Approaches to Insuring Direct Care Workers

1. Approaches to Insuring Direct Care Workers Lessons from the States Health Care for Health Care Workers Paraprofessional Healthcare Institute Louisiana Dept. of Health and Hospitals July 2007

2. Framework for Discussion • What are the core models of coverage? • What types of models are states experimenting with? • Discussion: What are the key issues for Louisiana's direct care workers?

3. Models of Insurance Coverage • Public health plans or programs • Employer-sponsored insurance plans • Individual Insurance

4. Public Health Plans or Coverage • Medicare: Many direct care workers over 65 and enrolled in Medicare; some dual eligibles • Medicaid: Many direct care workers with children eligible; many enrolled • SCHIP: Some states allow parental enroll-ment (e.g., WI BadgerCare) • State-only plans (e.g., RI) • County-operated health plans (e.g., 3rd share plans in MI)

5. Employer Sponsored Insurance • Employer and/or individual mandates • MA and VT - variation on pay or play and expansion of public plans • Maryland “Fair Share” bill • CA proposal (similar to MA) • Subsidizing ESI premiums • Premium assistance programs, e.g. HIPP • Discounted products to subsidize premiums for individuals or small businesses • “Buy-in” to public plans (e.g. CT, UT)

6. Individual Insurance • Health Savings Accounts (HAS) or Health Reimbursement Accounts (HRA) • Tax Credits • Vouchers

7. Three Ways to Subsidize Insurance • Assistance for workers (e.g., premium subsidies) • Assistance to employers (e.g., increase in Medicaid reimbursement rate targeted specifically to pay for health insurance costs) • Reinsurance to help lower costs of premiums by “insuring the insurers” (e.g., Healthy New York)

8. Premium Assistance for Employees • HIPP: States have option of providing premium assistance to all Medicaid eligibles under a Health Insurance Premium Payment program (Sec. 1906 of Social Security Act) • DirigoChoice: Maine’s P/P partnership • Adult Basic: PA’s plan for low-income adults • RIteCare: RI’s subsidized plan – now covers child care workers • Health Partnership: MA’s plan to cover fisherman

9. Premium Assistance for Employers • DirigoChoice: Maine businesses <50 ees pay 60% of premium • State employee health benefit plan: Access to employers in Utah providing services for state & fed-funded programs • Purchasing Pools: For small businesses or organized workforce groups

10. Purchasing Pools • CA, OR and WA have organized public authorities that pool consumer -directed workers and serve as purchasing agents • Jointly-administered Health Funds: 66 home care agencies in NYC pay cents/hour rate into Taft-Hartley fund • Professional Employer Organization: Pilot program in WI for home and child care workers

11. Reinsurance Plans • State covers portion of private insurers’ claims • Stop-loss mechanism may cover catastrophic claims • Small employers premiums more affordable • Healthy New York: pilot project for NYC garment workers and UNITE/HERE labor union benefit fund

12. CMS Health Insurance Interventions • Six state grants in mid-2000 • NC, IN, ME, WA, NM, VA • Evaluations underway to see if health insurance influences retention • Two states subsidized coverage; two states conducted outreach to existing coverage; one state offered a reimbursement arrangement; one state used funds to study rates of uninsruance

13. State Plans Varied • CMS grantees in NC and IN using grant funds to subsidize coverage • Benefits range from mini-meds and cafeteria plans to comprehensive coverage • New Mexico: Offered prescription discounts, basic insurance, tax-free accounts • Maine and Washington: Outreach to home care agencies (ME) and consumer-directed workers (WA) for available coverage

14. CMS States’ Assessments • Grantees found need for coverage great • Cost of coverage key concern for sustainability; source of subsidy unclear when grant funds end • Part-timer and family coverage key challenges • ME and WA funds focused on outreach and enrollment into good plans – key challenges remain

15. What Have We Learned from CMS Initiatives? • Accessible to all DCW regardless of hours they work • Affordable for workers and employers • Comprehensive coverage, with benefits that help older workers with chronic health conditions • Simple and easy enrollment • For more information http://www.hchcw.org/uploads///pdfs/CMS%20DSW%20Grant%20Health%20Coverage%20Analysis%20final.pdf

16. Rate Enhancements • Support employer-sponsored insurance by directly reimbursing costs in Medicaid payment rate • CA counties: add cost into rate as cost of doing business with IHSS program • New York: State OMRDD pays for benchmark plan; agencies must demonstrate coverage -- will get funds based on $2,500 per employee • Montana: Beginning 1/2009 will include cost of health insurance in Medicaid rate to home care providers

17. OMRDD – New York Reimbursement for Health Insurance • “This funding initiative will enable agencies to address the health care costs of their employees and enhance the ability of providers to hire and train indispensable direct care staff” • $2,500 per employee to establish health benefits or reduce employee out-of-pocket health expenses • If coverage already at or above the benchmark plan, provider will receive a 3.0% increase to operating costs • For more information, go to: http://www.omr.state.ny.us/hp_healthcare_index.jsp

18. Third Share Plans • Community-based plans • Subsidized coverage or insurance for low-wage employees and businesses • Govt, employers and individual share cost (not always equal parts) • Public subsidy usually tied to Medicaid funding (e.g., DSH payments) • Growing in popularity – NC, TX, MI

19. Muskegon’s Access Health Plan • Businesses located in county eligible • No insurance for 12 months • Median wage of $11.50 per hour • Broad array of services provided; 97% of physicians participate • Monthly cost reasonable - $46 for employee and employer; $56 for county • www.Access-Health.org

20. Lessons Learned • Good coverage – Comprehensive insurance providing a range of benefits is critical for a workforce where many have chronic health problems and workplace injuries • Affordable coverage – Direct care workers can only afford coverage with minimal premium sharing and co- pays on services • Simplified enrollment – Without a formal “workplace”, and to encourage maximum coverage, enrollment must be simplified and streamlined

21. Lessons Learned • Low eligibility threshold – Due to the nature of the less-than-full-time work, setting the eligibility for coverage low will promote access • Employment-based strategies in question: Less than full-time work, and insurance rules are obstacles