The Road Forward: Simple Seamless Path to Affordable

Coverage

Vikki WachinoDirector, Children and Adults Health Programs Group

Center for Medicaid and CHIP Services

October 19, 2011

1

Medicaid, CHIP and Exchange Coverage:

Income Eligibility Levels

138% FPL

250%FPL

400%FPL

CHIP/Medicaid for Children

FPL Varies by StateMedicaid/CHIP

Children

Medicaid Adults

Qualified Health Plan withPremium Tax Credits-138%-400% FPL

Cost-sharing reductions between 138% - 250% FPL

Qualified Health Planswithout Financial Assistance

Scope of the Three Proposed Rules

Source: KCMU/Urban Institute analysis of 2010 ASEC Supplement to CPS.

Covering the Low-Income Uninsured is a Key To Success

66%

19%

81%

Insured Uninsured

50 million Americans are Uninsured

42%Adults

Children

52% of Uninsured Have Income < 138% FPL

33%

<138% FPL

139-399% FPL

400%+ FPL

Seamless, Streamlined Eligibility and Enrollment

Our Goal: Better Care, Better Health, Lower

Costs

Per CapitaCost

ExperienceOf Care

PopulationHealth

Simple, Seamless and Affordable Coverage

Medicaid Eligibility NPRM Expanding access to affordable coverage with

significant federal support

Simplifying Medicaid & CHIP

Establishes a seamless system of coverage across insurance affordability programs

Building on State Success

Louisiana: Renews without a paper form in most instances and uses existing data from other databases to determine eligibility

Reduced the percentage of children losing coverage at renewal to less than 1%

Utah: E-Find system streamlines the verification process by using existing information about applicants from a “data warehouse” of multiple databases to determine eligibility

Wisconsin: The ACCESS system allows people to apply for and enroll in coverage online and set up a personal account to report changes and renew coverage

Cuts the time it takes to apply for coverage in half

Simplifying Medicaid & CHIP

Simpler Income Rules (MAGI)Consolidates eligibility categories into four main

groupsFollowing State lead, modernizes eligibility verification

rules to rely primarily on electronic dataFederal government will perform some of the data

matches for States, relieving administrative burdenRenewals every 12 months

If eligibility can be renewed based on available data, no return form is needed

Medicaid Eligibility Groups Affected by Proposed Simplification

Number of Eligibility Groups pre-ACANumber of Eligibility Groups Proposed after Simplification

Number ofMedicaidEligibilityGroups

±Certain optional eligibility groups for certain children currently covered by some States are not affected by the proposed simplification.

Coordination: A Seamless System of

CoverageCoordinated policies and processes across Medicaid,

CHIP and the ExchangesIncome rulesState residencyVerifications

Exchanges would conduct eligibility determinations for premium tax credits, Medicaid, and CHIP following the State Medicaid agency rules

Challenges to Continuity of Care

Continuous Health Coverage

Concentration of Medicaid Spending

5%

25%

50%54%

5%1%

Source: Medicaid Statistical Information System Claims Data for FY 2008

Percent of Total Medicaid SpendingPercentile of Medicaid Population(ranked by spending)

Primary care provider increase (2013)

Accountable Care Organizations

Medical and health homes

Bundled payments to integrate care

Global payment demonstrations

No payment for HACs

Center for Medicare and Medicaid Innovation Center

Office of Medicare and Medicaid Coordination

New Tools: Delivery System and Payment Reform

Achieving a High Performing Medicaid Program

Simplified, accurate, customer-friendly, data driveneligibility/renewal processes that are coordinated with the

Exchange

Access to person-centered, high quality, integrated care with options for continuity of coverage with plans on the Exchange

Continuing improvements in quality and cost throughout the health care system

Based on consumer experience, stakeholder input, data, and collaboration