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

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

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

Changes to Medicaid and CHIP KEY ELEMENT Affordable Care Act Medicaid Expansion Expand eligibility to 133% Federal Poverty Level beginning 1/1/2014 133% 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 2014 100% CY 2015 100% CY 2016 95% CY 2017 94% CY 2018 93% CY 2019 90% CY 2020 and beyond Regular FMAP (58.85%) for FY 13-14 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 (2013-2014 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% 2013-2014: 70.20% 2014-2015 88.45% 2015-2016 94.20% 2016-2017 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: 70.20+23.0=94.20% 100% federal funded increase to select codes for primary care providers for 2013 and 2014. This impacts approximately 35% of primary care codes under the Florida Medicaid Program 2

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

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 2013-2014: 20% FY 2014-2015: 65% FY 2015-2016: 95% FY 2016-2017 2017 and beyond: 100% 4

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 1/1/2014. 5

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 2013-2014: 20% FY 2014-2015: 65% FY 2015-2016: 95% FY 2016-2017 and beyond: 100% 6

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 2013-2014: 20% FY 2014-2015: 65% FY 2015-2016: 2016: 95% FY 2016-2017 and beyond: 100% 7

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

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

Assumptions Expenditures: Expenditures are based on October 17, 2011, SSEC estimate t for 2012-13 and then held flat for remainder of analysis. FMAP used is based on estimates from October 17, 2011, FMAP Estimating Conference for 2013-1414 and 2014-15, 15 then held flat for remainder of analysis. Caseload: Title XIX Caseloads are based on September 9, 2011, Caseload Conference estimate for 2011-12 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

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 2013-2014 State Cost $118,753,033 $0 $118,753,033 $1,451,247,775 $495,960,684 $1,947,208,459 391,765 391,765 2014-2015 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 1,273,235 2015-2016 2016-2017 State Cost $460,999,366 $378,866,288 $839,865,654 $6,938,986,058 $1,141,616,993 $8,080,603,051 1,860,880 880 1,860,880 880 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 1,958,822 2017-2018 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 1,958,822 2018- State Cost $892,215,816 215 816 $394,667,294 $1,286,883,110 883 110 2019 $7,301,007,247 $1,155,833,068 $8,456,840,315 1,941,041 1,941,041 11

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 2019-2020 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 1,958,822 2020-2021 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 1,958,822 2021-2022 2022-2023 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 1,958,822 822 1,958,822 822 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

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 134-200% 134-200% FPL FPL 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19 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 $1,451,247,775 258,230 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 $4,737,423,705 423 705 839,247 209,812 150,722 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 1,226,592 306,648 220,285 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 1,291,150 150 322,787 231,879 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 1,291,150 322,787 231,879 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 1,291,150 322,787 214,098 77,137 (77,137) 113,006 $0 $7,301,007,247 1,941,041 13

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 134-200% 134-200% FPL FPL 2019-20 2020-21 2021-22 2022-23 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 1,291,150 322,787 231,879 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) $248,001,230 230 $7,297,147,203 203 1,291,150 322,787 231,879 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 1,291,150 322,787 231,879 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 1,291,150 150 322,787 231,879 92,069 (92,069) 113,006 $7,292,929,270 $0 1,958,822, 14

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 2013-14 FMAP 100% 100% 100% 100% 100% State Cost $0 $0 $0 $0 $0 $0 2014-15 2015-16 2016-17 $439,486,158 486 $37,990,798 798 $9,497,700 700 $2,129,800 $6,856,228 $495,960,684 258,230 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 $1,059,945,080 839,247 209,812 65,353 150,722 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 1,226,592 306,648648 67,680680 220,285285 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 $385,520,469 2017-18 $878,972,316 $189,953,988 $47,488,423 $4,702,480 $34,280,991 1,291,150 322,787 70,608 231,879 $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 1,291,150 322,787 73,800 231,879 FMAP 59.20% 93.5% 59.20% 59.20% 93.5% 2018-19 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 1,291,150 322,787 77,137 231,879 $1,155,833,068 15

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 2019-20 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 $399,246,783 2020-21 2021-22 2022-23 $878,972,316 $189,953,988 953 988 $47,488,423 488 423 $5,369,676 676 $34,280,991 $1,156,065,394 1,291,150 322,787 80,626 231,879 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 1,291,150 322,787 84,272 231,879 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 1,291,150 150 322,787 88,084 231,879 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 1,291,150 322,787 92,069 231,879 $1,156,827,490 16