidfunded Managed Care Versus Fee-for-Service Plans' Effects on Mental Health Service
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Health Services & Research, 31(4), 384-402.
Coughlin, Teresa A., & Long, Sharon K. (2000). Effects of medicaid managed care on adults.
Medical Care, 38(4), 433-446.
Cunningham, Peter J., & Nichols, Len M. (2005). The Effects of Medicaid Reimbursement on
the Access to Care of Medicaid Enrollees: A Community Perspective. Medical Care
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Felix, Holly C., Mays, Glen P., Stewart, M. Kathryn, Cottoms, Naomi, & Olson, Mary. (2011).
Medicaid Savings Resulted When Community Health Workers Matched Those With
Needs To Home And Community Care. Health Affairs, 30(7), 1366-1374. doi:
10.1377/hlthaff.2011.0150
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Gold, Marsha, & Mittler, Jessica. (2000). "Second-generation" Medicaid managed care: Can it
deliver? Health Care Financing Review, 22(2), 29-47.
Kaye, H. Stephen, LaPlante, Mitchell P., & Harrington, Charlene. (2009). Do noninstitutional
long-term care services reduce Medicaid spending? Health Affairs, 28(1), 262-272. doi:
10.1377/hlthaff.28.1.262
Keenan, Patricia S., Elliott, Marc N., Cleary, Paul D., Zaslavsky, Alan M., & Landon, Bruce E.
(2009). Quality assessments by sick and healthy beneficiaries in traditional Medicare and
Medicare managed care. Medical Care, 47(8), 882-888.
Liu, Heng-Hsian Nancy. (2012). Policy and practice: An analysis of the implementation of
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Sciences and Engineering, 72(7-B), 4324.
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McFarland, Bentson H., Deck, Dennis D., McCamant, Lynn E., Gabriel, Roy M., & Bigelow,
Douglas A. (2005). Outcomes for Medicaid Clients With Substance Abuse Problems
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Norris, Margaret P., Molinari, Victor, & Rosowsky, Erlene. (1998). Providing mental health care
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