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SoonerCare and National Health Care Reform
Oklahoma Health Care Authority Board Retreat
August 26, 2010
Chad Shearer
Senior Program Officer
Center for Health Care Strategies
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CHCS Mission
To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care.• Our Priorities
► Improving Quality and Reducing Racial and Ethnic Disparities► Integrating Care for People with Complex and Special Needs► Building Medicaid Leadership and Capacity
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Medicaid’s Challenges and Opportunities
60 million People in the United States with Medicaid coverage.
$380 billion Projected Medicaid spending for FY 2009.
1 millionMedicaid beneficiaries resulting from a 1% increase in unemployment; enrollment increased by 5.4% in FY2009 and is projected to increase by 6.6% in FY2010.
16 - 20 million Additional Medicaid/CHIP beneficiaries by 2019 due to health reform.
41% Births in the United States covered by Medicaid.
28% Children in the United States covered by Medicaid.
27% Percentage of total mental health costs financed by Medicaid.
41% Total long-term care costs financed by Medicaid.
5% Medicaid beneficiaries accounting for 57% of total Medicaid spending.
8.8 millionPeople who are dually eligible for Medicare and Medicaid; roughly 18% of Medicaid beneficiaries. 3
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National Health Reform Impacts & Opportunities
• Major Medicaid expansion► Transition Medicaid from welfare program to
insurance program► Complicated Medicaid interface with health insurance
exchanges
• Exciting grant and demonstration opportunities
• Substantial health insurance reforms
• Vast implementation challenges may require enhanced state capacity
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Health Reform Facts - Coverage
• Currently insured retain employer coverage• Estimated 25 million Americans covered through
new health insurance exchanges (subsidized to 400% FPL)
• Estimated 16-20 million Americans covered through Medicaid expansion (available to everyone up to 133% FPL)
• Tax penalties for individuals failing to obtain coverage (with some exceptions)
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Health Reform Facts - Financing
• Demonstrations to test financing and delivery system reforms focusing on:
► Medical/Health Homes► Bundled payments around episodes of care► Accountable care organizations
• New entities will focus on financing issues► Center for Medicare and Medicaid Innovation► Federal Coordinated Health Care Office (duals)► Medicaid and CHIP Payment and Access Commission► Medicare Independent Payment Advisory Board
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Health Reform Facts - Quality
• New quality measures for adults that apply to the Medicaid expansion population
• Expanded quality data collection and reporting (extends to all payers and plans)
• Focus on community based approaches (e.g., health teams and community based prevention)
• Connecting HIT efforts to delivery system quality improvement initiatives
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Health Reform Facts - Timeline
• 2010 ► Medicaid maintenance of effort► State option for Medicaid expansion► High risk pool► Insurance regulations
• December 31, 2012► States must notify HHS of exchange intentions
• January 1, 2014► Medicaid expansion and exchange/subsidies begin► Additional heath insurance regulations take effect
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Reform and SoonerCare - Coverage
• Estimated 350,000 – 470,000 new SoonerCare members due to expansion
• SoonerCare enrollment and eligibility systems must interact seamlessly with the exchange
• Many adults in expansion population will have chronic conditions and pent up demand (workforce and access to care concerns)
• Basic health plan option for state to cover up to 200% FPL and receive federal subsidies
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Reform and SoonerCare - Financing
• 100% FMAP for expansion population (decreasing to 90% in 2020 and beyond)
• 100% FMAP to increase primary care provider payments in 2013-2014
• Enhanced FMAP for long-term services and supports
• Enhanced FMAP for covering preventative and immunization services
• Eliminates FMAP for preventable health care acquired conditions
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Reform and SoonerCare - Quality• Health homes for enrollees with chronic conditions
(planning grants and 90% FMAP for 2 years)
• Demonstrations for bundled payments and ACOs
• Community health teams to support medical homes
• Medication management for chronic disease
• Grants to provide incentives to Medicaid beneficiaries to participate in programs to prevent chronic disease
• Awards for co-locating primary and specialty care in community based mental health settings
• Center for Medicare and Medicaid Innovation pilots to test payment and system reforms
• Federal Coordinated Health Care Office for dual eligibles
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Challenges
• Budget – increasing expenditures and decreasing revenues
• Staffing – Lots of new work• Systems/Infrastructure – Eligibility and
enrollment, MMIS enhancements• Exchange and Medicaid – Interaction will be
difficult and CMS guidance has been lacking• Grants and demonstrations – Require
substantial resources for application and program management
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Reform Resources• CMS
► https://www.cms.gov/Center/healthreform.asp
• Health Reform GPS ► http://www.healthreformgps.org/
• Kaiser Family Foundation ► http://healthreform.kff.org/
• National Academy for State Health Policy ► http://nashp.org/health-reform
• National Governors Association► Health Reform Implementation Resource Center
• AcademyHealth – State Coverage Initiatives► http://www.statecoverage.org/health-reform-resources
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Visit CHCS.org to …• Download practical resources to improve the quality and
cost-effectiveness of Medicaid services.
• Subscribe to CHCS eMail Updates to learn about new programs and resources.
• Learn about cutting-edge efforts to improve care for Medicaid’s highest-need, highest-cost beneficiaries.
www.chcs.org
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Contact information• Chad Shearer, Senior Program Officer
Center for Health Care Strategies