Medicaid, BHP, and CHIP: Current Issues in ACA Implementation

Eliot Fishman, PhDDirector, Children and Adults Health Program GroupCenter for Medicaid & CHIP Services

Melissa HarrisDirector, Division of Benefits and CoverageDisabled and Elderly Health Programs Group

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• Implementation• Alternative Benefit Plans• CHIP and BHP

Topics to be Covered

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Implementation

• States will begin reporting enrollment numbers for the new adult group after March 31, 2014.

• State progress on eligibility and enrollment can be found in the Medicaid & CHIP Monthly Applications and Eligibility Determinations report. Data are collected on types and quantities of submitted applications and eligibility determinations.

How CMS is Reporting onEligibility & Enrollment

SOURCE: http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaid-CHIP-Monthly-Enrollment-Report-Nov-2013.pdf 4

States Moving Forward on Expansion

DC

DE

Expanding Medicaid For 2014

Not expanding Medicaid to date

So far, 25 states and DC have indicated they will expand Medicaid to low-income adults in 2014 – discussions continue

to evolve.

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Process and Coverage Improvements

• To date, half the states expanding Medicaid to low-income adults; other states in discussion

• All states implementing new MAGI rules, new systems, new applications, new verification policies, coordination with Marketplace

• Continuity of coverage through modernized renewals and coordination between Medicaid and the Marketplace

• Upcoming reports to Congress will provide details about states’ reporting on core measure sets for children and adults.

• Highlights:– The number of states reporting on children’s measures

has increased since last year’s report– CMS has asked states to voluntarily report uniform

adult quality measures for the first time in FY2014 and has provided grants to 26 states to assist them in collecting data

Quality Measurement

SOURCE: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2013-Ann-Sec-Rept.pdf 7

Medicaid.gov

On Medicaid.gov, data can be easily located on a variety of topics, including:• Eligibility• Outreach &

Enrollment• Quality of Care

Data can be found in multiple formats, such as reports, charts, and maps.

SOURCE: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2013-Ann-Sec-Rept.pdf

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Alternative Benchmark Plans

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Medicaid ABP Benefit Design

Foundation for Essential Health Benefits (EHB):• Step 1: States must select a coverage option from the choices

found in section 1937 of the Act.• Step 2: States must determine if that coverage option is also

one of the base-benchmark plan options identified by the Secretary as an option for defining EHBs. • If so, the standards for the provision of coverage, including

EHBs, would be met, as long as all EHB categories are covered.

• If not, states must select one of the base-benchmark plan options identified as defining EHBs.

• Step 3: Select a base benchmark plan to define the EHBs.

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Considerations for States

• Implications of benefit alignment between the ABP and the underlying state plan:– Ease of administration– No need to identify individuals who are medically frail– Benefit uniformity across all Medicaid populations

• Implications of different benefits between the ABP and the underlying state plan– Straightforward alignment with commercial product– Necessitates process for identifying individuals who are

medically frail and counseling them on benefit options

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Medical Frailty: Definition, Screening Process, and Benefits

• Definition: • “Individuals with disabling mental disorders (including

children with serious emotional disturbances and adults with serious mental illness), individuals with chronic substance use disorders, individuals with serious and complex medical conditions, individuals with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living, or individuals with a disability determination based on Social Security criteria or in States that apply more restrictive criteria than the Supplemental Security Income program, the State plan criteria.”

• Determination or Screening Process

• Benefits for Medically Frail Individuals• Individuals in the new adult group, if

determined to be medically frail, will receive the choice of ABP defined using EHBs or ABP defined as state’s approved Medicaid state plan

Medical Frailty: Screening Process and Benefits

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CHIP and BHP

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CHIP Coverage Issues

• Requirement of certification for pediatric coverage offered through the Exchange as comparable to CHIP• Efforts underway to analyze nature of CHIP

benefits and cost-sharing• Maintenance of Effort (MOE) requirement for

states to maintain eligibility standards• ACA requires that children <133% FPL move

from separate CHIP to Medicaid coverage

• BHP will be an option for states in the 2015 coverage year.

• States will have the option to cover individuals between 133% and 200% FPL who would otherwise receive tax credits through the Exchange.

• By March 31, 2014, we hope to publish final regulations, payment methodologies, and the tool (“Blueprint”) by which states can apply to gain approval.

Basic Health Program (BHP)

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