Delaware HRSA State Planning Grant Alice Burton Director
Delaware HRSA State Planning Grant Alice Burton, Director Academy. Health December 2, 2004
Presentation § HRSA pilot grants are helping states to further develop coverage strategies § Broad range of state initiatives meet different needs § You are not alone - there are resources to help states move through planning and policy analysis process
HRSA Update § Fiscal Year (FY) 2004, HRSA has awarded more than $13 million through: - 9 new state planning grants - 17 continuation planning grants - 9 “pilot project planning” grants—which are new this year.
Pilot Project Planning Grants Pilot grants are providing funds to states that have already developed policy options through state planning grant funds to enable them to: § Plan for the implementation of a specific policy option(s) on which consensus has been reached; § Test a particular option in one or more areas and/or for a specific population in the state or territory; and § Implement a plan that will cover a significant portion of the uninsured.
Pilot Project Planning Grants, cont. § Nine FY 2004 Recipients § Connecticut, Delaware, Georgia, Illinois, Indiana, Kansas, Oklahoma, the U. S. Virgin Islands, and West Virginia
Connecticut Pilot Grant Two different approaches: -Provide premium assistance targeted to low-income workers in firms that already offer coverage; and - Implement a small employer health insurance subsidy pilot targeted to small firms that do not currently offer coverage.
Georgia Pilot Grant Will implement separate pilots in four communities. Exploring several options, including a threeshare pilot program and another pilot that will partner with commercial insurers to reduce costs to a target population.
Indiana Pilot Grant The project team intends to create a small business pool coupled with an employer/employee buy-in and premiumassistance program.
Illinois/Kansas/Oklahoma Pilots § INDIANA - looking into contracting with an actuary to develop a three-share program in two counties. § KANSAS - exploring the option of reinsurance and planning a pilot to modify how to model tax credits to employers. § OKLAHOMA - considering creating a small group purchasing pool with their grant funds.
U. S. Virgin Islands Pilot Grant § Plans to develop an association health plan as a purchasing collaborative. In the process, they will develop a comprehensive Preferred Provider Organization (PPO) network, implement effective disease management in the PPO, increase Medicaid enrollment, and continue to analyze the costs of uncompensated care.
West Virginia Pilot Grant § Developing options to offer affordable health insurance to the pre-Medicare population (aged 50 to 64), specifically those who have lost and are at risk of losing their retiree benefits.
Strategies to expand coverage 1. Expanding Medicaid and SCHIP to new populations 2. New models for Medicaid/SCHIP and private sector partnerships 3. Making new private insurance options more affordable 4. Mandates 5. Comprehensive (access, cost and quality) approaches
New options for Medicaid coverage § SCHIP (1997) § 1115 waivers and HIFA (2001) § Breast and Cervical Cancer (2000) – 50 states (including DC) § Ticket to Work – Working individuals with disabilities (2001 – Medicaid expansion) – 32 states, some states with no income limit
States with expanded coverage for parents through Medicaid AK WA ME MT ND MN OR VT ID WI SD NY * UT KS CA AZ PA IL CO * CT IA NE NV MA MI WY OH IN OK NC AR SC MS TX AL DE VA KY TN NM RI NJ MD WV MO NH GA LA FL 0 – 49% FPL 50 - 99% FPL 100 – 199% FPL 200%+ FPL no new enrollment or capped enrollment * Program not implemented HI
States that cover childless adults through Medicaid AK WA ME MT ND MN OR VT ID WI SD NY MI WY CO KS CA AZ PA IL UT * CT IA NE NV OH IN MD WV MO OK SC TX AL GA LA FL HI NJ DE NC AR MS RI VA KY TN NM NH MA no coverage under 100% FPL 100 – 199% FPL 200% FPL and greater no new enrollment or capped enrollment * Program not implemented
New approaches to benefits and cost sharing § § Fewer benefits for higher income groups Primary care programs Pharmacy Plus – Rx only benefits Cost-sharing
One state’s example of redesigning Medicaid benefits for new populations Medicaid & SCHIP Benefits s a Incre ene ed B Expansion Benefits Inpatient & Outpatient Services Physician & Specialty Services Prescription Drugs OT, PT, ST DME & Supplies (prosthetics & orthotics) Lab & X-ray Emergent & Urgent Care Home Health Mental Health & Substance Abuse $100, 000 Annual Maximum Some limits on services offered Inpatient Services & Outpatient Services Physician & Specialty Services Prescription Drugs OT, PT, ST, DME & Supplies (prosthetics & orthotics) Lab & X-ray Emergent & Urgent Care Home Health Mental Health & Substance Abuse (limits for adults) Podiatry Dental Optometry & Eyeglasses Long Term Care - ICFMR/Nursing Home/Pre-PACE Personal Care & Home Nursing for Children EPSDT & Early Intervention & Nutrition Targeted Case Management Hospice Transportation & Lodging No Annual Maximum Service limits based on medical necessity
Private sector partnerships § Meet a broad set of policy & political goals § Current models pay the employee’s contribution for qualifying employer sponsored insurance when it is costeffective – 14 states, just over 50, 000 enrolled out of over 50 million enrolled in Medicaid and SCHIP § Newer models create a new product, targeting working uninsured – Target either employer or employees
What is the problem you are trying to solve? Small portion of workers decline ESI. SOURCE: Kaiser Comissionon Medicaid and Uninsured, Key Facts, December 2003
Making new private insurance options more affordable: Healthy New York § Eligibility: Small firms w/ low-wage workers, low income self-employed, uninsured workers w/o access to ESI § Reduced premiums through: – Stop-loss fund: state pays 90% claims $5 k-75 k – Streamlined benefits, in-network only – High cost-sharing § Commercial insurance product that state requires all HMOs to offer
Making new private insurance options more affordable: West Virginia § Eligibility: Firms w/2 -50 employees § Minimum employer contribution of 50%, 75% of eligible employees must participate § Allows carriers to access State Employees' reimbursement rates and drug purchasing plan
New benefit designs § Limited benefits (mandate-lite) – Continued interest despite low enrollment – Popular benefits often drive rates § High deductible health plans § Consumer directed health plans
Mandating health insurance § Employer mandates – Several states have considered, only 1 with law on the books • Hawaii’s Prepaid Health Care Act – 30 years old this year • California’s Health Insurance Act of 2003 – defeated in 2004 referendum § Individual mandates – States have talked about, but none have enacted
Comprehensive Models: Maine’s Dirigo Health § Voluntary program addressing cost, quality and access § Dirigo Health Insurance (DHI) § Offered to small business (<50 workers), selfemployed, workers without offered coverage, low -income in large firms § Maine. Care (Medicaid) expansion § 200% FPL for parents; 125% FPL for childless adults; sliding scale subsidies to 300% FPL
…Maine’s Dirigo Health § Cost containment – – CON moratorium Voluntary limits on operating margins Required electronic claims submission by 2005 Price disclosure § “Savings offset payment” on carriers from UC savings (capped at 4%) § Maine Quality Forum created § Enrollment begins October 1, 2004; Anticipated start date January 1, 2005
Help available from Academy. Health State Health Policy Group RWJF’s State Coverage Initiatives Program (SCI) Contract with HRSA to provide TA to SPGs TA STATES & TERRITORIES TA
State Coverage Initiatives SPG Contract with (SCI) HRSA l Initiative of The Robert l Site visits Wood Johnson Foundation l Share lessons from l Direct Technical other states Assistance (TA) available l Options development to all states l Guidance for advisory l Meetings committees l Small group consultations on specific issues l Final report guidance l Publications l Maintain Web page with l Statecoverage. net SPG reports l Grants
How Can We Help? § Academy. Health is available over the phone or onsite for assistance – Ongoing support – Thinking through preliminary ideas, lit. searches, contacts in other states, suggestions on experts, etc. – Kicking off policy process for steering committee – Education of steering committee on coverage options, other state SPG activities – Facilitation of stakeholder meetings to decide on coverage options – Assistance with evaluating options and narrowing recommendations
http: //statecoverage. net § State Reports § State Coverage Matrix § About Coverage § Grants - HRSA SPG page § SCI Publications – St@teside – monthly e-newsletter
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