HEALTH POLICY AFFORDABLE CARE ACT AND STATE MEDICAID CHANGES. NEW Members Conference of the Illinois General Assembly November 27-28, 2012

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1 HEALTH POLICY AFFORDABLE CARE ACT AND STATE MEDICAID CHANGES NEW Members Conference of the Illinois General Assembly November 27-28, 2012 Robert Kaestner, PhD Institute of Government and Public Affairs, University of Illinois Department of Economics, University of Illinois at Chicago Nicole Kazee, PhD Director, Health Policy and Programs University of Illinois Hospital & Health Sciences System 1

2 THE AFFORDABLE CARE ACT: MEDICAID EXPANSION (2014) Expands eligibility to all people below 133% of poverty currently single adults and some parents are not covered Requires states to use streamlined eligibility determination, application, and enrollment procedures in their Medicaid programs Medicaid benefit package for the newly eligible can be different than that offered for traditional Medicaid 2

3 HOW MANY MORE WILL BE ON MEDICAID? Approximately 800,000 persons in Illinois are uninsured and have incomes below 133 percent of poverty Undocumented immigrants are ineligible for Medicaid under the ACA. The exact number is difficult to determine but we estimate 225,000 low-income persons are undocumented That leaves 575,000 uninsured persons who are estimated to become newly eligible for Medicaid 3

4 HOW MANY MORE WILL BE ON MEDICAID? Based on past research, it is expected that 10 to 25 percent of low-income persons with private health insurance coverage will drop that coverage and switch to Medicaid because it is cheaper ( crowd out ) Assume 20 percent of low-income people with private insurance switch to Medicaid another 130,000 Total estimated increase in Medicaid: 705,000 people or 30% increase over current program 4

5 HOW MUCH WILL IT COST ILLINOIS? Population State receives only 50% match from the federal gov t for new enrollees who were previously eligible. Estimate that there will be 100,000 in this group. Starting in 2020, state will be responsible for 10% of the costs of the newly eligible Starting in 2015, state will be responsible for the Medicaid reimbursement increase for primary care providers (note: this is optional for the state) TOTAL Future Estimated Cost $320,000,000 (4% increase in Medicaid costs) $200,000,000 (2% increase) $150,000,000 to $200,000,000 $700,000,000 (8.75% increase) 5

6 THE AFFORDABLE CARE ACT: HEALTH INSURANCE EXCHANGE (2014) Online marketplace for health insurance Premiums will cover: 60% (bronze), 70% (silver), 80% (gold) or 90% (platinum) of medical costs Premiums can vary by age, smoking, geographic area, and family size Health plans allowed to sell on the exchange have to meet state standards for benefit coverage, doctor availability, and quality 6

7 HOW MANY WILL USE THE EXCHANGE? 1.8 million uninsured in Illinois, 750,000 of whom will need to get insurance (others eligible for Medicaid or undocumented) 10% will not obtain insurance because of violating mandate or exception to mandate, and others will get employer-provided insurance because of new employer mandate Estimate that 300k people in Illinois will purchase insurance on the exchange in

8 FEDERAL SUBSIDIES FOR LOW-INCOME FAMILIES TO BUY INSURANCE % FPL limit premium contributions to 2% of income % FPL limit premium contributions to 3-4% of income % FPL limit premium contributions to 4-6.3% of income % FPL limit premium contributions to % of income % FPL limit premium contributions to % of income % FPL limit premium contributions to 9.5% of income Provide Subsidies for Low-income Families to Pay Out of Pocket Expenses % FPL limit cost sharing (out-of-pocket) to 6% % FPL limit cost sharing (out-of-pocket) to 13% % FPL limit cost sharing (out-of-pocket) to 23% % FPL limit cost sharing (out-of-pocket) to 30%

9 EXAMPLE: SIZE AND NATURE OF ACA SUBSIDY Silver Plan assume total cost of $6,000 premium is 70% of total cost or $4,200 per year out-of-pocket cost is $1,800 per year Person with income of $25,000 approximately 166% of FPL Maximum premium is $1,250 ($100 per month) so subsidy is $3,000 Cost sharing maximum is $780 so subsidy is $1,000 Total maximum annual cost for person is $2,000 Federal government subsidy is $4,000

10 THE AFFORDABLE CARE ACT: MANDATES (2014) Individual mandate All individuals must prove enrollment in health insurance on tax return or receive a penalty (greater of $695 per person or 2.5% of taxable family income) Exceptions: religious objection, financial hardship 10

11 THE AFFORDABLE CARE ACT: MANDATES (2014) Employer mandate Applies to all employers with 50 or more employees--intended to keep employers from dropping employees Employers who do not offer coverage: $2,000 fine per employee (after 30) if ANY employee receives a subsidy on the exchange Employers who offer coverage: lesser of $3,000 fine per employee that receives subsidy or $2,000 per employee (after 30) Employers argue that it discourages small business growth and actually acts as a disincentive for them to offer coverage 11

12 EMPLOYER MANDATE SOME ARITHMETIC AND POTENTIAL CONSEQUENCES Cost of employer-sponsored insurance is $6,000 per person Employee pays about $1,200 and employer pays about $4,800 Fine is $2,000 Employer saves $2,800 by dropping insurance Employer can give employee $2,000 raise (and still save $800) Employee can buy health insurance in exchange for $2000 employee saves $1200 So many employers with low-income workers will be better off dropping insurance 12

13 THE AFFORDABLE CARE ACT: INSURANCE MARKET REFORMS No co-payment for preventive services (e.g., annual checkup, screenings, vaccinations, contraception) Bans lifetime and annual dollar limits Bans rating based on gender or pre-existing conditions, limits age rating Bans recissions Cannot deny insurance because of pre-existing conditions Dependent coverage (children up to age 26) Medical Loss Ratio (MLR) requirements insurers are required to spend 80% of premiums on medical care 13

14 THE AFFORDABLE CARE ACT: OTHER PROVISIONS Closing of Medicare donut hole Reimbursement cuts or fees to hospitals, medical device companies, drug companies Funding for care coordination and other experimentation Workforce development 14

15 REQUIRED STATE ACTIONS Authorize Medicaid expansion Authorize new Medicaid benefit package May be less generous than traditional Medicaid benefits Authorize state-based exchange (for 2015) First year (2014) will be federal-state partnership exchange that requires no legislative action 15

16 ILLINOIS MEDICAID REFORM (2011) Tightened eligibility verification requirements; required that eligibility be re-determined annually Inconsistent with spirit of ACA that seeks to reduce barriers to obtaining Medicaid Placed income limit on AllKids (300% of poverty level) Required that 50% of Medicaid patients be moved into coordinated care by

17 CARE COORDINATION Most Medicaid enrollees will be put into traditional managed care plans; others will be in provider-led networks Persons with complex health needs in Chicago area and Central Illinois: Jan 2013 Dual eligibles: April 2013 Others? Will mandate managed care for seniors and persons with disabilities (SPD) as well as new Medicaid enrollees under ACA Risk-based managed care based on historical experience, best outcome is a 5% cost savings and no change or improvement in quality 17

18 SMART ACT (2012) SB2840 cut $1.6 billion from Medicaid through 62 different provisions that included eligibility and benefit cuts, utilization controls, and provider rate reductions Removed some parents from FamilyCare program Required new copayments Eliminated coverage for adult dental, chiropractic, and most podiatry services Imposed utilization controls on transplant medications, durable medical equipment, wheelchair repairs, etc. Eliminated IllinoisCares Rx drug program for lowincome seniors Established penalties for hospitals based on preventable readmissions Required prior authorizations for patients with more than 4 prescriptions in a month Reduced rates for most providers Increased cost sharing for children receiving home services Enhanced eligibility verification 18

19 SMART ACT SAVINGS ARE OPTIMISTIC Nearly 60% of savings comes from: Eligibility determinations--$350m Pharmaceutical Savings (not from eliminating Senior Rx) $320m $180,000,000 from prior certification $40,000,000 from rejecting claims not first made to primary payer $20,000,000 from collection of outpatient drug rebates $78,000,000 from expiring patents and switch to generics Cut provider payments--$240m 19

20 STATE MEDICAID LEGISLATION: THE REST OF THE PACKAGE Ø SB 2194: Included new hospital charity care requirements (as well as a tobacco tax increase) Ø SB 3261: Set forth new requirements for discounted and free care that hospitals must provide to lower-income patients who are uninsured Ø HB 5007 approved a waiver request from the Cook County Health System for early implementation of Medicaid expansion. County Care program will go into effect in Jan

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