EDPMA Solutions Summit XVI April 28, 2013

1. EDPMA Solutions Summit XVIApril 28, 2013 Laura Tobler, National Conference of State Legislatures, laura.tobler@ncsl.org,

2. Presentation Highlights • Health Insurance Exchanges • Essential Health Benefits • Medicaid expansion • Interoperability with exchanges • Churning • Medicaid Cost Containment • State progress on HIT • State budgets

3. Exchanges: Where States Stand Source: 2013 NCSL Research and NCSL Health Reform: State Legislative Tracking Database.

4. Legislatures Continue Addressing Exchanges in 2013 Source: 2013 NCSL Research and NCSL Health Reform: State Legislative Tracking Database

5. 17 States Introduce Legislation to Establish a State Exchange in 2013 *Authorized state-based exchange, blueprint and intent to establish state exchange was submitted to HHS in 2012 by governor, state health dept. or insurance commissioner.

6. 2013 State Legislation Related to Exchanges

9. Medicaid is a top Issue in 2013

10. Optional Medicaid Expansion

11. Median Medicaid/CHIP Eligibility Thresholds, January 2012 SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012. Minimum Medicaid Eligibility under Health Reform - 133% FPL ($25,390 for a family of 3 in 2012)

12. Bills To Expand Bills to Urge Gov. To Expand Medicaid Expansion, Bills So Far AR, CA, CO, IL, MN, MS, MO, MT, ND, OK, PA, SC, SD, TN, TX, UT, VA, WA and WY AL, AK, GA, HI, MI, NJ, PA and SC Bills To Require Legislative Approval For Expansion KY Bills To Reject Expansion Other Types of Expansion Related Bills IL, MS, NC, NH, SC, SD, TN and WY AR, CO, GA, HI, IA, TX, IN, IA, IL, MT, MO, MD, ME, MI, OR, TX and UT.

13. Medicaid Expansion Activity

14. CMS answers NO NO YES YES YES

15. Premium Assistance

16. More CMS Answers: Premium Assistance

17. Remaining Questions • How many “wood work” people will enroll? • What will happen to disproportionate share hospital (DSH) payments? • What are the medical needs and costs for the newly enrolled? • What about provider capacity? • Other costs to the state?

18. Interoperability: Exchanges and Medicaid Seamless Eligibility Determination

19. States Address Interoperability

20. Medicaid and Exchange Churning Family income or job status changes will change coverage plans.

21. Possible state policies to address churn • Integrating Exchange and Medicaid plans • Basic Health Program (delayed until 2015) • 12-month continuous eligibility • Employer Sponsored Insurance premium assistance • Exchange plan portability Source: The Urban Institute, Churning Under the ACA and State Policy Options for Mitigation,” June 2012.

22. Medicaid Cost Containment • Address overall health care costs: prevention and payment reforms • Move toward managed care • Reduce fraud and abuse • Reforms that focus on high-cost patients • Innovations to improve the value of Medicaid "Do the right thing at the right time, at the right place and to the right body part" • "Controlling costs is all about incentives — for employers, for consumers, for health-care providers, and for insurers.” YevgeniyFeyman, National Review

23. 42 M 74.2 %

25. Medicaid Managed Long Term Services and Supports (MLTSS)

26. States with MLTSS Programs, 2004 and 2012 Notes: 1. Does not include PACE programs. 2. Three States (Minnesota, New York, and Wisconsin) operate two MLTSS programs each. Source: Presentation by Susan Reinhard, AARP, NCSL’s Fall Forum, 12/5/12

27. States Planning to Implement New MLTSS Programs by January 2014 Note: We included States that have public plans for new MLTSS programs that include: a public planning document, request for information, request for proposals; proposal to CMS or waiver application to CMS. Submitting a letter of intent to CMS for the Medicare-Medicaid Financial Alignment Demonstration was not by itself sufficient to be included here. Source: Presentation by Susan Reinhard, AARP, NCSL’s Fall Forum, 12/5/12

28. Fraud Fighters

29. State Strategies toImprove Program Integrity

31. Focus on Dually Eligible People • Approximately nine million "duals" (eligible for Medicare and Medicaid). • Among the poorest and sickest Medicare and Medicaid enrollees. • Account for disproportionate spending—16 percent of Medicare beneficiaries but 27 percent of spending; 15 percent of Medicaid enrollees but 38 percent of spending. • 23 states are moving forward with proposals to participate in the CMS Medicare-Medicaid Coordination Office’s Financial Alignment Initiative for dually eligible people. When a state meets the standards and conditions for the Financial Alignment Demonstration, CMS and the state develop a memorandum of understanding; four states have MOU: Illinois, Massachusetts, Ohio and Washington.

33. State Innovation Models Awards State Innovation Model Testing Awards: AR, MA, ME, MN, OR, VT

34. In January 2013, about HALF of state legislators were freshmen or sophomores!

35. State Budget Overview • Better state fiscal conditions • Few budget gaps • Revenues continue to improve • Year-end balances are rising • Performance uneven & state budgets remain vulnerable. • Federal deficit reduction actions. • Spending pressures. • Sluggish economy recovery. • Deep holes.

36. Cumulative State Budget Gaps: FY 2002-FY 2014 Source: NCSL survey of state legislative fiscal offices, various years.

37. NCSL Resources Health Reform home page: http://www.ncsl.org/?TabID=160 State legislation database: http://www.ncsl.org/?TabId=22122 Health Reform State Action newsletter: http://www.ncsl.org/default.aspx?TabId=22281 Health Reform two-page briefs: http://www.ncsl.org/default.aspx?tabid=19023 Cost Containment Briefs: http://www.ncsl.org/default.aspx?tabid=19200

38. Questions? Laura.Tobler@ncsl.org 2013