1. The Affordable Care Act and Realignment Article 13 Counties

2. Background California elected to implement a state-run Medicaid Expansion starting in 2014. With the state taking on the obligation for the county indigent population currently served by counties, it is assumed that counties’ costs associated with the indigent population will decrease. Assembly Bill (AB) 85 lays out a process by which a portion of the 1991 County Health Realignment Funds would be redirected to support Social Services programs. Article 13 Counties2

3. Background (cont.) The formula, should these counties not choose to redirect 60%, is addressed in Section 17613. Redirection to begin effective January 2014 Article 13 Counties3

4. Fresno Merced Orange Placer Sacramento San Diego San Luis Obispo Santa Barbara Santa Cruz Stanislaus Tulare Yolo Article 13 Counties4

5. Overview Counties have 2 options for determining the redirected amount. Each county must inform DHCS of tentative decision by 11/1/13 Must adopt a resolution by 1/22/14 60% of 1991 Health Realignment Funds + 60% of Maintenance of Effort Maintenance of Effort is capped at 14.6% of the total value of each county’s 10-11 allocation. County Savings Determination Process (Formula) Lesser of: (Revenues-Costs) x.80 (.70 in 13/14) Or County Indigent Care Health Realignment Amount (=Health Realignment Amount x Health Realignment Indigent Care Percentage) If the counties do not adopt a resolution or fail to inform DHCS of their chosen option, then the calculation is 62.5% of County Realignment funds and 62.5% of the MOE. Counties that select the 60%/40% option may later petition the Health Care Funding Resolution Committee to elect the formula option. Article 13 Counties5

6. 6 Overview Continued - County Savings Determination Process (Formula) The purpose of the formula is to calculate the health care savings the county is experiencing as a result of health care reform. This is achieved by determining if the overall available revenues exceed the costs the county is incurring (subject to a cost containment limit) Revenue 1. Indigent Program Revenues 2. Special Local Health Funds 3. County Indigent Care Health Realignment Amount 4. Imputed County Low-Income Health Amount Costs 5. Indigent Program Costs incurred by the county for the fiscal year, not to exceed the cost containment limit. County Indigent Care Health Realignment Amount Health Realignment Amount x Health Realignment Indigent Care Percentage =MIN((SUM(1+2+3+4)-5) x.80*, [or] County Indigent Care Health Realignment Amount) *In 2013/14, the savings percentage will be.70

7. Revenues Article 13 Counties7

8. Definitions – Indigent Program Revenues Self-pay payments made by or on behalf of indigent program individuals to the county for services rendered in the fiscal year. Excludes revenues received for mental health and substance use disorder services. Article 13 Counties8

9. Definitions – Special Local Health Funds  Tobacco Settlement Funds The amount of tobacco settlement funds used in the revenue calculation will be the greater of: A. The actual amount of tobacco settlement funds expended by the county during the fiscal year OR B. The tobacco settlement funds that the counties receive x the average of the historical percentages (FY08/09- FY11/12). Article 13 Counties9

10. Definitions – County Indigent Care Health Realignment Amount = Health Realignment amount for the fiscal year x Historical health realignment indigent care percentage OR = 85%  85% will be used if the county does not provide the information needed to calculate the health realignment indigent care percentage Article 13 Counties10

11. Article 13 Counties11 Health Realignment Indigent Care Percentage County-specific percentage determined as follows: The average of the percentages for each historical fiscal year of the percentage of county health realignment that was used to provide health services to the indigent. If the county does not provide the required information or insufficient data, the percentage shall be set at 85%.

12. Definitions – Imputed County Low-Income Health Amount Predetermined, county general fund subsidy used for county indigent care Calculated as follows: 1. Take the historical amount for each historical fiscal year (FY08/09-FY11/12) 2. Find the average percentage increase 3. Average the historical amounts in (1.) and multiply it by the lessor of the average percentage increase (2.) or the applicable blended CPI Article 13 Counties12

13. Costs Article 13 Counties13

14. Definitions – Indigent Program Costs Costs incurred by the county for purchasing, providing or ensuring the availability of services to the indigent program individuals during the fiscal year.  Mental health and substance use disorder costs are not included Article 13 Counties14

15. Blended Consumer Price Index (CPI) Bureau of Labor Statistics data Non-seasonally adjusted CPI for All Urban Consumers – US city average Category 1 – Hospital and Related Services – weighted at 75% Category 2 – Medical Care Services – weighted at 25% Article 13 Counties15

16. Cost Containment Limit (formula) = Base Year Cost Per person X Blended CPI X Indigent program individuals in the relevant fiscal year *base year = FY ending 3 years prior to subject FY. Article 13 Counties16

17. Cost Containment Limit IF – the subject years actual indigent program costs exceed the calculated cost containment limit for the year THEN the cost containment limit is used for the calculation OR adjustments to the cost containment limit can be sought. Article 13 Counties17

18. Adjustments to the Cost Containment Limit The following costs, if applicable, can be added to the cost containment limit prior to the application of the limit in the formula: Costs related to state or federally mandated activities, requirements, or benefit changes. Costs resulting from a court order or settlement. Costs incurred as a result of a natural disaster or act of terrorism. Other costs as requested and approved by DHCS. Article 13 Counties18

19. Article 13 Counties19 Cost Containment Limit Example

20. Timeline FY 2013/14 10/31/13 – Counties using formula give data needed for formula to state for 1) Health Realignment Amount 2) Imputed County Low-Income Health Amount 3) Indigent Program Costs o 12/15/13 – State notifies counties if we disagree with data listed above o 1/13/14 – If no agreement has been reached regarding data, DHCS shall use county’s data until a decision is made. o The County Health Care Funding Resolution Committee shall decide whether the data is accurate/sufficient within 45 days. By 6/30/15 – Counties submit final data to state By 12/31/15 – State provides final FY 2013/14 calculations to counties Article 13 Counties20

21. Timeline Continued FY 2014/15 and future years November - 5 months after the end of each fiscal year, counties using the formula submit reports on all revenue and cost data to DHCS. January - DHCS completes the interim calculation the January prior to the starting fiscal year, using the most current/accurate data available. May – DHCS updates the interim calculation in May before the start of the fiscal year. June - 12 months/by June 30th of the year after subject fiscal year, counties submit final data to DHCS. July - December – DHCS completes the final calculation and submits to counties by December 31 st of the fiscal year following the receipt of the final data – one and a half years after the subject fiscal year. Article 13 Counties 21