Multi-shares and the Affordable Care Act

1. Multi-shares and the Affordable Care Act March 2, 2011 This webinar will begin at 1:00pm eastern. Please hold until Anne Gauthier starts the conference.

2. ND MT VT ID NH MA ` SD MI WY RI CT PA IA NJ NE OH UT IN DE IL MD CA DC MO KY TN AZ OK SC AR NM GA AL MS LA AK FL HI The State Health Access Program (SHAP)

3. Today’s Agenda

4. What Are Multi-Shares? Kathy Witgert Program Manager, NASHP

5. What Are Multi-shares?

6. Multi-share Models

7. The ACA and Multi-shares • Individual Responsibility • Insurance Regulations • No annual or lifetime limits • Essential benefits • Grandfathering rules • Hospital community benefit

8. Issues for Multi-Shares and States • Is this coverage an insurance product? • Who is the population currently served? • What will their potential coverage sources be in 2014? • How will multi-shares assist enrollees with possible transition to different coverage sources in 2014? • Will partners in the multi-share shift? • How will states support those who do not have coverage after 2014?

9. Health Care Reform and the Multi-Share Plan Gary Packingham, Vice President CHV March 2, 2011 Community Health Ventures, Inc. 2011

10. How do MSPs fit in the ACA? • 20 million people remain uninsured - CBO estimate • These are people largely exempt from individual mandate • Most will have "affordability exemptions"- premiums available on exchange exceed 8% household income • Most will work in small businesses exempt from employer requirement • Likely to earn above 250% FPL Community Health Ventures, Inc. 2011

11. Affordability Table Based The Kaiser Health calculator for a Silver Plan in 2014 on the exchanges costing $3,500 / yr. for a 40 year old individual. Community Health Ventures, Inc. 2011

12. Policy Challenges for MSPs in the ACA • Must provide essential health benefit in sec. 1302 (b) • MSP essential health benefit must be accepted by IRS • MSPs are "grandfathered plans" operating outside the exchange • Nothing in ACA terminates coverage in existing grandfathered plans under sec. 1251 • Uncertainty for new MSPs • Must be recognized as Qualified Health Plans to be on exchanges Community Health Ventures, Inc. 2011

13. Barriers to Becoming a Qualified Health Plan (QHP) • ACA criteria for QHP is specific to insurance • State licensing and related insurance requirements • Must meet ACA insurance reform criteria • MSPs are not insurance • Licensed by states as alternatives to Insurance • Typically regulated outside of state insurance commission Community Health Ventures, Inc. 2011

14. Potential opportunities for MSPs • HHS regulators could recognize MSPs as meeting QHP criteria equivalency • Licensed and certified under state statutes to provide essential health benefit • Regulated by states to ensure solvency and consumer protections • CO-OPs could possibly include MSPs as QHPs • Subject to Regulations for Sec. 1332 • State Flexibility (sec. 1324) could allow states to include MSPs in 2017 (or 2014 if amended) • Can MSPs survive until 2017 or 2014 in current budget climate Community Health Ventures, Inc. 2011

15. Sec. 9007: Community Benefit Hospital Reporting to IRS • Changes in sec. 9007 require more specific hospital CB spending • Tied to Community Health Needs Assessment • Reflects decrease in charitable care • Potential increase in community program spending offset • MSPs can qualify as eligible CB spending under this section Community Health Ventures, Inc. 2011

16. Challenges for MSPs and State Exchange Planning • How to plan for MSP role on exchanges ahead of key regulatory decisions • Availability on SHOP Exchanges for small group coverage- Availability on individual exchanges • How to limit individual market to small business employees • How to have exchanges recognize MSP coverage for compliance to the individual mandate • How to create exchange legislation that would include MSPs Community Health Ventures, Inc. 2011

17. Summary of MSP Policy Issues • ACA leaves millions uninsured • MSPs have potential to remedy part of this problem • Policy and regulatory framework currently limits MSP opportunities • Budget priorities threaten some MSPs near term viability • Community partnerships can work through all these challenges Community Health Ventures, Inc. 2011

18. Colorado’s Multi-Share Programs Megan Wood HRSA SHAP Grant Project Director Megan.Wood@state.co.us March 2, 2011

19. Two Multi-Shares • Health Access Pueblo (www.healthaccesspueblo.org) • Five year legislation passed in June 2007 • Enrollment began October 2008 • Serves Pueblo county • 32 employers and 101 enrollees • CarePoint • Five year legislation passed in June 2009 • Enrollment began May 2010 • Covers six counties in southern Colorado (Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache) • 19 employers and 68 enrollees Colorado Department of Health Care Policy and Financing

20. Multi-Share Counties Colorado Department of Health Care Policy and Financing

21. Colorado Multi-Share Overview • Traditional multi-share concept • Monthly premium divided evenly among (1) employees, (2) employers and (3)community share • Not an insurance product • Contracting with employers with 2 or more employees • Working a minimum of 15 hours/week • Not currently offered any other health insurance coverage • Earn between minimum wage and $25/hour • Locally governed Colorado Department of Health Care Policy and Financing

22. Colorado’s Multi-Share Roles • Network of coordinated care within the community • Wellness programs for enrollees • Educate and refer people to public coverage • Coordination with local community efforts for getting people health care coverage • Plays a key role in covering lives until ACA is implemented Colorado Department of Health Care Policy and Financing

23. Colorado and the ACA • Uninsured individuals post ACA • Exempt from individual mandate • Below the tax filing threshold that are eligible for Medicaid (no penalty for not enrolling in Medicaid) • Opting to pay tax penalty • Undocumented individuals • Incomes that fluctuate and they become eligible for different programs on a regular basis (churn) Source: Colorado Health Institute analysis of 2008-09 Colorado Household Survey and 2008 American Community Survey Colorado Department of Health Care Policy and Financing

24. Colorado’s Numbers after ACA Implementation Multi-share counties Colorado Colorado Department of Health Care Policy and Financing

25. Current Questions on the Table • Who will be the (new) target population? • Of those uninsured post ACA, how many will enroll in ‘charity care’? • Will there still be enough providers given the spike of new enrollees in an already strained system? • Will (and/or how will) multi-shares integrate with the Exchange? • Will multi-shares continue in their current capacity or will their role change? Colorado Department of Health Care Policy and Financing

26. Minnesota’s SHAP Multi-Share Programs Cara Bailey, Project Director cara.l.bailey@state.mn.us Minnesota Department ofHuman Services

27. Local Access to Care Programs (LACPs) LACPs cover enrollees ≤ 350% FPG • HealthShare • Contracts with employers • Northeast Minnesota (Duluth) • Jan. 2011 SHAP-funded enrollment: • 110 employers, 308 members • Portico HealthNet • Works directly with low-income uninsured individuals • Twin Cities Metro Area (St. Paul) • Jan. 2011 SHAP-funded enrollment: • 682 members • Values Health [PrimeWest] • Contracts with employers • Greater Minnesota (Alexandria) • Jan. 2011 SHAP-funded enrollment: • 8 employers, 46 members

28. HealthShare • Serves 4 Northeast counties: • Carlton, Cook, Lake, and Saint Louis • Traditional “multi-share” • Three shares: Employer, employee, and community share • Recruits small employers (< 50 employees) • Median wage must be ≤ $18.22/hour ($37,905/year) • Limited benefit set: Primary, specialty, hospital, lab/X-ray/imaging, pharmacy, equipment/supplies • Care management supported through annual health risk appraisal • Online: www.healthsharemn.com

29. Portico Healthnet • Located in 4 Metro counties: • Dakota, Hennepin, Ramsey, Washington • Limited benefit pre-paid individual plan • Recruits individuals, typically working poor • Also assists with MHCP application process • Limited benefit set: Primary, preventive, specialty, urgent, outpatient mental health, prescriptions, interpreters • Care management supported by face-to-face family interview upon enrollment • Online: www.porticohealthnet.org

30. Values Health • Will enroll in 13 Western counties: • Beltrami, Big Stone, Clearwater, Douglas, Grant, Hubbard, McLeod, Meeker, Pipestone, Pope, Renville, Stevens, Traverse • Counties already served by PrimeWest (parent company) • Traditional “multi-share” • Three shares: Employer, employee, and community share • Recruits employers; targets small businesses (< 50 employees) • Benefit set: Preventive, primary, specialty, urgent care, maternity/childbirth, emergency room, lab/X-ray/imaging, prescription drugs, chiropractic, outpatient mental health • Care management supported through initial health risk assessment • Online: www.primewest.org, www.valueshealth.org

31. Minimum LACP Components • Affordable limited benefit set • Comprehensive network of designated providers • Preventive care • Care management • Health assessment, coaching • Easily navigable services • Enrollee empowerment • Cost-sharing

32. Value Added • Expand affordable coverage options • Reduce disparities in access to health care coverage • Provider network, coordinated care • Increase enrollment of eligible individuals into Medicaid

33. Lessons Learned • Steep start up costs • Challenging to break into the small business market, but once done, enrollment accelerates due to “word of mouth” • Community-based organizations can facilitate enrollment into public programs and reach populations considered “hard to reach” • Limited benefit set, but access to coordinated primary care valuable

34. State Perspective: Multi-shares and the ACA We know that multi-shares can bridge the gap until implementation of the ACA in 2014.

35. State Perspective: Multi-shares and the ACA For planning beyond 2014, questions to be asked: • Will there continue to be a gap in coverage after 2014 that can be served by the multi-share model? What are the characteristics of that population and how are they best served? • How can we assure that access to coordinated care is provided and not just “coverage”? • How can populations not likely to engage the Exchange be reached?

36. Question and Answer Use the chat function to submit your questions

37. Additional Resources • Webinar archived on www.healthcarecommunities.org • Visit www.nashp.org for additional resources • For additional resources related to health reform, visit State Refor(u)m at www.statereforum.org

38. Thank You Anne Gauthier Senior Fellow agauthier@nashp.org Kathy Witgert Program Manager kwitgert@nashp.org Denise Osborn Policy Specialist dosborn@nashp.org Chris Cantrell Research Assistant ccantrell@nashp.org Christina Miller Research Assistant cmiller@nashp.org Please feel free to contact the SHAP team with any questions.