Medicaid Priorities in a Changing 21st Century Health Care Environment

Transcription

1 Medicaid Priorities in a Changing 21st Century Health Care Environment Michael J. Melendez, LMSW Associate Regional Administrator New York Regional Office Division of Medicaid and Children s Health Operations Centers for Medicare & Medicaid Services March 5,

2 Overview v My presentation today will cover: CMS Medicaid & Oversight Affordable Care Act recent State Plan Amendments Government Health Plan Implementation CMS oversight and partnership with Puerto Rico ACA Medicaid Funding Benefit and Risks Medicaid Management Information Systems (MMIS) 2

3 CMS Role & Oversight CMS NYRO v Program Services Branch Approves SPAs & MCO Contracts MMIS Oversight Medicaid Eligibility Technical Assistance to states and beneficiary inquiries v Financial Management Branch Quarterly Financial Reporting Audit Resolutions Oversight of Medicaid and CHIP budget Deferral and disallowance 3

4 Affordable Care Act v Two landmark legislations Patient Protection and Affordable Care Act and the Health Care Education Reconciliation Act v Comprehensive Health Insurance Reforms Hold insurance companies accountable Lower health care cost Guarantee more choice Enhance the quality of care 4

5 ACA Medicaid Provisions Eligibility Financing Benefits IT Systems and Data Quality of Care and Delivery Systems Prevention Dual Eligible Provider Payment Program Transparency Program Integrity Children s Health Insurance Program 5

6 Key ACA Eligibility Provision v Childless Adults Beginning April 1, 2010, states have the option to cover childless adults up to 133% FPL under a state plan amendment v Maintenance of Effort (MOE) Maintaining existing coverage for adults until the implementation of coverage changes effective January 2014, and for children through September 2019 v Former foster care children Who previously received Medicaid while in foster care are eligible until age 26 v Family Planning Establishes a new Medicaid eligibility group v Presumptive Eligibility in Hospitals Permits hospitals to make presumptive eligibility determinations for all eligible Medicaid populations 6

7 Medicaid Expansion v What types of benefits will the new Medicaid expansion population receive? The new Medicaid population will receive the Alternative Benefit Plan (ABP) / benchmark-equivalent coverage consistent with section 1937 of the Social Security Act Certain populations remain eligible for full Medicaid benefits. Specifically, States must ensure EPSDT requirements for children under age 21 Pregnant women and people with disabilities will also continue to receive the full scope of Medicaid benefits 7

8 Uniform Income Eligibility Determinations v Do the new income standards apply to all Medicaid and CHIP populations? v Section 2002 of the Affordable Care Act created a new section 1902(e) (14) of the Social Security Act (the Act) Effective January 1, 2014 Medicaid financial eligibility for most individuals is based on Modified Adjusted Gross Income (MAGI) Medicaid financial eligibility for eligibility groups for aged, blind, or disabled (ABD) individuals remains the same. This process essentially prohibits the use of income disregards and asset tests when determining Medicaid and CHIP eligibility for most individuals 8

9 Puerto Rico 9

10 Medicaid Expansion in Puerto Rico v Early Option State Plan Amendment: Effective 07/01/2011 Coverage of Early Option Group through a Benchmark Plan, Benchmark benefit Plan for Mi Salud Benefit Package A Health Care Reform/Benchmark State Plan Amendment 10

11 Medicaid Expansion in Puerto Rico v Pre MAGI eligibility group SPA: Effective 12/31/2013 Establishing a Puerto Rico poverty level (PRPL) and increasing the income limit to 133% of the PRPL for the early option group, 1931 group, pregnant women Optional reasonable classifications of children under age 21 and to 266% of the PRPL for optional targeted low-income children v Pending MAGI SPA 11

12 Medicaid Expansion in Puerto Rico v ABP (Alternative Benefit Plan) Puerto Rico Standard Alternative Benefit Plan: This plan will provide benefits to the new adult eligibility group effective 01/01/14. This SPA creates alignment between the ABP and the State plan. The ABP must cover the 10 Essential Health Benefits (EHB) 12

13 Government Health Insurance Plan (GHP) v April 1, 2015, five managed care entities will provide health services for individuals in GHP First Medical MMM PMC Molina Health Care Triple S v These entities must provide physical and behavioral health services v ASES has conducted Readiness Reviews of all health plans 13

14 ACA Funding v Exchange vs. Medicaid Federal funds to establish an Exchange OR $925 million increase in Medicaid funding, Puerto Rico s choice was the laier 14

15 ACA Funding v The largest ever increase in federal healthcare funding: Medicaid Ceiling (Cap) more than tripled Total of $5.4 billion increase in Medicaid cap for Puerto Rico from July 1, September 30, 2019 Equal distribution of the ACA funds throughout the entire period is $166 million in Q and $664 million per year starting FFY 2012 Statutory FMAP local matching rate increased from 50% / 50% to 55% federal / 45% local, effective July 1,

16 Medicaid and CHIP Expenditures By Fiscal Year (in Millions) Federal Funds (allotment) Medicaid $ $ $ $ $ EAP * $ 23.7 $ 17.4 $ 21.8 $ 16.9 $ 20.0 CHIP $ 99.6 $ $ $ $ ACA $ $ $ $ $ 1,230.0 Fed Total $ $ $ 1,164.0 $ 1,255.4 $ 1,729.5 PR Share $ $ $ $ $ 1,252.7 Total $ 1,429.5 $ 1,796.8 $ 1,981.0 $ 2,048.1 $ 2,982.2 * EAP 2015 is esqmated amount 16

17 PR Usage of Federal ACA Funding (in Millions) Fiscal Year Allocated Expended Expended in Excess of Allocated 2011 * $ $ $ $ $ $ (99.23) 2013 $ $ $ $ $ $ ** $ $ 1,230.0 $ Total $ 2,821.2 $ 3,575.1 $ Balance Available thru FY 2019 $ 2,655.2 $ 1,901.3 * 2011 only had one quarter of ACA funding ** 2015 is amount requested by PR in ACA funds 17

18 Medicaid Management Information System v MMIS Planning Phase CMS approved an MMIS Planning Document (PAPD) for Puerto Rico in March, 2010 It was funded at 90% Federal funds and 10% Puerto Rico funds, totaling a federal investment of $2.9 million and a cost to Puerto Rico of only $400,000 In 2013 Puerto Rico obtained a Letter of Intent and a Memorandum of Understanding from the state of Florida for an MMIS partnership 18

19 Medicaid Management Information System v MMIS Requirement Phase Puerto Rico is currently in the Requirement Phase (work that will be a prerequisite to any Puerto Rico MMIS) If/when Florida commits to a partnership, a detailed MOU will be signed and contracts between Puerto Rico, Florida and Florida s fiscal agent for MMIS will be sought 19

20 Benefits of MMIS for Puerto Rico Readiness for ICD-10 implementation T-MSIS (Transformed Medicaid Statistical Information System) compliance Improve management and oversight of the Medicaid Program 20

21 COMPARISON WITH STATES Historical importance of these two initiatives Puerto Rico is treated no differently than a state. Planning funds matched at 90 % federal Operation Funds matched at 75% Federal Outside Medicaid Funding Cap 21

22 CHALLENGES 22

23 Questions? 23

24 Michael J. Melendez, LMSW Associate Regional Administrator Division of Medicaid & Children s Health Michael.Melendez@cms.hhs.gov 24