Section 5: Public Health Insurance Programs Medicare Medical Assistance (Medicaid) MinnesotaCare General Assistance Medical Care (GAMC) Minnesota Comprehensive Health Association (MCHA) A summary of the charts and graphs contained within is provided at Chartbook Summaries - Section 5. Direct links are listed on each page. Please contact the Health Economics Program at or if additional assistance is needed for accessing this information.Chartbook Summaries - Section 1

MEDICARE A federal health insurance program for people age 65 or older and people with certain disabilities and end-stage renal disease.

Medicare Enrollment and Spending, Minnesota and the U.S., 2002 to 2012 Enrollment Expenditures ($ millions)Spending per Enrollee Calendar Year MNU.S. MNU.S. MNU.S ,12039,597,440 $3,498 $256,551 $5,244 $6, ,74040,202,660 $3,653 $274,030 $5,406 $6, ,84240,784,276 $4,005 $300,136 $5,839 $7, ,52241,535,879 $4,569 $326,317 $6,551 $7, ,24242,335,590 $5,438 $382,335 $7,624 $9, ,14743,259,280 $5,798 $408,790 $7,951 $9, ,06544,384,954 $6,165 $442,908 $8,230 $9, ,80645,466,997 $6,564 $471,349 $8,560 $10, ,85246,584,745 $6,889 $489,340 $8,766 $10, ,63547,740,806 $7,157 $513,483 $8,906 $10, ,20549,682,146 $7,632 $538,023 $9,127 $10,829 3 Sources: Enrollment data are from the Medicare and Medicaid Statistical Supplement of the Centers for Medicare and Medicaid Services (CMS) as of July 1 each year; US expenditure data are from the Personal Health Care estimates of the National Health Expenditure Accounts (NHEA) for Minnesota spending estimates are based on MDH annual spending report data for Medicare – public payer data (updated through 2013).

Minnesota Medicare Enrollment and Spending Growth, Sources: Enrollment data are from the CMS Medicare and Medicaid Statistical Supplement, Minnesota spending estimates are based on MDH annual spending report data for Medicare – public payer data (updated through 2013). *Spending increase between 2005 and 2006 reflects the addition of the Medicare Prescription Drug Benefit (Part D). Summary of graph

Minnesota Aged and Disabled Medicare Beneficiaries, Source: CMS, Medicare Enrollment Reports, July 1, *Aged beneficiaries are people 65 and older. Disabled beneficiaries only includes enrollees with disabilities that are under age 65. Summary of chart

Minnesota Medicare Beneficiaries with Dual Coverage, Sources: Minnesota Department of Human Services, data for calendar year *Dually enrolled Medicare beneficiaries are individuals that qualify for Medicare and Medical Assistance. Summary of chart

Minnesota’s Medicare Enrollment as Percent of Population, by Region, For the regional boundaries, see slide 44 at the end of this chartbook. Sources: CMS, Medicare Enrollment Reports, 2012 Aged and Disabled by State and County; U.S. Census Bureau, Population Estimates for Minnesota Counties for July 1, Summary of graph

Statewide Distribution of Medicare Enrollees, by Region, For the regional boundaries, see slide 44 at the end of this chartbook. Source: CMS, Medicare Enrollment Reports, 2012 Medicare Aged and Disabled by State and County; U.S. Census Bureau, Population Estimates of Minnesota Counties for July 1, Summary of chart

Types of Prescription Drug Coverage for Medicare Enrollees, Source: CMS, Medicare and Medicaid Statistical Supplement. *Creditable coverage is defined as coverage that meets or exceeds the actuarial value of the standard Medicare Part D Benefit. Summary of graph

Medicare Private Plan Enrollment Trends, 2002 to Source: CMS, Medicare and Medicaid Statistical Supplement ( ); CMS, Medicare Advantage Monthly Enrollment by State/County/Contract as of December 2006 – December 2012). Private plans include Medicare Advantage and Medicare Cost Plans that cover Medicare hospital and provider benefits (Part A and Part B), and may cover Part D (drug). It does not include stand-along Medicare Part D (drug) plans, or other Medicare supplement plans. Summary of graph

Minnesota Medicare Private Plan Enrollment in Urban and Rural Counties, Source: CMS, Medicare Advantage Monthly Enrollment by State/County/Contract Report as of December Summary of graph

Distribution of Minnesota Medicare Private Plan Enrollees by Region and Type of Plan, These plans cover Medicare hospital and provider benefits (Part A and Part B), and may cover Part D benefits (prescription drugs). It does not include stand-along Medicare Part D (drug) plans, or other Medicare supplement plans. CCP is Coordinated Care Plans; PFFS is Private Fee For Service Plans. Source: CMS, Medicare Advantage Monthly Enrollment by State/County/Contract Report as of December Summary of graph

Medicare Private Plan Types in Minnesota, 2007 and These plans cover Medicare hospital and provider benefits (Part A and Part B), and may cover Part D benefits (prescription drugs). It does not include stand-along Medicare Part D (drug) plans, or other Medicare supplement plans. CCP is Coordinated Care Plans; PFFS is Private Fee For Service Plans. Source: CMS, Medicare Advantage Monthly Enrollment by State/County/Contract, data as of December 2007 and Summary of graph

MEDICAL ASSISTANCE (MA) Minnesota’s Medicaid program – jointly financed by the state and the federal government – provides health insurance to low-income senior citizens, children, adults, and people with disabilities. In 2014, under the Affordable Care Act (ACA) Medical Assistance eligibility was increased to all adults with incomes at or under 133% of Federal Poverty Guidelines (FPG), and all children with incomes at or under 275% FPG.

Medical Assistance Enrollment and Spending History, 2003 to 2013 Growth in: State Fiscal Year Avg. Monthly Enrollment Spending ($ millions) Avg. Monthly Spending per EnrolleeEnrollment Total Spending Spending per Enrollee ,595$4,741$8939.6%14.6%4.5% ,650$4,991$8974.8%5.3%0.5% ,861$5,196$8974.1% 0.0% ,406$5,452$9113.2%4.9%1.6% ,155$5,858$9572.4%7.5%5.0% ,001$6,277$9933.3%7.2%3.7% ,337$6,779$1,0145.8%8.0%2.1% ,651$7,236$9919.2%6.7%-2.3% ,483$7,530$9439.3%4.1%-4.8% ,390$8,241$9449.3%9.4%0.1% ,158$8,046$9071.6%-2.4%-3.9% 15 Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years.

Medical Assistance Enrollment and Spending Growth, 2003 to Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. Summary of graph

Medical Assistance Enrollees as Percent of Population, by Region, For the regional boundaries, see slide 44 at the end of this chartbook. Source: Minnesota Department of Human Services, enrollment data for calendar year 2013; U.S. Census Bureau, population estimates of Minnesota counties for July 1, Summary of graph

Statewide Distribution of Medical Assistance Enrollees, by Region, For the regional boundaries, see slide 44 at the end of this chartbook. Source: Minnesota Department of Human Services, enrollment data for calendar year Summary of chart

Medical Assistance Enrollment by Eligibility Category, 2003 and 2013 Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years based on similar eligibility categories as of *In 2010, the Minnesota Legislature gave the Governor the authority to pursue Medicaid expansion. In March 2011, the Governor expanded eligibility for Medical Assistance to childless adults with incomes at or below 75% of the Federal Poverty Guidelines (FPG). This is often referred to as “early Medicaid expansion.” Summary of graph 19

Medical Assistance Spending by Eligibility Category, 2013 Source: Minnesota Department of Human Services, data for calendar year Summary of graph 20

Actual and Projected Cumulative Changes in Medical Assistance Spending and Eligibility In January 2014, eligibility for Medical Assistance expanded to children and pregnant women with incomes at or below 275% Federal Poverty Guidelines (FPG) and other individuals with incomes at or below 133% FPG, in accordance with the Medicaid Expansion in the Affordable Care Act. Sources: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. Actual spending for 2010 through Projected spending for 2014 through Summary of graph 21

Projections of Medical Assistance Funding by Source of Funds Sources: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. *Under the Affordable Care Act, the Federal Government will cover 100% of the costs of newly eligible enrollees from the Medicaid Expansion for calendar years , and 90% after 2016 Summary of graph 22

MINNESOTACARE A sliding-fee-scale Minnesota health insurance program - financed by state funds, federal funds, and enrollee premiums - for low income Minnesotans who are not offered insurance through their employer which meets certain criteria. In 2014, MinnesotaCare was converted to a Basic Health Plan (BHP) under the ACA, which expanded benefits and reduced the maximum income requirements to 200% of Federal Poverty Guidelines (FPG)

MinnesotaCare Enrollment and Spending History, 2003 to 2013 Growth in: State Fiscal Year Avg. Monthly Enrollment Spending ($ millions) Avg. Monthly Spending per EnrolleeEnrollment Total Spending Spending per Enrollee ,205$435$2409.6%23.8%13.0% ,505$487$ %11.9%14.0% ,822$409$ %-16.0%-12.1% ,727$438$ %7.1%18.0% ,893$434$ %-0.8%8.3% ,350$463$ %6.6%9.9% ,704$527$3732.9%13.8%10.5% ,784$665$ %26.4%12.9% ,152$738$ %10.9%-1.4% ,729$551$ %-25.3%-14.1% ,681$570$ %3.4%6.8% Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. 24

MinnesotaCare Enrollment and Spending Growth, 2003 to 2013 Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. *Enrollment and spending declines after 2010 reflect that some MinnesotaCare enrollees qualified for Medical Assistance (MA) following the March 2011 MA eligibility expansion to include childless adults with incomes at or below 75% of the Federal Poverty Guidelines (FPG). Summary of graph 25

MinnesotaCare Enrollees as Percent of Population, by Region, 2013 For the regional boundaries, see slide 44 at the end of this chartbook. Source: Minnesota Department of Human Services, enrollment data for calendar year 2013; U.S. Census Bureau, population estimates of Minnesota counties for July 1, Summary of graph 26

Statewide Distribution of MinnesotaCare Enrollees, by Region, 2013 For the regional boundaries, see slide 44 at the end of this chartbook. Sources: Minnesota Department of Human Services, enrollment data for calendar year Summary of chart 27

MinnesotaCare Enrollment by Eligibility Category, 2003 to 2013 State Fiscal Year Average Monthly Enrollment Parents and Children Childless Adults ,205116,97234, ,505114,79033, ,822109,18132, ,72798,85829, ,89383,87634, ,35073,21141, ,70470,05147, ,784 71,16560, ,152 85,48662, ,729 86,10637, ,681 86,60433,304 Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. 28

MinnesotaCare Enrollment by Eligibility Category, 2003 to 2013 Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. Summary of graph 29

MinnesotaCare Funding by Source Source: Minnesota Department of Human Services, November 2014 Expenditure Forecast, data for state fiscal years. Summary of graph 30

GENERAL ASSISTANCE MEDICAL CARE (GAMC) A state health insurance program that was for low-income adults, ages 21 to 64, who did not have dependent children under 18 and who did not qualify for other federal health care programs. It was replaced by demonstration projects, a temporary uncompensated care pool, and permitted Medicaid expansion under the ACA in March 2011.

General Assistance Medical Care Enrollment and Spending History, 2002 to 2012 Growth in: State FY* Avg. Monthly Enrollment Spending ($ millions) Avg. Monthly Spending per EnrolleeEnrollment Total Spending Spending per Enrollee ,886$182$ %35.3%11.3% ,340$248$ %36.1%8.9% ,957$246$ %-1.0%5.8% ,797$237$5365.3%-3.7%-8.5% ,199$289$6146.5%22.1%14.6% ,824$281$ %-2.7%12.8% ,853$263$ %-6.5%9.6% ,964$288$ %9.6%-1.0% ,386$296$ %2.8%20.0% ,540$76$ %-74.2%-63.9% 20120$ %-- Source: Minnesota Department of Human Services, enrollment, from February 2010 Expenditure Forecast and from February 2012 Expenditure Forecast, data for state fiscal years. *2010 and 2011 spending includes old GAMC program payments, Coordinated Care Delivery System (CCDS) block grants, uncompensated care pool payments, and pharmacy benefit payments. GAMC enrollees eligible for Medical Assistance expansion were converted March includes only old GAMC program payments. 32

General Assistance Medical Care Enrollment and Spending Growth, 2002 to 2011 Source: Minnesota Department of Human Services, enrollment, from February 2010 Expenditure Forecast and from February 2012 Expenditure Forecast, data for state fiscal years. Summary of graph 33

General Assistance Medical Care Enrollees as Percent of Population, by Region, 2010 For the regional boundaries, see slide 44 at the end of this chartbook. Sources: Minnesota Department of Human Services, enrollment data for calendar year 2010; U.S. Census Bureau, population estimates of Minnesota counties for July 1, Summary of graph 34

Statewide Distribution of General Assistance Medical Care Enrollees, by Region, 2010 For the regional boundaries, see slide 44 at the end of this chartbook. Sources: Minnesota Department of Human Services, enrollment data for calendar year Summary of chart 35

MINNESOTA COMPREHENSIVE HEALTH ASSOCIATION (MCHA) High-risk pool that offers health insurance to Minnesotans who are turned down in the private market due to pre-existing conditions. In March 2013, the Minnesota Legislature adopted legislation to phase out MCHA and create a state-based health insurance exchange, MNsure. MCHA stopped accepting new enrollees in January Former MCHA enrollees that do not qualify for Medical Assistance or MinnesotaCare may purchase private insurance on MNsure.

MCHA Enrollment and Spending History, 2003 to 2013 Growth in: Calendar Year Estimated Monthly Enrollment Avg. Monthly Premiums Avg. Monthly Claims per EnrolleeEnrollment Premium per Enrollee Claims per Enrollee ,397$240$ %9.2%11.9% ,900$264$4484.6%9.9%-0.5% ,953$291$ %10.1%24.2% ,593$322$ %10.9%9.5% ,271$326$ %1.2%7.1% ,107$347$ %6.5%12.6% ,396$370$ %6.4%2.4% ,086$397$ %7.3%7.2% ,091$408$8780.0%2.7%8.7% ,241$411$ %0.8%5.2% ,374$403$ %-2.0%5.9% Monthly enrollment estimated by MDH using annual member months figures for ; Enrollment for 2003 is estimated using average of end of year enrollment figures. Source: Minnesota Comprehensive Health Association. 37

MCHA Enrollment and Spending Growth, 2003 to 2013 Source: Minnesota Comprehensive Health Association. Summary of graph 38

MCHA Claims, Premiums, and Losses from Operations, 2003 to 2013 Calendar Year Claims ($ millions) Premiums ($ millions) Losses from Operations ($ millions) Premiums as % of Claims 2003$175$93$9053.4% 2004$182$107$ % 2005$214$111$ % 2006$217$114$ % 2007$229$115$ % 2008$248$117$ % 2009$248$122$ % 2010$262$129$ % 2011$285$133$ % 2012$291$129$ % 2013$298$122$ % Source: Minnesota Comprehensive Health Association (MCHA). 39

MCHA Enrollees as Percent of Population by Region, 2013 For regional boundaries, please see slide 44 at the end of this chartbook. Source: Minnesota Comprehensive Health Association (MCHA), enrollment by county as of December 1, 2013; US Census Bureau, population estimates for Minnesota counties as of July 1, Summary of graph 40

Statewide Distribution of MCHA Enrollees, by Region, 2013 For regional boundaries, please see slide 44 at the end of this chartbook. Source: Minnesota Comprehensive Health Association (MCHA), enrollment by county as of December 1, Summary of chart 41

Age Distribution of MCHA Enrollees, 2013 Source: Minnesota Comprehensive Health Association (MCHA), age distribution as of December 1, Summary of chart 42

Minnesota Counties and Regions Used in the Geographic Analysis Source: Minnesota Comprehensive Health Association (MCHA), age distribution as of December 1,

Additional Information from the Health Economics Program Available Online Health Economics Program Home Page ( Health Economics Program Home Page ( Publications ( Publications ( Health Care Market Statistics (Chartbook Updates) ( Health Care Market Statistics (Chartbook Updates) ( A summary of the charts and graphs contained within is provided at Chartbook Summaries - Section 5. Direct links are listed on each page. Please contact the Health Economics Program at or if additional assistance is needed for accessing this information.Chartbook Summaries - Section 5 44