July 31, 2013

Impact of the Affordable Care Act on Counties

Stephanie Radtke, Deputy Director Community Services

What is the Affordable Care Act?

• http://kff.org/health-reform/video/youtoons-

obamacare-video/

• Kaiser Family Foundation

ACA Highlights • Individual mandate to purchase insurance • Creation of Health Insurance Marketplaces • Enhanced federal match for optional Medicaid

Expansion, up to 133% FPG Single Adult = $1,274/month Family of 4 = $2,610/month

• Premium subsidy up to 400% FPG • Enhanced federal match for health care system

modernization (ongoing through 2015) • Payment reform: Accountable Care Organizations

(ACO) (ongoing)

What is MNsure? A new marketplace where individuals and small businesses can find, compare, choose, and get quality health care coverage that best fits their needs and their budget.

Important definitions & even MORE acronyms!

• ACA – Affordable Care Act The collection of bills that encompass federal health care reform.

• QHP – Qualified Health Plan A health plan that is certified to be issued through the Exchange.

• MAGI – Modified Adjusted Gross Income An income calculation method from the tax system that will be used to determine eligibility for Medicaid (certain populations) and for tax credits available to people buying insurance in the Exchange.

• APTCs – Advanced Premium Tax Credits Payments of a tax credit which provide premium assistance on an advance basis to help individuals enroll in a qualified health plan through the Exchange. APTCs are available to individuals with incomes between 100% - 400% FPG. They will reduce monthly premiums between 2% - 9.5% of monthly income.

• CURAM The new web-based system replacing MAXIS and PRISM.

Projected Audience – 1.3 million Minnesotans

Individual Consumers – 450,000

Small Business and Employees – 155,000

Medical Assistance Enrollees – 690,000

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What this means for us… Issue Estimated Timeline

1. Increased Cases • Public Assistance (MA & ‘Coat Tail” SNAP, etc.) • Child Support

Begin 10-1-2013 Begin 1-1-2014

2. Training Begin 8-1-2013

3. Conversion • Systems & Processes • Caseloads

Begin 10-1-2013 Begin 4-1-2014

4. Working in multiple systems for 3 – 5 years Begin 10-1-2013

5. Provide adequate service to ‘mixed’ families • Medical Assistance (MA) • Basic Health Plan (BHP) • Advanced Premium Tax Credits (APTC) • MNsure user without subsidies

Begin 10-1-2013

6. System efficiency gains over time Begin 1-1-2014 (Net gain beginning 2016)

Workload Changes

150%

200%

0%

50%

100%

150%

200%

250%

Prop

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Wor

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Quarter

Scenario 1

Scenario 2

Projected Workload Changes in Medical Assistance due to HIX and ACA Changes (Q1 2013 - Q1 2016)

Dakota County is projected to experience a temporary increase in workload relative to current workloads.

Contingent on technology

Projected Systems Modernization Timeline – Best Case Scenario

Medical Assistance

• October 1, 2013 – Open Enrollment for MAGI population • Summer, 2014 – Conversion for non-MAGI population

All other MAXIS programs

• Cash, SNAP, EA/EGA, etc. by end of year, 2015

PRISM • PRISM conversion to CURAM by end of year, 2016

In the meantime…..

• DHS Committee Participation • Internal Workgroups • Continued process improvements Case banking; phone banking Maximize EDMS; Compass Identify work that could be suspended or streamlined • Potential for more telecommuting opportunities 10% caseload increase

• Selective use of overtime • 3-Phase approach to MNsure Implementation Assess and modify staffing model as necessary

Additional Issues and Opportunities for Counties Medicaid Processing – Enhanced federal administrative match for new eligibility system “operations and maintenance”

75% enhanced federal match will be available for certain system and eligibility activities. No expiration date – will continue as long as the state

eligibility system is operating successfully

Some of the enhanced rate activity is performed only at the state level

County and tribal agencies can receive 75% reimbursement for specified MA eligibility activity performed by financial workers and their supervisors and support staff.

Issues and Opportunities for Counties The enhanced match is available for the following activity:

Intake – receipt of the application or application data

Acceptance – manual and automated edits and verification of data on the application including resolution of inconsistencies

Eligibility Determination – activities related to assisting the automated eligibility determination system in the evaluation of the edited, verified data to make an eligibility determination for all Insurance Affordability Programs (IAPs). This includes all financial assistance programs available through MNsure which are MA, MinnesotaCare, and Advance Premium Tax Credits (APTC)

Outputs – eligibility notices to clients, system notices, updates, transactions (state only)

On-going Case Maintenance - receipt of data related to continuing eligibility, annual renewals, address changes, income changes, household composition changes etc.

Customer Service – related to eligibility only

Maintenance and Routine System Updates – systems maintenance, security updates (state only)

Issues and Opportunities for Counties The enhanced match is NOT available for any other MA administrative activity

which will continue to be matched at the 50% rate. Some examples include:

Outreach and Marketing – general outreach, provision of information to clients and education

Referral to Services

Staff Development and Training (except system operational readiness training)

Screening and Assessments

Program Integrity and Client Appeals

Fraud and Abuse Prevention and Detection

Customer Service and complaint resolution related to benefits, staff, and plan choice and enrollment.

Issues and Opportunities for Counties

Impact of individual mandate and Medicaid expansion on county maintenance of effort (MOE) costs • Mental health and substance abuse benefits • What is the need for additional county and state $?

Issues and Opportunities for Counties Medicaid expansion and “Jail-involved” individuals • High percentage of jail-involved eligible for Medical

Assistance or premium tax credit • Payment source for substance abuse and

behavioral/mental health treatment • Impact of treatment on recidivism

Opportunities for outreach and enrollment • Condition of release • Early intervention and enrollment

Issues and Opportunities for Counties

• MNsure Consumer Assistance Outreach and Infrastructure Grant – Funds to support outreach on health care coverage – Funds to support infrastructure support with health care

enrollment

• MNsure In-person Assister Application

– Pay for performance funds for assisting people with successful health care enrollment in qualified health plan on MNSure

– $70/individual enrollment

Dakota County Community Services Value Curve

“What” do we need to address

for a successful path toward

Self-Sufficiency?

Regulative Business Model

Integrative Business Model

Collaborative Business Model

Generative Business Model

Consumer

Consumer Assistance Outreach and Infrastructure Grant

• Tier One – Community Partners

– 360 Communities; Neighbors, Inc.; Hastings Family Services; Dakota, Carver, Scott CAP Agency*

– Outreach Activities - provide information on health

care and financial empowerment with other services – Enrollment Activities - provide immediate opportunity

to apply with light assistance

Consumer Assistance Outreach and Infrastructure Grant

• Tier Two – Dakota County, Portico Healthnet*, University of Minnesota Extension* – Specialized Enrollment Activities – mobile Dakota County

enrollment specialist(s); referrals to Portico Healthnet; all enrollment specialists certified as In-Person Assisters

– Customer Contact Center – “hot” handoff for those people requiring additional enrollment assistance or services beyond health care

– Training and Resources – training on health care outreach best practices; link between financial stability and health care

In Summary • Minnesota “all in” with ACA • More temporary? work for counties; contingent on

system modernization • Implementation will be iterative and messy • Greater systems integration • Opportunities for service delivery integration

– Within county: Corrections, Sheriff, Social Services, Medical Assistance, Public Health, Housing, etc…

– With community partners: consumer outreach and enrollment; referral mechanisms

• Opportunity to re-evaluate mental health county maintenance of effort

Questions?