Profiles in Coverage: Indiana Check-Up Plan

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1 August 2008 State Coverage Initiatives Profies in Coverage: Indiana Check-Up Pan Overview The Indiana Check-Up Pan, as passed by the Indiana Genera Assemby in 2007, contains severa pubic and private reforms aimed at improving access to heath insurance, funded through an increase in the cigarette tax. The centerpiece of the pan is the Heathy Indiana Pan (HIP), a highdeductibe heath pan (HDHP) couped with a Heath Savings-type Account (HSA) offered to owincome residents who have been without heath insurance for six months, and earn ess than 200 percent of the Federa Poverty Leve (FPL) (i.e., $41,300 for a famiy of four in 2007). Uninsured individuas above 200 percent FPL can buy-in to the HIP pan at market rates. State Coverage Initiatives is a nationa program of the Robert Wood Johnson Foundation administered by AcademyHeath. HIP is financed by a 44-cent increase in the state s cigarette tax, bringing Indiana s tota cigarette tax to 99.5 cents. This increase wi provide coverage for 120,000 additiona Hoosiers. The Indiana Check-Up Pan egisation aso: Provides tax credits to sma businesses to estabish Section 125 pans and weness programs; Increases the age for dependent coverage to age 24; Funds tobacco cessation and immunization programs; Provides presumptive eigibiity for pregnant women; Extends Medicaid coverage to pregnant women from 150 to 200 percent FPL; Aows the state to expand coverage for the State Chidren s Heath Insurance Program (SCHIP) from 200 to 300 percent FPL; and Increases reimbursement rates for current Medicaid providers. Whie the HIP is the main coverage expansion, these other components aso take important steps toward improving the overa heath of Hoosiers and improving access to heath care coverage. Program Overview The State Coverage Initiatives (SCI) program recenty spoke with Mitche Roob, Jr., secretary of the Indiana Famiy and Socia Services Administration. Q. Can you te us about the origin of the Indiana Check-Up Pan? In 2006, Indiana Governor Mitch Danies and the Indiana Genera Assemby asked us to create a heath pan for the working poor and chronicay uninsured. Our obstaces to a arge degree were no more chaenging than what other states are facing in this regard. The state had no successfu effort to address uninsured aduts since the inception of the Medicaid program in the 1960s, and consequenty was

2 Profies in Coverage: State Coverage Inititatives FPL The Coverage Gap in Indiana 250% 200% 150% 133% 100% 70% 80%* 22% SCHIP 2 SCHIP 1 Standard Medicaid Pregnancy Services Ony ranked one of the worst in the nation for coverage. From 1999 to 2004, Indiana aso had experienced the second argest decine in empoyer-sponsored insurance in the nation and had seen a 30 percent increase in the number of uninsured since Compounding the probem, Indiana aso has extremey high rates of smoking and obesity and Hoosiers fa short in obtaining requisite preventive care as compared to nationa rates. Despite these chaenges, in a itte over a year, Indiana passed egisation, negotiated a federa waiver, and impemented a pan to expand coverage to ow-income uninsured residents. Q. What chaenges did you experience in deveoping such a program? Looking back, our chaenge was to construct a framework to promote persona responsibiity, conscientious use of heath care resources, and the prudent use of taxpayer doars. Utimatey our greatest chaenge was to create a pan that coud garner not ony broad bipartisan support, but that aso coud secure swift federa approva to obtain Medicaid funding. Q. How did you get the support of important stakehoders in the state? Through months of meetings, thousands of mies of trave, and hundreds of presentations, we sought to frame our argument by articuating that the financia burden of THE GAP IN COVERAGE Ages Medicare Medicare/ Medicaid Dua Age < Pregnant Disabed Bind MEDWorks Buy-in MEDWorks The Gap in Coverage shown in Orange Current Medicaid popuation shown in bue the uninsured resuted in increased premiums for the insured and thwarted price and quaity transparency for a Hoosiers. We utiized data that demonstrated that 10 percent of each premium doar paid by the insured popuation supported the cost of the uninsured due to cost-shifting by providers. We aso expained that 67 percent of Indiana s insured are ow-income individuas earning ess than 200 percent FPL, without any feasiby affordabe heath care option. These statistics made some form of a government subsidy inevitabe. The data were irrefutabe and most understood that doing nothing about the growing owincome uninsured woud resut in steeper premium increases and further exacerbate the imbaance of market forces. In order to gain support for a coverage expansion, our pan had to ensure that it woud encourage the prudent use of taxpayer doars by the participants. We fet that participants must be partners with the state, and therefore must be aware of the cost of services they received in order to make responsibe decisions about appropriate and medicay necessary care. Q. Can you expain the consumerdirected eement that is part of the pan? As we began to formuate the pan, Governor Danies introduced the idea of using HDHPs and HSAs as a coverage vehice. They promote the notion of consumerism and promise greater price transparency, competition, and quaity. They not ony encourage heathy ifestyes, but aso provide individuas a financia incentive to seek information to make cost- and vaueconscious heath care decisions, which in turn increases pressure on providers to demonstrate vaue and quaity. Since these mechanisms were very new and criticized for creating perverse incentives, especiay for ow-income individuas, to obtain needed care and critica preventive services, we had to deveop a pan that woud pay off of the strength of HDHPs and HSAs, but coud aso be effective for vunerabe ow-income popuations under the Medicaid umbrea. With these parameters, the Heathy Indiana Pan with the Persona Weness & Responsibiity (POWER) Account was created. Q. Can you describe how the POWER Account works? Modeed in the spirit of HSAs, the POWER Account is used to fund the $1,100 deductibe required by HIP. Moving away from premiums and co-pays that are typicay too ow to incentivize coection by providers, HIP requires individuas to make mandatory monthy contributions to their POWER Account. After their monthy contribution, participants have no other cost-sharing requirement except for co-pays for non-emergency usage of the emergency room. Whie contributions are higher than traditiona Medicaid premiums, participants have contro over how these doars are spent for eigibe medica expenses. They become consumers with an incentive to demand price transparency and make decisions about how to obtain the best vaue for their purchase. Q. Since eary studies have indicated HDHPs/HSAs do not work we for ow-income individuas because the deductibes were often not affordabe and discouraged participants from obtaining necessary heath care services, how did you address the skepticism about using them?

3 We created two mechanisms to specificay address these issues. First, recognizing that even after the required contributions many woud sti be unabe to afford the $1,100 deductibe, the HIP pan provides upfront subsides to the POWER Account to ensure that the account is fuy funded to cover the deductibe. Second, whie we want participants to think carefuy before utiizing heath care, we did not want participants to appy this rationae to preventive heath services. Originay, HIP was going to provide $500 of first-doar coverage for preventive care, which the state broady defined to incude even smoking cessation and smoking patches in an effort to curb the state s high rates of tobacco use. In the end, the resut was better than what was outined in the egisation. Due to successfu competition between Anthem Bue Cross Bue Shied and MDWise with Americhoice, the two pans that won the state s bid to offer the product chose to offer unimited coverage for preventive care services, so the $500 threshod is not being used. Q. How did you address the issue of POWER Account baances eft over at end of year? During the formative process, there was much debate about how to hande year-end POWER Account baances to reward costconscious behavior. Traditiona HSAs aow account baances to ro over and are used to pay for future heath care expenses. Because contributions are made on a pre-tax basis, there is an incentive to keep the money in the account to avoid penaties. Contributions made to the POWER Account, however, are not made on a pre-tax basis, as most owincome individuas woud not benefit. Many egisators wanted the baance to be paid back to the individua so he or she coud purchase heath care services not covered by the pan, such as denta care, or even aow participants to simpy receive cash back, both of which are very attractive features for promoting heathy ifestyes and vaue and cost-conscious behavior. However, it seemed circuar to pay out the baance and then require subsequent contributions. Many were aso concerned about cash payments being used for nonheath care items, especiay if the payouts incuded state and federa monies. In the end, we aowed the baance of the POWER Accounts to be used to offset required participant contributions in the foowing years. At the end of the year, the baance of the POWER Account wi ro over to reduce the foowing year s required contribution, if the participant has received their age-, gender-, and diseasespecific preventive services. If they have not received these services, ony their own, pro-rated contribution to the POWER Account wi ro over, but the state s contribution wi be returned to the state. This design is intended to create an incentive for recipients to obtain appropriate preventive care and use services in a costconscious manner. Q. How are the monthy contributions determined? Required contributions range from 2 to 5 percent based on income, never exceeding $92 a month for an individua. Empoyers are aso aowed to make contributions up to 50 percent of the individua required contribution. In order to prevent participants from obtaining temporary coverage, penaties are stiff for payment apses. Participants have up to 60 days to make their contribution and are then terminated and cannot reappy for 12 months. HIP Pan Structure Preventive Services Unimited Preventive Care Services in addition to POWER Account funds Q. How do participants manage their POWER Accounts? Participants are responsibe for managing their POWER Accounts and receive monthy statements for the account, as we as a summary of progress toward annua and ifetime imits ($300,000 annua coverage/$1 miion ifetime coverage). Q. What benefits are covered under the pan? POWER Account $1,100 Individua & State Contributions Controed by participants to cover initia medica expenses Insurance Coverage $300,000 Annua Coverage $1 Miion Lifetime Coverage Benefits are comprehensive and incude physician services, in-patient and out-patient hospita services, generic prescriptions if avaiabe, menta heath and substance abuse treatment, and durabe medica equipment (DME). Vision, denta, and chiropractic services are not covered. Maternity is not covered because it is covered by the Medicaid program. Q. The potentia fisca impact of new coverage programs is aways a difficut issue for egisators. How did you address this chaenge? The fisca impact was of concern to everyone. No one wanted to create a program that coud not be sustained over time. In order to address this, we designed an anti-entitement provision. The egisation restricts the state from providing services beyond the eve of state appropriations authorized for the pan. The provision contains the pan s budget to the amount of revenues coected through the cigarette tax, and woud require the state to Individua POWER Account contribution wi not exceed 5% of gross annua income approximatey $200 $900 annuay

4 Profies in Coverage: State Coverage Inititatives Annua Contribution HIP Power Account Funding Singe Adut: $1, $896 $204 $717 $383 adjust the program through either the number of enroees or the benefits provided to stay within budget. This ensures that the program wi not be a burden to future generations and that growth can be controed and maintained. In reaity, if there is growth in the program, egisators wi ikey be pressured to find additiona funding to support growing enroees and costs. Nevertheess, the impications of a non-entitement program were enormous, as it gave many egisators the peace of mind to aow them to support the bi. Q. One esson that has become apparent with other state reforms that have passed in the ast few years is that support has to come from both sides of the poitica aise. Was this the case in Indiana? The bi obtained bipartisan support to pass in our spit egisature argey due to the efforts of both our Repubican Senate sponsor and our Democratic House sponsor. They worked effectivey together and their eadership reached across the aise to coeagues who had ong kept heath care issues outside of partisanship. These reationships were further cemented by a passionate coaition of antismoking and heath advocates who provided $487 $613 $88 $1,012 $10,210 $12,763 $15,315 $20,420 Annua Income Participant State support and activey engaged in the diaogue. The menta heath community, in particuar, improved the pan by raying for fu menta heath parity, which was incuded in the fina version of the bi. Q. How did hospitas and practitioners react to the bi? Hospitas presented a specia chaenge for us. We knew that in order to secure federa funding and meet federa budget neutraity requirements, we woud have to divert a portion of hospitas institutiona entitement in the form of their Disproportionate Share Hospita (DSH) funding to the new program. After making changes to the DSH program and other programs, the association that represents Indiana hospitas provided their fu support. Practitioners were aso initiay reuctant to support the pan, as current Medicaid reimbursement rates had not been increased since In response, the egisature not ony raised Medicaid rates, but aso required the use of Medicare rates, instead of Medicaid rates, under the HIP pan to ensure an adequate deivery system for the new covered popuation. Q. What roe, if any, do empoyers have? Empoyers may contribute up to 50 percent of the individua s required contribution. We aso have a program to faciitate payro deduction for individua contributions, which requires the empoyer s assistance. Q. What was the greatest chaenge in the negotiations with the Centers for Medicare and Medicaid Services (CMS)? Perhaps the greatest chaenge and most worthwhie exercise in our federa negotiations was in regard to chidess aduts. Whie funding is not avaiabe to cover a of the uninsured under 200 percent FPL, the egisation makes the program widey avaiabe and does not imit the program to specific categories such as parents of SCHIP-eigibe chidren. Utimatey, we fet that ony the federa Medicaid rues care whether a person is a parent or is a chidess adut. If someone is ow-income, uninsured, and wiing to make the monthy contributions and pay by the HIP rues, he or she shoud be aowed to participate regardess of parenta status. We shoud not vaue a parent over a chidess adut. Medicaid aws, however, see this issue differenty and budget neutraity rues thwarted our effort. In the end, coverage for chidess aduts was capped at 34,000 ives, eaving the remaining sots for parents of SCHIP-eigibe chidren. However, CMS did give us permission to change eigibiity requirements in the future. As our funding eves change, we can cap the program; however, individuas aready enroed in the program wi be protected. Q. What modifications had to be made to the origina egisation in order to secure CMS approva? CMS was cear that neither the empoyer s nor the individua s contributions to the POWER Account woud be matched and that no federa doars in the account coud be paid out to individuas. The state was aso unsuccessfu in obtaining approva for a denta and vision rider program that woud aow individuas to pay more than

5 the required 5 percent contribution to obtain denta and/or vision coverage. We aso had to ower the monthy contributions imit to accommodate co-pays and were imited in the amount of co-pays we coud charge for emergency room use. Q. How are you evauating the effectiveness of the pan? We have deveoped an evauation pan that wi examine caims data, membership fies, use of the POWER Account, and utiization trends. The evauation wi aso incude a provider and member survey. Q. What is the current enroment in the program (number of businesses and/or covered ives)? What do you anticipate the enroment to be at the end of this year and in the ong term? CMS approved the 1115b waiver in December of 2007, and by mid-january 2008, more than 17,000 individuas had appied. We have received more than 46,000 appications in ess than five months and currenty over 15,000 Hoosiers have been approved for coverage. Q. Do you have any crowd-out provisions other than the requirement that an individua did not have insurance during the previous six months? Yes individuas cannot be eigibe for empoyer-sponsored heath insurance. Q. How are you reaching the target popuation? What marketing and outreach has the state done to draw individuas to the program? We have deveoped a series of TV, biboard, and radio ads that promote a to-free number. We aso deveoped a network of vounteer and community organizations, safety net providers, and hospitas throughout the state that have heped promote the program. The community engagement and a marketing campaign that features the Governor have been crucia to our marketing success. Q. Have many participants ost coverage as a resut of payment apses? At this time probaby ess than 10, but it is so eary in the program that it is too eary to te the rea impact of our persona responsibiity requirements. Q. Do you think the $1,100 is appropriate amount for those with chronic conditions? The $1,100 deductibe may in fact be too ow for those persons with chronic conditions. Persons with chronic conditions wi ikey go through $1,100 very quicky. Because this is a Medicaid program, we are bound by the 5 percent out-of-pocket maximum imposed by CMS. Once participants spend the $1,100, they are not financiay iabe for services rendered during the rest of the year, as the state wi cover a services. As we gain more experience in the program, we wi continue to evauate the heath status of participants to assess whether the deductibe shoud be increased. By increasing the deductibe, there woud be greater financia incentives to compete requisite preventive care and to manage the arger POWER Account. Q. Are you seeing any changes in the system as a resut of the HIP program? Are any goas being expicity set for institutions in the state? With ony five months into the program, it is too eary to te, but this is something that we wi be evauating. Q. Despite being eary in the impementation phase, are there areas that you woud ike to improve upon? Absoutey. We wonder if there shoud be additiona co-pays for those individuas not paying up to the 5 percent CMS imit to further encourage appropriate utiization as we as minimum contributions for a participants. Currenty POWER Accounts contributions can ony be made by the state, individuas, and empoyers. Perhaps heath pans shoud be abe to operate incentive programs, and make contributions to the Accounts as we. Interest in the overa HIP is high and it is ikey that the amount of the cigarette tax may need to be revisited. Q. What essons have you earned from this process that shoud be considered by other state and nationa poicymakers ooking to successfuy pass heath reform? Private Market Soutions: Soutions to address the uninsured must work in tandem with the private market, and shoud not aow individuas to obtain services for free. A market consumers must pay by the same rues and make some contributions toward their care. Government subsidies shoud be redirected to empower individuas to act as prudent consumers of heath care. The fundamenta Medicaid program must be reevauated to encourage responsibe behavior, rather than sustaining dependence and paternaism. Loca Soutions: The face of the uninsured in each state is different. States must be empowered to deveop oca soutions. To make this successfu, the federa waiver process must be overhaued to assist and support states, rather than to sow innovations. Finding a Champion: States ooking to reform must identify a high-eve oca champion(s); one that not ony has estabished reationships and the trust of the community, but aso has access to the data and technica support to spearhead such efforts. The champion must aso possess the poitica savvy to ray support from oca eaders across vasty different phiosophica and poitica backgrounds. Above a, the oca champion must possess a tenacious determination to succeed. Never Let the Perfect Be the Impediment of the Good: HIP is pragmatic in both its design and approach. The pan incudes mutipe mechanisms to not ony empower individuas to enter the heath care marketpace, but to aso promote persona responsibiity and the prudent use of heath care resources. It attracted wide bipartisan support because it provides a reasonabe coverage option to the uninsured, whie working in harmony with the private market for the currenty insured.

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