The County Health Plan Model: Expanding Basic Health Coverage to Low Income Adults

1. The County Health Plan Model: Expanding Basic Health Coverage to Low Income Adults Expansion Model Evaluation Template 120505 BB SS County Health Plan Model EMET

2. County-Based Health Coverage Programs for Low Income Persons Current coverage programs Under discussion 120505 BB SS County Health Plan Model EMET

3. Target – uninsured adults age 19-64 with income 200% of poverty • Target = 383,500 people • Currently covered: 54,500 • Cost neutral expansion could reach 40-50 percent of the target population • Non-DSH source needed to cover all people in the target group 120505 BB SS County Health Plan Model EMET

4. Coverage Models • Basic coverage • Small employer subsidy models • Volunteer networks 120505 BB SS County Health Plan Model EMET

5. Current Coverage – 54,500 people Funding sufficient to cover 20 percent of target population 120505 BB SS County Health Plan Model EMET

6. Current financing • $38 million in local funds • $50 million in federal funds • Average cost = approx $60 pmpm 120505 BB SS County Health Plan Model EMET

7. Expansion funding • Additional DSH • Additional local funds • Non-DSH source 120505 BB SS County Health Plan Model EMET

8. Total Funding needed to cover target population • $50 million current DSH (net) • $50 million additional DSH (net) • $176 million new non-DSH source 120505 BB SS County Health Plan Model EMET

9. Coverage (Basic & Small Employer Subsidy) • Primary care & specialty care • Outpatient lab and x-ray • Prescription drugs • Not covered • Hospital care (except in Small employer subsidy programs) • Coordinated with Hospital Charity Care programs 120505 BB SS County Health Plan Model EMET

10. Portability of Coverage & Continuity of Care • CHP’s cover a county or multi-county region • Operate using managed care principles • Provide outreach and enrollment • Determine eligibility for other programs • Reciprocity across counties contingent on funding 120505 BB SS County Health Plan Model EMET

11. Quality of Care/Effect on Delivery System • Managed care principles • Access to medicine for treatment of diabetes, hypertension, depression • U/R & case management 120505 BB SS County Health Plan Model EMET

12. Resource and Budgetary Cost • Cost neutral to state – model uses local funds to generate federal funds • Expansion requires additional DSH capacity & additional local match • Expansion could involve Section 1115 Medicaid waiver 120505 BB SS County Health Plan Model EMET

13. Resource and Budgetary Savings • Treatment of diabetes, hypertension, depression, etc. reduces preventable hospitalizations and reduces absenteeism for working enrollees • Reduced administrative cost through use of small number of TPA’s (five) • Co-pays and premiums help balance public and private sector costs 120505 BB SS County Health Plan Model EMET

14. Cost Containment • Managed care principles • Focus on disease management • Link with other community resources 120505 BB SS County Health Plan Model EMET

15. Implementation & Administration • Five TPA’s used for “back room” functions. • Use of existing infrastructure reduces administrative costs • Relationship with State for ABW program assure accountability for performance, quality and efficiency 120505 BB SS County Health Plan Model EMET

16. Access to Coverage & Subsidies • Covered population dynamic • Coverage could be made more uniform under expansion • Enrollment generally limited to people with income below 200% poverty • Careful planning of small employer subsidy models avoids crowd out issue 120505 BB SS County Health Plan Model EMET

17. Financing of Costs • Uncommitted DSH capacity presumed • Some areas are short on qualified local funds • Non-DSH financing needed to cover more (eg. Medicaid expansion) 120505 BB SS County Health Plan Model EMET

18. Consumer Choice of Providers & Health Plans • Most CHP’s reimburse providers at Medicaid plus 4% • Provider choice varies • Higher reimbursement would attract more providers 120505 BB SS County Health Plan Model EMET

19. Provider Autonomy • Provider contracts resemble those of any managed care organization 120505 BB SS County Health Plan Model EMET

20. Government Compulsion/Regulation • No compulsory enrollment • Regulation limited to essential element 120505 BB SS County Health Plan Model EMET

21. Variations & Their Effects • Desirable: cover more people via Small employer subsidy model • Desirable: easy to enroll people in Basic models • Section 1115 Medicaid waiver 120505 BB SS County Health Plan Model EMET

22. Key Tradeoffs among Attributes • “Look and feel” of insurance • Small employer subsidy model can be insurance • Financing cost neutral to the state • Eligibility at or below that for hospital charity care programs 120505 BB SS County Health Plan Model EMET

23. Pros • Cost neutral to state • Infrastructure in place • Links with other community resources • Local money brings $50 million federal funds into state • Positioned for small employer subsidy option • Grass-roots can foster support for non-DSH supported expansion when time comes 120505 BB SS County Health Plan Model EMET

24. Cons • Financed by DSH (not an entitlement) • Except for Small employer subsidy models hospital care not covered • Benefit is limited • Non-DSH financing needed to cover more remaining uninsured (section 1115 waiver) • Requires ongoing commitment of all partners 120505 BB SS County Health Plan Model EMET