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Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform
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Harmonizing Eligibility, Enrollment and Coverage: NY State’s Roadmap for Reform

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  • 1. Harmonizing Eligibility, Enrollment and CoverageOne State’s (NY) Roadmap for ReformNational Academy of State Health PolicyOctober 5, 2010
    Deborah Bachrach, JD
    Bachrach Health Strategies LLC
    DBachrach@BHSStrategies.com
  • 2. Starts with evaluating NYS and ACA:
    Eligibility requirements
    Enrollment rules
    Benefit provisions
    And applying to each coverage option:
    Medicaid
    CHIP (CHPlus in NYS)
    Basic Health Program (BHP)
    Exchange Plans
    Ensuring Continuous Coverage for Consumers Below 400% of FPL
    10/5/10
    Bachrach Health Strategies, LLC
    2
  • 3. 4.5 million NYers currently enrolled in Medicaid & Medicaid expansion for adults (Family Health Plus)
    400,000 enrolled in Child Health Plus (CHPlus)
    2.6 million uninsured under age 65
    1.1 million eligible for Medicaid/FHPlus/CHPlus, but not enrolled
    90,000 additional childless adults will become eligible for Medicaid in 2014
    700,000 eligible for Exchange subsidies
    340,000 eligible for Exchange without subsidy
    390,000 undocumented immigrants
    Over 6 Million NYers Eligible for Subsidized Coverage in 2014
    10/5/10
    Bachrach Health Strategies, LLC
    3
  • 4. Cross Walking NYS and ACA Eligibility Levels
    10/5/10
    Bachrach Health Strategies, LLC
    4
  • 5. NY must determine whether to:
    Maintain Medicaid eligibility for pregnant women above 133% of the FPL
    Maintain Medicaid eligibility for parents and 19 and 20 year olds above 133% of the FPL
    How best to cover 5-year immigrants
    Consider alternatives: BHP or Exchange subsidy
    NY must pass legislation in 2011 or 2012
    Evaluate budget implications
    NY must secure CMS approval
    NY must assure smooth transitions from FHPlus&CHPlus to Medicaid, BHP or Exchange plans
    Implementing ACA Eligibility Rules
    10/5/10
    Bachrach Health Strategies, LLC
    5
  • 6. Determine benchmark plan for childless adults
    Full Medicaid?
    FHPlus (no nursing home coverage)?
    Essential Benefits Package (no nursing home, home health, dental or vision)?
    Determine whether parents and childless adults will be offered different benefit package
    Pass legislation in 2011 or 2012 and secure federal approval
    Implementing ACA Coverage Rules
    10/5/10
    Bachrach Health Strategies, LLC
    6
  • 7. Determine whether to offer a Basic Health Program for individuals between 133% and 200% of FPL
    Is BHP a cost-effective alternative to Exchange coverage?
    What benefits beyond essential?
    What is the risk profile of eligibles and what is the impact of removing them from Exchange?
    Pass legislation; competitively contract with plans
    Assure seamless coverage among plans
    Determine whether some/all plans in Exchange must offer both subsidized (including Medicaid) and non-subsidized products
    Implementing ACA Coverage Rules
    10/5/10
    Bachrach Health Strategies, LLC
    7
  • 8. Implement new income counting rule for Medicaid and Exchange subsidies: Modified Adjusted Gross Income (MAGI)
    NY Medicaid uses net income standard today
    Legislation authorizing gross income passed in 2009.
    FHPlus and CHPlus use gross income standard
    Eliminate asset test (done)
    Utilize a single, streamlined application form for Medicaid, CHPlus and Exchange subsidies
    Assure “no wrong door” & build rules into systems
    Federal guidance key (e.g. point in time)
    Implementing ACA Enrollment Standards: Rules
    10/5/10
    Bachrach Health Strategies, LLC
    8
  • 9. Section 1561 of the ACA requires HHS to develop interoperable standards to facilitate electronic enrollment and renewal into health and social services programs
    Supporting the new coverage paradigm
    Transparent processes
    Consumer friendly
    Consumer controls
    Systems talk to each other; they do the work
    Seamless integration of coverage options
    Implementing ACA Enrollment Standards: Systems
    10/5/10
    Bachrach Health Strategies, LLC
    9
  • 10. Core data elements should be able to be sent between agencies and programs
    Verification Interfaces should allow sharing of information to verify personal information on real time basis
    Business rules to administer coverage options should be consistent and technology neutral
    Standards should enable timely transfer of eligibility & enrollment information to health plans
    Personally identifiable health information must be protected
    Standards for Electronic Eligibility Enrollment and Renewal
    10/5/10
    Bachrach Health Strategies, LLC
    10
  • 11. Current systems: out-dated, disjointed, manual
    Welfare Management System: 30-year old eligibility system of record for food stamps, cash assistance and Medicaid; separate system in NYC
    EDITS accepts electronic applications in NYC; no decision logic
    KIDS is a separate system for CHIP
    Statewide Enrollment Center authorized in2008; contract pending
    My Benefits: consumer facing on line application for multiple programs
    Building an ACA-compliant system by 2014
    Assess functional requirements of ACA
    Analyze capabilities of existing systems
    Determine where existing systems can be modified and where an entirely new system is required
    Design system and procure vendor
    Implementing ACA Enrollment Standards in NY: “As Is” to “To Be”
    10/5/10
    Bachrach Health Strategies, LLC
    11
  • 12. Today, 59 counties and NYC make eligibility determinations
    2010 legislation requires NYS to assume administrative responsibilities from local social services agencies; Commissioner of Health to develop plan by November 2010 that addresses:
    Operational objectives that create efficiencies
    Standards that assure continuity of coverage
    Information system that facilitates enrollment and permits information exchange
    Coordination with the ACA
    Implementing ACA Enrollment Standards: On the Ground
    10/5/10
    Bachrach Health Strategies, LLC
    12
  • 13. Pulling It All Together by 2014
    Governor appointed inter-agency cabinet and stakeholder advisory group
    Collaboration between health and insurance agencies key to achieving seamless coverage
    New York has limited human and fiscal resources
    NYS Health Foundation providing critical support
    Preparation of Implementation road map
    Copies available at www.nyshealthfoundation.org
    Funding Exchange and BHP analyses
    Funding consultant to prepare eligibility and enrollment systems inventory and specifications for new integrated enrollment system
    10/5/10
    Bachrach Health Strategies, LLC
    13

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