Medicaid & CHIP After Health Reform - South Carolina Institute of ...

Medicaid & CHIP After Health
Reform
An Overview of Medicaid and CHIP
Provisions of the Affordable Care Act

Medicaid Eligibility Expansion
• New mandatory eligibility category for nonelderly
adults, income up to 133% of poverty
($28,000 for a family of 3 in 2010)
– Must be citizen or legal resident >5 years
– Increases mandatory eligibility for children ages 6-
18 from 100% to 133% of poverty (CHIP
matching rate)
– Estimated 76.% decline in uninsured adults

Financing

Financing the Expansion, 2014-2019
Source: John Holahan and Irene Headen, “Medicaid Coverage and Spending in
Health Reform: National and State-by-State Results for Adults at or Below 133%
FPL” (Washington: Kaiser Commission on Medicaid and the Uninsured, May 2010).
Estimates above reflect higher participation rate scenario.
5

Medicaid Expansion in South Carolina:
Current vs. New Eligibles, 2014-2019
Source: John Holahan and Irene Headen, “Medicaid Coverage and Spending in
Health Reform: National and State-by-State Results for Adults at or Below 133%
FPL” (Washington: Kaiser Commission on Medicaid and the Uninsured, May 2010).
Estimates above reflect higher participation rate scenario.
6

Medicaid Spending in South Carolina, 2014-2019
$45,000
$40,000
$35,000
$12,109
$30,000
$25,000
$20,000
$15,000
$615
$30,353
New Spending
Baseline Spending
$10,000
$5,000
$12,984
$0
South Carolina
Federal Government
Source: John Holahan and Irene Headen, “Medicaid Coverage and Spending in Health
Reform: National and State-by-State Results for Adults at or Below 133% FPL”
(Washington: Kaiser Commission on Medicaid and the Uninsured, May 2010).
Estimates above reflect higher participation rate scenario.
7

Who Will Gain Coverage?
• Estimated 443,020 new Medicaid enrollees by
2019
• 76.2% decrease in uninsured adults with
income

Growth in Medicaid Enrollment in South
Carolina
Source: John Holahan and Irene Headen, “Medicaid Coverage and Spending in Health
Reform: National and State-by-State Results for Adults at or Below 133% FPL”
(Washington: Kaiser Commission on Medicaid and the Uninsured, May 2010).
Estimates above reflect higher participation rate scenario.
9

Benefits for the Newly Eligible
• Benchmark/benchmark equivalent benefits
• Must include “essential health benefits”
– Ambulatory care, emergency, hospital, maternity/newborn,
behavioral health, Rx drugs, rehabilitative and habilitative
services, lab services, preventive/wellness/disease
management, pediatric services including oral and vision
• Also must include family planning services
and transportation services
• Dental and vision not required for adults
10

Benefits (continued)
• Existing Medicaid cost-sharing rules apply
• New enrollees may have greater need for:
– Mental health services
– Chronic disease management
• Given 2/3 were previously uninsured, may be
pent up demand in early years of expansion
11

MAGI
What does MAGI mean for health reform?
12

MAGI
• Modified Adjusted Gross Income
• Applies to children, parents, pregnant women
and other adults in Medicaid and CHIP
• Income as reported on federal tax forms
• No disregards other than universal 5%
• No assets tests
•Does not apply to seniors, ABD, duals
13

MAGI: Easier for Some Groups to Qualify
• People with disabilities or chronic conditions
• People in 2 year Medicare waiting period
• People with child support income
• People with social security survivor income
• Issue: ensuring the eligibility determination
process is set up to screen people who do not
qualify under disability rules with MAGI
14

Potential Problems with MAGI
• Could cause gaps for:
– Children who live with a stepparent
– Pregnant women
– Children claimed by non-custodial parent on tax
forms
• Coordination for those on border between
Medicaid and premium tax credit eligibility
15

Access to Care for New Eligibles
• Increased reimbursement rates for primary care
providers
– Pegged to Medicare rates
– Two years starting in 2013
– Fully federally financed
• Incentive to provide preventive services
– One percentage point increase in federal matching rate
if A and B level preventive services covered (as
defined by the US Preventive Services Task Force)
16

Immigrants
• Undocumented immigrants
– Remain ineligible for public programs
– Ineligible for premium tax credits
– May not purchase coverage through the exchange
• Documented immigrants, in country 5 years
– Eligible for public programs
– Eligible for premium tax credits if income too high for Medicaid
– Eligible to purchase coverage through the exchange if ineligible for tax
credits
17

Improving Enrollment in Public Programs
• New policy options
– Presumptive eligibility for all new Medicaid eligibles
plus currently-eligible parents
– Hospitals that accept Medicaid can conduct
presumptive eligibility for all Medicaid
• Outreach to vulnerable populations required
• Additional $40 million for CHIPRA outreach
grants
• Streamlining enrollment and renewal processes
with the exchange
18

Coordinating Enrollment between the Exchange and
Public Programs
• Simple for consumers; not simple for state and
advocates to integrate and implement
• No wrong door
• Data sharing
• Screening requirements
19

What Can My State Do Before 2014?
• States can expand coverage before 2014
• Expansions get regular match, but then still
get full 100% match in 2014
• Simplification of eligibility & enrollment
can be done anytime

What Must My State Do Before 2014?
• Plan for access to care for additional
enrollees: provider networks
• Plan for coordination of Medicaid eligibility
system with state or federal exchange