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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Health Care Expansions in the District of Columbia
Healthy DC and Other Coverage Strategies
Dave ChandraDirectorOffice of Health Care InnovationDepartment of Health Care Finance
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Department of Health Care Finance
Established as separate cabinet-level agency on October 1, 2008
Continues oversight of publicly funded health care programs
New and greater emphasis on private market and access to care for uninsured
Established Office of Health Care Innovation
Department of Health Care
Finance
Department of Health
Medical Assistance
Administration
Department of Mental
Health
Department of Human Services
Department of Health
Department of Mental
Health
Department of Human Services
Mayor Mayor
Prior Structure New Structure
Office of Health Care Innovation
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Coverage Distribution - DC
1District of Columbia: Health Insurance Coverage of the Total Population, states (2007-2008), U.S. (2008), Kaiser Family Foundation,
2 Department of Health Care Finance Enrollment Data (as of September 30, 2009)
3 Current Population Survey 2008, US Census Bureau (2009)
4 percentages summate to over 100% because 1) data is from multiple surveys and 2) Alliance members may be categorized as uninsured in
the Current Population Survey4 State Heath Facts, Kaiser Family Foundation (2008) available at http://www.statehealthfacts.org/profileind.jsp?ind=125&cat=3&rgn=10
Type of Coverage # of DC
Residents Percent of DC
Residents4
Percent of US Population5
Private Coverage1 348,800 58.9% 57.0%Medicare1 59,300 10.0% 12.4%Medicaid2 158,551 26.8% 14.1%DC HealthCare Alliance2 54,784 9.3% n/a Uninsured3 59,000 10.0% 15.4%
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Coverage Distribution - Region
State Heath Facts, Kaiser Family Foundation (2008) available at http://www.statehealthfacts.org/profileind.jsp?ind=125&cat=3&rgn=10
Type of Coverage District of Columbia
Maryland Virginia
Private Coverage 58.9% 64.9% 62.0%Medicare 10.0% 11.2% 12.2%Medicaid 26.8% 9.9% 8.6%Other Public 9.3% 1.0% 3.5%Uninsured 10.0% 12.9% 13.8%
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Safety Net Insurance In DC
Children ParentsSeniors/People w/ Disabilities
Childless Adults
Undocumented Adults
400%
Uninsured
300%
Medicaid/CHIP
Qualified Medicare
Beneficiaries (QMB)
200%Medicaid/ DC
Healthy Families
DC HealthCare Alliance
DC HealthCare Alliance100%
Medicaid
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Safety Net Insurance In DC
Children ParentsSeniors/People w/ Disabilities
Childless Adults
Undocumented Adults
400%
Healthy DC
300%
Medicaid/CHIP
Qualified Medicare
Beneficiaries (QMB)
200%Medicaid/ DC
Healthy Families
DC HealthCare
Alliance
DC HealthCare Alliance100%
Medicaid
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
DC MedicaidPrimarily serves children, parents, low-income seniors and
individuals with disabilities, and certain other populations
SCHIP implemented as Medicaid Expansion
158,551 enrollees (26.9% of DC population):
– 57,378 in fee-for-service
– 101,173 in one of three managed care plans
Enrollment through Single Point of Entry IMA (DHS)
70/30 federal matching percentage (79/21 under ARRA)
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
DC HealthCare AllianceEstablished in 2001 out of closure of DC General Hospital
Covers uninsured DC residents up to 200% FPL
No citizenship documentation requirement
~54,784 enrollees
Coverage through the three Medicaid MCOs
Benefit limits greater than those in Medicaid (no mental health/
long term care, defined formulary, closed pharmacy network)
Supported by DC funds
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Healthy DCHealthy DC legislation passed in 2008
Establishes coverage for uninsured residents up to 400% FPL
Member premiums statutorily capped at 3%/5% of income
Benefit Package/Cost sharing equivalent to large group products
Coverage through managed care plan(s)
Enrollment cap commensurate with available funds
Funded by assessment on health insurance premium revenues
Enrollment to be handled by DHCF
Target launch – Spring 2010
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
BudgetFunded by 2% premium tax on DC HMOs and Hospital and
Medical Services Corporations
FY10 - $11,714,963* (projected available funds)
FY11 - $17,486,000* (projected available funds)
*B18-401 directs an additional $5 million to the Healthy DC Fund as part of a public-private partnership between DC Government and a Hospital and Medical Services Corporation
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
EligibilityTo be eligible for the Healthy DC Program, applicants must:
Be a DC resident for at least 6 months; and
Have a household income at or below 400% FPL; and
Be ineligible for any other local or federal health benefit programs; and
Have been uninsured for at least 6 months; or
Have lost insurance coverage for a qualifying reason
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Member PremiumsHealthy DC Statutory limits for Monthly Member Premiums:
Projected FY10 Monthly Member Premiums:
<300% FPL Adults $35
301% - 400% FPLChildren $40
Adults $70
Individual Family of 4 Limit
<300% FPL <$32,490 >$66,150 3% of income
301% - 400% FPL $32,491 - $43,320 $66,151 - $88,200 5% of income
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Proposed Benefit Package Service Cost-Sharing/ Co-Pay
Annual Deductible $200 (except for preventive care visits)
Out of Pocket Max None
Lifetime Benefit Max none
Annual Benefit Max none
Primary Care Visits $15
Specialist Visits $25
Maternity Visits $10
ED Visits $100 (waived if admitted)
EMS Transport $100 (waived if emergent)
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Proposed Benefit Package Service Cost-Sharing/ Co-Pay
Pharmaceuticals $10 Tier I/$20 Tier II/$40 Tier III
Inpatient Hospital $100
Behavioral Health $25 per visit
Nursing Home/SNF 15% after deductible (30 days per year)
Home Care Services $40 per visit (25 visits per year)
Dental 30% preventive, 50% basic restorative
DME, Vision, Podiatry etc varying co-pays
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
District-wide public awareness campaign via print,broadcast, and online media
Targeting working DC residents likely to be uninsured:
Guided by findings from pending Urban Institute Insurance Survey
Collaboration with DC business/small business organizations
Will link residents to Healthy DC, or other public assistance programs where appropriate
Marketing and Outreach
- Parents of CHIP children- Restaurant/bar employees- Construction workers
- Sole practitioners- Low-wage/part time workers- Home care aides
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Broad legislative language is preferred to very prescriptive terms
Dedicated tax revenue source ensures level of sustainability
Establishing new enrollment system is administratively cumbersome
Compromises are inevitable to ensure affordability and feasibility
Overhead/infrastructure development cost is extensive regardless of program size
Crowd-out and Adverse Selection remain concerns
Community partnerships are critical to developing benefit design, premium levels, rules, outreach plan etc
Lessons Learned
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
National Health Reform & DCHealthy DC infrastructure to accommodate state-required functions
in health reform legislation
New customer service unit can process eligibility for Health Exchange
Healthy DC can serve as a possible public option in a local exchange
Can establish regional exchange with metro partners
Childless Adult expansion in Medicaid
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
1115 Medicaid Waiver for Childless Adults up to 200% FPL
Refine DSH formula based on new uncompensated care reporting
Establish pilot program high cost/chronically-ill Medicaid members
CareFirst Blue Cross/Blue Shield Open Enrollment Program
Create Premium Assistance Program in Medicaid/Healthy DC
Enhance Purchasing in DC Employee Benefit Plan
Reform Small Group/Non-Group Market
Provider Payment Reform
Other Local Reform
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Government of the District of Columbia Department of Health Care Finance
For Official Government Use Only
Department of Health Care FinanceGovernment of the District of Columbia
Questions?
ContactDave ChandraDepartment of Health Care [email protected]