1. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE MASSHEALTH: THE BASICS PREPARED BY CENTER FOR HEALTH LAW AND ECONOMICS UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL Webinar: May 29, 2014

2. INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE CONTACT INFORMATION 1 WEBINAR OVERVIEW  MassHealth: The Basics, April 2014 Update  Eligibility, enrollment and spending in MassHealth PRESENTERS  Kate Nordahl, Massachusetts Medicaid Policy Institute  Center for Health Law and Economics, University of Massachusetts Medical School: –Robert Seifert –Kate Russell –Carol Gyurina

3. INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE CONTACT INFORMATION 2 FUNDAMENTALS OF MASSHEALTH  MassHealth is Medicaid (Title XIX of the Social Security Act) and the State Children’s Health Insurance Program (CHIP, Title XXI)  Federally- and state-funded and state-administered  1.4 million members; increasing under the ACA  Includes benefits not covered by other insurance  Supports workers’ access to private insurance MASSACHUSETTS 1115 WAIVER  Section 1115 Research and Demonstration Waiver (“MassHealth”) since 1997 –Expanded eligibility for higher incomes and broader categories; subsidies in Commonwealth Care –Programmatic innovations such as CommonHealth, payment reforms and delivery system transformation –Supplemental financial support for safety net providers  Vehicle for reform  5-year renewal request pending (effective 7/1/2014)

4. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION MassHealth StandardMassHealth CarePlus MassHealth CommonHealthMassHealth Family Assistance Connector Care/Qualified Health Plan (QHP) MASSHEALTH ELIGIBILITY UNDER THE ACA 3 300% 200% 133% 100% CHILDREN ADULTS AGES 21 THROUGH 64 DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 01-1819-20 AGE IN YEARS NO UPPER LIMIT PARENTS OF CHILDREN < 19 NO UPPER LIMIT 300% 200% 133% 100% HIV POSITIVE INDIVIDUALS WITH BREAST OR CERVICAL CANCER DISABLED *FPL = income as percent of federal poverty level ** Includes members previously eligible for Commonwealth Care and for MassHealth Basic and Essential. PREGNANT ALL AGES 150% ALL OTHER** 250% INDIVIDUALS RECEIVING SERVICES FROM DMH HCBS WAIVER GROUP FORMER FOSTER CARE YOUTH UP TO AGE 26 MEDICALLY FRAIL ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD 400% ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN FPL* NO UPPER LIMIT

5. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION 300% 200% 185% 150% 133% 100% 86% % of FPL* CHILDREN DISABLEDPREGNANT01-56-1415-1718 NO UPPER LIMIT ADULTS UNDER 65 WORK FOR QUALIFIED EMPLOYER (INSURANCE PARTNERSHIP) DISABLED NO UPPER LIMIT ALL OTHER PREGNANTHIV POSITIVE LONG-TERM UNEMPLOYED WORK FOR QUALIFIED EMPLOYER (INSURANCE PARTNERSHIP) 300% 200% 133% 100% DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 01-1819-20 NO UPPER LIMIT PARENTS OF CHILDREN < 19 NO UPPER LIMIT HIV POSITIVE INDIVIDUALS WITH BREAST OR CERVICAL CANCER DISABLEDPREGNANT ALL AGES 150% ALL OTHER** INDIVIDUALS RECEIVING SERVICES FROM DMH HCBS WAIVER GROUP FORMER FOSTER CARE YOUTH UP TO AGE 26 MEDICALLY FRAIL ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD FPL* NO UPPER LIMIT ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN 300% 200% 185% 150% 133% 100% 86% 400%

6. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION MassHealth StandardMassHealth CarePlus MassHealth CommonHealthMassHealth Family Assistance Connector Care/Qualified Health Plan (QHP) MASSHEALTH ELIGIBILITY UNDER THE ACA 5 300% 200% 133% 100% CHILDREN ADULTS AGES 21 THROUGH 64 DISABLED CHILDREN & YOUNG ADULTS THROUGH AGE 20 01-1819-20 AGE IN YEARS NO UPPER LIMIT PARENTS OF CHILDREN < 19 NO UPPER LIMIT 300% 200% 133% 100% HIV POSITIVE INDIVIDUALS WITH BREAST OR CERVICAL CANCER DISABLED *FPL = income as percent of federal poverty level ** Includes members previously eligible for Commonwealth Care and for MassHealth Basic and Essential. PREGNANT ALL AGES 150% ALL OTHER** 250% INDIVIDUALS RECEIVING SERVICES FROM DMH HCBS WAIVER GROUP FORMER FOSTER CARE YOUTH UP TO AGE 26 MEDICALLY FRAIL ELIGIBLE FOR CARE PLUS BUT ELECT STANDARD 400% ELIGIBLE FOR TAX CREDITS FOR QUALIFIED HEALTH PLAN FPL* NO UPPER LIMIT

7. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION MASSHEALTH IS IMPORTANT TO MANY POPULATION GROUPS 6 PERCENT OF SELECT MASSACHUSETTS POPULATIONS COVERED BY MASSHEALTH, 2012 SOURCES: Author’s calculations using the 2012 American Community Survey (ACS). Nursing home data from Kaiser State Health Facts (C. Harrington, H. Carrillo, M. Dowdell, P. Tang, and B. Blank. Table 6, "Nursing, Facilities, Staffing, Residents, and Facility Deficiencies, 2005 Through 2010," Department of Social and Behavioral Sciences, University of California, San Francisco, accessed January 2012). Data for “all children” and “all elderly adults” calculated from Census 2012 population data projections and MassHealth Snapshot report, 2013 monthly average.

8. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION MASSHEALTH COVERS CHILDREN, ADULTS & SENIORS, AND OFTEN SUPPLEMENTS OTHER INSURANCE 7 SOURCE: MassHealth, December 2013 Snapshot Report. PERCENT OF TOTAL MASSHEALTH ENROLLMENT, DECEMBER 2013 Non-Disabled Children – 527,623 Children with Disabilities – 31,726 Seniors in Community – 102,466 Other – 22,709 Non-Disabled Adults – 316,270 Adults with Disabilities – 245,129 LT Unemployed Adults – 128,721 Seniors in Nursing Facilities – 24,476

9. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION GROWING MASSHEALTH ENROLLMENT HAS ACCOMPANIED THE DECLINE IN THE NUMBER OF UNINSURED 8 SOURCES: MassHealth figures are from the Office of Medicaid and are monthly averages, except 1998-2002 which are as of June 30. Uninsured numbers for 1998-2011 from the Division of Health Care Finance and Policy, from a survey in that year, and for 2012 from the Center for Health Information and Analysis, from ACS data. 1995 Uninsured numbers from Blendon et al., “Massachusetts Residents Without Health Insurance, 1995,” Harvard School of Public Health. TRENDS IN MASSHEALTH ENROLLMENT AND UNINSURED, 1995-2011 (THOUSANDS) MassHealth Uninsured

10. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION MORE THAN THREE IN FIVE MASSHEALTH MEMBERS ARE ENROLLED IN MANAGED CARE 9 MASSHEALTH ENROLLMENT BY PAYER TYPE, DECEMBER 2013 SOURCE: MassHealth, December 2013 Snapshot Report; EOHHS May 2014 One Care Enrollment Report MCO — 522,311 SCO — 30,540 FFS & Premium Assistance — 463,474 As of May, 13,274 individuals have enrolled in One Care, a new MassHealth program. PCC PLAN — 382,795

11. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION 10 MANAGED CARE PROGRAM POPULATIONS SERVED COVERED SERVICES Managed Care Organizations (MCO) Children and adults under 65 Medical and Behavioral Health services covered by a capitated payment to health plans. Long-term support services (LTSS) and dental benefits not included in MCO benefit but available through MassHealth Fee-For-Service Primary Care Clinician Plan (PCC) Children and adults under 65 Behavioral Health services covered by capitated payment to behavioral health plan. Medical services, which are not capitated, are managed by a primary care clinician. Dental and LTSS benefits are available through MassHealth Fee-for-Service Some primary care clinicians receive capitated payments as part of the Primary Care Payment Reform Initiative (PCPRI) One CareAges 21-64 Eligible for MassHealth and Medicare Full spectrum of services covered by capitated payment to one health plan (includes medical, LTSS, Dental, & Behavioral Health) Senior Care Options (SCO) 65 + Eligible for MassHealth and Medicare Full spectrum of services covered by capitated payment to one health plan (includes medical, LTSS, Dental, & Behavioral Health)

12. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION MCOs SERVE A LESS MEDICALLY COMPLEX POPULATION THAN THE PCC PLAN 11 NOTE: Chart shows enrollment for members under age 65. SOURCE: MassHealth, December 2013 Snapshot Report. MASSHEALTH MCO AND PCC PLAN ENROLLMENT BY POPULATION TYPE, DECEMBER 2013 Total: 382,795 Total: 522,311 3% 15% 19% 17% 3% 27% 52% 8% 11% 45% TYPE OF MANAGED CARE

13. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING NOMINAL MASSHEALTH SPENDING HAS GROWN BY MORE THAN HALF SINCE 2005; WHEN ADJUSTED FOR MEDICAL INFLATION SPENDING HAS GROWN ON AVERAGE 2% ANNUALLY 12 SOURCE: MassHealth Budget Office. Inflation adjustment uses the Medical Consumer Price Index for the Boston area, from the Bureau of Labor Statistics. MASSHEALTH SPENDING, SFY 2005-2013 (BILLIONS OF DOLLARS) STATE FISCAL YEAR

14. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING ENROLLMENT HAS DRIVEN GROWTH IN MASSHEALTH SPENDING IN RECENT YEARS 13 SOURCES: EOHHS (total spending and enrollment) and authors’ calculations. GROWTH IN MASSHEALTH TOTAL SPENDING, ENROLLMENT AND PER MEMBER PER MONTH (PMPM) COSTS (YEAR 2005 = 100) Total Spending $PMPM Enrollment

15. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING MASSHEALTH SPENDING PER ENROLLEE IS HIGHER FOR SENIORS AND THE DISABLED 14 MASSHEALTH PAYMENTS PER ENROLLEE PER YEAR, FY 2013 SOURCES: Calculations based on total spending form the MassHealth Budget Office, and average membership for July 2012 – June 2013 from the MassHealth Snapshot Report.

16. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING MASSHEALTH SPENDING IS IMPORTANT TO MANY TYPES OF PROVIDERS 15 SOURCES: Center for Health Information and Analysis, 403 Cost Reports (Acute Hospitals, data from FY2012); Massachusetts Senior Care Association (Nursing Homes – data from CY 2012); Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System Report (CHCs – data from Federal FY 2012); “Securing the Future: Report of the Massachusetts Long-Term Care Financing Advisory Committee,” November 2010 (LTSS – data from Calendar Year 2005); Mass. DPH, Massachusetts Births 2010 (Pre-natal Care – data from Calendar Year 2010), March 2013. MASSHEALTH REVENUE AS A PERCENTAGE OF PROVIDERS’ TOTAL PATIENT REVENUES HospitalsNursing Homes Community Health Centers Long-term Services and Supports Pre-natal Care

17. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING MASSHEALTH SPENDING BY SERVICE TYPE FOR STATE FISCAL YEAR 2013 16 NOTE: “Other” includes Transportation, community health centers, and smaller amounts of spending on rest homes, vision care, EI/Chapter 766, hearing care, group practice organization, family planning clinics, renal dialysis clinics, ambulatory surgery center, eye glasses, DME/Oxygen, imaging/radiation centers, certified independent labs, psychologists, mental health clinics, psychiatric day treatment, substance abuse services, and Medicare crossover payments. SOURCE: MassHealth Budget Office. TOTAL MASSHEALTH SPENDING FY2013 = $9.8B Managed Care Capitation Payments — $3.2B Nursing Homes — $1.4B Community LTC Supports — $1.4B Hospital Inpatient — $740M Dental — $245M Physician — $331M Other — $534M Hospital Outpatient — $585M Pharmacy — $512M SCO/PACE Capitation Payments — $774M

18. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING DISTRIBUTION OF MASSHEALTH ENROLLMENT AND SPENDING BY POPULATION GROUP SOURCES: MassHealth Budget Unit, SFY 2013 data. MOST MASSHEALTH DOLLARS ARE SPENT ON SERVICES FOR A MINORITY OF MEMBERS 17

19. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING STATE FISCAL YEAR FEDERAL AND STATE SPENDING ON MASSHEALTH NOW REPRESENTS 30 PERCENT OF THE STATE BUDGET 18 SOURCES: EOHHS (MassHealth data); Office of the Comptroller, Statutory Basis Financial Reports (other state spending). 27% 28% 30% Other state spending MassHealth-covered services 25% 30% MASSHEALTH AS A PROPORTION OF ALL STATE SPENDING (BILLIONS OF DOLLARS)

20. CONTACT INFORMATION MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDING MEDICAID IS THE MAIN SOURCE OF FEDERAL REVENUES TO MASSACHUSETTS 19 SOURCE: Massachusetts Budget and Policy Center Non-Medicaid federal revenue Medicaid/CHIP federal revenue MASSHEALTH AS A PROPORTION OF ALL FEDERAL REVENUES (MILLIONS OF DOLLARS)

21. MAY 2014MASSACHUSETTS MEDICAID POLICY INSTITUTE INTRODUCTIONELIGIBILITY AND ENROLLMENTSPENDINGCONTACT INFORMATION Massachusetts Medicaid Policy Institute Blue Cross Blue Shield of Massachusetts Foundation Center for Health Law and Economics University of Massachusetts Medical School Kate Nordahl Katharine.Nordahl@bcbsma.com Robert Seifert Robert.Seifert@umassmed.edu Carol Gyurina Carol.Gyurina@umassmed.edu Kate Russell Kate.Russell@umassmed.edu 20 Download the complete MassHealth: The Basics chart pack at http://bluecrossmafoundation.org/publication /updated-masshealth-basics-facts-trends-and-national-context