Medicaid & the Private Sector

1. Medicaid & the Private Sector How Private Health Plans Are Working to Tame the Infamous Medicaid “Monster” Toni Bigby Director of Consumer Advocacy Toni.bigby@caresource.com

2. Today’s Topics Medicaid – What is it? Who’s Eligible? What Do They Get & How Do They Get It? How Private Plans Play A Role in Medicaid What Opportunities May Exist in the Future as a Result of Health Care Reform

3. Myth or Fact? Only seniors qualify for Medicaid. Medicare and Medicaid is the same, right? • Anyone who is unemployed or low income can qualify for Medicaid? • You can’t work and get Medicaid coverage?

4. Medicaid Today Medicaid is Ohio’s largest health and long-term care program. It combines state and federal funds to purchase health care coverage for low-income and medically vulnerable citizens. 1.7 million enrolled (average monthly) Spends $13.8 Billion annually Accounts for 23 percent of state budget Administered by Ohio Department of Job & Family Services (ODJFS) Through 6 state agencies 88 County Offices Determine Eligibility Entitlement Payor of Last Resort

5. Who’s Eligible? • Covered Families and Children (CFC) • Children (up to 19) • Pregnant Women (any age) • Parents • Total: 1.4 million • Aged, Blind or Disabled (ABD) • Seniors (65+) • Individuals with Disabilities • Total: ~300,000

6. Medicaid Eligibility vs Spending Eligibility Spending

7. Medicaid Eligibility vs Income Thresholds

8. Medicaid Income Chart (2009) Disregards that may reduce income may apply. These are proxy amounts.

9. Basic Eligibility Requirements Children & Families Aged, Blind or Disabled In addition, must also provide proof of: Limiting Physical Factor (e.g., age, disability) Resources Have a face-to-face interview at initial application Must reapply every 12 months • Income • No Resource Test • Ohio Resident • Social Security Number • Citizenship • Proof of Pregnancy (if applicable) • Other health insurance • No face-to-face interview required; mail in application • Must reapply every 12 months (except pregnant women)

10. Medicaid Benefit Package MANDATORY OPTIONAL Dental* Vision* Mental Health Pharmacy* Community alcohol & drug addiction treatment Occupational/Physical/ Speech Therapies Durable Medical Equipment Hospice • Doctor Visits • Hospital* • Lab & X-rays • Healthchek (wellness check ups to age 21) • Home Health • Nursing Facility • Transportation *Co-pays may apply.

11. Ok, So How Do They Get Care? Home & Community Based Waivers Fee-for-Service (in community) Managed Care Institutional 300,000+ 1.4 million 65,240 65,136 including

12. Medicaid & Managed Care • Began in 1978 • Statewide enrollment became mandatory in SFY 06/07 per HB 66 for CFC and a portion of ABD consumers • 7 plans, 8 regions • Two to three plans per region • Plans accept full risk; paid on a capitated basis per enrollee, per month • Rates determined by independent actuary • Plans must meet ODI licensure & solvency requirements • Managed care model allows budget predictability for state

14. Goals of Managed Care • Focus on the individual needs of enrollees • Promote and coordinate care rather than just pay for services • Improved health outcomes for enrollees • Increased provider access • Cost savings and predictability for state

15. Value Added MC Services • Case management • 24-hour hotline for medical advice & direction • Provider directory/Find a Doctor Search • Member handbook • Grievance resolution system • Provider network management • Member services • Preventive care reminders • Health education materials & activities • Expanded benefits with incentives (varies among MCPs) • Extended office hours (varies among MCPs)

16. MC Outcomes To Date • Use of primary and outpatient care went up 57%. • Infant emergency room visits were down 28% • Hospital stays were down 54% • Prenatal care increased 17% • 20% decrease in low birth weight babies • 14% more children got first-year check-ups • 20% more 1-year olds and 24% more 2-year olds got tested for lead poisoning • 98% of clean claims paid within 30 days • Saving Ohio $368.8 million (2007-2009) • Expected to generate $1Billion in revenue in current biennium

17. Looking to The Future: A New Era in Health Care • Medicaid Expansion To All (Under Age 65) Up to 133% of poverty • Removes categorical eligibility • Includes childless adults • Individual Mandate w/ Subsidies • State Based Health Exchange • Insurer Reforms (not new to Medicaid plans) • Dual integration for Medicare & Medicaid beneficiaries • Health Information Technology/Electronic Medical Records

18. Potential Challenges • Individuals faced with poverty do not always prioritize health care in their daily lives • Medicaid patients tend to access the health care system in spontaneous and unpredictable ways • Transient, hard to reach population • Literacy issues or language barriers • State budget • Uncertainty of unintended consequences of health care reform

19. Review • Medicaid is a major driver of the state budget • Not everyone who is struggling with poverty is covered by Medicaid today • Medicaid provides comprehensive benefit package with limited cost sharing • Use of private insurers is not new to Medicaid in Ohio – majority of population is enrolled in a plan • Managed care has proven to save $$, improves outcomes, increases access relative to fee-for-service and offers budget predictability • Future looks promising for managed care to be part of reform solution

20. Resources • Medicaid Web Site: www.jfs.ohio.gov/ohp • Program Info • Applications (download or order at no cost) • Brochures/Fact Sheets • Medicaid Consumer Hotline: 800-324-8680 • Ohio Association of Health Plans: www.oahp.org • Health care reform: www.kff.org