Larry Tisdale
Vice-President of Finance , IHA
2013 Legislative Wrap Up –
Insurance Exchange and Medicaid Expansion
Medicaid Program Changes
Legislative Wrap Up
HB 17: Board of Pharmacy Recodification (Law)
HB 98: Indigent Statute Amendments (Law)
HB 109: Board of Pharmacy Diversity (Law)
HB 188: Authentication of Physician Orders (Law)
HB 190: Health Provider Truth in Advertising (House H&W Failed)
HB 268: Minors Tanning Beds (House Failed)
HB 291: Mental Health Holds for Minors (Law)
HB 292: Assault and Battery on Healthcare Workers (Senate Failed by 1)
HB 308: Repeal of Medical Indigent/CAT Fund (Not Formally Heard)
HB 315: Personal Property Tax Repeal (Law)
HCR 10: Time-sensitive Emergency Care System (Adopted)
SB 1063: Medical Consent/Natural Death Act Amendments (Law)
SB 1115: Radiologic Imaging and Radiation Therapy Licensure (Not Heard)
2
PPACA Initiatives
State Based Insurance Exchange (HB248)
Medicaid Expansion (HB309)
3
State Based Insurance Exchange
 Governor’s Insurance Exchange Work Group
 Broad Based Coalition Including Multiple Associations
 Focal Issue is Local Control and Risk Pool
 Political Environment became Toxic
 Bill passed and Signed into Law
4
Medicaid Expansion
 Governor’s Medicaid Expansion Work Group
 Broad Based Coalition Including Multiple Associations
 Financial Cost of Not Expanding
 Economic Cost of Not expanding
 Bill was Printed but Not Heard in Committee
5
Governor’s Medicaid Work Group
 The work group unanimously recommended that Idaho
expand its Medicaid program in a manner that provided
more efficiency and participant accountability
 The work group included three legislators, multiple
association representatives, representatives from the
Department of Health and Welfare and others
6
Broad Based Coalition Support
 IHA participated in a broad based coalition to support the
expansion of the Medicaid program in Idaho.
 The coalition included IHA, IMA, Chambers of Commerce
and Others
7
Financial Cost of Not Expanding
Medicaid
 Ten year cost of Mandatory Medicaid Coverage is $394
Million*
 State and local savings if Idaho were to expand Medicaid to
138% of FPL would be $403.9 Million* over ten years.
 Expanding the Medicaid program would more than offset the
cost of the mandatory expansion of the Medicaid program.
* Milliman Client Report: Impact of PPACA On the Medicaid Budget Including
state and Local Cost offsets
8
Economic Cost of Not Expanding
 The Milliman Client Report was provided to Professor Steven
Peterson, of the University of Idaho, to project the economic
effects of Medicaid Expansion using the 2010 IMPLAN model
for the State of Idaho.
 Federal funding for expanded Medicaid program represents
new money entering the Idaho economy.
 $985.5 Million* for mandatory and $8.2 Billion* for optional
expansion in new federal funds/money.
 When new money enters into an economy it creates jobs as
well as state and local tax revenue.
9
Idaho Tax Revenues *
Year
Sales/Excise
Property
Income
Total
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
$1.4
$2.3
$2.4
$2.5
$2.6
$2.7
$2.6
$2.6
$2.7
$2.8
$2.8
$27.4
$0.8
$1.3
$1.3
$1.4
$1.4
$1.4
$1.4
$1.4
$1.5
$1.5
$1.5
$14.9
$1.3
$2.1
$2.2
$2.3
$2.4
$2.4
$2.4
$2.4
$2.4
$2.5
$2.6
$24.9
$3.5
$5.7
$6.0
$6.2
$6.4
$6.5
$6.4
$6.4
$6.6
$6.7
$6.9
$67.3
County Indigent **
Funds Savings
Add'l State Savings **
Behavioral and Public Health
Total
Taxes and Savings
Manditory Medicaid **
Enrollment Costs
Annual
Net Savings/Costs
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$3.5
$5.7
$6.0
$6.2
$6.4
$6.5
$6.4
$6.4
$6.6
$6.7
$6.9
$67.3
$14.8
$33.2
$32.8
$32.2
$33.1
$33.8
$39.5
$42.1
$43.2
$44.2
$45.2
$394.1
$11.3
$27.5
$26.8
$26.0
$26.7
$27.3
$33.1
$35.7
$36.6
$37.5
$38.3
$326.8
Year
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
Total Idaho
State CAT **
Tax Revenues Fund Savings
$3.5
$5.7
$6.0
$6.2
$6.4
$6.5
$6.4
$6.4
$6.6
$6.7
$6.9
$67.3
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
$0.0
Impact of Manditory Medicaid Expansion
The manditory expansion of the Medicaid program creates a state general funds obligation of $341.8 million from SFY 2014 thru 2024.
The manditory expansion of the Medicaid program provides excess county and district funds of $14.9 million from SFY 2014 thru 2024.
* Tax Revenues taken from economic impact study conducted by Steven Peterson, Professor of Economic at the University of Idaho
** Financial costs and savings estimates taken from Milliman actuarial report commissioned by the State of Idaho
10
Idaho Tax Revenues *
Year
Sales/Excise
Property
Income
Total
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
$9.9
$20.4
$20.9
$20.9
$20.7
$21.0
$21.1
$21.3
$21.8
$22.3
$22.9
$223.2
$5.4
$11.1
$11.3
$11.3
$11.3
$11.4
$11.5
$11.6
$11.9
$12.2
$12.5
$121.4
$9.0
$18.5
$18.9
$18.9
$18.8
$19.1
$19.1
$19.3
$19.8
$20.3
$20.8
$202.4
$24.3
$49.9
$51.1
$51.1
$50.8
$51.5
$51.7
$52.1
$53.4
$54.8
$56.1
$546.9
Year
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
Total Idaho
State CAT ** County Indigent **
Add'l State Savings **
Tax Revenues Fund Savings
Funds Savings Behavioral and Public Health
$24.3
$49.9
$51.1
$51.1
$50.8
$51.5
$51.7
$52.1
$53.4
$54.8
$56.1
$546.9
$20.1
$40.9
$41.6
$43.7
$45.8
$47.8
$49.9
$52.1
$54.4
$56.9
$59.4
$512.6
$16.6
$34.7
$36.2
$37.7
$39.1
$40.5
$41.9
$43.5
$45.1
$46.7
$48.3
$430.3
$5.2
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$109.8
Impact of Optional Medicaid Expansion
Total
Taxes and Savings
Optional Medicaid **
Expansion Costs
Annual
Net Savings/Costs
$66.3
$135.9
$139.4
$143.0
$146.2
$150.3
$154.0
$158.2
$163.4
$168.8
$174.3
$1,599.6
$4.4
$9.0
$9.2
$28.9
$53.5
$63.0
$81.3
$96.2
$98.6
$101.1
$103.6
$648.8
$61.9
$126.9
$130.2
$114.1
$92.7
$87.3
$72.7
$62.0
$64.8
$67.7
$70.7
$950.8
The optional expansion of the Medicaid program provides excess state general funds of $399.2 million from SFY 2014 thru 2024.
The optional expansion of the Medicaid program provides excess county and district funds of $551.7 million from SFY 2014 thru 2024.
* Tax Revenues taken from economic impact study conducted by Steven Peterson, Professor of Economic at the University of Idaho
** Financial costs and savings estimates taken from Milliman actuarial report commissioned by the State of Idaho
11
Idaho Tax Revenues *
Year
Sales/Excise
Property
Income
Total
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
$11.3
$22.7
$23.3
$23.4
$23.3
$23.7
$23.7
$23.9
$24.5
$25.1
$25.7
$250.6
$6.2
$12.3
$12.7
$12.7
$12.7
$12.9
$12.9
$13.0
$13.3
$13.6
$14.0
$136.3
$10.3
$20.6
$21.1
$21.2
$21.1
$21.5
$21.5
$21.7
$22.2
$22.8
$23.3
$227.3
$27.8
$55.6
$57.1
$57.3
$57.1
$58.0
$58.1
$58.5
$60.0
$61.5
$63.0
$614.1
Year
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
Total Idaho
State CAT ** County Indigent ** Add'l State Savings **
Tax Revenues Fund Savings
Funds Savings Behavioral and Public Health
$27.8
$55.6
$57.1
$57.3
$57.1
$58.0
$58.1
$58.5
$60.0
$61.5
$63.0
$614.1
$20.1
$40.9
$41.6
$43.7
$45.8
$47.8
$49.9
$52.1
$54.4
$56.9
$59.4
$512.6
$16.6
$34.7
$36.2
$37.7
$39.1
$40.5
$41.9
$43.5
$45.1
$46.7
$48.3
$430.3
$5.2
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$109.8
Impact of Optional and Mandatory
Medicaid Expansion Combined
Total
Taxes and Savings
Total Medicaid **
Expansion Costs
Annual
Net Savings/Costs
$69.7
$141.7
$145.3
$149.2
$152.5
$156.8
$160.3
$164.6
$170.0
$175.6
$181.2
$1,666.9
$19.2
$42.2
$42.0
$61.1
$86.6
$96.8
$120.8
$138.3
$141.8
$145.3
$148.8
$1,042.9
$50.5
$99.5
$103.3
$88.1
$65.9
$60.0
$39.5
$26.3
$28.2
$30.3
$32.4
$624.0
The manditory expansion of the Medicaid program creates a state general funds excess of $57.4 million from SFY 2014 thru 2024.
The manditory expansion of the Medicaid program provides excess county and district funds of $566.6 million from SFY 2014 thru 2024.
* Tax Revenues taken from economic impact study conducted by Steven Peterson, Professor of Economic at the University of Idaho
** Financial costs and savings estimates taken from Milliman actuarial report commissioned by the State of Idaho
12
Idaho Tax Revenues *
Year
Sales/Excise
Property
Income
Total
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
$11.3
$22.7
$23.3
$23.4
$23.3
$23.7
$23.7
$23.9
$24.5
$25.1
$25.7
$250.6
$6.2
$12.3
$12.7
$12.7
$12.7
$12.9
$12.9
$13.0
$13.3
$13.6
$14.0
$136.3
$10.3
$20.6
$21.1
$21.2
$21.1
$21.5
$21.5
$21.7
$22.2
$22.8
$23.3
$227.3
$27.8
$55.6
$57.1
$57.3
$57.1
$58.0
$58.1
$58.5
$60.0
$61.5
$63.0
$614.1
Year
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Total
Impact of Optional and Mandatory
Medicaid Expansion combined
With the Complete Elimination of CAT and County Indigent Programs
Total Idaho
State CAT ** County Indigent ** Add'l State Savings **
Tax Revenues Fund Savings
Funds Savings Behavioral and Public Health
$27.8
$55.6
$57.1
$57.3
$57.1
$58.0
$58.1
$58.5
$60.0
$61.5
$63.0
$614.1
$21.2
$43.1
$43.8
$46.0
$48.2
$50.4
$52.5
$54.8
$57.3
$59.8
$62.5
$539.6
$18.5
$38.6
$40.2
$41.8
$43.5
$45.1
$46.6
$48.3
$50.1
$51.9
$53.7
$478.3
$5.2
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$10.5
$109.8
Total
Taxes and Savings
Total Medicaid **
Expansion Costs
Annual
Net Savings/Costs
$72.7
$147.8
$151.5
$155.6
$159.3
$164.0
$167.6
$172.1
$177.9
$183.7
$189.7
$1,741.9
$19.2
$42.2
$42.0
$61.1
$86.6
$96.8
$120.8
$138.3
$141.8
$145.3
$148.8
$1,042.9
$53.5
$105.6
$109.5
$94.5
$72.7
$67.2
$46.8
$33.8
$36.1
$38.4
$40.9
$699.0
The manditory expansion of the Medicaid program creates a state general funds excess of $57.4 million from SFY 2014 thru 2024.
The manditory expansion of the Medicaid program provides excess county and district funds of $566.6 million from SFY 2014 thru 2024.
* Tax Revenues taken from economic impact study conducted by Steven Peterson, Professor of Economic at the University of Idaho
** Financial costs and savings estimates taken from Milliman actuarial report commissioned by the State of Idaho
13
Medicaid Expansion Will
Continue to be IHA’s Top
Legislative Priority
14
Medicaid Program Changes
 Medicaid Patient-centered Medical Homes (PCMH)
This is part of the governor’s Multi-Payer Medical
Home Collaborative. IHA is a member of the
Collaborative.
 Medicaid Community Care Networks (CCN)
This is a provider based network approach to Medicaid
managed care. It is part of Idaho’s State Multi-Payer
Innovation Model (SIM) grant project from CMS.
15
Medicaid Patient Centered Medical Homes
 In 2010 Governor Otter Established the Multi-Payer Medical
Home Collaborative to create a more coordinated approach to
care for patient with certain chronic conditions and at least one of
the identified risk factors.
 Chronic Conditions:
 Diabetes type 1&2
 Asthma
 Mental Illness
Risk Factors: Hypertension, Dyslipidemia, Tobacco Use, BMI>25,
Coronary Arterial Disease, Disease of the Respiratory System
16
PCMH Enhanced Payment
For patients that qualify under the program, PCMH practices/clinics
will be paid $15 per month by Medicaid instead of the lower Healthy
Connections fee. Private insurance payment will vary.
The additional payment is intended to cover the cost of care
coordination and the attainment of NCQA medical home
recognition.
Currently Medicaid, Blue Cross, Blue shield and Pacific source are
participating in the pilot program that began in January.
17
Medicaid Community Care Networks (CCN)
 The 2011 Legislature declared that Medicaid was
unsustainable.
 Passed House Bill 260 mandating a move to managed care.
 Improve current healthcare delivery system
 Institute gain sharing, risk sharing or capitation
 Increase participant accountability
18
Joint Managed Care Forum.
 In December of 2011 The Department of Health and Welfare
jointly hosted a forum on managed care.
 Joint participant were the Department, IHA, IMA and IPCA
 IHA hired a consultant to explore alternatives to
traditional MCO models
 Provider-based managed care was presented as an
alternative MCOs
19
NASHP/North Carolina Grant
 Shortly after the joint health care forum, NASHP solicited
grant application for a State Learning Transformation
opportunity based on the experience of the Community Care
North Carolina Program.
 A coalition from Idaho applied for the grant and was selected
to participate.
 After a visit to North Carolina the coalition decided to
pursue an adaptation of their CCN Model.
20
CMS/CMMI SIM Grant
 The coalition developed an application for Governor Otter to
apply for a State Innovation Model (SIM) Grant offered by
CMS’ Center for Medicare and Medicaid Innovation.
 The state was awarded $3 million for the purpose of
designing the CCN managed care delivery system for Idaho.
 The grant was for a multi-payer design which put the
coalition better in line wit the Governor’s multi-payer
medical home initiative which would be leveraged by the
CCN model.
21
CCN SIM Project Organization
22
CCN SIM Project Roles & Responsibilities
RESPONSIBILITIES AND TIMELINE
ROLES
APRIL
2013
MAY
2013
JUNE
2013
JULY
2013
AUGUST
2013
SEPTEMBER
2013
Idaho
Medical
Home
Collaborative
Meets monthly to provide decision making as needed to engage
stakeholders and develop plan. Identifies Work Group Stakeholders.
Advises on
Plan Draft
Endorses
Plan
Integrated
Delivery
System
Advisory Grp
Meets regularly to review overall progress, and work on the public
policy aspect of the plan. The group reports on progress to the
Stakeholder Advisory group and initiates key discussion around
decisions.
Advises on
Plan Draft
Endorses
Plan
Medicaid
Administration
Hires Consultant,
Business Analyst and
Administrative
Assistant.
Project Staff
Project Manager
prepares
Consulting Request
for Proposals
Project Manager monitors consulting contract,
project timeline and deliverables.
Business Analyst consults with agency about
integration of proposed operational changes.
Advises on Plan Draft
Submits
Plan To
CMI
Consulting
Company
Responds to RFP
Conducts comprehensive needs assessment as
guided by stakeholders. Facilitates regular
work group meetings. Conducts regional focus
groups. Drafts the plan.
Revises Plan Until it
Receives
Endorsement
Submits
Final
Plan to
State
Stakeholder
Work Groups
Stakeholder Work
Groups are formed.
Meet Weekly to study their assigned topic,
analyze data from the focus groups and subject
matter experts, and make recommendations.
Stakeholders
23
Oversees staff and administers the grant.
Consultants
State Staff
Advises on
Plan Draft
State Administration
Endorses
Plan
CCN Project Timeline
24
QUESTIONS?
25