BB SS County Health Plan Model EMET The County Health Plan Model: Expanding Basic Health Coverage to Low Income Adults Expansion Model Evaluation Template

BB SS County Health Plan Model EMET County-Based Health Coverage Programs for Low Income Persons Current coverage programs Under discussion

BB SS County Health Plan Model EMET Target – uninsured adults age with income 200% of poverty Target = 383,500 people Currently covered: 54,500 Cost neutral expansion could reach percent of the target population Non-DSH source needed to cover all people in the target group

BB SS County Health Plan Model EMET Coverage Models Basic coverage Small employer subsidy models Volunteer networks

BB SS County Health Plan Model EMET Current Coverage – 54,500 people Funding sufficient to cover 20 percent of target population

BB SS County Health Plan Model EMET Current financing $38 million in local funds $50 million in federal funds Average cost = approx $60 pmpm

BB SS County Health Plan Model EMET Expansion funding Additional DSH Additional local funds Non-DSH source

BB SS County Health Plan Model EMET Total Funding needed to cover target population $50 million current DSH (net) $50 million additional DSH (net) $176 million new non-DSH source

BB SS County Health Plan Model EMET Coverage (Basic & Small Employer Subsidy) Primary care & specialty care Outpatient lab and x-ray Prescription drugs Not covered – Hospital care (except in Small employer subsidy programs) – Coordinated with Hospital Charity Care programs

BB SS County Health Plan Model EMET Portability of Coverage & Continuity of Care CHP’s cover a county or multi-county region Operate using managed care principles Provide outreach and enrollment Determine eligibility for other programs Reciprocity across counties contingent on funding

BB SS County Health Plan Model EMET Quality of Care/Effect on Delivery System Managed care principles Access to medicine for treatment of diabetes, hypertension, depression U/R & case management

BB SS County Health Plan Model EMET Resource and Budgetary Cost Cost neutral to state – model uses local funds to generate federal funds Expansion requires additional DSH capacity & additional local match Expansion could involve Section 1115 Medicaid waiver

BB SS County Health Plan Model EMET Resource and Budgetary Savings Treatment of diabetes, hypertension, depression, etc. reduces preventable hospitalizations and reduces absenteeism for working enrollees Reduced administrative cost through use of small number of TPA’s (five) Co-pays and premiums help balance public and private sector costs

BB SS County Health Plan Model EMET Cost Containment Managed care principles Focus on disease management Link with other community resources

BB SS County Health Plan Model EMET Implementation & Administration Five TPA’s used for “back room” functions. Use of existing infrastructure reduces administrative costs Relationship with State for ABW program assure accountability for performance, quality and efficiency

BB SS County Health Plan Model EMET Access to Coverage & Subsidies Covered population dynamic Coverage could be made more uniform under expansion Enrollment generally limited to people with income below 200% poverty Careful planning of small employer subsidy models avoids crowd out issue

BB SS County Health Plan Model EMET Financing of Costs Uncommitted DSH capacity presumed Some areas are short on qualified local funds Non-DSH financing needed to cover more (eg. Medicaid expansion)

BB SS County Health Plan Model EMET Consumer Choice of Providers & Health Plans Most CHP’s reimburse providers at Medicaid plus 4% Provider choice varies Higher reimbursement would attract more providers

BB SS County Health Plan Model EMET Provider Autonomy Provider contracts resemble those of any managed care organization

BB SS County Health Plan Model EMET Government Compulsion/Regulation No compulsory enrollment Regulation limited to essential element

BB SS County Health Plan Model EMET Variations & Their Effects Desirable: cover more people via Small employer subsidy model Desirable: easy to enroll people in Basic models Section 1115 Medicaid waiver

BB SS County Health Plan Model EMET Key Tradeoffs among Attributes “Look and feel” of insurance Small employer subsidy model can be insurance Financing cost neutral to the state Eligibility at or below that for hospital charity care programs

BB SS County Health Plan Model EMET Pros Cost neutral to state Infrastructure in place Links with other community resources Local money brings $50 million federal funds into state Positioned for small employer subsidy option Grass-roots can foster support for non-DSH supported expansion when time comes

BB SS County Health Plan Model EMET Cons Financed by DSH (not an entitlement) Except for Small employer subsidy models hospital care not covered Benefit is limited Non-DSH financing needed to cover more remaining uninsured (section 1115 waiver) Requires ongoing commitment of all partners