MASSHEALTH: THE BASICS
PREPARED BY
CENTER FOR HEALTH LAW AND ECONOMICS
UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL
Webinar: May 29, 2014
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
WEBINAR
OVERVIEW
 MassHealth: The Basics, April 2014 Update
 Eligibility, enrollment and spending in
MassHealth
PRESENTERS
 Kate Nordahl,
Massachusetts Medicaid Policy Institute
 Center for Health Law and Economics,
University of Massachusetts Medical School:
– Robert Seifert
– Kate Russell
– Carol Gyurina
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 1
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
FUNDAMENTALS
OF MASSHEALTH
 MassHealth is Medicaid (Title XIX of the Social Security Act)
and the State Children’s Health Insurance Program (CHIP,
Title XXI)
 Federally- and state-funded and state-administered
 1.4 million members; increasing under the ACA
 Includes benefits not covered by other insurance
 Supports workers’ access to private insurance
MASSACHUSETTS
1115 WAIVER
 Section 1115 Research and Demonstration Waiver
(“MassHealth”) since 1997
– Expanded eligibility for higher incomes and broader
categories; subsidies in Commonwealth Care
– Programmatic innovations such as CommonHealth,
payment reforms and delivery system transformation
– Supplemental financial support for safety net providers
 Vehicle for reform
 5-year renewal request pending (effective 7/1/2014)
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 2
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MASSHEALTH ELIGIBILITY UNDER THE ACA
400%
ELIGIBLE FOR
TAX CREDITS
FOR QUALIFIED
HEALTH PLAN
CHILDREN
300%
NO
UPPER
LIMIT
NO
UPPER
LIMIT
ADULTS AGES 21 THROUGH 64
300%
250%
200%
200%
150%
133%
150%
133%
100%
100%
FPL*
NO
UPPER
LIMIT
FPL*
0
1-18
19-20
AGE IN YEARS
DISABLED
CHILDREN
& YOUNG
ADULTS
THROUGH
AGE 20
FORMER
FOSTER
CARE
YOUTH
UP TO
AGE 26
ALL
OTHER**
MEDICALLY
FRAIL
ELIGIBLE
FOR CARE
PLUS BUT
ELECT
STANDARD
MassHealth Standard
MassHealth CarePlus
MassHealth CommonHealth
MassHealth Family Assistance
HIV
POSITIVE
DISABLED INDIVIDUALS PARENTS PREGNANT INDIVIDUALS
HCBS
RECEIVING
OF
ALL AGES
WITH
WAIVER
SERVICES CHILDREN
BREAST OR
GROUP
FROM DMH
< 19
CERVICAL
CANCER
Connector Care/Qualified Health Plan (QHP)
*FPL = income as percent of federal poverty level
** Includes members previously eligible for Commonwealth Care and for MassHealth Basic and Essential.
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 3
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CHILDREN
300%
NO
UPPER
LIMIT
400%
300%
200%
185%
200%
150%
133%
150%
NO
UPPER
LIMIT
100%
FPL*
0
1-5
6-14
15-17
18
PREGNANT
DISABLED
0
1-18
19-20
ADULTS UNDER 65
300%
NO
UPPER
LIMIT
ELIGIBLE FOR
TAX CREDITS
FOR QUALIFIED
HEALTH PLAN
133%
100%
86%
% of FPL*
CONTACT INFORMATION
NO
UPPER
LIMIT
DISABLED
FORMER
CHILDREN & FOSTER
YOUNG
CARE
ADULTS YOUTH UP
THROUGH TO AGE 26
AGE 20
ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN
NO
UPPER
LIMIT
200%
185%
150%
133%
100%
86%
PREGNANT
MAY 2014
DISABLED
HIV
POSITIVE
WORK FOR
ALL
WORK FOR LONG-TERM
ALL
QUALIFIED
OTHER
QUALIFIED UNEMPLOYED OTHER
EMPLOYER
EMPLOYER
(INSURANCE
(INSURANCE
PARTNERSHIP)
PARTNERSHIP)
ALL
OTHER**
MEDICALLY
HIV
FRAIL
POSITIVE
ELIGIBLE FOR
CARE PLUS BUT
ELECT STANDARD
DISABLED INDIVIDUALS PARENTS PREGNANT INDIVIDUALS
HCBS
RECEIVING
OF
ALL AGES
WITH
WAIVER
SERVICES CHILDREN
BREAST OR
GROUP
MASSACHUSETTS
INSTITUTE
FROM DMH
< 19MEDICAID POLICY
CERVICAL
CANCER
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MASSHEALTH ELIGIBILITY UNDER THE ACA
400%
ELIGIBLE FOR
TAX CREDITS
FOR QUALIFIED
HEALTH PLAN
CHILDREN
300%
NO
UPPER
LIMIT
NO
UPPER
LIMIT
ADULTS AGES 21 THROUGH 64
300%
250%
200%
200%
150%
133%
150%
133%
100%
100%
FPL*
NO
UPPER
LIMIT
FPL*
0
1-18
19-20
AGE IN YEARS
DISABLED
CHILDREN
& YOUNG
ADULTS
THROUGH
AGE 20
FORMER
FOSTER
CARE
YOUTH
UP TO
AGE 26
ALL
OTHER**
MEDICALLY
FRAIL
ELIGIBLE
FOR CARE
PLUS BUT
ELECT
STANDARD
MassHealth Standard
MassHealth CarePlus
MassHealth CommonHealth
MassHealth Family Assistance
HIV
POSITIVE
DISABLED INDIVIDUALS PARENTS PREGNANT INDIVIDUALS
HCBS
RECEIVING
OF
ALL AGES
WITH
WAIVER
SERVICES CHILDREN
BREAST OR
GROUP
FROM DMH
< 19
CERVICAL
CANCER
Connector Care/Qualified Health Plan (QHP)
*FPL = income as percent of federal poverty level
** Includes members previously eligible for Commonwealth Care and for MassHealth Basic and Essential.
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 5
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MASSHEALTH IS IMPORTANT TO MANY POPULATION GROUPS
PERCENT OF SELECT MASSACHUSETTS POPULATIONS COVERED BY MASSHEALTH, 2012
All non-elderly adults
19%
Non-elderly adults earning > 100% FPL and <300% FPL
36%
Non-elderly adults earning <100%FPL
51%
All children
40%
Children in families earning > 100% FPL and <300% FPL
49%
Children in families earning <100%FPL
72%
Births (child born in last 12 months)
33%
Medicare beneficiaries
27%
People with disabilities (require assistance with self-care)
58%
Nursing home residents
63%
0%
20%
40%
60%
80%
SOURCES: Author’s calculations
using the 2012 American Community Survey (ACS). Nursing home data from Kaiser State Health Facts (C. Harrington, H. Carrillo, M. Dowdell, P. Tang, and B. Blank.
Table 6, "Nursing, Facilities, Staffing, Residents, and Facility Deficiencies, 2005 Through 2010," Department of Social and Behavioral Sciences, University of California, San Francisco, accessed
January 2012). Data for “all children” and “all elderly adults” calculated from Census 2012 population data projections and MassHealth Snapshot report, 2013 monthly average.
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 6
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MASSHEALTH COVERS CHILDREN, ADULTS & SENIORS, AND OFTEN
SUPPLEMENTS OTHER INSURANCE
PERCENT OF TOTAL MASSHEALTH ENROLLMENT, DECEMBER 2013
Seniors in Community – 102,466
Seniors in Nursing Facilities – 24,476
2%
2%
Other – 22,709
7%
18%
Adults with Disabilities – 245,129
9%
Non-Disabled Children – 527,623
LT Unemployed Adults – 128,721
38%
23%
Non-Disabled Adults – 316,270
2%
Children with Disabilities – 31,726
SOURCE: MassHealth,
MAY 2014
December 2013 Snapshot Report.
MASSACHUSETTS MEDICAID POLICY INSTITUTE 7
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
GROWING MASSHEALTH ENROLLMENT HAS ACCOMPANIED THE
DECLINE IN THE NUMBER OF UNINSURED
TRENDS IN MASSHEALTH ENROLLMENT AND UNINSURED, 1995-2011
(THOUSANDS)
1,600
MassHealth
1,400
1,200
1,000
800
600
400
Uninsured
200
0
1995
1998
2000
2002
2004
2006
2007
2008
2009
2010
2011
2012
2013
MassHealth figures are from the Office of Medicaid and are monthly averages, except 1998-2002 which are as of June 30. Uninsured numbers for 1998-2011 from the Division of
Health Care Finance and Policy, from a survey in that year, and for 2012 from the Center for Health Information and Analysis, from ACS data. 1995 Uninsured numbers from Blendon et al.,
“Massachusetts Residents Without Health Insurance, 1995,” Harvard School of Public Health.
SOURCES:
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 8
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MORE THAN THREE IN FIVE MASSHEALTH MEMBERS ARE
ENROLLED IN MANAGED CARE
MASSHEALTH ENROLLMENT BY PAYER TYPE, DECEMBER 2013
FFS & Premium
Assistance — 463,474
33%
PCC PLAN — 382,795
37%
27%
2%
MCO — 522,311
SCO — 30,540
As of May, 13,274 individuals have enrolled in One Care, a new MassHealth program.
SOURCE: MassHealth,
MAY 2014
December 2013 Snapshot Report; EOHHS May 2014 One Care Enrollment Report
MASSACHUSETTS MEDICAID POLICY INSTITUTE 9
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MANAGED CARE
PROGRAM
POPULATIONS
SERVED
Managed Care
Organizations
(MCO)
Children and
adults under
65
Medical and Behavioral Health services covered by a capitated
payment to health plans. Long-term support services (LTSS) and
dental benefits not included in MCO benefit but available
through MassHealth Fee-For-Service
Primary Care
Clinician Plan (PCC)
Children and
adults under
65
Behavioral Health services covered by capitated payment to
behavioral health plan. Medical services, which are not
capitated, are managed by a primary care clinician. Dental and
LTSS benefits are available through MassHealth Fee-for-Service
• Some primary care clinicians receive capitated payments as
part of the Primary Care Payment Reform Initiative (PCPRI)
One Care
Ages 21-64
Eligible for
MassHealth
and Medicare
Full spectrum of services covered by capitated payment to one
health plan (includes medical, LTSS, Dental, & Behavioral
Health)
Senior Care
Options (SCO)
65 + Eligible
for MassHealth
and Medicare
Full spectrum of services covered by capitated payment to one
health plan (includes medical, LTSS, Dental, & Behavioral
Health)
MAY 2014
COVERED SERVICES
MASSACHUSETTS MEDICAID POLICY INSTITUTE 10
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MCOs SERVE A LESS MEDICALLY COMPLEX POPULATION
THAN THE PCC PLAN
MASSHEALTH MCO AND PCC PLAN ENROLLMENT BY POPULATION TYPE, DECEMBER 2013
600,000
Total:
522,311
500,000
400,000
11%
Total:
382,795
27%
Basic Essential Adults
17%
300,000
Non-Disabled Adults
8%
Disabled Adults
19%
Non-Disabled Children
15%
200,000
Disabled Children
52%
45%
100,000
3%
0
MCO
3%
PCC
TYPE OF MANAGED CARE
NOTE:
Chart shows enrollment for members under age 65.
MassHealth, December 2013 Snapshot Report.
SOURCE:
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 11
INTRODUCTION
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SPENDING
CONTACT INFORMATION
NOMINAL MASSHEALTH SPENDING HAS GROWN BY MORE THAN HALF SINCE 2005; WHEN
ADJUSTED FOR MEDICAL INFLATION SPENDING HAS GROWN ON AVERAGE 2% ANNUALLY
MASSHEALTH SPENDING, SFY 2005-2013
(BILLIONS OF DOLLARS)
$10
$9.8
$9.3
$9.1
$9
Current
Dollars
$8.8
$8.1
$8
$7.7
Inflation-adjusted
Dollars
$7.0
$6.8
$7
$7.0
$6.3
$6.5
$6.3
$6
$6.7
$6.7
2008
2009
$7.1
$7.2
2011
2012
$7.3
$6.4
$5
2005
2006
2007
2010
2013
STATE FISCAL YEAR
SOURCE:
MassHealth Budget Office. Inflation adjustment uses the Medical Consumer Price Index for the Boston area, from the Bureau of Labor Statistics .
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 12
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
ENROLLMENT HAS DRIVEN GROWTH IN
MASSHEALTH SPENDING IN RECENT YEARS
GROWTH IN MASSHEALTH TOTAL SPENDING, ENROLLMENT AND PER MEMBER PER MONTH (PMPM) COSTS
(YEAR 2005 = 100)
155
Total Spending
150
145
140
Enrollment
135
130
125
120
115
110
105
$PMPM
100
95
2005
SOURCES:
2006
2007
2008
2009
2010
2011
2012
EOHHS (total spending and enrollment) and authors’ calculations.
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 13
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MASSHEALTH SPENDING PER ENROLLEE IS HIGHER
FOR SENIORS AND THE DISABLED
MASSHEALTH PAYMENTS PER ENROLLEE PER YEAR, FY 2013
$-
$5,000
$10,000
$15,000
$20,000
Seniors
$21,613
Adults with Disabilities
$12,633
Children with Disabilities
Adults
Children
Total
SOURCES: Calculations
MAY 2014
$25,000
$14,617
$3,959
$3,590
$7,072
based on total spending form the MassHealth Budget Office, and average membership for July 2012 – June 2013 from the MassHealth Snapshot Report.
MASSACHUSETTS MEDICAID POLICY INSTITUTE 14
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MASSHEALTH SPENDING IS IMPORTANT TO MANY TYPES
OF PROVIDERS
MASSHEALTH REVENUE AS A PERCENTAGE OF PROVIDERS’ TOTAL PATIENT REVENUES
60%
49%
50%
51%
45%
40%
27%
30%
20%
14%
10%
0%
Hospitals
Nursing
Homes
Community
Health Centers
Long-term
Services and
Supports
Pre-natal
Care
Center for Health Information and Analysis, 403 Cost Reports (Acute Hospitals, data from FY2012); Massachusetts Senior Care Association (Nursing Homes – data from CY 2012); Health
Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System Report (CHCs – data from Federal FY 2012); “Securing the Future: Report of the Massachusetts Long-Term
Care Financing Advisory Committee,” November 2010 (LTSS – data from Calendar Year 2005); Mass. DPH, Massachusetts Births 2010 (Pre-natal Care – data from Calendar Year 2010), March 2013.
SOURCES:
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 15
INTRODUCTION
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SPENDING
CONTACT INFORMATION
MASSHEALTH SPENDING BY SERVICE TYPE
FOR STATE FISCAL YEAR 2013
TOTAL MASSHEALTH SPENDING FY2013 = $9.8B
Other — $534M
Physician — $331M
Dental — $245M
Pharmacy — $512M
3%
3%
5%
5%
32%
Hospital Outpatient — $585M
Hospital Inpatient — $740M
Community LTC Supports — $1.4B
Managed Care Capitation
Payments — $3.2B
6%
8%
8%
15%
SCO/PACE Capitation
Payments — $774M
15%
Nursing Homes — $1.4B
NOTE: “Other”
includes Transportation , community health centers, and smaller amounts of spending on rest homes, vision care, EI/Chapter 766, hearing care, group practice organization, family
planning clinics, renal dialysis clinics, ambulatory surgery center, eye glasses, DME/Oxygen, imaging/radiation centers, certified independent labs, psychologists, mental health clinics, psychiatric day
treatment, substance abuse services, and Medicare crossover payments.
SOURCE: MassHealth Budget Office.
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 16
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MOST MASSHEALTH DOLLARS ARE SPENT ON SERVICES
FOR A MINORITY OF MEMBERS
DISTRIBUTION OF MASSHEALTH ENROLLMENT AND SPENDING BY POPULATION GROUP
100%
9%
90%
27%
80%
Seniors
20%
70%
Adults and Children with
Disabilities
60%
34%
36%
50%
Non-Disabled Adults
40%
30%
20%
18%
38%
10%
Non-Disabled Children
19%
0%
Enrollment
SOURCES: MassHealth
MAY 2014
Spending
Budget Unit, SFY 2013 data.
MASSACHUSETTS MEDICAID POLICY INSTITUTE 17
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
FEDERAL AND STATE SPENDING ON MASSHEALTH
NOW REPRESENTS 30 PERCENT OF THE STATE BUDGET
MASSHEALTH AS A PROPORTION OF ALL STATE SPENDING
Other state spending
MassHealth-covered services
(BILLIONS OF DOLLARS)
$35
$32.5
$30
$27.8
$28.9
$28.9
$29.6
$30.3
$31.3
$25.4
$25
$23.5
$20
$20.8
$21.2
$20.8
$20.9
$21.2
$21.9
$22.7
$18.6
$15
$17.2
$10
$5
$8.1
$8.8
$9.8
$6.3
$7.7
$9.3
$7.0
$9.1
$6.8
27%
27%
25%
27%
28%
30%
30%
30%
30%
2005
2006
2007
2008
2009
2010
2011
2012
2013
$0
STATE FISCAL YEAR
SOURCES:
EOHHS (MassHealth data); Office of the Comptroller, Statutory Basis Financial Reports (other state spending).
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 18
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
MEDICAID IS THE MAIN SOURCE OF FEDERAL REVENUES
TO MASSACHUSETTS
MASSHEALTH AS A PROPORTION OF ALL FEDERAL REVENUES
Non-Medicaid federal revenue
Medicaid/CHIP federal revenue
(MILLIONS OF DOLLARS)
$10,000
$9,000
$925
$945
$8,000
$928
$1,005
$943
$7,000
$6,000
$5,000
$858
$856
$824
$971
$871
$4,000
$7,698
$7,963
$8,413
$6,825
$3,000
$5,388
$5,372
85%
86%
85%
89%
90%
90%
88%
88%
2006
2007
2008
2009
2010
2011
2012
2013
$4,733
$4,546
$4,783
85%
85%
2004
2005
$2,000
$7,210
$1,000
$0
SOURCE:
Massachusetts Budget and Policy Center
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 19
INTRODUCTION
ELIGIBILITY AND ENROLLMENT
SPENDING
CONTACT INFORMATION
CONTACT INFORMATION
Massachusetts Medicaid Policy Institute
Blue Cross Blue Shield of Massachusetts Foundation
Center for Health Law and Economics
University of Massachusetts Medical School
Kate Nordahl
Katharine.Nordahl@bcbsma.com
Robert Seifert
Robert.Seifert@umassmed.edu
Carol Gyurina
Carol.Gyurina@umassmed.edu
Kate Russell
Kate.Russell@umassmed.edu
Download the complete MassHealth: The Basics chart pack at
http://bluecrossmafoundation.org/publication
/updated-masshealth-basics-facts-trends-and-national-context
MAY 2014
MASSACHUSETTS MEDICAID POLICY INSTITUTE 20