( Exhibit 1B-Summary tab). The primary fiscal impact results in the second year from the shift of medical costs for coverage for the lowerincome

Transcription

1 Items of Revenue or Expense, or Both B/A 3243 DHCFP Nevada Medicaid (Expense) EXECUTIVE AGENCY Fiscal Year Fiscal Year B/A 3158 DHCFP Administration (Expense) $42,500 Fiscal Year BDR AB 255 FISCAL NOTE AGENCY'S ESTIMATES Date Prepared: April 3, 2009 Agency Submitting: Health Care Financing and Policy, Health and Human Services Effect on Future Biennia B/A 3228 Welfare Administration (Expense) $483,070 $224,173 $440,652 B/A 3247 HIFA Medical (Expense) $27,000 $9,000 $10,590,749 $21,181,498 Total 0 $525,570 $10,841,922 $21,631,150 Explanation (Use Additional Sheets of Attachments, if required) AB 255 (Section 4) requires the Department of Health and Human Services to provide presumptive eligibility for pregnant women with household incomes 0-185% FPL. Total cost for SFY10-11 biennium is estimated to be $11.3 million. Total general fund impact for SFY10-11 is estimated to be $5,108,547; for SFY12-13, it is estimated to be $10,819,625. The program, to be implemented July, 2010, requires programming, Information Systems support, and staffing. Primary fiscal impact results in year two from the shift of medical costs for Medicaid-eligible pregnant women (0-133% FPL) approximately 2 months earlier than the current norm, and for pregnant women currently covered under the HIFA Waiver ( % FPL). It is assumed participants in the HIFA Employer-Subsidized Insurance program will continue to receive monthly reimbursements (up to $100) until the HIFA Waiver s mandatory closure (due to CHIPRA) on September 30, 2011; this amended waiver would require approval by Centers for Medicare and Medicaid Services (CMS). Presumptive eligibility, determined by qualified providers, begins on the day of determination. Qualifying individuals must file a timely application with the Division of Welfare and Supportive Services (DWSS). Providers will require training; DWSS requests a Program Specialist and 2 Training Officers. This fiscal note assumes the lowerincome group will qualify for enhanced FMAP; if all pregnant women covered by this bill's provisions are considered by CMS to qualify only for the 50% FMAP, fiscal impact will increase. State-only funds must be used to pay benefits received during presumptive eligibility by enrollees who do not submit follow-up applications. In cases of retroactive denials, the state share of medical costs is not recoverable. It is unknown whether tobacco-tax revenues can be used for required repayment of federal funds. This fiscal note does not consider costs of outreach to the community or quality assurance of the application process. Name Title Darlene Amarie-Hahn ASO II DEPARTMENT OF ADMNISTRATION'S COMMENTS Date Friday, April 03, 2009 The agency's response appears reasonable. Name Title Andrew K. Clinger Director FN 2881

2 BDR , AB 255 DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF HEALTH CARE FINANCING AND POLICY (DHCFP) MARCH 27, 2009 EXPLANATION BDR , AB 255 (section 4) requires the Department of Health and Human Services to include in the State Plan for Medicaid and the Children s Health Insurance Programs presumptive eligibility for, and medical-service coverage for, pregnant women, including those with household incomes from percent of the federally designated level signifying poverty (FPL). This bill essentially accelerates Medicaid coverage for pregnant women with incomes at or less than 185 percent FPL. The total cost for this program for the SFY biennium is estimated to be $11.3 million. The total general fund impact for the SFY biennium is estimated to be $5,108,147 The total general fund impact for the SFY biennium is estimated to be $10,819,625 The program mandated by this bill is estimated to require one year to establish, for implementation July 1, 2010, with associated costs for programming ( Exhibit 1F-DWSS IT Costs and "Exhibit 1G-DHCFP IT Costs" tabs), Information Systems support, and staffing ( Exhibit 1B-Summary tab). The primary fiscal impact results in the second year from the shift of medical costs for coverage for the lowerincome group of pregnant women approximately two months earlier than is the current norm, and the shift to Medicaid of an entire group of pregnant women (with household incomes from percent FPL) currently covered under a waiver ( Exhibit 1D-DHCFP Medical Services Costs tab). Target populations include the following: (1) Population #1 Medicaid-eligible pregnant women with incomes from percent FPL (currently estimated to number 13,500, including those with fee-for-service and with managed-care coverage, and allowing for an estimated number of duplicates between the two groups); and (2) Population #2 pregnant women with incomes from percent FPL, who currently are covered as part (HIFA-P) of the Health Insurance Flexibility and Accountability, or HIFA, Waiver. Projected HIFA-enrollment at implementation on July 1, 2010, of the presumptiveeligibility program (to which they would transfer) is 200 women. Note that the number of pregnant children (i.e., aged under 19 years) in these populations is too small to cause a separate fiscal impact. The maximum length of coverage for women in both groups is 11 months each, to include 9 months of prenatal and 2 months of postpartum care. Also covered under the HIFA Waiver (HIFA-E) are monthly insurance-premium reimbursements (up to $100 monthly) for employees participating in the Employer-Subsidized Insurance (ESI) program. It is assumed these ESI enrollees, who are projected to number approximately 20 as of July, 2010, when the program begins for presumptive eligibility, will continue to receive monthly reimbursements for the 15 months until the HIFA program is mandated to close (due to CHIPRA) on September 30, (See the Exhibit 1E-HIFA-E Medical Services Costs" tab.) ESI continuation following the transfer in July, 2010, of HIFA pregnant women to the presumptive-eligibility program would require the approval of an amended waiver by the Centers for Medicare and Medicaid Services (CMS). BDR , AB 255 Exhibit 1A-EXPLANATION RevB 3/27/2009

3 While it is expected that 100 percent of target Population #2, the HIFA enrollees, will require a presumptive eligibility decision to move to the Medicaid program, it is not known what percent of target Population #1 already would be enrolled in Medicaid when they become pregnant, and thus would not require a presumptive-eligibility decision. Worksheets include three scenarios requiring presumptive Medicaid enrollment for 100, for 50, and for 25 percent of the estimated Population #1; fiscal-impact estimates assume a presumptive Medicaid enrollment of 50% of target Population #1 ( Exhibit 1D-DHCFP Medical Services Costs tab - Scenario 2). Presumptive eligibility will be determined by qualified providers, to include schools, child care centers, and homeless centers. The period of presumptive eligibility begins on the day a pregnant woman is determined presumptively eligible. Only ambulatory prenatal services will be covered during the presumptive-eligibility period. There will be the requirement that the qualifying individual file an application with DWSS by the last day of the month following the month in which presumptive eligibility is determined. The Division of Welfare and Supportive Services (DWSS) will create eligibility for an individual based on providers determinations. Since providers are making this determination, there is the possibility that all persons who present themselves for medical services will be found eligible, whether or not they actually meet the requirements. This could result in Medicaid costs being paid for ineligible persons for at least 1 to 2 months prior to a final determination. To reduce the number of ineligibles receiving benefits in error, providers would require training on the eligibility process. DWSS requests the addition to staff of 3 positions, to include a Program Specialist and 2 Training Officers, who will provide training for and oversight of medical facilities engaged in presumptive-eligibility determinations ( Exhibit 1B-Summary and Exhibit 1C-DWSS DU Download tabs). These positions will develop and maintain materials to facilitate submission of information about pregnant women for presumptive eligibility enrollment in DWSS s automated systems, and will provide initial and renewal training to medical facilities to familiarize them with the logic necessary to identify and quickly overcome operational concerns. This fiscal note assumes that target Population 1 will qualify for the enhanced Stimulus FMAP, while target Population 2 (HIFA) will qualify only for the 50/50 percent FMAP, since, at the startup of the presumptive-eligibility program, the HIFA group will be considered a new eligibility group. If, when the population formerly covered by the HIFA Waiver is introduced into the presumptive-eligibility program, the entire group of pregnant women covered by this bill s provisions is considered by the Centers for Medicare and Medicaid Services (CMS) to qualify only for the 50/50 percent FMAP, the fiscal impact of this bill on the State of Nevada will increase. Another potential increase in the fiscal impact of this bill could arise from the unknown number of pregnant women who may not submit the follow-up application to DWSS that is required to be filed by the last day of the month following the month in which presumptive eligibility is determined. In these cases, per CMS, state-only funds must be used to pay benefits received during the period of presumptive eligibility. Also, the unknown fiscal impact of the potential high number of cases of retroactive denials is of concern to the state. Retroactive denials result when an individual who has been receiving benefits is determined to be ineligible. With regard to these cases, the number of which cannot be estimated, the state share of medical costs is not recoverable. In addition, repayment by the state of federal funds is required; it is unknown whether revenues from tobacco taxes can be used for repayment. If state general funds need to be utilized for this repayment, the fiscal impact of this bill on the State of Nevada will increase. BDR , AB 255 Exhibit 1A-EXPLANATION RevB 3/27/2009

4 Adopting a very conservative point of view, this fiscal note does not include the cost of outreach to or education of the community on this issue, beyond the public posting of information, nor does it consider any perceived need for tracking, evaluating, and reporting on the quality of the presumptive-eligibility application process. If the Committee chooses to implement these functions, this fiscal note will require adjustment. BDR , AB 255 Exhibit 1A-EXPLANATION RevB 3/27/2009

5 BDR , AB 255 FMAP ESI FMAP STIMULUS DEPARTMENT OF HEALTH AND HUMAN SERVICES SFY % 63.93% DIVISIONS OF HEALTH CARE FINANCING AND POLICY (DHCFP) and WELFARE AND SUPPORTIVE SERVICES (DWSS) SFY % 65.00% 56.96% MARCH 27, 2009 SFY % SUMMARY SFY % BA CAT DESCRIPTION OF ITEM Total General Fund Federal Total General Fund Federal Total General Fund Federal Total General Fund Federal DWSS ADMINISTRATION EXPENDITURES Personnel Services 164,811 82,406 82, ,508 86,254 86, ,660 84,330 84, ,660 84,330 84, Out-of-State Travel Instate Travel 15,839 7,920 7,920 15,839 7,920 7,920 15,840 7,920 7,920 15,840 7,920 7, Operating 15,466 7,733 7,733 13,276 6,638 6,638 13,277 6,638 6,638 13,277 6,638 6, Equipment 9,891 4,946 4, Information Services 7,063 71,032 71, ,875 5, , Training TOTAL DWSS ADMINISTRATION 213, , , , , , ,726 99,363 99, , ,763 99,363 DHCFP MEDICAL ASSISTANCE PAYMENTS (from DHCFP Medical Costs Spreadsheet) TANF/CHAP 10,590,749 4,661,549 5,929,200 10,590,749 5,295,375 5,295,375 10,590,749 5,295,375 5,295, MAABD Waiver County Child Welfare TOTAL DHCFP MEDICAL ASSISTANCE 10,590,749 4,661,549 5,929,200 10,590,749 5,295,375 5,295,375 10,590,749 5,295,375 5,295,375 HIFA-ESI MEDICAL ASSISTANCE PAYMENTS (from HIFA-E Medical Costs Spreadsheet) HIFA-E (Employer-Subsidized Insurance) 27,000 9,450 17,550 9,000 3,150 5,850 TOTAL DHCFP MEDICAL ASSISTANCE 27,000 9,450 17,550 9,000 3,150 5,850 DHCFP IT EXPENDITURES Programming Costs 42,500 10,625 31,875 TOTAL DHCFP IT EXPENDITURES 42,500 10,625 31,875 DWSS IT EXPENDITURES Programming Costs 270, , ,000 21,600 10,800 10,800 21,600 10,800 10,800 21,600 10,800 10,800 TOTAL DWSS IT EXPENDITURES 270, , ,000 21,600 10,800 10,800 21,600 10,800 10,800 21,600 10,800 10,800 TOTAL FISCAL IMPACT 525, , ,912 10,841,922 4,788,485 6,064,237 10,820,075 5,408,688 5,411,388 10,811,075 5,410,938 5,405,538 GENERAL FUND FISCAL IMPACT 10, 11 5,108,147 GENERAL FUND FISCAL IMPACT 12, 13 10,819,625 BDR , AB 255 Exhibit 1B-SUMMARY RevB 3/27/2009

6 BDR , AB 255 DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF WELFARE AND SUPPORTIVE SERVICES (DWSS) MARCH 27, 2009 DWSS DU DOWNLOAD WELFARE ADMINISTRATION BUDGET ACCOUNT (B/A 3228) General Fund Federal General Fund Federal General Fund Federal G.L. TITLE Program FY10 FY11 Future Biennia G.L. # DESCRIPTION Allocation FY10 FY10 FY11 FY11 FUTURE FUTURE 2501 GENERAL FUND APPROPRIATION 50.00% 106, , , FED USDA FOOD STAMP PROGRAM 3533 FED CHILD SUPPORT PROGRAM 3567 FED TANF PROGRAM 3583 FED CHILD CARE DEVELOPMENT FUND 3872 FED TITLE XIX 50.00% 106, , , FEDERAL GRANT-LIHEA TOTAL REVENUE 213, , ,452 CAT 01 - PERSONNEL FY10 FY11 Future Biennia GL TITLE GRADE FY10 SAL FY10 BEN FY11 SAL FY11 BEN July-09 SOC SVC PGM SPECIALIST II 12TRNG 35 NEBS $$ >> 38,809 17,526 40,552 18,406 56,335 58, ,293 July-09 TRAINING OFFICER I TRNG 34 NEBS $$ >> 37,173 17,065 38,809 17,966 54,238 56, ,013 July-09 TRAINING OFFICER I TRNG 34 NEBS $$ >> 37,173 17,065 38,809 17,966 54,238 56, , , ,508 TOTAL CAT , , ,319 82,406 82,406 86,254 86, , ,660 CAT 03 - IN STATE TRAVEL FY10 FY11 Future Biennia Estimates based on FY08 staff travel performing similar duties GL cost # trips # staff 6200 PER DIEM $ ,357 4,357 8, MOTOR POOL $ ,999 2,999 5, PERSONAL VEHICLE $ ,504 5,504 11, AIRFARE $ ,979 2,979 5,958 TOTAL CAT 03 15,839 15,839 31,680 7,920 7,920 7,920 7,920 15,840 15,840 CAT 04 - OPERATING FY10 FY11 Future Biennia GL Estimates based on FY08 actuals per FTE cost # staff 7020 SUPPLIES $ SUPPLIES - PRINT SHOP $ PRINTING & COPYING $ ,272 1,272 2, COPY PAPER $ STATE PRINTING $ EMPLOYEE BOND per NEBS AG TORT INSURANCE per NEBS OUTSIDE POSTAGE $ POSTAGE - STATE MAILROOM $ 3, ,488 9,488 18, PHONES $ , LONG DISTANCE $ PHONE WIRING $ MISC EQUIPMENT $ ,590 - TOTAL CAT 04 15,466 13,276 26,553 7,733 7,733 6,638 6,638 13,277 13,277 CAT 05 - EQUIPMENT FY10 FY11 Future Biennia GL cost # staff 8240 EXECUTIVE FURNITURE UNIT $ 3, , TOTAL CAT 05 9, ,946 4, CAT 26 - INFORMATION SYSTEMS FY10 FY11 Future Biennia GL cost # staff ANNUAL SOFTWARE MLAs $ DATA WIRING $ per NEBS DOIT ASSESSMENT per NEBS DOIT ASSESSMENT per NEBS SOFTWARE - Licensing for PCs $ , HARDWARE - PCs $ 1, , TOTAL CAT 26 7, ,900 3,532 3, TOTAL STAFFING COSTS 213, , , , , , , , ,726 BDR , AB 255 Exhibit 1C-DWSS DU DOWNLOAD RevB 3/27/2009

7 BDR , AB 255 DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF HEALTH CARE FINANCING AND POLICY (DHCFP) MARCH 27, 2009 FMAP Population 1 Population 2 1 DHCFP MEDICAL SERVICES COSTS Budget Account3243 SFY % 63.93% SFY % 50.00% Two Populations #1 #2 2 SFY % 50.00% Eligible Population 13,500 Eligible Population SFY SFY % 50.00% CPE SFY CPE SFY CPE SFY CPE SFY CPE SFY CPE SFY Program Implementation - SFY 2011 Population 1: Estimated number of pregnant women enrolled in Medicaid with fee-for-service (FFS) coverage (i.e., approximately 10,000, based on the number of women who completed pregnancy in SFY 08 with either live or terminated births); AND the estimated number of pregnant women enrolled in Medicaid with managed-care (MCO) coverage (i.e., 7,063, based on the number of women who received a "birthing supplement" payment in SFY 08), for a total of 17,063 women. The total enrollment number used contains (an unknown number of) duplicates, because pregnant women with MCO coverage may have been enrolled under FFS coverage at some point in their pregnancy. For purposes of this fiscal note, it is assumed that approximately 50% of women (i.e., 3,500) who received a "birthing supplement" payment in SFY 08 were also covered under FFS during their pregnancies (Scenario 2, below). Population 2: The average number of pregnant women projected to be enrolled monthly in the HIFA program until September 30, 2011, when the HIFA-P program is expected to be terminated. Caseload Medical Costs 2011, 2012, 2013 Medical Costs Pop1 3 Pop 2 2 CPE Pop 1 SFY11 CPE Pop 2 SFY11 Total Annual Enrollment / CPE 13, Total $ $ Medical Cost State Title XIX FISCAL IMPACT: Total SFY 10 (Program Definition) SFY 11 Scenario 1: Months: 100% enrollees for 11 months 0 2,200 Months: 100% enrollees for 2 months 27, ,200 Total SFY 11 18,213,390 1,484,054 19,697,444 8,581,070 11,116,374 Scenario 2: Months: 100% enrollees for 11 months 0 2,200 Months: 50% enrollees for 2 months 13, ,700 Total SFY 11 9,106,695 1,484,054 10,590,749 4,661,549 5,929,200 Scenario3: Months: 100% enrollees for 11 months 0 2,200 Months: 25% enrollees for 2 months 6, ,950 Total SFY 11 4,553,348 1,484,054 6,037,402 2,701,788 3,335,614 SFY 12 CPE Pop 1 SFY12 CPE Pop 2 SFY12 Total $ $ Medical Cost State Title XIX Scenario 2: Months: 100% enrollees for 11 months 0 2,200 Months: 50% enrollees for 2 months 13, ,700 Total SFY 12 9,106,695 1,484,054 10,590,749 5,295,375 5,295, SFY 13 CPE Pop 1 SFY13 CPE Pop 2 SFY13 Total $ $ Medical Cost State Title XIX Scenario 2: Months: 100% enrollees for 11 months 0 2,200 Months: 50% enrollees for 2 months 13, ,700 Total SFY 13 9,106,695 1,484,054 10,590,749 5,295,375 5,295, Assumptions 1 Due to CHIPRA (Children's Health Insurance Program Reauthorization Act), mandated closure for the HIFA program is September 30, 2011, after which HIFA enrollees would become a new eligibility group for whom DHHS would no longer receive the enhanced FMAP. 2 In all scenarios, 100% of the HIFA group is assumed to be transferred to the presumptive eligibility program with a fiscal impact of 11 months of coverage. 3 Pregnant women in both populations could apply for benefits as of July 1, 2010; enrollees in October, 2010, could receive benefits retroactive to July, Notes The start-up time required for this program is one year, with implementation planned for July, Pregnant women in both populations could receive coverage for a maximum of 11 months each: 9 months prenatal care plus 2 months postpartum care. Only ambulatory prenatal care would be covered during the presumptive-eligibility period. BDR , AB 255 Exhibit 1D-DHCFP MEDICAL SERVICES COSTS RevB 3/27/2009

8 BDR , SB 255 DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF HEALTH CARE FINANCING AND POLICY (DHCFP) MARCH 27, 2009 HIFA-E MEDICAL SERVICES COSTS Budget Account 3247 One Population: Employer-Subsidized Insurance (ESI) FMAP SFY % Assumptions: SFY % (1) The ESI program (and, thus, the HIFA Waiver) is mandated to close on September 30, (2) The program for presumptive eligibility will be implemented July 1, (3) Therefore, the fiscal impact of the new presumptive-eligibility program on ESI monthly insurance-premium subsidy payments will extend for the 15 months from July 1, 2010, to September 30, (4) ESI enrollment is projected to number 20 as of July 1, 2010, with a semi-annual increase of 5 enrollees. (5) The maximum monthly insurance-premium subsidy for an ESI enrollee is $100. (6) As the ESI enrollees do not constitute a new eligibility group, the enhanced SCHIP FMAP will apply to subsidy payments through the end of the HIFA program. Caseload Medical Costs 2010, 2011, 2012, 2013 Medical Costs Pop 1 Pop 1 Total CPE Total $ Medical Cost State Title XIX Total SFY 10 (Program Definition) 0 July ,000 2, ,300 August ,000 2, ,300 September ,000 2, ,300 October ,000 2, ,300 November ,000 2, ,300 December ,000 2, ,300 January ,500 2, ,625 February ,500 2, ,625 March ,500 2, ,625 April ,500 2, ,625 May ,500 2, ,625 June ,500 2, ,625 Total SFY ,000 27,000 9,450 17,550 July ,000 3,000 1,050 1,950 August ,000 3,000 1,050 1,950 September ,000 3,000 1,050 1,950 Total SFY ,000 9,000 3,150 5,850 BDR , SB 255 Exhibit 1E-HIFA-E MEDICAL SERVICES COSTS RevB 3/27/2009

9 BDR , SB 255 DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF WELFARE AND SUPPORTIVE SERVICES (DWSS) MARCH 27, 2009 DWSS IT COSTS Budget Account 3228 CAT 26 - INFORMATION SYSTEMS FY10 FY11 FY12 FY MSA (Contract) - Two new aid codes are required (one each for the HIFA population and the presumptive eligibility group). The development of a new aid code usually requires 1,500 hours of programming, which would need to be done in FY10. The rate for MSA Programmers is expected to average $90.00 per hour. 120 hours of maintenance for each code is anticipated in future years. 270,000 21,600 21,600 21,600 TOTAL IS - CAT ,000 21,600 21,600 21,600 BDR , SB 255 Exhibit 1F-DWSS IT COSTS RevB 3/27/2009

10 BDR , SB 255 DEPARTMENT OF HEALTH AND HUMAN SERVICES FMAP DIVISION OF HEALTH CARE FINANCING AND POLICY (DHCFP) 75.00% MARCH 27, 2009 DHCFP IT COSTS Budget Account 3158 CAT 26 - INFORMATION SYSTEMS FY10 FY11 FY12 FY13 According to information received from First Health, DHCFP's fiscal agent, implementation will require 500 hours of programming in SFY 2010 at a cost of $85 per hour. 42,500 TOTAL IS - CAT 26 42, TOTAL GENERAL FUND FEDERAL 42,500 10,625 31,875 BDR , SB 255 Exhibit 1G-DHCFP IT COSTS RevB 3/27/2009