Modernizing Idaho Medicaid Value-Based Reform Prevention/Wellness/Responsibility

1. Modernizing Idaho MedicaidValue-Based ReformPrevention/Wellness/Responsibility August 4, 2006 SCI Summer Workshop Kate VandenBroek, Sr. Project Mgr., Idaho Medicaid

2. Idaho Medicaid, Pre-Reform • Fiscally unsustainable, crowding out other state budgets. • Program administration focus vs. outcomes focus. • Eligibility categories do not describe health needs of populations. • Eligibility structure results in cost controls without regard to health needs. • One size fits all benefits.

3. Modernization “Filters” for Decision Making • Is the change holistic? • Does the change foster simplicity? • Does the change promote fairness? • Does the change create value?

4. Approach to Modernization • Simplify eligibility to match identified needs. • Establish policy goals relevant to specific populations. • Modify benefits to meet identified needs and promote policy goals. • Alter delivery systems to efficiently and effectively meet needs and policy goals. • Match quality and performance improvement to population served.

5. Idaho Medicaid Simplification Act • Provides framework and policy goals for Idaho Medicaid reform. • Three distinct health need categories: • Low-income children and working-age adults • Individuals with disabilities or special health needs • Dually eligible for Medicaid & Medicare (Elder Plan) • Three distinct benefit packages: • Medicaid Basic Plan • Medicaid Enhanced Plan • Medicare-Medicaid Coordinated Benefits

6. Health Need Categories HRA Special Health Need

7. New Benefit Plans

8. Coordinated Plan • Proposed Integration of Medicare Part D Excluded Drugs. • Ongoing Collaboration with Medicare Advantage Plans. Idaho Medicaid Will Now Pay Premiums/Cost-Sharing for Full Duals Enrolled in Medicare Advantage

9. Also: Preventive Health Assistance (PHA) benefits • Originally “Personal Health Accounts” • PHA type #1: Behavior PHA • Supports weight management and tobacco cessation. • Targets adults with high or low BMI or who want to quit tobacco. • Initial loading of points; more points with participation. • PHA type #2: Wellness PHA • Helps pay delinquent premiums and purchase goods/services to support activity/wellness. • Targets children eligible for premiums (above 133% FPL). • Points loaded if immunizations and well child checks are current.

10. Idaho Reform Timeline DRA

11. Technical Submissions  Approved by CMS  New DRA Provisions

12. Outstanding Issues • Modify (scale back) “standard” Medicaid • Caregiver support benefits • Premium assistance expansion • Targeted co-payments • Prescription Drugs • Inappropriate ER Use • Inappropriate Ambulance Use • Missed Appointments • Health information technology grants for primary care providers • Incorporating existing waivers

13. Questions?