The HIP benefit package is modeled after an HDHP with an HSA and consists of the following three components provided through managed care plans:

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1 Last Updated: February 6, 2014 Introduction MEDICAID TRANSFORMATION ISSUE BRIEF Health Savings Accounts Consumer-Directed Health Plans In Medicaid Health Savings Accounts State policymakers across the country are considering a variety of strategies that could fundamentally restructure the Medicaid program. Originally conceived as a way to address costs in the private insurance market by shifting responsibility for health care decision-making from insurers to consumers, consumerdirected health plans (CDHPs) have garnered interest as one approach to improve quality and outcomes and control costs in Medicaid. The consumer-directed approach assumes that informed consumers should have the authority to assess their own health care needs and make choices about the services they receive. One CDHP garnering attention is the Health Savings Account (HSA) a personal spending account which the enrollee can use to fund health expenditures not covered by a health insurance plan. HSAs are typically paired with high-deductible health plans (HDHPs). HDHPs/HSAs in the Medicaid Context Although originally intended for employers and individuals in the commercial insurance market, CDHPs in public health insurance programs have gained increasing interest in recent years, with several states are exploring the use of HDHP/HSAs in Medicaid. With the considerable flexibility states have in designing their Medicaid programs, current law permits many forms of consumer-direction in the Medicaid context. The specific features of the consumer-directed program govern whether the state is able to implement consumerdirection through its existing Medicaid state plan or by requesting permission from the federal government through a waiver. What follows is a description of two states that have initiated HSAs programs: Indiana and Michigan. Healthy Indiana Plan In 2007, Indiana received approval from the Centers for Medicaid and Medicare Services to establish the Healthy Indiana Plan (HIP), the first statewide program to provide a benefit package modeled after an HDHP with an HSA for Medicaid recipients. In September 2013, the state received a one-year waiver extension to continue HIP through December 31, As approved in 2008, HIP expanded coverage to parents with dependent children with incomes above 22 percent Federal Poverty Level (FPL) and below 200 percent FPL, and for other childless adults with incomes between 0 and 200 percent FPL. Eligible participants must have been uninsured for at least six months and without access to employer-sponsored health insurance. While there was no enrollment cap for parents, other childless adults were subject to an enrollment cap of 34,000. The 2013 waiver extension decreased HIP eligibility levels from 200 percent FPL to 100 percent FPL for both parents and childless adults, effective April 30, Pursuant to the waiver extension, Indiana will transition current HIP enrollees and childless adults on the waitlist with incomes between 100 and 200 percent FPL to the new Health Insurance Marketplaces established by the ACA. These individuals will be eligible for premium tax credits to assist in purchasing health coverage. Similar to the original waiver, under the - 1 -

2 extension, parents will not be limited by enrollment caps or open enrollment periods, and will have the ability to enroll in HIP provided they make the required contributions. Enrollment for childless adults, however, will be capped at 36,500 individuals and limited by open enrollment periods. Although the extension does not cap parent enrollment, it allows Indiana to amend the waiver to change eligibility criteria for both parents and childless adults if the state finds that expenditures will exceed annual state funds. Estimated take-up has ranged from 5 percent to 16 percent of those eligible, with predicted total enrollment in HIP reaching about 45,000 in The HIP benefit package is modeled after an HDHP with an HSA and consists of the following three components provided through managed care plans: High-deductible coverage: HIP provides a basic commercial benefit package that covers medical costs that exceed the $1,100 deductible, subject to a $300,000 annual and $1 million lifetime cap. Personal Wellness and Responsibility (POWER) Account: HIP s version of an HSA is used to cover the $1,100 deductible for initial medical costs. To stay enrolled in coverage, HIP members must make monthly contributions to their POWER Accounts (based on income but no more than 2 percent of income for enrollees at or below 100 percent FPL). Not-for-profits are allowed to make up to 75 percent of the members required contribution to the POWER Account. Medicaid funds cover the gap between the enrollees payments and the $1,100 deductible amount required for the POWER Account. The POWER Accounts provide incentives for participants to utilize services in a costefficient manner. Preventive care: By obtaining state-specified preventive care, enrollees can carry over state POWER Account contributions to the next year, which helps offset required enrollee payments. The first $500 of preventive care services are provided at no charge to the member and the amount is not deducted from a member's POWER Account. Early Observations Between January 2008 and December 2011, HIP served 90,034 individuals. Early observations suggest differences in care utilization patterns compared with traditional Medicaid programs, including greater use of preventive care, lower ER usage, and increased utilization of generic pharmaceuticals. 1 Eighty percent of HIP enrollees completed the preventive services required for a POWER account rollover and, on average, over the first 12 months of enrollment HIP member non-emergency utilization of the ER decreased by 14.8 percent. 2 It is important to note, however, that the non-contributing population in general suffers from higher morbidity. 3 Additionally, in two separate independent evaluations of the program, HIP members have indicated a high level of satisfaction with their coverage and member satisfaction surveys conducted by the contracted health plans also show satisfaction rates consistently greater or comparable to commercial plans. 4 1 Mathematica 2010 Survey of HIP Members. 2 Ibid. 3 Ibid. 4 Ibid

3 Healthy Michigan Plan On November 8, 2013, the state of Michigan submitted a Section 1115 waiver to the Centers for Medicare and Medicaid Services (CMS) requesting approval to implement an expansion of the state s current Medicaid program, Healthy Michigan Plan, which would include changes to the existing Medicaid program as it is outlined by the federal government. On December 30, 2013, CMS approved Michigan s waiver request to go into effect April 1, Prior to Michigan s waiver approval, non-disabled childless adults did not qualify for Medicaid benefits in Michigan, and parents of dependent children had to earn below 37 percent FPL if jobless and under 64 percent FPL if working to qualify. The expansion will increase eligibility to 133 percent FPL for all Michigan residents age The Healthy Michigan Plan will include the 10 Essential Health that are required by the ACA as well as three additional benefits not currently covered: habilitative services, hearing aids and preventive health care services. The Healthy Michigan Plan will also include a component called the MI Health Account an account into which both the state and beneficiary will deposit funds and from which health care costs will be withdrawn. All beneficiaries will make deposits to their MI Health Account based on a monthly co-pay average, but only those between 100 and 133 percent FPL will be required to make additional contributions, not to exceed 2 percent of annual income. For all beneficiaries, funds remaining at the end of the year will be rolled over to the following year and will apply towards the next year s required contributions. In its approval letter to Michigan, CMS required Michigan to submit an explanation of how the MI Health Account will be administered. Co-Pays Healthy Michigan Plan participants will be subject to co-pays consistent with the framework established by the relevant Medicaid Health Plan or as established by the State s current fee for service system prior to managed care enrollment. Providers will not collect co-pays, and instead will receive reimbursement from the MI Health Account through the contracted Medicaid Health Plan. Program participants will make a monthly deposit into their MI Health Account, the amount of which is to be determined by taking the average monthly co-pay total for the first six months of an individual s participation in the program. The amount will be recalculated every six months to reflect up-to-date utilization patterns. The total amount of the beneficiary s annual cost-sharing, which includes co-payments and any required contributions, will not exceed 5 percent of the beneficiary s annual income. Incentives for Healthy Behaviors The Waiver briefly describes an element of the program that would reduce cost-sharing requirements if certain healthy behaviors were completed or maintained by the beneficiary. The only specific requirement cited in the Waiver is the completion of a Michigan Department of Community Health (MDCH) approved annual health-risk assessment in order to identify unhealthy behaviors (alcohol use, substance abuse, tobacco use, obesity, etc.). The Waiver states that the MDCH would design specific healthy behavior incentives for the program. CMS is requiring Michigan to submit a Healthy Behaviors Incentives Program Operation Protocol - 3 -

4 that will outline the specific requirements of the incentive program and how it will be implemented. The draft must be received by CMS at least 90 days prior to implementation of the program. CONSIDERATIONS IN DESIGNING MEDICAID HDHP/HSAs If Missouri considers pursuing a Section 1115 Waiver to implement a Medicaid HDHP/HSA demonstration, one of the key design questions concerns the appropriate target population and sample size for a viable demonstration. When considering the subject of target population and size, important questions include: Who will enroll in the consumer-directed Medicaid program and is screening appropriate? Do certain populations have stronger preferences for consumer-directed Medicaid than others? Do different populations fare better or worse under consumer-directed Medicaid? While the ACA mandates expanded state Medicaid programs must cover the 10 Essential Health, states may still have some flexibility under Section 1115 regarding the specific benefits they provide and the models they use to provide those benefits. Important questions may include: What will the HDHP deductible amount be? How much will members be required to contribute to the benefit? What can be purchased with the consumer-directed benefit? Can the benefit be saved and carried over month to month? Year to Year? Outreach and Education Recruitment and retention into consumer-directed Medicaid programs can be challenging because the concept is often unfamiliar to potential participants. Under a consumer-directed Medicaid program, consumers take on new roles and responsibilities for managing their health, and potential participants may have concerns about their responsibilities under the program, such as how to meet contribution requirements and behavior incentives once they enroll. Potential participants would need to receive information and training about their responsibilities as participants in a consumer-directed program. CONCLUSION With a limited number of states having implemented HSA-type accounts into their Medicaid programs, many questions remain about the effectiveness of such programs in improving outcomes and controlling costs in state Medicaid programs. While the preliminary findings of the HIP can be interpreted as promising, the program is still in its infancy and the data is incomplete. For Missouri policymakers considering a Medicaid focused HSA program, a number of design issues need to be addressed including but not limited to size of the demonstration; type and cost of health plan associated with HSAs; costs both to the state and the participant; type of 1115 waiver necessary; scope and education of education effort; and the dynamics of how HSAs paired with HDHPs will affect healthier Missourians

5 Health Indiana Plan and Healthy Michigan Plan: Comparison Overview Healthy Indiana Plan Healthy Michigan HIP Adults: Noncustodial parents and childless adults ages with income below 100% FPL Adults ages with income below 138% FPL High-Deductible coverage: $1,100 deductible and $300,000 annual and $1 million lifetime benefit caps POWER Account: HIP version of an HSA valued at $1,100 per adult used to cover the deductible Preventive Services: Up to $500 in preventive care per year, not subject to the deductible and does not draw from the POWER Account MI Health Account: Individuals with income between % FPL will be required to contribute up to 2% of their income through the use of a dedicated health account ABOUT THE MISSOURI FOUNDATION FOR HEALTH This nonpartisan policy brief was prepared by the Health Policy Staff at the Missouri Foundation for Health. The Missouri Foundation for Health is an independent philanthropic organization dedicated to empowering Missourians to achieve equal access to quality health services. The Foundation provides research, education, and analysis of topics of importance to policymakers and the community