1. Incremental Expansions in Maryland: Medicaid and Small Group Coverage Dr. Rex Cowdry, Executive Director Maryland Health Care Commission Stacey Davis, Deputy Director Office of Planning, Medicaid Maryland Department of Health and Mental Hygiene

2. State of the State in Early 2007 Over 700,000 uninsured individuals Public coverage of children relatively generous Public coverage for parents, non-parental adults relatively poor Robust, modified community rated small group market with participation rates just under 50% Healthy underwritten individual market with an innovative high risk pool Rates approx 130-135% of standard risk Rates below standard risk for low income populations Non-HIPAA: Choice of pre-ex or a temporary premium surcharge Democratic governor (defeated Republican incumbent); General Assembly strongly Democratic but fiscally conservative

3. Working Families and Small Business Health Coverage Act (SB 6) Two main goals –Expand health coverage to low income Marylanders –Expand coverage among small, low income businesses Planning team principles for success: –Right-size the planning group. Team included Governor’s policy/legislative staff, key Senate and House committee chairs, Secretary of Health and Mental Hygiene and policy staff, Medicaid director, Insurance Commissioner, Health Care Commission ED –Get out of town. The brilliance of the SCI Coverage Institute Chicago strategy Passed during a Special Legislative Session, November 2007 SCI grant funds used for Medicaid expansion messaging and small group subsidy modeling

4. Public Coverage Prior to SB 6 200 100 300 133 40 Age 65 and Over+ 19610 250 PW 185 MCHP Premium MCHP Medicaid Pregnant Women Medicare 300 116 Note: This chart is for illustrative purposes only. Each coverage group has specific eligibility and some asset requirements, which are not shown. Poverty Level: 1 person = $10,830 2 persons =$14,570 3 persons = $18,310 4 persons = $22,050 As of 1/23/2009 Medicaid & Medicare Primary Adult Care Program – Limited Services Major gap in public coverage for low-income families Parents or disabled age 19 to 64

5. Public Coverage As of July 2008 200 100 300 133 40 Age 65 and Over+ 19610 250 PW 185 MCHP Premium MCHP Medicaid Pregnant Women Medicare 300 116 Note: This chart is for illustrative purposes only. Each coverage group has specific eligibility and some asset requirements, which are not shown. Poverty Level: 1 person = $10,830 2 persons =$14,570 3 persons = $18,310 4 persons = $22,050 As of 1/23/2009 Medicaid & Medicare Parents to 116% FPL Primary Care for Other Adults to 116% FPL Parents or disabled age 19 to 64 Phase I: Parents to 116% FPL

6. Public Coverage (Delayed implementation) 200 100 300 133 40 Age 65 and Over+ 19610 250 PW 185 MCHP Premium MCHP Medicaid Pregnant Women Medicare 300 116 Note: This chart is for illustrative purposes only. Each coverage group has specific eligibility and some asset requirements, which are not shown. Poverty Level: 1 person = $10,830 2 persons =$14,570 3 persons = $18,310 4 persons = $22,050 As of 1/23/2009 Medicaid & Medicare Parents to 116% FPL _____________ Incremental Increases to other adults below 116% Parents or disabled age 19 to 64 Childless Adults Phase II: ED/Specialty Phase III: Outpatient Phase IV: Inpatient

7. Enrollment Changes to Medicaid Changes in the Application Process No face-to-face interview Income and childcare expenses are declaratory Eliminated asset test Accepted applications at both the local health departments in addition to the local departments of social services Declaratory information is verified through automated systems Accuracy of eligibility claims will be examined in upcoming Medicaid fraud and abuse assessment

8. Medicaid Expansion for Parents Parent Enrollment Trends (Incomes between 30% FPL and 116% of FPL) Results of the Expansion: Over 44,000 Parents have enrolled in One Year

9. Enrollment Trends are significantly higher than prior years - Economy is a factor also Excluding Expansion Parents

10. Expansion Medicaid Implementation - Lessons The economic downturn and the state budget deficit can stall the expansion of coverage. Phases II-IV have been modified. The second phase is limited to adding substance abuse services. Enhanced coordination is needed between health and social services departments to provide a true “no wrong door” enrollment process. Necessary revisions to legacy administrative systems can be challenging and expensive. Growth has exceeded expectations. Calculating enrollment growth directly tied to Medicaid expansion is difficult because of simultaneous economic downturn.

11. The Starting Point: MD Small Business More Likely to Offer Insurance Than in Many Other States --- Still, less than ½ offer insurance Small Business Premium Subsidy Program

12. SB6- Small Business Subsidy Design choices: –Target the uninsured or assist all small businesses? –Target small businesses that are least likely to offer insurance and most in need of premium assistance? Low wage, low number of employees –Subsidize employers or individuals? –Offer choices of plans / promote competition? –Administer through the tax code or through health plans? Design guiding principles: –Achieve credibility with small employers –Provide enough subsidy to change behavior –Avoid sudden loss of eligibility / subsidy (no cliffs) –Use insurance brokers or sell directly through an insurance exchange. –Inform and enroll this new “coverage” group in the subsidy option Governor’s initiative Anticipated funding $15-30 million annually

13. Health Insurance Partnership Resulting design: target small businesses who: –have not offered insurance in the past year –have 2-9 eligible employees (including the owner) –have a low average wage (full subsidy up to $25,000, phased out at $50,000) Spouses and children eligible for subsidies in families with AGI under $75,000 Choice of carriers and plans (any willing carrier) Pay plans directly to reduce complexity and fraud; subsidy passed through to employer and employee in the form of lower premiums Maximum subsidy is the lesser of 50% of the premium or an amount set by the Commission Subsidy phases out at renewal as firms grow in size and income

14. Enrollment in the Health Insurance Partnership: Swimming Upstream (or Uptorrent) SB6 passes Partnership subsidy begins Actual = 867 covered lives Partnership Enrollment Projected = 13,000 covered lives S&P 500

15. Lessons from the Health Insurance Partnership Confirmation: price elasticity of demand for health insurance is very low among smallest employers. Non-offering employers require substantial subsidies - and in the face of a recession and economic uncertainty, even a 50% reduction in premium and extensive outreach are not enough. Employers are wary that a program may not be there in a year or two – and mistrust reassurances. As with any modified community rated market, adverse selection is expected, especially in smallest groups. Effective targeting requires complex eligibility rules. Complex eligibility rules complicate employer/employee outreach and affect enrollment. However, the Partnership has been a useful trial run for a state Health Insurance Exchange with individual responsibility, broker participation, carrier and plan choice, and income/wage-based premium subsidies.

16. Related Initiatives Kids First Act (HB 1391) –Uses tax forms to identify uninsured children eligible for Medicaid –Two types of outreach provided to families Year 1: Letters Year 2: Letters & Applications –Goal - create a system which identifies uninsured, Medicaid-eligible children and efficiently enrolls them in health coverage Maryland Health Quality and Cost Council (Executive Order) –Develops strategic health policy reforms to improve the health and health care of Maryland’s citizens. Current foci: formulating a strategy to address chronic illnesses, developing a patient centered medical home demonstration, and identifying and implementing best practices in areas like infection control. COBRA and mini-COBRA subsidies –ARRA enabled subsidies of both state and federal COBRA coverage

17. Moving Forward Despite the Economy (with a lot of help from ARRA) Limited Medicaid expansion ARRA FMAP increase helps with enrollment growth Phase II - add substance abuse services to the Primary Adult Care Program –Dependent-less adults to 116% FPL Proposed coverage expansion: SSI individuals up to 300% FPL Consider expansion of the Partnership to firms with 2-20 employees Health Information Technology Health information exchange –Extensive policy, privacy, and security discussions, five comprehensive reports on issues –Competitive planning and design process –Implementation funding $10 million through Maryland’s unique all-payer hospital rate setting system –State will apply for ARRA state implementation grant –Policy to be set by a separate Policy Board with strong representation of public interests EHR adoption –CMS project on EHR adoption in small physician practices –ARRA Medicare/Medicaid incentives –Private payers in Maryland must also provide parallel incentives for EHR adoption –MSO/ASP model for small physician offices –Purchase of EHR system for state hospitals

18. The Long View of Health Care Coverage Contingency planning for the state’s role in national health care reform Procurement delays in state’s crystal ball acquisition Examination of individual and small group market reform proposals underway Health insurance exchange already modeled with SCI support Funding the planned Medicaid expansion challenging, even with enhanced FMAP Dealing with the costs of our health care system Enhance Maryland’s all-payer hospital rate setting system –Particularly important in an era of hospital consolidations, oligopoly power –Move beyond “Never Events” to “Potentially Preventable Complications” adjustments Change consumer incentives –Value-based benefit designs –Price transparency and outcomes reporting Change provider incentives – bundled payments instead of FFS –Patient-centered medical home – with “shared savings” or “efficiency payments” –Prometheus reimbursement (primary and specialist care) –Accountable care organizations