0 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Health Care Expansions in the District of Columbia.

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Presentation transcript:

0 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Health Care Expansions in the District of Columbia Healthy DC and Other Coverage Strategies Dave Chandra Director Office of Health Care Innovation Department of Health Care Finance

1 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Department of Health Care Finance Established as separate cabinet-level agency on October 1, 2008 Continues oversight of publicly funded health care programs New and greater emphasis on private market and access to care for uninsured Established Office of Health Care Innovation Department of Health Care Finance Department of Health Medical Assistance Administration Department of Mental Health Department of Human Services Department of Health Department of Mental Health Department of Human Services Mayor Prior StructureNew Structure Office of Health Care Innovation

2 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Coverage Distribution - DC 1 District of Columbia: Health Insurance Coverage of the Total Population, states ( ), U.S. (2008), Kaiser Family Foundation, 2 Department of Health Care Finance Enrollment Data (as of September 30, 2009) 3 Current Population Survey 2008, US Census Bureau (2009) 4 percentages summate to over 100% because 1) data is from multiple surveys and 2) Alliance members may be categorized as uninsured in the Current Population Survey 4 State Heath Facts, Kaiser Family Foundation (2008) available at Type of Coverage # of DC Residents Percent of DC Residents 4 Percent of US Population 5 Private Coverage 1 348, %57.0% Medicare 1 59, %12.4% Medicaid 2 158, %14.1% DC HealthCare Alliance 2 54,7849.3%n/a Uninsured 3 59, %15.4%

3 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Coverage Distribution - Region State Heath Facts, Kaiser Family Foundation (2008) available at Type of Coverage District of Columbia Maryland Virginia Private Coverage58.9%64.9%62.0% Medicare10.0%11.2%12.2% Medicaid26.8%9.9%8.6% Other Public9.3%1.0%3.5% Uninsured10.0%12.9%13.8%

4 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Safety Net Insurance In DC ChildrenParents Seniors/People w/ Disabilities Childless Adults Undocumented Adults 400% Uninsured 300% Medicaid/CHIP Qualified Medicare Beneficiaries (QMB) 200% Medicaid/ DC Healthy Families DC HealthCare Alliance 100% Medicaid

5 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Safety Net Insurance In DC ChildrenParents Seniors/People w/ Disabilities Childless Adults Undocumented Adults 400% Healthy DC 300% Medicaid/CHIP Qualified Medicare Beneficiaries (QMB) 200% Medicaid/ DC Healthy Families DC HealthCare Alliance 100% Medicaid

6 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only DC Medicaid Primarily serves children, parents, low-income seniors and individuals with disabilities, and certain other populations SCHIP implemented as Medicaid Expansion 158,551 enrollees (26.9% of DC population): –57,378 in fee-for-service –101,173 in one of three managed care plans Enrollment through Single Point of Entry IMA (DHS) 70/30 federal matching percentage (79/21 under ARRA)

7 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only DC HealthCare Alliance Established in 2001 out of closure of DC General Hospital Covers uninsured DC residents up to 200% FPL No citizenship documentation requirement ~54,784 enrollees Coverage through the three Medicaid MCOs Benefit limits greater than those in Medicaid (no mental health/ long term care, defined formulary, closed pharmacy network) Supported by DC funds

8 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Healthy DC Healthy DC legislation passed in 2008 Establishes coverage for uninsured residents up to 400% FPL Member premiums statutorily capped at 3%/5% of income Benefit Package/Cost sharing equivalent to large group products Coverage through managed care plan(s) Enrollment cap commensurate with available funds Funded by assessment on health insurance premium revenues Enrollment to be handled by DHCF Target launch – Spring 2010

9 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Budget Funded by 2% premium tax on DC HMOs and Hospital and Medical Services Corporations FY10 - $11,714,963* (projected available funds) FY11 - $17,486,000* (projected available funds) *B directs an additional $5 million to the Healthy DC Fund as part of a public-private partnership between DC Government and a Hospital and Medical Services Corporation

10 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Eligibility To be eligible for the Healthy DC Program, applicants must: Be a DC resident for at least 6 months; and Have a household income at or below 400% FPL; and Be ineligible for any other local or federal health benefit programs; and Have been uninsured for at least 6 months; or Have lost insurance coverage for a qualifying reason

11 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Member Premiums Healthy DC Statutory limits for Monthly Member Premiums: Projected FY10 Monthly Member Premiums: <300% FPLAdults$35 301% - 400% FPL Children$40 Adults$70 IndividualFamily of 4Limit <300% FPL<$32,490>$66,1503% of income 301% - 400% FPL $32,491 - $43,320$66,151 - $88,2005% of income

12 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Proposed Benefit Package ServiceCost-Sharing/ Co-Pay Annual Deductible$200 (except for preventive care visits) Out of Pocket MaxNone Lifetime Benefit Maxnone Annual Benefit Max none Primary Care Visits $15 Specialist Visits $25 Maternity Visits $10 ED Visits $100 (waived if admitted) EMS Transport$100 (waived if emergent)

13 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Proposed Benefit Package ServiceCost-Sharing/ Co-Pay Pharmaceuticals$10 Tier I/$20 Tier II/$40 Tier III Inpatient Hospital$100 Behavioral Health$25 per visit Nursing Home/SNF15% after deductible (30 days per year) Home Care Services$40 per visit (25 visits per year) Dental30% preventive, 50% basic restorative DME, Vision, Podiatry etcvarying co-pays

14 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only District-wide public awareness campaign via print, broadcast, and online media Targeting working DC residents likely to be uninsured: Guided by findings from pending Urban Institute Insurance Survey Collaboration with DC business/small business organizations Will link residents to Healthy DC, or other public assistance programs where appropriate Marketing and Outreach - Parents of CHIP children - Restaurant/bar employees - Construction workers - Sole practitioners - Low-wage/part time workers - Home care aides

15 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Broad legislative language is preferred to very prescriptive terms Dedicated tax revenue source ensures level of sustainability Establishing new enrollment system is administratively cumbersome Compromises are inevitable to ensure affordability and feasibility Overhead/infrastructure development cost is extensive regardless of program size Crowd-out and Adverse Selection remain concerns Community partnerships are critical to developing benefit design, premium levels, rules, outreach plan etc Lessons Learned

16 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only National Health Reform & DC Healthy DC infrastructure to accommodate state-required functions in health reform legislation New customer service unit can process eligibility for Health Exchange Healthy DC can serve as a possible public option in a local exchange Can establish regional exchange with metro partners Childless Adult expansion in Medicaid

17 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only 1115 Medicaid Waiver for Childless Adults up to 200% FPL Refine DSH formula based on new uncompensated care reporting Establish pilot program high cost/chronically-ill Medicaid members CareFirst Blue Cross/Blue Shield Open Enrollment Program Create Premium Assistance Program in Medicaid/Healthy DC Enhance Purchasing in DC Employee Benefit Plan Reform Small Group/Non-Group Market Provider Payment Reform Other Local Reform

18 Government of the District of ColumbiaDepartment of Health Care Finance For Official Government Use Only Department of Health Care FinanceGovernment of the District of Columbia Questions? Contact Dave Chandra Department of Health Care Finance