RIte Share Premium Assistance Program Then and Now Kate Brewster, Manager Employer Contact Unit Center for Child and Family Health RI Department of Human Services June 28, 2004

Why did Rhode Island implement a premium assistance program?

RIte Care enrollment growth Rhode Island’s Medicaid Managed Care program RIte Care grew by 25% in just 18 months (75,000 – 100,000) due to a number of events occurring in tandem Resulted in bi-partisan legislation: Health Reform RI 2000 Created RIte Share premium assistance program which allowed state to maintain Medicaid eligibility levels Required some members to “cost share” for Medicaid Reformed laws for small group market and implemented solvency standards for commercial carriers

What is RIte Share?  Public/private partnership whereby RIte Care eligible families who have access to “approved” employer health insurance enroll in the employer’s health plan  DHS pays the monthly employee share of the employer-based coverage, either to the employer or to the employee, and provides additional benefits through Medicaid program (e.g., co-payments, transportation, etc.)

Goals of RIte Share Premium Assistance: Prevent substitution (crowd-out) by allowing workers to purchase employer-based insurance Achieve significant program savings by leveraging dollars employers contribute to health insurance Slow growth in RIte Care program

SCI grant allowed us to conduct a business process analysis to improve operations in order to meet specific goals and objectives: 1.Enrollment: To enroll all eligible individuals and families in RIte Share 2.Cost-effectiveness: To realize cost-savings expected by enrolling MA eligible families in RIte Share 3.Access & Quality: Assure that the access and quality of care provided to RIte Share enrollees is equivalent to that of RIte Care enrollees

Goal 1: To enroll all eligible individuals in RIte Share Objective 1: Identify employers of RIte Care members and obtain information about their health insurance benefits THEN: Manually sent letters to employers and employees requesting information about employer-based insurance NOW: Modified eligibility systems to capture employer status (e.g., approved, unapproved, unknown); generate letters and forms to families automatically on a daily basis if the employer is “UNKNOWN” FUTURE: Hope to model legislation after federal legislation passed for child support enforcement that mandates employers give state information about health insurance benefits

There are approximately 6,000 employers that employ RIte Care members. Sixty-nine percent (69%), or 4,410, offer coverage. Currently, over 1,000 employers are approved for RIte Share; Approximately 300 are not approved for RIte Share because of benefit design, cost, etc. Therefore, we have reviewed approximately one-third (1/3) of potential RIte Share employers

Goal 1: To enroll all eligible individuals in RIte Share Objective 2: To identify potential RIte Share eligible families in a timely fashion and review their case for eligibility as soon as possible. THEN: Semi-annually “swept” MA eligible members working for “approved” employers in order to contact employer and determine if eligible NOW: Daily referrals to the Employer Contact Unit are generated from our eligibility systems based on the employer status

Between April 2003 and March 2004, approximately 8,200 individuals were reviewed for RIte Share. Of the 8,200 individuals: - 45% of cases were cost effective - 3,785 individuals were enrolled - 1,736 individuals were disenrolled

Goal 1: To enroll all eligible individuals in RIte Share Objective 3: To obtain accurate and timely information about the enrollment status of RIte Share enrollees in their employer-based insurance THEN: Relied on member to call ECU about changes in employment/enrollment; lots of confusion ; potential for overpayments NOW: Eligibility systems inform ECU on a daily basis of changes in employment

Goal 2: To realize the cost-savings expected by enrolling employees and their families in RIte Share versus RIte Care. THEN: ONLY three tests used to determine cost effectiveness of employer plan (MA families; MA children only; MA pregnant women only) NOW: Modified to take into account tier structure, prescription co-pay structure, and member cost sharing (deductibles, coinsurance) in response to changing employer health plans

Goal 2: To realize the cost-savings expected by enrolling employees and their families in RIte Share versus RIte Care.  Costs are half for premium assistance compared to full public coverage; FY 2003 savings per member per month were $79  For every 1,000 full year RIte Share enrollees, total savings are $1Million; with 6,000 full-year enrollees we will be savings $6Million

RIte Share Remaining Challenges and Opportunities

Remaining Challenges: Ensuring Access and Quality of Care Goal 3: To assure that the access and quality of care provided to RIte Share enrollees is equivalent to the experience of RIte Care enrollees. - Difficult to measure access and quality of care because commercial carriers are not required to report on health outcomes of RIte Share members; they are not distinguished in their membership - Satisfaction survey found almost 100% of RIte Share members are satisfied with the program

Remaining Challenges: Health Insurance Industry Changes -Increases in premiums are being passed on to employees, making it more difficult to meet cost effectiveness tests -Employers are adopting health plans with increased member cost sharing (e.g., high deductibles) and scaled down benefits that make it harder to “wrap around” -Health Savings Accounts (HSAs) and other flexible benefit programs will make it more difficult to mandate employees take up coverage

Future Opportunities: Expanding RIte Share -Legislation passed in 2001 requires commercial insurers to provide DHS with membership so DHS can match against Medicaid recipients to determine who has other coverage -Individuals with third party coverage will be identified through data matches with commercial insurers in Rhode Island -Anyone with comprehensive third party coverage through an employer, absent parent, etc., will be removed from managed care and put into RIte Share, regardless of whether they pay for the employer-based insurance or not

Future Opportunities: Expanding RIte Share Continue to focus on public/private partnerships! As Medicaid agencies have fewer state and federal resources, states will need to develop partnerships with the private sector to purchase services, leverage funds, etc., in an effort to integrate populations and programs HRSA grant will provide opportunities for RI to look at existing and potential partnerships to cover the uninsured