120505 bb ss county health plan model emet the county health plan model: expanding basic health...

120505 BB SS County Health Plan Model EMET

The County Health Plan Model: Expanding Basic Health Coverage to Low Income Adults

Expansion Model Evaluation Template


County-Based Health Coverage Programs for Low Income Persons

Current coverage programs

Under discussion


Target – uninsured adults age 19-64 with income 200% of poverty

Target = 383,500 people Currently covered: 54,500 Cost neutral expansion could reach 40-50

percent of the target population Non-DSH source needed to cover all people

in the target group


Coverage Models

Basic coverage Small employer subsidy models Volunteer networks


Current Coverage – 54,500 people

Basic CoverageModels(48,500)

SmallEmployerSubsidyModels (4,500)

VolunteerNetworks(1,500)

Funding sufficient to cover 20 percent of target population


Current financing

$38 million in local funds $50 million in federal funds Average cost = approx $60 pmpm


Expansion funding

Additional DSH Additional local funds Non-DSH source


Total Funding needed to cover target population

$50 million current DSH (net) $50 million additional DSH (net) $176 million new non-DSH source


Coverage (Basic & Small Employer Subsidy)

Primary care & specialty care Outpatient lab and x-ray Prescription drugs Not covered

– Hospital care (except in Small employer subsidy programs)

– Coordinated with Hospital Charity Care programs


Portability of Coverage & Continuity of Care

CHP’s cover a county or multi-county region Operate using managed care principles Provide outreach and enrollment Determine eligibility for other programs Reciprocity across counties contingent on

funding


Quality of Care/Effect on Delivery System

Managed care principles Access to medicine for treatment of diabetes,

hypertension, depression U/R & case management


Resource and Budgetary Cost

Cost neutral to state – model uses local funds to generate federal funds

Expansion requires additional DSH capacity & additional local match

Expansion could involve Section 1115 Medicaid waiver


Resource and Budgetary Savings

Treatment of diabetes, hypertension, depression, etc. reduces preventable hospitalizations and reduces absenteeism for working enrollees

Reduced administrative cost through use of small number of TPA’s (five)

Co-pays and premiums help balance public and private sector costs


Cost Containment

Managed care principles Focus on disease management Link with other community resources


Implementation & Administration

Five TPA’s used for “back room” functions. Use of existing infrastructure reduces

administrative costs Relationship with State for ABW program

assure accountability for performance, quality and efficiency


Access to Coverage & Subsidies

Covered population dynamic Coverage could be made more uniform

under expansion Enrollment generally limited to people with

income below 200% poverty Careful planning of small employer subsidy

models avoids crowd out issue


Financing of Costs

Uncommitted DSH capacity presumed Some areas are short on qualified local funds Non-DSH financing needed to cover more

(eg. Medicaid expansion)


Consumer Choice of Providers & Health Plans

Most CHP’s reimburse providers at Medicaid plus 4%

Provider choice varies Higher reimbursement would attract more

providers


Provider Autonomy

Provider contracts resemble those of any managed care organization


Government Compulsion/Regulation

No compulsory enrollment Regulation limited to essential element


Variations & Their Effects

Desirable: cover more people via Small employer subsidy model

Desirable: easy to enroll people in Basic models

Section 1115 Medicaid waiver


Key Tradeoffs among Attributes

“Look and feel” of insurance Small employer subsidy model can be

insurance Financing cost neutral to the state Eligibility at or below that for hospital charity

care programs


Pros

Cost neutral to state Infrastructure in place Links with other community resources Local money brings $50 million federal funds

into state Positioned for small employer subsidy option Grass-roots can foster support for non-DSH

supported expansion when time comes


Cons

Financed by DSH (not an entitlement) Except for Small employer subsidy models

hospital care not covered Benefit is limited Non-DSH financing needed to cover more

remaining uninsured (section 1115 waiver) Requires ongoing commitment of all partners

120505 bb ss county health plan model emet the county health plan model: expanding basic health...

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