ROBIN LUNGEDIRECTOR OF HEALTH CARE REFORM

NOVEMBER 18 , 2011

Integration of Medicaid and the Exchange

Purpose & Agenda

Overview of issues & options for how to integrate Medicaid and the Exchange

Summary of analysis underwayYour thoughts and input!

Goals

Universal coverage (for low and moderate income Vermonters)

Comprehensive High Quality Benefits / Innovative services to meet individuals’ needs

Focus on Better Consumer ExperienceProvider Access and QualityPayment ReformSimplified AdministrationControlling Health Care Costs

STAGE 3:

Vermont Single Payer (2017 and

beyond – 2014 if ACA waiver date

changed in

federal law)

Two financing

plans develope

d for universal coverage under: 1.

Green Mountain Care (single payer) and 2.

Exchange –

report back to legislatu

re in 2013

STAGE 2:

Vermont Health Benefit Exchan

ge become

s operatio

nal (2014)

Integration Plan Developed for

“Single Payer

Exchange” – report back to legislature in 2012

STAGE 1:

Vermont Health Benefit Exchange and Vermont Health Reform Board

(established

2011)

Stages of Vermont Health Reforms

Medicaid Changes in 2014

Medicaid income eligibility increases to 133% FPL $1226/month

Income calculation changes for some people “MAGI” – modified adjusted gross income from tax

returnMore verification done electronically

Reduction in paperwork, we hope!!Web-based enrollment

Can still do phone & in person

Health Benefits Exchange in 2014

Individuals without employer-sponsored insurance

Small businesses & their employeesFederal tax subsidies for people with incomes

under 400% FPL $3684/month

Medicaid & the Exchange in 20147

What happens to VHAP, Catamount Health, and employer-sponsored insurance assistance? Individuals with incomes under 133% move to Medicaid Individuals with incomes over this amount – either

Basic Health Plan (option – next slide more details) Health Benefit Exchange with subsidies

Very much like Catamount Health & ESIAWhat happens to coverage for individuals with

disabilities and seniors? This coverage need not change Anticipate filing Medicaid waiver request to continue

coverage for certain populations currently covered

Children <19

SSI (Aged, Blind and Disabled)Parents and

Caretaker Relatives

Pregnant Women

UndrinsurdM

edicaid

UninsuredC

HIP

Adults ≥19 but < 65 Medically Needy

QHP without Subsidy

Medicare

PIL

SSI Income Level

AFDC

QHP with Tax Credits Only

300%

400%

225%

Vermont Health Benefit Programs

Options Under Consideration

QHP with Tax Credits and Cost-Sharing

250%

200%

133%

Medicaid & the Exchange: 2014 Health Coverage Options

Exchange with federal subsidies

100% federal funds In process of creating complete financial model

Premiums are lower than VHAP/CHAP for very low income & for 2 person families

Premiums are a bit higher at upper income levels of CHAP

Comparison of Subsidies: Exchange Subsidy & Current Vermont

Exchange with federal subsidies12

Cost-sharing (deductibles, co-payments, co-insurance) Higher in Exchange than for VHAP

Approx. 70-80% of people in VHAP move to Medicaid VHAP has no deductible or co-insurance, limited co-pays

Hard to compare CHAP & Catamount Need detailed benefit designs to compare deductibles,

etc Out of pocket maximums (total you MIGHT have to pay)

higher in the Exchange w/ subsidy than Catamount Health

Provider rates – by insurer

Possible solutions to cost-sharing issues

State subsidy “wrap” in addition to federal subsidy Similar to wrap for employer-sponsored insurance

program now Could provide additional assistance so people don’t

have dramatic increases In process of costing this out

Flexibility in income phase-out 60-40 if included in new Medicaid waiver request

Basic Health Plan (see next slides)

Basic Health Plan

95% federal funds that would have been received in Exchange

More protective of consumers financially More chance of people losing coverage due to

transitionsImpacts on Exchange financial sustainability

& viabilityProvider rates uncertain at this point

Could be Medicaid; could be Catamount Health level; could be private insurance level

Medicaid Option above 133%

May cover populations above 133% in Medicaid

60/40 fed/state split More expensive – lose 100% fed funds

Issues with Exchange viability and sustainability

Provider rates at Medicaid level