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Sir medicaid opportunity presentation



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  • 1. Society of Insurance Research Conference:The Business Opportunity  that Health Reform created in Medicaid Managed Care
    November 16, 2010
  • 2. How to Get Excited about the Medicaid Opportunity
    Half of the formerly uninsured will be insured through Medicaid
    Estimate of 15 of the 32 million newly insured
    Medicaid will be 17% of the national insurance market
    Individual commercial insured will be 10.7% and Small Employer group will be 13%
    Medicaid and Individual commercial plans will be linked in the exchange and through eligibility
    Today’s fully subsidized individual may be tomorrow's Medicaid eligible
    States are looking for Medicaid Managed Care plans to take the membership and the risk
    Provides additional patients and dollars for delivery system initiatives around medical home, ACO’s, and other care transformation
    Funds future R&D
    Source: McKinsey and AHIP
  • 3. Florida’s response to the Medicaid Opportunity
    As costs rise, lawmakers eye HMOs
     Posted on Sunday, 02.28.10
    Some legislators are pushing to put the growing number of Medicaid recipients into HMOs to save money, but others say the change might not reduce costs.
    Herald/Times Tallahassee Bureau
    This is the year of big talk about healthcare. And potentially bigger profits for HMOs.
    As Medicaid swells in cost and number of recipients, some Republican legislative leaders are increasingly interested in putting more of the program's patients into HMOs, giving the private companies more control over the state-federal program for the poor.
    Read more: http://www.miamiherald.com/2010/02/28/1505828/as-costs-rise-lawmakers-eye-hmos.html?story_link=email_msg#ixzz13ZselGgU
  • 4. Medicaid Landscape and DefinitionsMaintenance of Effort clause is the source of the state’s complaints about budget impact
    Federal Poverty Level (FPL): 100% Federal Poverty Level is currently $10,830 for the lower 48 states. Eligibility will be increased to 133% Federal Poverty Level which is $14,404 for a single individual.
    Federal Matching Funds (FMAP): matching funds that the federal government provides for every dollar spent by the state. On average, the federal government covers 57% of funding.
    American Recovery and Investment Act Impact: Increased FMAP to states from 50%-76% to 61%-84% through December 2010, 100% in 2014-2016 and then phases down.
    Maintenance of Effort (MOE) clause: Effective 3/23/2010 when reform was passed, states are prohibited from reducing Medicaid eligibility. As a result, states can no longer use Medicaid eligibility as a lever to balance budgets.
    CHIP: Children’s Health Insurance Program extended to 2015 and for children up to 200% Federal Poverty Level.
    New eligibles: 13 million adults (2.9 million parents and 10.1 million non-custodial adults).
  • 5. Medicaid TimelineBelow are the start and end dates that provide funding for new opportunities
    Source: AHIP
  • 6. Expansion Opportunity by StateOpportunity combination of existing eligibility and state population
    Source: Ingenix Consulting/Lewin Group
  • 7. State-by-State ImpactImpact will vary based on state’s current eligibility requirements for adults
    Source: Kaiser Family Foundation
    * For Medicaid programs only. Does not include state-sponsored premium assistance programs for working adults or limited insurance programs in Connecticut, DC, Indiana, Iowa, Maryland, Michigan, Minnesota, New Mexico Oregon, Pennsylvania, Utah, Washington, or Wisconsin since these are outside of the scope of reform
  • 8. New Medicaid Enrollees: Similarities and DifferencesMedicaid enrollee characteristics have already started to shift
    Source: Health Plan Week, Atlantic Information Services, Sept 20, 2010
  • 9. Health Plan Opportunity Assessment: The questions a health plan needs to ask (and hopefully answer) before entering or expanding
    What will the new class of eligibles be like in terms of utilization, how they access services, and how they select a plan?
    Not like the current Medicaid population in terms of ER utilization
    Answers will vary by zip code
    Where will they come from?
    Formerly uninsured or formerly from commercial group?
    What will the State Medicaid Departments require to play?
    Participation in the Exchange
    Benefit requirements
    Managed care participation
    Speed of implementation and level of interest
    What are the products or benefits?
    Benefits are typically mandated
    Main decisions will be to partner or build in-house (Integration opportunity for carved out benefits)
    How do I ensure provider capacity and the right providers to serve new eligibles?
    This requires another slide
    Source: Ingenix
  • 10. Provider PartnershipsThe Medicaid membership opportunity can provide an additional incentive to invest in new financing partnerships that are likely future methodologies
    Reimbursement models that reward phone and mid-level practitioner (nurse and social worker) care and aren’t dependent on a physician visit
    Full Capitation
    Primary care capitation
    FFS with quality or other incentives
    Risk sharing model can help with any future MLR requirements
    Reimbursement model can drive creation of team-based care
    Nurse Case Management
    Panel managers for outreach and appointment scheduling
    Carriers can provide grants to encourage these models
    Tap into other models that health reform is funding
    Section 3022 of PPACA created Accountable Care Organizations (ACO’s)
    Funding for Medical Homes
    Risk Adjustment is a possible future funding mechanism
  • 11. Federally Qualified Health Centers (FQHC)The role of the low income primary care infrastructure will grow and possibly compete with private providers
    $11 billion available to double current FQHC capacity
    Currently 1,080 FQHC’s serve 17.2 million patients with 66 million visits annually. This is expected to double
    Lessons from Massachusetts, build the primary care infrastructure before expanding eligibility
    FQHC’s bill at cost for Medicaid visits
    Payment is FFS rate + wraparound payment for covered physician visit
    Medicaid is their best payer
    Formerly uninsured patients will become either Medicaid or subsidized individual commercial insured
    Will start competing with private providers for patients with their expertise in chronic and complex care management
    Build their own niche based on skills in culturally competent care, homeless, migrant farm worker population, or other special areas
    Opportunities to contract for other lines of business such as Medicare Advantage, SNP, or high utilizing commercial groups
  • 12. How to start an FQHC in your communityAn option to buying Independent Physician Associations (IPA’s)
    Apply for grant with Bureau of Primary Health Care
    Locate a Medically Underserved Area (MUA)
    Provide required medical and enabling service including preventive, dental, case management, behavioral health, radiology, lab, prenatal care, transportation, interpretation, and medication
    Service available regardless of ability to pay and maintain certain percentage of uninsured patients
    Annual reporting requirements
    Community Governance Board
    This is the most difficult requirement for large health care organization to comply with
  • 13. Top 20 Managed Medicaid Companies by EnrollmentEnrollment is less consolidated than Medicare Advantage.
    Source: Health Plan Week, Atlantic Information Services, Sept 20, 2010
    Enrollment through end of 2009