virginia: legislative update brent rawlings and keith hare vhha and vhca march 11, 2015
TRANSCRIPT
Virginia:Legislative Update
Brent Rawlings and Keith Hare
VHHA and VHCA
March 11, 2015
Outline for Today’s Discussion
I. IntroductionsII. Overview of VHHA and VHCA
– Who we are– Focus of state legislative activities
III. Overview of Political EnvironmentIV. Review of 2015 General Assembly
– Key legislation tracked by VHHA and VHCA– VHHA and VHCA state budget priorities– Studies (Medicaid, COPN, and Provider Tax)
V. State Health Reform Initiatives– Why reform is needed– Medicaid reform objectives– Medicaid Expansion
VI. Q&A
Overview of VHHA and VHCA:
• Trade association of hospitals and health systems• Advocacy• Policy• Patient safety and quality improvement• Health care data and information• Top tier performance and health care value/population health• Emergency preparedness
“The Virginia Hospital & Healthcare Association is an alliance of 110 hospitals and 36 health delivery systems that develops and advocates for sound health care policy in the Commonwealth. Its vision is to achieve excellence in both health care and health.”
VHHA at a Glance
Virginia’s hospitals and health systems contributed $34.8 billion to the economy and directly and indirectly supported 913,636 jobs in 2012.
The health care industry as a whole directly employs 444,298 professionals, while hospitals alone employ 123,508 Virginians.
Hospitals and health systems are among the top five employers in 60% of cities and counties in Virginia, among top three employers in 45% of cities and counties.
For every $1 dollar spent by a Virginia hospital, $1.61 is spent in other parts of the economy.
Virginia hospitals accounted for $200 million in state and local taxes in 2012.
The total value of community support provided by Virginia’s hospitals and health systems exceeded $2.6 billion in 2012.
Virginia hospitals provided over $600 million in charity care in 2012.
Virginia hospitals are implementing evidence-based best practices to improve quality of care by reducing central line-associated blood stream infections, preventable readmissions and early elective deliveries, saving millions of dollars in the process.
VHHA at a Glance
VHHA Focus of State Legislative Activities
• “Closing the Coverage Gap” – Medicaid Expansion– Enrollment in Exchanges
• Budget and fiscal priorities dominate– Medicaid payments to hospitals have not kept pace with inflation– Significant Medicare payment cuts under ACA and Sequestration
• Focus on rural health– More than half of rural hospitals had negative operating margins in
2012– Rural hospitals one of top 5 employers in 82% of rural Virginia
communities
• Healthcare workforce– Supporting existing and incentivizing more health professional graduate
training
• Provider Assessments?
• Certificate of Public Need (COPN) Reform?
VHCA - Virginia’s Nursing Facilities• Virginia’s 286 nursing facilities employ over 36,000 people and
care for over 28,000 residents every day. • Nursing facilities often are among the largest employers in
many Virginia towns and communities and have an annual statewide payroll of approximately $1.5 billion
• Overall, all long term care facilities, of which nursing facilities represent a vital component, along with their suppliers represent about 2% of Virginia’s economy
• Long term care providers provide additional economic support through their significant role as taxpayers at the local, state and federal levels
VHCA - Challenges• By 2030 Virginia will have 1.8 million citizens age 65 or older
• Citizens age 65 and older will make up 19 percent of the total population
• Average life expectancy is almost 80 years old compared to 70 years in the 1960s – Life expectancy will continue to rise with advances in
medical technology and healthier lifestyles
• The public and private sector will need to work together to meet the growing demands of an aging population
VHCA - Challenges
• VHCA members are caring for residents with more complex medical needs than in the past
• Residents in Virginia’s nursing facilities have some of the
most complex medical needs in the United States due to strict eligibility criteria
• The average age of a nursing home resident in Virginia
almost 80 years old
• Reimbursement rates from Medicare and Medicaid are not keeping pace with the cost of providing care
Overview of Political Environment:
Political Environment• With 2015 being an election year for all 140 members of
the General Assembly, the political environment remains challenging on many fronts
• High turnover in last five years in General Assembly
• Key retirements of knowledgeable health care leaders since 2010
• The Commonwealth’s budgetary challenges continue to play a large role in what the Governor and General Assembly do and do not do
• Republicans likely to maintain strong majority in House, but majority control of Senate uncertain heading into elections
Virginia’s Political Environment • General Assembly is losing over 150 years of experience
with the retirements of Senators Colgan, Stosch, Watkins and Puller
• Since 2010, there have been 57 new members elected to the House of Delegates and 14 new members elected to the Senate
• If you go back to 2008 they are 63 new members of the
House and 21 new members of the Senate. – That is a combined turnover rates of 58% in 8 years.
*Source: Virginia Free
Review of 2015 General Assembly:VHHA Key Legislation
VHHA Key Legislation• No movement on Medicaid Expansion
- Recognition that substantive movement on this issue in 2015 was unlikely
- Virginia can still develop and implement a program to draw down 100% federal funding through FY 2016
- Should be done in fiscally responsible manner that promotes value, improves access to preventive services, elevates quality, and further reduces costs
• Governor’s introduced budget authorized Medicaid Expansion, but eliminated from House and Senate budget
• HB 2212 (Hope) Healthy Transitions Program (tabled)
• HB 1830 (Plum) State Plan Eligibility (tabled)
VHHA Key Legislation• COPN
– HB 2030 (Byron) - remove certain projects to obtain medical equipment with a minimum value below $1 million from COPN requirements (tabled)
– HB 2177 (Orrock) - remove capital expenditures, bed additions, additional operating rooms, NICUs and open heart surgery from the requirement to obtain a COPN and eliminate regional health planning agency for Northern Virginia• Subsequently amended to only remove capital expenditures
– SB 1283 (Martin) – Senate companion bill to HB 2177• Subsequently amended to conform to HB 2177 as amended
– SB 1415 (Dance) - remove capital expenditures from the requirement to obtain a COPN (incorporated into SB 1283)
VHHA Key Legislation• COPN (cont.)
– VHHA supports a comprehensive, system-wide approach to any efforts to reform the COPN law that takes into account the effects of any changes on charity care, patient safety and quality of care, access to essential health care services, and other critical aspects of our health care delivery system
– Procedural reforms and improvements are necessary and appropriate, but piecemeal deregulation of COPN that fails to address the principles above may not yield a better system for Virginians
– HB 2177 (Orrock) and SB 1283 (Martin) (as amended) presented a compromise that allows Virginia hospitals and health systems to work with the General Assembly and the Secretary to undertake a comprehensive review of the COPN process and avoid piecemeal deregulation
VHHA Key Legislation• Behavioral Health
– SB 1265 (Deeds) and HB 2118 (Cline) clarify definition of “real time” for psych bed registry (when there is a change or if no change, at least daily)
– SB 773 and SB 779 (McWaters) and HB 1717 (LeMunyon) modify law governing inpatient psychiatric admission of objecting minors between the ages of 14 and 18
– SB 1114 (Barker) – Provides that a TDO for medical testing, observation and treatment may be issued for a person who is also the subject of an ECO as a way to reconcile the 8-hour limit on an ECO with a hospital’s EMTALA obligations
– SB 1410 (Deeds) – establishes new requirement for the CSB employees who conduct evaluations of persons held under ECOs
VHHA Key Legislation• Workers Compensation
– HB 1820 (Farrell) initially directed the Workers’ Compensation Commission to develop a prevailing community rate fee schedule based upon representative charges for services on an annual basis, subject to a cap on growth tied to CPI
– Final bill simply authorizes the Commission to establish “communities” for purposes of determining a prevailing community rate and directs the Commission to study possible data sources for determining charges to be used in developing prevailing community rate fee schedule and to report back to the House and Senate Commerce and Labor Committees by December 15, 2015.
• Drug Prior Authorization– HB 1942 (Habeeb)/SB 1262 (Newman)– Requires provider contracts with insurers to include specific provisions
for practices pertaining to prior authorization of drugs
VHHA Key Legislation
• “CARE (Caregiver Advise, Record, Enable) Act” Bills
– HB 1413 (Filler-Corn)/SB 851 (Favola) – Requires hospitals to follow specified procedures to identify and
educate “caregivers” who will be providing post-discharge care for patients
– Part of AARP national initiative
• Observation Status Bills
– HB 1509 (Sullivan)/HB 1561 (Rust)/SB 750 (Black/Barker)/ SB 857 (Ebbin)
– Requires hospitals to give observation patients notice of their status and the potential for higher patient costs, hospital, post-discharge skilled nursing and pharmaceutical services
VHHA Key Legislation• “Right to Try” Laws
– Permits prescribing of experimental drugs for terminally ill patients – HB 1750 (Ransone)/SB 732 (Stanley)– Part of national initiative (Goldwater Institute)
• Stillbirth Policies– SB 1197 (Norment) requires hospitals with obstetrical services to have
a policy for managing stillbirths and incorporates into existing reporting requirements for congenital birth anomalies the reporting of stillbirths
• Telemedicine– HB 2063 (Kilgore)/SB 1227 (McWaters) amends definition of
“telemedicine” and authorizes prescription of Schedule VI drugs via telemedicine
– SB 718 (Stanley) establishes a 3-year telemedicine pilot program to reduce ED visits for low-acuity services (left in Appropriations)
Review of 2015 General Assembly:VHCA Key Legislation
VHCA Legislation of Interest - PASSED
Criminal History Check for Nurse Licensure - SB1018 (Dance)• Establishes state and federal criminal history background
check requirements for applicants for licensure as a practical nurse or registered nurse beginning January 1, 2016
Hospice - HB1738 (Hodges) • The bill requires every hospice licensed by the Department of
Health or exempt from licensure to notify every pharmacy that dispensed drugs to a hospice patient for the purpose of pain management of the patient's death within 48 hours
VHCA Legislation of Interest - FAILED
Staffing Standards - HB1396 (Leftwich) • Was tabled by the House Committee on Health, Welfare &
Institutions. The bill had a large fiscal impact to the Medicaid program in future years
• Would have required the Boards of Health and Social Services to set staffing standards for nursing facilities and assisted living facilities
CNA Training Hours Increase - HB1583 (Watts) • Would have increased the minimum duration of education programs
to prepare nurse aides for certification from 120 to 200 hours was also tabled in the House Committee on Health, Welfare & Institutions.
• Concern was expressed that the cost of training would increase and be burdensome on potential CNAs who paid for their own training and for facilities that provided the training free for potential CNAs
VHCA Legislation of Interest - FAILED
Punitive Damages Cap - HB2360 (Toscano) • Would have changed the punitive damages cap, including for medical
malpractice, from $350,000 to $750,000
Paid Sick Leave - HB2008 (Kory) and HB2387 (Sickles) • Would have required private employers to give to each full-time
employee paid sick days, to be accrued at a prescribed schedule
Minimum Wage Bills• Several minimum wage bills were introduced, but all were tabled
Review of 2015 General Assembly:VHHA Budget Issues
VHHA Budget Priorities• Support Governor’s introduced budget authorizing Medicaid expansion
• Recognizing that hospitals have not received inflation updates to Medicaid payment in recent years, focused on additional funding in critical areas of need
• Rural Health Amendment– Item 301 #8s (Carrico) directed DMAS to pay costs for Medicaid services provided by
Virginia's 37 rural hospitals– Cost approx. $10 million GF ($20 total)
• Health Care Workforce/GME Amendment– Item 301 #12s (Howell) and #22s (Watkins) directed DMAS to rebase Medicaid GME
payments (which haven’t been updated in 15 years) to strengthen current programs and support further growth in residencies with incentive fund program in FY17
– Cost $6.5 million GF (yielding $13 million in support) in FY16
• Provider Assessment Amendment– Item 278#1s (Watkins) directed the Secretary of HHR to develop a process to study and
design a mutually beneficial program that meets certain criteria– Report and implementation plan to the Governor and General Assembly for FY16 if such
criteria are met
VHHA Analysis of Budget ResultsMedicaid Expansion / Closing the Coverage Gap• Eliminates Governors’ language authorizing Medicaid expansion
Healthy Virginia Plan• Retains coverage for medical services included in Governor’s Access Plan (GAP).• Reduces income eligibility criteria for severely mentally ill from 100 percent of the
federal poverty level (FPL) to 60 percent FPL, but includes “grandfather” provisions for individuals covered under original 100 percent FPL criteria.
• Estimates number of individuals to be covered at 21,600.
Healthcare Workforce and Rural Health Items• Neither body included VHHA’s proposed amendments for additional funds to address
rural health or GME payment improvements• Senate recommends study of the GME issues, but not included in final bill
VHHA Analysis of Budget ResultsProvider Assessment• Directs Secretary of HHR to develop a plan with options for a hospital provider assessment
program and report back to the General Assembly by November 1, 2015• Eliminates provision that sought to redirect “at least 20 percent” of potential assessment away
from supporting supplemental provider payments• Adds language incorporating the VHHA suggested design proposal with additional provisions
directing that the plan consider the other related proposals that were offered
COPN• Adds evaluation of COPN process by a work group convened by the Secretary of HHR, using
language equivalent to that included in HB2177/SB1283
Safety Net Services• Adds $3.1 million to support for free clinics in fiscal year (FY) 2016 (moving General Fund
support from $1.7 million to $4.8 million)• Adds $1 million to support community health centers in FY16 (from $1.8 million to $2.8 million)
Other Items• Adds $2.2 million General Fund to avoid a cut to non-emergency professional emergency
department claims
Review of 2015 General Assembly:VHCA Budget Issues
What Happened in Last Year’s Budget
• Nursing facilities were poised to receive an additional $123 million (total funds) over the course of the biennium
• And THEN, the floor dropped of the Commonwealth’s Budget
– The discussion became one of holding onto as much of the “gains” for nursing facilities as possible through a full court press with legislators and other policy-makers.
• It meant re-emphasizing the importance of the rebasing and inflationary adjustments in order to support the change in payment methodology and our challenges for facilities as they transitioned to managed care under CCC
• It also meant reminding them of the previous savings ($150 million, since 2009) extracted from nursing facility payments
What Happened in Last Year’s Budget (continued)
• VHCA protected full rebasing and inflationary adjustments for SFY 2015
• However, the Budget as passed last year removed the inflation adjustment for SFY 2016, meaning Medicaid nursing facility rates would essentially be level funded from 2015 to 2016
• The Budget also accelerated the scheduled reduction in capital reimbursement (Fair Rental Value) under the new payment methodology
• This represented a reduction in Medicaid funding of approximately $14 million for 2015 and 2016 combined
What Happened in Last Year’s Budget (continued)
• The Bottom Line
• Last Session, we held onto $81.4 million (total funds) in new money to Medicaid nursing facility providers despite a very significant revenue shortfall in the Commonwealth
• This represented two-thirds of the previously anticipated increase and importantly, 85 percent of the anticipated 2015 increase to nursing facilities which was viewed as vital in implementing both Commonwealth Coordinated Care (CCC) and Price-Based rates
This Year’s Budget• The General Assembly closed the revenue gap that had
arisen last Spring, however the gap had widened by the Fall
• Thus, we entered this year’s Budget cycle with two main goals:
– Hold onto the gains made last year as they carry through to 2016 in terms of base funding
– Seek restoration of inflation for 2016 in the event revenue became available
This Year’s Budget (continued)
Several factors were working against our two goals:• Sequestration was significant due to Virginia’s reliance on the
defense industry (and our general reliance of federal government spending)
• The Governor and General Assembly tapped Virginia’s “Rainy Day Fund” in order to balance the budget.
• Items, such as State employee and teacher raises had been eliminated to achieve savings last year; these were priorities for funding should revenue become available.
• NFs had been largely spared in 2015, so becoming a priority in front of programs that had been cut was an uphill battle
This Year’s Budget (continued)
• On Thursday, February 26th, the General Assembly passed their budget amendments
• VHCA was successful in avoiding additional reductions to reimbursement for Medicaid services by nursing facilities
• However, the revenue situation had not improved to the point of restoration of 2016 inflation.
Review of 2015 General Assembly:Studies
Studies: Medicaid Reform• SJR268/HR637 directs the Joint Legislative Audit and Review
Commission (JLARC) to conduct a study of Medicaid– Look at eligibility screening processes and fraud and abuse– Look at appropriateness and cost-effectiveness of services– Look at evidence-based practices and strategies used successfully in
other states– Report is due November 30, 2016
• House bill initially called for a comprehensive financial audit of DMAS while the Senate version was limited to a study of long term care
• Conference bill narrowed the House version to include a more limited review of the program focusing on areas not previously audited
• Relevant to ongoing debate over Medicaid Expansion
Studies: Provider Assessment
The Secretary of Health and Human Resources shall conduct an analysis and develop a plan with options for a hospital provider assessment program, including a review of other issues deemed necessary, for consideration by the General Assembly in the 2016 Session, that: (i) complies with applicable federal law and regulations; (ii) is designed to operate in a fashion that is mutually beneficial to the Commonwealth and affected health care organizations; (iii) addresses health system challenges in meeting the needs of the uninsured and preserving access to essential health care services (e.g. trauma programs, obstetrical care) throughout the Commonwealth; (iv) supports the indigent care and graduate medical education costs at hospitals in the Commonwealth; (iv) advances reforms that are consistent with the goals of improved health care access, lower overall costs and better health for Virginians; and (v) takes into account the extent to which it provides equity in the assessment and funding distribution to affected health care organizations. In the development of this program, the Secretary’s office shall be assisted by the Department of Medical Assistance Services, the Virginia Center for Healthcare Innovation, the Virginia Hospital and Healthcare Association and other affected stakeholders.
Studies: Provider Assessment• Provider assessment is a mechanism by which the state can
raise revenues needed to fund the state Medicaid program and obtain a federal match
• A growing interest in provider assessments among the Governor, the General Assembly, and our members has made this a policy priority for VHHA
• Virginia is one of 8 states without a hospital assessment or tax program (TX and Louisiana are listed as not having hospitals taxes, but they have local authority or inter-governmental transfer programs which are functionally equivalent)
Studies: Provider Assessment
CA
WI
WA
ORID
WY
COUT
AZNM
NV
TX
MN
IA
MO
OK
NE
KS
SD
NDMT
MA
ALLA
FL
TN
MI
IN OHIL
PA
AK
WVVA
KY
NC
SC
GA
AR
MS
NHVT
HI
DE
ME
NY
MD
CTNJ
RI
Has Hospital Provider Tax
Exploring Hospital Provider Tax
No Hospital Provider Tax
DC
Source: Health Management Associates
Studies: Provider Assessment• CMS requires that such assessments be broad-based, uniformly
applied and, after any resulting payment increases back to affected providers, that there be winners and losers (42 CFR 433.68)
• Experience in other states shows that assessment programs, if implemented, should have clear parameters that specify who is taxed, how it is assessed, and how the proceeds will be used
• The current federal limitation on provider taxes is 6 percent of net patient revenue of taxed entities.
Studies: Provider Assessment• Complex issue, with both political and technical judgments to make
PROs CONs
• Federal parameters and tests must be satisfied
• Protections against diversion for other funding priorities is key
Creates state share to leverage additional Medicaid reimbursement
Enhances relationship with Medicaid agency
Enhances base rates under expansion Can help address inequities within current
reimbursement structure Mitigation may occur naturally within
systems or facilitated by the association
Assessment programs must be redistributive and therefore not all hospitals will gain, or gain equally
Assessment programs don’t usually go away and therefore providers become permanent source of financing
Not unusual to have administrative fee paid to the state
Limited direct payments under managed care
Studies: COPN
• SB1283/HB2177 and budget direct the Secretary of HHR to convene a workgroup of stakeholders to review the current COPN process
• Work group to develop specific recommendations for changes to the COPN process to address any problems or challenges identified, which shall include recommendations for changes to the process to be introduced during the 2016 Session of the General Assembly
• The Secretary shall report on the recommendations developed by the work group by December 1, 2015
Studies: COPN
• In 2000, the General Assembly directed the Joint Commission on Health Care (JCHC) to develop a plan for phasing out the COPN program (SB 337 – 2000)
• After comprehensive study, a VHHA-supported plan for responsible deregulation was developed and submitted to the 2001 General Assembly (HB 2155/SB1084 – 2001).
• Each phase associated with improvements in access to care for low-income uninsured, Medicaid payment improvements, and funding for graduate medical education
• While broadly endorsed, the state’s fiscal difficulties precluded the plan’s adoption
Studies: COPN
• Efforts to change COPN law are cyclical in nature occurring every five years or so
• Last significant changes made in 2009 (HB1598 – Hamilton)– Streamlining and reducing the criteria for determining
need from twenty down to eight criteria– Transitioning the review process for psychiatric beds to a
Request for Application process– Expediting the review process for certain capital projects– Other changes to COPN process
Studies: COPN
• 36 states and the District of Columbia have a CON law• Virginia ranks 24th out of 36 states and the District of Columbia based
upon the number of different types of facilities and services regulated by certificate of need– Tied with Alaska at 19 different types– The highest number of types is 30 and the lowest is 1, with an
average of 15• 16 states have eliminated or drastically curtailed their CON laws• Eleven (11) of those states repealed their CON laws after 1983 and
before 1990• Only states to repeal after 1990 and North Dakota and Pennsylvania• Pennsylvania experience suggests that deregulation could, at least
initially, result in a decrease in general hospitals and an increase in ASCs and imaging centers
Studies: COPN
• COPN law allows Commissioner to attach charity care condition to COPN approval– About 2/3 of COPNs have charity care conditions with an average
of 3.3% of gross revenues– In FY 2011 $856,950,546 was reported as provided in meeting the
obligations of COPN conditions plus $15,528,163 of in-kind and cash donations to safety net providers
• Health care is not a “free market”– Hospitals required to treat patients who need immediate medical
attention regardless of ability to pay– Largest payors – Medicare and Medicaid set payment amounts
below cost for health care services– No incentive to provide certain specialized, low-profit or money-
losing, but essential health care services
State Health Reform Initiatives: Why reform is needed
Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
Health Care Reforms - Why they matter
Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
Health Care Reforms - Why they matter
Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
Health Care Reforms - Why they matter
Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
Health Care Reforms - Why they matter
Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
Health Care Reforms – Why they matter
Source: Institute of Medicine: The Healthcare Imperative: lowering costs and improving outcomes
Health Care Reforms – Why they matter
State Health Reform Initiatives: Medicaid Reform
Health Care Reforms – DMAS Specific• Dual Eligible Demonstration Pilot –
Commonwealth Coordinated Care Program
• Reduce Medicaid Fraud and Increase Administrative Efficiencies ( Recovery Audit Contract, Fraud, Waste and Abuse Contract, MFCU Program and PERM Rate Review)
• Inclusion of children enrolled in foster care in managed care
Health Care Reforms – DMAS Specific• eHHR efforts to overhaul Virginia’s Medicaid
and Social Service enrollment systems
• Improve Veterans Access to Services
• Behavioral Health tightening of standards, service limits, provider qualifications and licensure requirements
• Governor’s Access Plan (GAP)
• One system to coordinate care for Medicare and Medicaid enrollees
• High-quality, person-centered care for the Dual Eligible that is focused on their needs and preferences
• All the same benefits currently available under Medicaid and Medicare
• Single program with built-in Care Coordination for primary, preventive, acute, behavioral, and long-term services and supports
• Promotes improved transitions between acute and long-term facilities
Commonwealth Coordinated Care
Commonwealth Coordinated Care - Eligibility • Medicare-Medicaid Enrollees (entitled to benefits
under Medicare Part A and enrolled under Medicare Parts B and D, with full Medicaid benefits)
• Participants in the Elderly or Disabled with Consumer Direction Waiver
• Residents of nursing facilities
• Live in designated regions (Northern VA, Tidewater, Richmond/Central, Western/Charlottesville, and Roanoke)
Commonwealth Coordinated Care - Duals • Receive both full benefit Medicare and
Medicaid coverage
• 58.8% age 65 or older
• 41.2% under age 65
• Often have multiple, complex health care needs
Commonwealth Coordinated Care - Participation
Blue Circles / Diagonals : Opt-in OnlyRed Circle/Gray: No ParticipationEverywhere Else: Auto-Enrollment
Commonwealth Coordinated Care - Enrollment• Enrollment has been less than expected
• For nursing facilities, 40.9% of the eligible population has been enrolled (not including Northern Virginia); 42.6 percent have opted-out
• Primary Care Physician “mis-assignment” has lead to Opt-Outs
• Service denials / authorization delays lead to Opt-Outs
• Enrollee identification has been difficult
• CCC has increased the administrative complexity, adding significant administrative burden on nursing facility staff at the expense of other administrative functions
Commonwealth Coordinated Care - Nursing Facility Enrollment
RegionOriginal Estimate
Revised Estimate
Actual Enrollment
Difference (Revised to Actual) % Uptake
Central/Richmond 4,430 2,999 1,263 (1,736) 42.1%
Northern 1,935 1,355 172 (1,183) 12.7%
Tidewater 3,031 2,348 1,045 (1,303) 44.5%
Western/C’ville 1,477 1,026 438 (588) 42.7%
Roanoke 2,833 1,998 680 (1,318) 34.0%
TOTAL 13,706 9,726 3,769 (5,702) 37.0%
Commonwealth Coordinated Care - Enrollment Trends
Governor's Access Plan (GAP)• In early January, the Governor launched the
Governor’s Access Plan (GAP)
• The three key goals of the GAP plan were are to: – Improve access to care for uninsured Virginians with
significant behavioral health needs– Improve physical and behavioral health outcomes– Serve as a bridge to closing the insurance coverage
gap for uninsured Virginians with serious mental illness
Governor's Access Plan (GAP) Eligibility • Screened and meet the criteria for GAP SMI• Uninsured and age 21 through 64 years old• Resident of Virginia• Household income that is 60 percent of the (FPL) • Not otherwise eligible for any state or federal full
benefits program including: Medicaid, FAMIS, Medicare, or TriCare
• Not residing in a long term care facility, mental health facility, long-stay hospital or penal institution
State Health Reform Initiatives: Medicaid Expansion
Short History of the Affordable Care Act
• “Obamacare”– Reduce the Uninsured– Reform Insurance Practices– Reduce Costs
• Expand Access to Affordable Health Care Coverage– Expand Medicaid eligibility to 133% of FPL– Implement Exchanges– Pay or Play
• Employer Mandate• Individual Mandate
• Supreme Court makes Medicaid expansion optional
Coverage Options before the Affordable Care Act
Medicare65+
Employer Sponsored Insurance
65+19-64Children
Individual Market
Medicaid
UNINSURED
Coverage Options under the Affordable Care Act
Medicare65+
Employer Sponsored Insurance
65+19-64Children
Health Insurance Marketplace
Medicaid
Medicaid Expansion
Coverage Options after Supreme Court Decision
Medicare65+
Employer Sponsored Insurance
65+19-64Children
Health Insurance Marketplace
Medicaid
Medicaid ExpansionOPTIONAL
Pregnant Women
Children 0-5 Children 6-18 Elderly & Disabled
Parents Childless Adults 19-64
0%
50%
100%
150%
200%
250%
300%
350%
400%
75%47% 0%
Current Medicaid Coverage Gap Health Insurance Marketplace
5M
ACA "Coverage Gap" in States Not Expanding Medicaid
Source: Kaiser Family Foundation, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (October 2013)
Most are working or live in working families
(60% in a family with one worker, 54% are working themselves)
Below poverty(≤ $11,940 individual / $23,550 for
a family of four)
ACA "Coverage Gap" in States Not Expanding Medicaid
State Action to Close Coverage Gap
PA, IN, and NH recently expanded under alternative plan. UT has also recently adopted plans to move forward. TN close to approving alternative plan, but ultimately failed to get votes needed.
In total 30 states and DC are oriented in some way towards a solution to closing the coverage gap.
29 states and DC have taken action to close the coverage gap through Medicaid expansion or alternative plans approved by CMS.
ACA "Coverage Gap" in States Not Expanding Medicaid
Source: Profile of Virginia’s Uninsured, 2011, The Urban Institute, prepared for the Virginia Health Care Foundation, October 2013.
• Live in families with income below 100% FPL43%
• Live in working families with at least one full or part-time worker70%
• Live in working families with at least one full-time worker 47%
• Of uninsured adults are U.S. Citizens78%
• Of Virginians in rural areas are uninsured compared to 15% statewide25%
• Are nonelderly adults 19 to 64 years of age89%
• Are 19 to 34 years of age41%
• Live in families with income below 200% FPL71%
Profile of Virginia’s Uninsured
Profile of Virginia’s Uninsured
Source: The Virginia Atlas of Community Health
To Expand or Not to Expand?Proponents Argue:
• 400,000 Virginians are without access to affordable health care
• Failure to act threatens the financial stability of hospitals in our communities
• The status quo is crippling businesses in Virginia
Opponents Argue:
• Medicaid is the fastest growing segment of the budget
• Need to reform broken system first
• Federal government cannot continue to fund growth in entitlement programs
2014 Action on Medicaid Expansion
Governor
Senate
House
• Budget included Medicaid Expansion under 2-year pilot
• Budget included Marketplace Virginia
• Audit and Reform• No Coverage Gap
Provision• Decouple Medicaid
Expansion from Budget
Budget Showdown
• A deal in Senate to include a path forward for closing the coverage gap, but . . .
• Black or Bust: Senate conservatives rebel– Black/Stanley amendment: no funds for
Medicaid expansion without legislative approval
Budget Showdown
•Governor vetoes Stanley amendment
•Override requires 2/3 vote of both chambers
•Speaker rules veto of Stanley amendment out-of-order
•“Clean” budget passed•Governor vows to move ahead with efforts to close the coverage gap
McAuliffe Plan – A Healthy Virginia
A Healthy Virginia • 10-step incremental approach
– Governor’s Access Plan – limited benefit to 20,000 with serious mental illness
– Improve care coordination– Spur enrollment to Medicaid, FAMIS,
and Marketplace– Dental benefits to pregnant moms– New website
• Not a comprehensive approach to closing the coverage gap, but makes meaningful strides in right direction
Special Session Debate over Medicaid Expansion
• “Fair and honest” debate over Medicaid Expansion• Virginia Health Care Independence Act (Rust)
– Alternative to traditional Medicaid Expansion– Block grant-like approach– Failed on 3rd Reading
• Other Medicaid reform bills proposed, but not debated
Key Message: Find a Path Forward
• Virginia knows better than Washington
• Pro-business, common sense solution
• We are already paying for this – return the dollars
• A lot of smart people working together should be able to find a path forward for Virginia
