Harmonizing Eligibility, Enrollment and CoverageOne State’s (NY) Roadmap for ReformNational Academy of State Health Policy...
Starts with evaluating NYS and ACA:<br />Eligibility requirements<br />Enrollment rules<br />Benefit provisions<br />And a...
4.5 million NYers currently enrolled in Medicaid & Medicaid expansion for adults (Family Health Plus)<br />400,000 enrolle...
Cross Walking NYS and ACA Eligibility Levels<br />10/5/10<br />Bachrach Health Strategies, LLC<br />4<br />
NY must determine whether to:<br />Maintain Medicaid eligibility for pregnant women above 133% of the FPL<br />Maintain Me...
Determine benchmark plan for childless adults<br />Full Medicaid? <br />FHPlus (no nursing home coverage)?<br />Essential ...
Determine whether to offer a Basic Health Program for individuals between 133% and 200% of FPL<br />Is BHP a cost-effectiv...
Implement new income counting rule for Medicaid and Exchange subsidies: Modified Adjusted Gross Income (MAGI)<br />NY Medi...
Section 1561 of the ACA requires HHS to develop interoperable standards to facilitate electronic enrollment and renewal in...
Core data elements should be able to be sent between agencies and programs<br />Verification Interfaces should allow shari...
Current systems: out-dated, disjointed, manual<br />Welfare Management System: 30-year old eligibility system of record fo...
Today, 59 counties and NYC make eligibility determinations<br />2010 legislation requires NYS to assume administrative res...
Pulling It All Together by 2014<br />Governor appointed inter-agency cabinet and stakeholder advisory group<br />Collabora...
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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

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

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