Agency for Health Care Administration. Overview of Federal Affordable Care Act

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1 Agency for Health Care Administration Overview of Federal Affordable Care Act October 17, 2011

2 Analysis This analysis addresses only the direct impact of changes to enrollment in the Title XIX (Medicaid) and Title (XXI) CHIP programs and the required increase in reimbursement rates to Medicaid primary care providers. At this time, impacts are not included for administration of new program elements, changes to the federal pharmacy rebate or changes to state disproportionate share allowances. 1

3 Changes to Medicaid and CHIP KEY ELEMENT Affordable Care Act Medicaid Expansion Expand eligibility to 133% Federal Poverty Level beginning 1/1/ % FPL for a family of 4: $29,326 FMAP/ Medicaid Expansion FMAP/ Current Eligibility Level CHIP Transition CHIP/ Eligible but not enrolled Provides for enhanced FMAP for expansion population: 100% CY % CY % CY % CY % CY % CY % CY 2020 and beyond Regular FMAP (58.85%) for FY and (59.20%) there after. Based on 10/17/11 FMAP Calculation Children under 133% FPL move from Title XXI CHIP Program to Title XIX Medicaid program. The regular Medicaid FMAP (58.85% and 59.20%) received for these children. Since our analysis begins on July 1,2013 ( Fiscal Year), and the enhanced CHIP FMAP does not begin until 1/1/2015, the following FMAP are used for CHIP eligible but not enrolled 70.20% : 70.20% % % and beyond FMAP/ CHIP Increased Rate for Practitioners Anticipated enhanced FMAP for CHIP Population begins 10/1/2015 (134% Federal Poverty Level and above) 10/1/2015: =94.20% 100% federal funded increase to select codes for primary care providers for 2013 and This impacts approximately 35% of primary care codes under the Florida Medicaid Program 2

4 225% Current and Future Medicaid / CHIP Eligibility Levels 200% 175% CHIP 200%FPL CHIP 200%FPL CHIP 200%FPL Home and Community Based Services, Nursing Homes, Hospice 222% 150% 133 % FPL 125% 100% 75% Current Medicaid 185 % FPL Current Medicaid 133 % FPL New Medicaid 133 % FPL New New New Current Medicaid Medicaid New Medicaid Medicaid 133 % FPL 133 % FPL 133 % FPL 185 % FPL Current Medicaid 100% FPL Medicaid 133 % FPL 50% 25% Current Medicaid 74 % FPL MEDS AD 88% 22% FPL 22% FPL 0% Infants up to Age 1 Children (Age 1 thru 5) Children (Age 6 thru 18) Age 19 & 20 Pregnant Women SSI, Aged, Disabled Parents Childless Adults 3 Long Term Care

5 Assumptions: Newly Eligible Population Assumed 40% of new enrollees for the first year of expansion (beginning 1/1/2014). Assumed 90% of new enrollees for the second year of expansion (beginning 1/1/2015). Assumed 100% of new enrollees for the third year of expansion and beyond (beginning 1/1/2016). By fiscal year, that phase in translates as follows: FY : 20% FY : 65% FY : 95% FY and beyond: 100% 4

6 Assumptions: Eligible but not Enrolled Assumed that t 20% of the uninsured population under 133% FPL would be eligible for Medicaid under the current program and for those enrollees the state would receive the normal FMAP. A weighted average FMAP is then used to calculate the cost to the program of the total caseload, including that 20%. Assumed the Title XIX expansion population will receive the enhanced FMAP beginning 1/1/

7 Assumptions: Eligible but not Enrolled Phase in assumptions: Assumed 40% of these enrollees for the first year of expansion (beginning 1/1/2014). Assumed 90% of these enrollees for the second year of expansion (beginning 1/1/2015). Assumed 100% of these enrollees for the third year of expansion and beyond (beginning 1/1/2016). By fiscal year, that phase in translates as follows: FY : 20% FY : 65% FY : 95% FY and beyond: 100% 6

8 Assumptions: Crowd Out Population Assumed that 80% of those under 133% FPL who are currently privately purchasing insurance (excludes employer sponsored insurance) will enroll in Medicaid under this proposal. Assumed enhanced FMAP would be received for these enrollees. Phase in assumptions: Assumed 40% of these enrollees for the first year of expansion (beginning 1/1/2014). Assumed 90% of these enrollees for the second year of expansion (beginning 1/1/2015). Assumed 100% of these enrollees for the third year of expansion and beyond (beginning 1/1/2016). By fiscal year, that phase in translates as follows: FY : 20% FY : 65% FY : 2016: 95% FY and beyond: 100% 7

9 Assumptions: Impact to CHIP Population Children transitioning from CHIP to Medicaid: Assumed that for children under 133% FPL who move from CHIP to Title XIX, Florida will receive regular Medicaid FMAP. Based on October 2011 for Florida Healthy Kids and Children s Medical Services enrollment. CHIP Eligible but not enrolled population based on 2011 Census data, with expenditures based on October 2011 enrollment and PMPM for all KidCare categories from September 16, 2011 KidCare SSEC. 8

10 Assumptions: Impact to CHIP Population Assume phase in for CHIP Population: On January 1, 2014: 27% of Healthy Kids Title XXI children will move to Title XIX (based on current distribution of Healthy Kids Children by Income Level). For future years it is assumed that the number of children will grow in Medicaid at 4.50% per year (the same rate as approved by SSEC for the 7/15-6/16 FY for Healthy Kids). On January 1, 2014: 24.5% of CMS Title XXI children will move to CMS Title XIX (Based on current distribution of CMS Children by Income Level). For future years it is assumed that the number of children will grow in Medicaid at 3.8% per year (the same rate as approved by SSEC for the 7/14 6/15 FY for CMS children). Beginning January 2014, Full Pay Program Growth for both Healthy Kids and MediKids will stop and 5% of Full Pay as of December 2013 will migrate to an Exchange each month (assumption). 9

11 Assumptions Expenditures: Expenditures are based on October 17, 2011, SSEC estimate t for and then held flat for remainder of analysis. FMAP used is based on estimates from October 17, 2011, FMAP Estimating Conference for and , 15 then held flat for remainder of analysis. Caseload: Title XIX Caseloads are based on September 9, 2011, Caseload Conference estimate for and then held flat for remainder of analysis. The expansion caseload is based on 2011 U.S. Census data regarding the uninsured. Increased by 1.6% through 2014 and then held flat for remainder of analysis. Other Assumptions: Based on analysis of those under 65 years of age. 10

12 Impact of Affordable Care Act Total: Impact of and FMAP Changes to Title XIX and Title XXI Total: Impact of Increased Rates for Primary Care Practitioners Grand Total All Elements State Cost $118,753,033 $0 $118,753,033 $1,451,247,775 $495,960,684 $1,947,208, , , State Cost $379,916,002 $186,495,248 $566,411,250 $4,737,423,705 $1,059,945,080 $5,797,368,785 1,273,235 1,273, State Cost $460,999,366 $378,866,288 $839,865,654 $6,938,986,058 $1,141,616,993 $8,080,603,051 1,860, ,860, State Cost $603,443,158 $385,520,469 $988,963,627 $7,304,539,819 $1,155,398,198 $8,459,938,017 1,958,822 1,958, State Cost $779,370,352 $392,334,266 $1,171,704,618 $7,302,812,669 $1,155,610,815 $8,458,423,484 1,958,822 1,958, State Cost $892,215, $394,667,294 $1,286,883, $7,301,007,247 $1,155,833,068 $8,456,840,315 1,941,041 1,941,041 11

13 Impact of Affordable Care Act Total: Impact of and FMAP Changes to Title XIX and Title XXI Total: Impact of Increased Rates for Primary Care Practitioners Grand Total All Elements State Cost $955,622,117 $399,246,783 $1,354,868,900 $7,299,119,996 $1,156,065,394 $8,455,185,390 1,958,822 1,958, State Cost $1,043,768,884 $402,709,393 $1,446,478,277 $7,297,147,203 $1,156,308,251 $8,453,455,454 1,958,822 1,958, State Cost $1,044,109,423 $402,812,970 $1,446,922,393 $7,295,084,981 $1,156,562,116 $8,451,647,097 1,958, ,958, State Cost $1,044,465,403 $402,921,243 $1,447,386,646 $7,292,929,270 $1,156,827,490 $8,449,756,760 1,958,822 1,958,822 12

14 and Enhanced FMAP and Title XIX: Title XIX: Title XIX: Title XIX: Under Savings CHIP : CHIP: Savings CHIP: Total: Enhanced Federal Expansion to Eligible but Crowd Out 133% FPL in Under 133% FPL Eligible but Enhanced Matching Rate 133% FPL not enrolled CHIP program in CHIP move to not enrolled FMAP between move to Title XIX Title XIX % % FPL FPL FMAP 100% 58.85% 100% 58.85% 71.20% 71.20% State Cost $0 $102,052,598 $0 $22,868,844 ($19,817,376) $13,648,967 $0 $118,753,033 $992,005,807 $248,001,452 $178,941,532 $55,574,347 ($72,875,317) $49,599,954 $0 $1,451,247, ,230 64,558 46,376 63,958 (63,958) 22,601 $0 391,765 FMAP 100% 59.20% 100% 59.20% 71.20% 71.20% State Cost $0 $329,718,126 $0 $46,338,090 ($40,499,507) $44,359,293 $0 $379,916,002 $3,224,016,951 $806,005,198 $581,558,050 $113,573,749 ($148,930,640) $161,200,397 $4,737,423, , , ,722 65,353 (65,353) 73,454 $0 1,273,235 FMAP 100% 59.20% 100% 59.20% 71.20% 88.45% State Cost $0 $480,626,618 $0 $47,987,592 ($41,941,173) $26,000,712 ($51,674,383) $460,999,366 $4,712,025,661 $1,178,006,416 $849,968,418 $117,616,647 ($154,232,142) $235,601,058 $6,938,986,058 1,226, , ,285 67,680 (67,680) 107,355 $0 1,860,880 FMAP 97.50% 59.20% 97.50% 59.20% 71.21% 94.20% State Cost $124,000,726 $505,922,178 $22,367,595 $50,063,669 ($43,755,665) $13,743,832 ($68,899,177) $603,443,158 $4,960,029,033 $1,240,005,338 $894,703,801 $122,705,070 ($160,904,653) $248,001,230 $7,304,539,819 1,291, , ,879 70,608 (70,608) 113,006 $0 1,958,822, FMAP 94.50% 59.20% 94.50% 59.20% 71.21% 94.20% State Cost $272,801,597 $505,922,178 $49,208,709 $52,327,240 ($45,734,027) $13,743,832 ($68,899,177) $779,370,352 $4,960,029,033 $1,240,005,338 $894,703,801 $128,253,040 ($168,179,773) $248,001,230 $7,302,812,669 1,291, , ,879 73,800 (73,800) 113,006 $0 1,958,822 FMAP 93.50% 59.20% 93.50% 59.20% 71.21% 94.20% State Cost $322,401,887 $505,922,178 $58,155,747 $54,693,395 ($47,802,046) $13,743,832 ($68,899,177) $892,215,816 $4,960,029,033 $1,240,005,338 $894,703,801 $134,052,438 ($175,784,593) $248,001,230 1,291, , ,098 77,137 (77,137) 113,006 $0 $7,301,007,247 1,941,041 13

15 and Enhanced FMAP and Title XIX: Title XIX: Title XIX: Title XIX: Under Savings CHIP : CHIP: Savings CHIP: Total: Enhanced Federal Expansion to Eligible but Crowd Out 133% FPL in Under 133% FPL Eligible but Enhanced Matching Rate 133% FPL not enrolled CHIP program in CHIP move to not enrolled FMAP between move to Title XIX Title XIX % % FPL FPL FMAP 91.50% 59.20% 91.50% 59.20% 71.20% 94.20% State Cost $421,602,466 $505,922,178 $76,049,823 $57,166,790 ($49,963,795) $13,743,832 ($68,899,177) $955,622,117 $4,960,029,033 $1,240,005,338 $894,703,801 $140,114,681 ($183,734,087) $248,001,230 $0 $7,299,119,996 1,291, , ,879 80,626 (80,626) 113,006 $0 1,958,822 FMAP 90% 59.20% 90% 59.20% 71.20% 94.20% State Cost $496,002,903 $505,922,178 $89,470,380 $59,752,296 ($52,223,528) $13,743,832 ($68,899,177) $1,043,768,884 $4,960,029,033 $1,240,005,338 $894,703,801 $146,451,706 ($192,043,905) $248,001, $7,297,147, ,291, , ,879 84,272 (84,272) 113,006 $0 1,958,822 FMAP 90% 59.20% 90% 59.20% 71.20% 94.20% State Cost $496,002,903 $505,922,178 $89,470,380 $62,455,005 ($54,585,698) $13,743,832 ($68,899,177) $1,044,109,423 $4,960,029,033 $1,240,005,338 $894,703,801 $153,075,993 ($200,730,414) $248,001,230 $7,295,084,981 1,291, , ,879 88,084 (88,084) 113,006 $0 1,958,822 FMAP 90% 59.20% 90% 59.20% 70.21% 94.20% State Cost $496,002,903 $505,922,178 $89,470,380 $65,280,241 ($57,054,954) $13,743,832 ($68,899,177) $1,044,465,403 $4,960,029,033 $1,240,005,338 $894,703,801 $160,000,590 ($209,810,722) $248,001,230 1,291, , ,879 92,069 (92,069) 113,006 $7,292,929,270 $0 1,958,822, 14

16 Increase Select Primary Care Rates to Medicare Rate Increase reimbursement to Currently New Enrollees Eligible but Not KidCare Crowd Out: Population Total: Primary Care Providers Enrolled Enrolled Transition to the Medicare Rate Population Population FMAP 100% 100% 100% 100% 100% State Cost $0 $0 $0 $0 $0 $ $439,486, $37,990, $9,497, $2,129,800 $6,856,228 $495,960, ,230 64,558 63,958 46,376 FMAP 79.60% 100% 79.60% 79.60% 100% State Cost $179,310,352 $0 $6,296,979 $887,917 $0 $186,495,248 $878,972,316 $123,470,019 $30,867,542 $4,352,536 $22,282,667 $1,059,945, , ,812 65, ,722 FMAP 59.20% 100% 59.20% 59.20% 100% State Cost $358,620,705 $0 $18,406,534 $1,839,049 $0 $378,866,288 $878,972,316 $180,456,215 $45,114,054 $4,507,474 $32,566,934 $1,141,616,993 1,226, , , , FMAP 59.20% 97.5% 59.20% 59.20% 97.5% State Cost $358,620,705 $4,748,850 $19,375,277 $1,918,612 $857,025 $385,520, $878,972,316 $189,953,988 $47,488,423 $4,702,480 $34,280,991 1,291, ,787 70, ,879 $1,155,398,198 FMAP 59.20% 94.5% 59.20% 59.20% 94.5% State Cost $358,620,705 $10,447,469 $19,375,277 $2,005,360 $1,885,455 $392,334,266 $878,972,316 $189,953,988 $47,488,423 $4,915,097 $34,280,991 $1,155,610,815 1,291, ,787 73, ,879 FMAP 59.20% 93.5% 59.20% 59.20% 93.5% State Cost $358,620,705 $12,347,009 $19,375,277 $2,096,039 $2,228,264 $394,667,294 $878,972,316 $189,953,988 $47,488,423 $5,137,350 $34,280,991 1,291, ,787 77, ,879 $1,155,833,068 15

17 Increase Select Primary Care Rates to Medicare Rate Increase reimbursement to Currently New Enrollees Eligible but Not KidCare Crowd Out: Population Total: Primary Care Providers Enrolled Enrolled Transition to the Medicare Rate Population Population FMAP 59.20% 91.5% 59.20% 59.20% 91.5% State Cost $358,620,705 $16,146,089 $19,375,277 $2,190,828 $2,913,884 $399,246, $878,972,316 $189,953, $47,488, $5,369, $34,280,991 $1,156,065,394 1,291, ,787 80, ,879 FMAP 59.20% 90% 59.20% 59.20% 90% State Cost $358,620,705 $18,995,399 $19,375,277 $2,289,913 $3,428,099 $402,709,393 $878,972,316 $189,953,988 $47,488,423 $5,612,533 $34,280,991 $1,156,308,251 1,291, ,787 84, ,879 FMAP 59.20% 90% 59.20% 59.20% 90% State Cost $358,620,705 $18,995,399 $19,375,277 $2,393,490 $3,428,099 $402,812,970 $878,972,316 $189,953,988 $47,488,423 $5,866,398 $34,280,991 $1,156,562,116 1,291, ,787 88, ,879 FMAP 59.20% 90% 59.20% 59.20% 90% State Cost $358,620,705 $18,995,399 $19,375,277 $2,501,763 $3,428,099 $402,921,243 $878,972,316 $189,953,988 $47,488,423 $6,131,772 $34,280,991 1,291, ,787 92, ,879 $1,156,827,490 16

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