Wisconsin Entitlement Reforms, Patient Protection, and the Affordable Care Act

1. Wisconsin Entitlement Reforms, Patient Protection, and the Affordable Care Act Preparing for the Health Insurance Marketplace: A View From Wisconsin June 14, 2013

2. Wisconsin Entitlement Reforms • Governor Walker’s proposed entitlement reforms will: • Ensure every Wisconsin resident has access to affordable health insurance • Create a BadgerCare Plus program that is sustainable • Help more Wisconsin citizens become independent and rely less on government health insurance • Maintain the health care safety net for those who need it the most

3. Current BadgerCare Health Plans

4. BadgerCare Health Plan - 2014

5. Wisconsin’s Currently Uninsured • The following is Wisconsin’s uninsured population taken from the Current Population Survey (CPS) estimates for 2011.

6. Wisconsin Entitlement Reforms • Governor Walker’s proposed entitlement reforms will specifically: • Reduce the number of uninsured non-elderly adults by 50%, from 14% to 7% • Provide an estimated 259,198 childless adults and parents and caretaker coverage in BadgerCare Plus • Provide an estimated 692,308 childless adults and parents and caretaker relatives will be covered in the Marketplace

7. PPACA - MAGI • Requires that states use the IRS’ methodology for determining Modified Adjusted Gross Income (MAGI), with certain exceptions, to determine household composition, family size, and income eligibility, thereby eliminating most income deductions and disregards • Will be used as the basis for determining Medicaid, CHIP, and Exchange eligibility for certain populations starting in 2014 • MAGI will not be used for determining eligibility for the elderly, blind, and disabled (EBD) population • MAGI introduces tax filing status and tax relationships as new factors in determining how households are tested for eligibility • The new rules are highly complex and will require massive systems and operational changes by state Medicaid agencies between now and January 2014 • DHS is developing MAGI based training material and will deliver using a variety of media and face-to-face meetings • DHS enrollment and budget impacts assume that MAGI will have a relatively small impact on the program • The greatest impact related to MAGI for existing members is the introduction of tax relationships into how their household sizes are determined and whose income will be considered. For some families, this will result in greater eligibility, while for others, it will result in loss of eligibility. • In addition, child support payments will no longer be counted as income in the eligibility determination process. About 15 percent of our cases currently have child support income.

8. Overview of Projected Impacts to Medicaid/BadgerCare Plus • BadgerCare Plus Enrollment Impacts • An estimated 87,000 parent and caretaker relatives and 5,000 childless adults will transition to coverage in the new federal marketplace • An estimated 84,000 childless adults and 9,000 parent and caretaker relatives that are currently uninsured will be enrolled in BadgerCare Plus • Overall BadgerCare Plus enrollment is projected to stay between 770,000 to 800,000 over the next biennium • DHS assumed that the uninsured rate for non-elderly (non-pregnant) adults would be reduced by 50% - from 14% to 7%. The following take-up rates were used in our modeling: • Parents/Caretakers – 25% • Childless Adults (new adult group) – 65%

9. Overview of Estimated Marketplace Enrollment • Marketplace Enrollment Estimates • An estimated 232,000 parent and caretaker relatives and 460,000 childless adults will enroll in Marketplace • Includes transition of people in the current non-group and small group markets • Includes transition of existing state and federal high risk pool (HIRSP) members • Includes employees from large employers that are estimated to drop coverage (10% of current ESI coverage) • Includes take-up of the currently uninsured (using the same take-up assumptions as previously noted for BadgerCare Plus) • Includes the transition of an estimated 95,000 adults from BadgerCare Plus • Small take-up of children assumed; current uninsured rate for children is 5%

10. Looking Ahead… • Governor Walker is committed to two goals when it comes to ensuring all Wisconsin citizens have access to affordable coverage: • Ensure that existing BadgerCare Plus members that will be eligible to enroll in a QHP have a smooth transition to the Marketplace • Reduce the uninsured rate for non-elderly adults by 50% over the next two years • DHS will work side-by-side with all of our existing community partners as well as new partners, Navigators and Certified Application Counselors (CACs). • DHS is already working with Enrollment for Health Wisconsin, Inc. (e4Health) on this front, along with other provider organizations and insurers on ideas for outreach to both of these populations. • DHS is also working closely with CMS on the transition for the BadgerCare Plus members and ways that we can monitor and track members’ transition and enrollment into the qualified health plans offered in the marketplace.

11. Looking Ahead… • Implementation • DHS is working closely with the Office of the Commissioner of Insurance on transition. • Key components: • Income Maintenance Offices • Milwaukee Enrollment Services Center • Certified Application Counselors • stakeholders, provider and advocate engagement • Navigators

12. Looking Ahead… • Key Dates: • Summer 2013 – Qualified Health Plans in place • Late Summer 2013 – “The Marketplace” is unveiled • August/September 2013 – DHS and CMS finalize waiver for childless adults under 100% FPL • October 1, 2013 – enrollment in “The Marketplace” begins

13. Questions

15. From Medicaid to the Marketplace: Accounting for Low-Income Enrollees Jeremy Levin RWHC Director of Advocacy for Wisconsin Institute for Public Policy and Service June 14, 2013

16. RWHC by the Numbers Founded 1979. Non-profit coop owned by 39 rural hospitals (with net rev ≈ $1.5B & 2,100 hospital & LTC beds). 9 PPS & 30 CAH; ≈ 24 freestanding and 15 system affiliated. ≈ 70 employees (50 FTE). ≈ $11M RWHC budget (75% member sales, 17% non-member sales, 6% dues & 2% grants).

17. RWHC Mission, Vision & Structure Mission: Rural WI communities will be the healthiest in America. Vision: RWHC is a strong and innovative cooperative of diversified rural hospitals; it is (1) the “rural advocate of choice” for its Members and (2) develops and manages a variety of products and services.

18. Rural Health Has a Lot to Brag About “Rural Relevance Under Healthcare Reform” (based on Medicare Shared Savings Data Files) 1/23/12 http://www.ivantagehealth.com/ Approximately $2.2 billion in annual cost differential (savings) occurred in 2010 because the average cost per rural beneficiary was 3.7% lower than the average cost per urban beneficiary. Rural hospital performance on CMS Process of Care measures is on par with urban hospitals. Rural hospital performance on CMS Outcomes measures is better than urban hospitals. Rural hospital performance on HCAHPS inpatient experience survey measures is better than urban hospitals. Rural hospital performance on price and cost efficiency measures is better than urban hospitals.

19. Rural Hospitals: Backbone of Rural Health North Carolina Health Research Policy Analysis Center, 8/12 1,327 CAHs as of 6/30/12

20. Source: WHA—U.S. Census Data

22. Source: Enrollment for Health Wisconsin—WPHCA

23. 340B Drug Program Concerns Source: Safety Net Hospitals for Pharmaceutical Access • Requires drug manufacturers participating in Medicaid and/or Medicare Part B to sell “covered outpatient drugs” to “covered entities” at discounted prices • Part of eligibility criteria is driven by Medicaid and SSI inpatient days • As of September of 2010 over 900 hospitals had enrolled • 120+ rural hospitals in at least 37 states have enrolled • Sole community hospitals and rural referral centers that have Medicare DSH adjustment ≥ 8% • Critical access hospitals (no DSH threshold) • 340B prices for brand name drugs are, on average, 51 percent of average wholesale prices, according to a report released by the Congressional Budget Office. Another government study found 340B prices to be 27 percent lower than prices available to group purchasing organizations.

25. From Medicaid to the Marketplace: Accounting for Low-Income Enrollees Presented by: Greg Nycz, Executive Director Family Health Center of Marshfield, Inc. Preparing for the Federal Health Insurance Marketplace: A View from Wisconsin June 14, 2013

27. Data Obtained from Table 4“Department of Health ServicesWisconsin Medicaid Premium Reforms: Preliminary Price Impact Findings”

28. Table 5Premium Effects for Adults in BadgerCare Plus, All ProgramsDHS, Wisconsin Medicaid Premium Reforms: Preliminary Price Impact Findings, July 2012

33. Helping Wisconsin Residents Navigate the Health Insurance Marketplace Wisconsin Institute of Public Policy and Services Conference Caroline B. Gomez, MSW June 14, 2013 Updated January 1, 2013

34. Covering Kids and Families operates a range of programs and convenes a coalition of social service professionals, health care providers, school personnel, policy makers, and researchers. CKF works to improve individual and population health, reduce health disparities, ensure full participation in public and other health insurance and increase access to high quality health care for all residents in Wisconsin. Updated April 2013

35. What will make the Marketplace work? Updated January 1, 2013

36. What will make the Marketplace work? • The three-legged stool approach • Community organizations working together • Clear, understandable, and accessible resources Updated January 1, 2013

37. The Three-legged Stool Approach Employer-based and PrivateCoverage Health Insurance Marketplace Coverage Public Programs (Medicaid/CHIP/Medicare)

38. What will make the Marketplace work? • The three-legged stool approach • Community organizations working together • Clear, understandable, and accessible resources Updated January 1, 2013

39. Community organizations need to work together to seamlessly assist people through the different types of coverage. • To create a Marketplace where there is no wrong door, a team effort and process will be required to help navigate the system. No wrong door? Updated January 1, 2013

40. What will make the Marketplace work? • The three-legged stool approach • Community organizations working together • Clear, understandable, and accessible resources Updated January 1, 2013

41. What is Covering Kids & Families doing to help with the Marketplace? Updated January 1, 2013

42. BadgerCare+ Toolbox to Health Coverage Toolshed? Learn the Basics of BadgerCare+:Who’s eligible, services covered, how families can apply Promote BadgerCare+: Bookmarks, newsletter articles, school lunch/calendar ads Identify Uninsured Kids in Your District: Templates to obtain student Health Insurance Status and strategies to reach out to families Enroll Families in BadgerCare+: Links to important Fact Sheets, community partners, and steps to offering Express Enrollment Access County Tools and Data:County One-Page Brochures for useful programs in the state Assist Families with Renewal/Coverage: Links to find a provider or clinic that accepts BadgerCare+ http://ckfwi.org/toolbox.html Updated January 1, 2013

43. UW-Extension, Cooperative Extension Partnership Covering Kids & Families and UW-Extension, Cooperative Extension have been working together to provide resources and tools to county educators to bring information the communities they work with, such as: Small Businesses Farmers Community Agencies Providers Consumers

44. Navigators • Navigators will be available to help individuals access the online marketplace and enroll in coverage beginning in the late summer of 2013 • Navigators are people who will help people apply on the marketplace or find where a person can apply • Covering Kids & Families has participated with the Wisconsin Access Network to help draft the proposal for the Navigator funding

45. School-based Outreach

46. What will Marketplace success look like? • We will see: • More informed individuals • More people enrolled into a form of health insurance and using their health coverage • Including the invincibles • People being able to afford coverage • We will be: • Meeting people where they are at • Ready to measure the outcome • Prepared for next year’s enrollment period Updated January 1, 2013

47. Questions, Discussion Let CKF know your questions and we will help get them answered! Covering Kids & Families Info@ckfwi.org www.ckfwi.org 608-261-1455 Caroline B. Gomez, MSW cbgomez@wisc.edu Updated January 1, 2013