MASSHEALTH THE BASICS PREPARED BY CENTER FOR HEALTH

MASSHEALTH: THE BASICS PREPARED BY CENTER FOR HEALTH LAW AND ECONOMICS UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL Webinar: May 29, 2014 MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION WEBINAR OVERVIEW § Mass. Health: The Basics, April 2014 Update § Eligibility, enrollment and spending in Mass. Health PRESENTERS § Kate Nordahl, Massachusetts Medicaid Policy Institute § Center for Health Law and Economics, University of Massachusetts Medical School: – Robert Seifert – Kate Russell – Carol Gyurina MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 1

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION FUNDAMENTALS OF MASSHEALTH § Mass. Health is Medicaid (Title XIX of the Social Security Act) and the State Children’s Health Insurance Program (CHIP, Title XXI) § Federally- and state-funded and state-administered § 1. 4 million members; increasing under the ACA § Includes benefits not covered by other insurance § Supports workers’ access to private insurance MASSACHUSETTS 1115 WAIVER § Section 1115 Research and Demonstration Waiver (“Mass. Health”) since 1997 – Expanded eligibility for higher incomes and broader categories; subsidies in Commonwealth Care – Programmatic innovations such as Common. Health, payment reforms and delivery system transformation – Supplemental financial support for safety net providers § Vehicle for reform § 5 -year renewal request pending (effective 7/1/2014) MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 2

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH ELIGIBILITY UNDER THE ACA 400% ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN CHILDREN 300% NO UPPER LIMIT ADULTS AGES 21 THROUGH 64 300% 250% 200% 150% 133% 100% FPL* NO UPPER LIMIT FPL* 0 1 -18 19 -20 AGE IN YEARS DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 FORMER FOSTER CARE YOUTH UP TO AGE 26 ALL OTHER** MEDICALLY HIV FRAIL POSITIVE ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD Mass. Health Standard Mass. Health Care. Plus Mass. Health Common. Health Mass. Health Family Assistance DISABLED INDIVIDUALS PARENTS PREGNANT INDIVIDUALS HCBS RECEIVING OF ALL AGES WITH BREAST WAIVER SERVICES CHILDREN OR CERVICAL GROUP FROM DMH < 19 CANCER Connector Care/Qualified Health Plan (QHP) *FPL = income as percent of federal poverty level ** Includes members previously eligible for Commonwealth Care and for Mass. Health Basic and Essential. MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 3

INTRODUCTION ELIGIBILITY AND ENROLLMENT 300% NO UPPER LIMIT SPENDING CHILDREN 400% 300% 200% 185% 200% 150% 133% 150% NO UPPER LIMIT 100% FPL* 0 1 -5 6 -14 15 -17 18 PREGNANT DISABLED 0 1 -18 19 -20 ADULTS UNDER 65 300% NO UPPER LIMIT ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN 133% 100% 86% % of FPL* CONTACT INFORMATION NO UPPER LIMIT DISABLED FORMER CHILDREN & FOSTER YOUNG CARE ADULTS YOUTH UP THROUGH TO AGE 26 AGE 20 ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN NO UPPER LIMIT 200% 185% 150% 133% 100% 86% PREGNANT MAY 2014 DISABLED HIV POSITIVE WORK FOR LONG-TERM ALL QUALIFIED UNEMPLOYED OTHER EMPLOYER (INSURANCE PARTNERSHIP) MEDICALLY HIV FRAIL POSITIVE ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD ALL OTHER** DISABLED INDIVIDUALS PARENTS PREGNANT INDIVIDUALS HCBS RECEIVING OF ALL AGES WITH BREAST WAIVER OR CERVICAL GROUP SERVICES CHILDREN MASSACHUSETTS INSTITUTE CANCER FROM DMH < 19 MEDICAID POLICY

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH ELIGIBILITY UNDER THE ACA 400% ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN CHILDREN 300% NO UPPER LIMIT ADULTS AGES 21 THROUGH 64 300% 250% 200% 150% 133% 100% FPL* NO UPPER LIMIT FPL* 0 1 -18 19 -20 AGE IN YEARS DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 FORMER FOSTER CARE YOUTH UP TO AGE 26 ALL OTHER** MEDICALLY HIV FRAIL POSITIVE ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD Mass. Health Standard Mass. Health Care. Plus Mass. Health Common. Health Mass. Health Family Assistance DISABLED INDIVIDUALS PARENTS PREGNANT INDIVIDUALS HCBS RECEIVING OF ALL AGES WITH BREAST WAIVER SERVICES CHILDREN OR CERVICAL GROUP FROM DMH < 19 CANCER Connector Care/Qualified Health Plan (QHP) *FPL = income as percent of federal poverty level ** Includes members previously eligible for Commonwealth Care and for Mass. Health Basic and Essential. MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 5

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH IS IMPORTANT TO MANY POPULATION GROUPS PERCENT OF SELECT MASSACHUSETTS POPULATIONS COVERED BY MASSHEALTH, 2012 All non-elderly adults 19% 36% Non-elderly adults earning > 100% FPL and <300% FPL Non-elderly adults earning <100%FPL 51% All children 40% Children in families earning > 100% FPL and <300% FPL 49% Children in families earning <100%FPL 72% Births (child born in last 12 months) 33% Medicare beneficiaries 27% People with disabilities (require assistance with self-care) 58% Nursing home residents 63% 0% 20% 40% 60% 80% SOURCES: Author’s calculations using the 2012 American Community Survey (ACS). Nursing home data from Kaiser State Health Facts (C. Harrington, H. Carrillo, M. Dowdell, P. Tang, and B. Blank. Table 6, "Nursing, Facilities, Staffing, Residents, and Facility Deficiencies, 2005 Through 2010, " Department of Social and Behavioral Sciences, University of California, San Francisco, accessed January 2012). Data for “all children” and “all elderly adults” calculated from Census 2012 population data projections and Mass. Health Snapshot report, 2013 monthly average. MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 6

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH COVERS CHILDREN, ADULTS & SENIORS, AND OFTEN SUPPLEMENTS OTHER INSURANCE PERCENT OF TOTAL MASSHEALTH ENROLLMENT, DECEMBER 2013 Seniors in Community – 102, 466 Seniors in Nursing Facilities – 24, 476 2% 2% Other – 22, 709 7% 18% Adults with Disabilities – 245, 129 9% Non-Disabled Children – 527, 623 LT Unemployed Adults – 128, 721 38% 23% Non-Disabled Adults – 316, 270 2% Children with Disabilities – 31, 726 SOURCE: Mass. Health, MAY 2014 December 2013 Snapshot Report. MASSACHUSETTS MEDICAID POLICY INSTITUTE 7

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION GROWING MASSHEALTH ENROLLMENT HAS ACCOMPANIED THE DECLINE IN THE NUMBER OF UNINSURED TRENDS IN MASSHEALTH ENROLLMENT AND UNINSURED, 1995 -2011 (THOUSANDS) 1, 600 Mass. Health 1, 400 1, 200 1, 000 800 600 400 Uninsured 200 0 1995 1998 2000 2002 2004 2006 2007 2008 2009 2010 2011 2012 2013 SOURCES: Mass. Health figures are from the Office of Medicaid and are monthly averages, except 1998 -2002 which are as of June 30. Uninsured numbers for 1998 -2011 from the Division of Health Care Finance and Policy, from a survey in that year, and for 2012 from the Center for Health Information and Analysis, from ACS data. 1995 Uninsured numbers from Blendon et al. , “Massachusetts Residents Without Health Insurance, 1995, ” Harvard School of Public Health. MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 8

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MORE THAN THREE IN FIVE MASSHEALTH MEMBERS ARE ENROLLED IN MANAGED CARE MASSHEALTH ENROLLMENT BY PAYER TYPE, DECEMBER 2013 FFS & Premium Assistance — 463, 474 33% PCC PLAN — 382, 795 37% 2% MCO — 522, 311 SCO — 30, 540 As of May, 13, 274 individuals have enrolled in One Care, a new Mass. Health program. SOURCE: Mass. Health, MAY 2014 December 2013 Snapshot Report; EOHHS May 2014 One Care Enrollment Report MASSACHUSETTS MEDICAID POLICY INSTITUTE 9

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MANAGED CARE PROGRAM POPULATIONS SERVED Managed Care Organizations (MCO) Children and adults under 65 Medical and Behavioral Health services covered by a capitated payment to health plans. Long-term support services (LTSS) and dental benefits not included in MCO benefit but available through Mass. Health Fee-For-Service Primary Care Clinician Plan (PCC) Children and adults under 65 Behavioral Health services covered by capitated payment to behavioral health plan. Medical services, which are not capitated, are managed by a primary care clinician. Dental and LTSS benefits are available through Mass. Health Fee-for-Service • Some primary care clinicians receive capitated payments as part of the Primary Care Payment Reform Initiative (PCPRI) One Care Ages 21 -64 Eligible for Mass. Health and Medicare Full spectrum of services covered by capitated payment to one health plan (includes medical, LTSS, Dental, & Behavioral Health) Senior Care Options 65 + Eligible (SCO) for Mass. Health and Medicare MAY 2014 COVERED SERVICES Full spectrum of services covered by capitated payment to one health plan (includes medical, LTSS, Dental, & Behavioral Health) MASSACHUSETTS MEDICAID POLICY INSTITUTE 10

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MCOs SERVE A LESS MEDICALLY COMPLEX POPULATION THAN THE PCC PLAN MASSHEALTH MCO AND PCC PLAN ENROLLMENT BY POPULATION TYPE, DECEMBER 2013 600, 000 500, 000 400, 000 Total: 522, 311 11% Total: 382, 795 27% Basic Essential Adults 17% 300, 000 8% Non-Disabled Adults 19% Non-Disabled Children 15% 200, 000 Disabled Children 52% 45% 100, 000 3% 0 MCO NOTE: TYPE OF MANAGED CARE 3% PCC Chart shows enrollment for members under age 65. December 2013 Snapshot Report. SOURCE: Mass. Health, MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 11

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION NOMINAL MASSHEALTH SPENDING HAS GROWN BY MORE THAN HALF SINCE 2005; WHEN ADJUSTED FOR MEDICAL INFLATION SPENDING HAS GROWN ON AVERAGE 2% ANNUALLY MASSHEALTH SPENDING, SFY 2005 -2013 (BILLIONS OF DOLLARS) $10 $9. 8 $9. 3 $9. 1 $9 Current Dollars $8. 8 $8. 1 $8 $7. 7 Inflation-adjusted Dollars $7. 0 $6. 8 $7 $7. 0 $6. 3 $6. 5 $6 $6. 3 $6. 7 2008 2009 $7. 1 $7. 2 2011 2012 $7. 3 $6. 4 $5 2006 2007 2010 2013 STATE FISCAL YEAR SOURCE: Mass. Health MAY 2014 Budget Office. Inflation adjustment uses the Medical Consumer Price Index for the Boston area, from the Bureau of Labor Statistics. MASSACHUSETTS MEDICAID POLICY INSTITUTE 12

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION ENROLLMENT HAS DRIVEN GROWTH IN MASSHEALTH SPENDING IN RECENT YEARS GROWTH IN MASSHEALTH TOTAL SPENDING, ENROLLMENT AND PER MEMBER PER MONTH (PMPM) COSTS (YEAR 2005 = 100) 155 Total Spending 150 145 140 Enrollment 135 130 125 120 115 110 $PMPM 105 100 95 2005 SOURCES: EOHHS MAY 2014 2006 2007 2008 2009 2010 2011 2012 (total spending and enrollment) and authors’ calculations. MASSACHUSETTS MEDICAID POLICY INSTITUTE 13

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH SPENDING PER ENROLLEE IS HIGHER FOR SENIORS AND THE DISABLED MASSHEALTH PAYMENTS PER ENROLLEE PER YEAR, FY 2013 $- $ 5, 000 $ 10, 000 $ 15, 000 $ 20, 000 Seniors $ 21, 613 Adults with Disabilities $ 12, 633 Children with Disabilities Adults Children Total SOURCES: Calculations MAY 2014 $ 25, 000 $ 14, 617 $ 3, 959 $ 3, 590 $ 7, 072 based on total spending form the Mass. Health Budget Office, and average membership for July 2012 – June 2013 from the Mass. Health Snapshot Report. MASSACHUSETTS MEDICAID POLICY INSTITUTE 14

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH SPENDING IS IMPORTANT TO MANY TYPES OF PROVIDERS MASSHEALTH REVENUE AS A PERCENTAGE OF PROVIDERS’ TOTAL PATIENT REVENUES 60% 49% 50% 51% 45% 40% 27% 30% 20% 14% 10% 0% Hospitals Nursing Homes Community Health Centers Long-term Services and Supports Pre-natal Care SOURCES: Center for Health Information and Analysis, 403 Cost Reports (Acute Hospitals, data from FY 2012); Massachusetts Senior Care Association (Nursing Homes – data from CY 2012); Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System Report (CHCs – data from Federal FY 2012); “Securing the Future: Report of the Massachusetts Long-Term Care Financing Advisory Committee, ” November 2010 (LTSS – data from Calendar Year 2005); Mass. DPH, Massachusetts Births 2010 (Pre-natal Care – data from Calendar Year 2010), March 2013. MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 15

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MASSHEALTH SPENDING BY SERVICE TYPE FOR STATE FISCAL YEAR 2013 TOTAL MASSHEALTH SPENDING FY 2013 = $9. 8 B Other — $534 M Physician — $331 M Dental — $245 M Pharmacy — $512 M Hospital Outpatient — $585 M Hospital Inpatient — $740 M Community LTC Supports — $1. 4 B 3% 3% 5% 5% 32% 6% Managed Care Capitation Payments — $3. 2 B 8% 8% 15% SCO/PACE Capitation Payments — $774 M 15% Nursing Homes — $1. 4 B NOTE: “Other” includes Transportation , community health centers, and smaller amounts of spending on rest homes, vision care, EI/Chapter 766, hearing care, group practice organization, family planning clinics, renal dialysis clinics, ambulatory surgery center, eye glasses, DME/Oxygen, imaging/radiation centers, certified independent labs, psychologists, mental health clinics, psychiatric day treatment, substance abuse services, and Medicare crossover payments. SOURCE: Mass. Health Budget Office. MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 16

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MOST MASSHEALTH DOLLARS ARE SPENT ON SERVICES FOR A MINORITY OF MEMBERS DISTRIBUTION OF MASSHEALTH ENROLLMENT AND SPENDING BY POPULATION GROUP 100% 9% 90% 80% 27% 20% 70% Adults and Children with Disabilities 60% 50% 34% 36% Non-Disabled Adults 40% 30% 20% Seniors 18% 38% 10% Non-Disabled Children 19% 0% Enrollment SOURCES: Mass. Health MAY 2014 Spending Budget Unit, SFY 2013 data. MASSACHUSETTS MEDICAID POLICY INSTITUTE 17

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION FEDERAL AND STATE SPENDING ON MASSHEALTH NOW REPRESENTS 30 PERCENT OF THE STATE BUDGET MASSHEALTH AS A PROPORTION OF ALL STATE SPENDING Other state spending Mass. Health-covered services (BILLIONS OF DOLLARS) $35 $30 $25 $27. 8 $28. 9 $30. 3 $32. 5 $25. 4 $23. 5 $20 $15 $29. 6 $31. 3 $17. 2 $18. 6 $20. 8 $21. 2 $20. 8 $20. 9 $21. 2 $21. 9 $22. 7 $10 $5 $0 $7. 7 $8. 1 $8. 8 $9. 1 $9. 3 $6. 3 $7. 0 $9. 8 $6. 8 27% 25% 27% 28% 30% 30% 2005 2006 2007 2008 2009 2010 2011 2012 2013 STATE FISCAL YEAR SOURCES: EOHHS MAY 2014 (Mass. Health data); Office of the Comptroller, Statutory Basis Financial Reports (other state spending). MASSACHUSETTS MEDICAID POLICY INSTITUTE 18

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION MEDICAID IS THE MAIN SOURCE OF FEDERAL REVENUES TO MASSACHUSETTS MASSHEALTH AS A PROPORTION OF ALL FEDERAL REVENUES Non-Medicaid federal revenue Medicaid/CHIP federal revenue (MILLIONS OF DOLLARS) $10, 000 $925 $945 $8, 000 $928 $1, 005 $943 $7, 000 $6, 000 $5, 000 $858 $856 $824 $971 $871 $4, 000 $7, 698 $1, 000 $8, 413 $6, 825 $3, 000 $2, 000 $7, 963 $7, 210 $5, 388 $5, 372 85% 86% 85% 89% 90% 88% 2006 2007 2008 2009 2010 2011 2012 2013 $4, 733 $4, 546 $4, 783 85% 2004 2005 $0 SOURCE: Massachusetts MAY 2014 Budget and Policy Center MASSACHUSETTS MEDICAID POLICY INSTITUTE 19

INTRODUCTION ELIGIBILITY AND ENROLLMENT SPENDING CONTACT INFORMATION Massachusetts Medicaid Policy Institute Blue Cross Blue Shield of Massachusetts Foundation Center for Health Law and Economics University of Massachusetts Medical School Kate Nordahl Katharine. Nordahl@bcbsma. com Robert Seifert Robert. Seifert@umassmed. edu Carol Gyurina Carol. Gyurina@umassmed. edu Kate Russell Kate. Russell@umassmed. edu Download the complete Mass. Health: The Basics chart pack at http: //bluecrossmafoundation. org/publication /updated-masshealth-basics-facts-trends-and-national-context MAY 2014 MASSACHUSETTS MEDICAID POLICY INSTITUTE 20