Vermont Health Care Reform National Academy for State Health Policy  Annual Conference   Denver, Colorado Pilgrim’s Pride ...
Vermont Context <ul><li>Population: 623,000 </li></ul><ul><li>19 U.S. cities are larger than Vermont </li></ul><ul><li>Ran...
Vermont Context – Health Care Costs <ul><li>Growing cost of health care is unsustainable </li></ul><ul><ul><li>Annual expe...
Vermont Context – The Insured   91.2% of Vermonters, 95.1% of Vermont children <ul><li>Private Health Insurance </li></ul>...
Vermont Data 2005 – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children <ul><li>An 1.4% increase in the rate of uni...
Vermont Data 2005 – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children <ul><li>77% reported cost as the main reaso...
Vermont’s Response <ul><li>2006 Legislation </li></ul><ul><ul><li>Health Care Affordability Acts  (Acts 190, 191) </li></u...
Health Care Reform Goals Increase Access Improve Quality Contain Costs 35+ Initiatives
Goal: Increase Access to Affordable Health Care Coverage <ul><li>Enhance Private Insurance Coverage </li></ul><ul><li>Cata...
Goal: Improve Quality of Care <ul><li>Chronic Care Management </li></ul><ul><li>Blueprint for Health </li></ul><ul><li>OVH...
Goal: Contain Costs Increase Access to Coverage and Care    Decrease Uncompensated Care    Lower Premium Costs <ul><li>D...
Health Care Coverage
Why is Coverage Important? <ul><li>Un-reimbursed care increases private insurance premiums </li></ul><ul><ul><li>Makes ins...
Catamount Health   <ul><li>A non-group insurance product for uninsured Vermont residents </li></ul><ul><li>Offered as a pr...
Catamount Health <ul><li>LEGISLATIVELY-MANDATED COST-SHARING </li></ul><ul><li>Deductibles:   In-Network: Out-of-Network: ...
Catamount Health Costs <ul><li>The cost will depend on individual / household income  </li></ul><ul><li>Cost for Individua...
Catamount Health Eligibility <ul><li>You can purchase Catamount Health if you are an  uninsured  Vermont resident, are 18+...
Catamount Health Eligibility <ul><li>You can purchase Catamount Health even if you are eligible for an Employer-Sponsored ...
Key Dates:   CATAMOUNT HEALTH PLANS <ul><ul><li>September 8, 2006 Rules filed with Secretary of State </li></ul></ul><ul><...
Premium Assistance <ul><li>Catamount Health </li></ul><ul><ul><li>Vermonters who qualify for Catamount Health with income ...
Premium Assistance   Cost Effectiveness Test <ul><li>VHAP Applicants (under 150 -185% FPL) </li></ul><ul><ul><li>If provid...
How will Premium Assistance be Paid? <ul><li>Catamount Health Premium Assistance </li></ul><ul><ul><ul><li>Beneficiary wil...
Key Dates:  PREMIUM ASSISTANCE FOR  ESI / CATAMOUNT <ul><ul><li>September, 2006 Waiver Amendment Request submitted to CMS ...
Outreach and Enrollment <ul><li>Integrated Medicaid, Catamount Outreach and Enrollment Strategies </li></ul><ul><ul><li>Ag...
 
 
 
Coverage Implementation Issues <ul><li>Estimating costs for new coverage plans </li></ul><ul><li>Estimating eligibles, tak...
FOCUS ON CHRONIC CARE
Blueprint for Health   <ul><li>State’s Plan for Better Management and Prevention of Chronic Illnesses across All Payers an...
Public Policy Public Health Health  Systems Community Health Provider Team Patients and  Families <ul><li>Policies </li></...
Examples of Blueprint Components <ul><li>Insurance company collaboration </li></ul><ul><li>Required payment reform in 2 pi...
Other Chronic Care Strategies  To Be Aligned with the Blueprint <ul><ul><li>Medicaid Chronic Care Management Program </li>...
Blueprint Alignment Topics Across Chronic Care Programs <ul><li>Coordination of care across the multiple programs working ...
Blueprint Impact on Health Care Costs <ul><li>It will not SAVE money – but it will reduce the  rise  in cost of care </li>...
Health Information Technology <ul><li>VITL = Statewide Regional Health Information Organization  (RHIO) </li></ul><ul><ul>...
Blueprint, IT Implementation Issues <ul><li>Private Payer Resource Commitments </li></ul><ul><li>Provider Belief, Vision <...
Reform Financing
Financing of Reforms <ul><li>Based on the principle that everybody is covered and everybody pays: </li></ul><ul><ul><li>Ca...
Employer Contribution <ul><li>Assessment for “uncovered FTEs”  </li></ul><ul><ul><li>Employers without a plan   that pays ...
Employer Contribution <ul><li>Employee = any individual 18 years or older on employer’s unemployment insurance filing </li...
What about ERISA? <ul><li>Employee Retirement Income Security Act of 1974  </li></ul><ul><ul><li>Regulates private sector ...
What about ERISA? <ul><li>We do not believe that Vermont’s Employer Assessment law does not meet the standards to be in vi...
Key Dates <ul><li>EMPLOYER CONTRIBUTION </li></ul><ul><ul><li>September, 2006 Draft Rules Distributed for Public Comment <...
Employer Contribution Implementation Issues <ul><li>ERISA barriers to good revenue estimates </li></ul><ul><li>As of Octob...
Reform Oversight <ul><li>Joint Legislative Commission on Health Care Reform </li></ul><ul><ul><li>Monthly meetings </li></...
<ul><li>For more information   </li></ul><ul><li>Vermont Health Care Reform Web-site:  </li></ul><ul><li>www.hcr.vermont.g...
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Vermont Health Care Reform

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Susan Besio

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Vermont Health Care Reform

  1. 1. Vermont Health Care Reform National Academy for State Health Policy Annual Conference Denver, Colorado Pilgrim’s Pride Workshop 1:30 - 3:00 pm October 15, 2007 Susan W. Besio, Ph.D. Director of Health Care Reform Implementation Vermont Agency of Administration
  2. 2. Vermont Context <ul><li>Population: 623,000 </li></ul><ul><li>19 U.S. cities are larger than Vermont </li></ul><ul><li>Ranked the 2nd healthiest state overall in 2005 and 2006 1 </li></ul><ul><li>Ranked 11th for proportion of population insured 2 </li></ul><ul><li>1 United Health Foundation </li></ul><ul><li>2 US Census 2005 revised </li></ul>
  3. 3. Vermont Context – Health Care Costs <ul><li>Growing cost of health care is unsustainable </li></ul><ul><ul><li>Annual expenditures of $3.5 billion </li></ul></ul><ul><ul><li>15.2% of Vermont’s gross state product </li></ul></ul><ul><ul><li>Vermont’s per capita costs still less than national average, but spending growth rates have been higher than national average for last 6 years </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Health Care Expenditures(2005) </li></ul></ul><ul><ul><li>Vermont U.S. </li></ul></ul><ul><ul><li>Total (billions) $3.5 $2,016 </li></ul></ul><ul><ul><li>Per capita $5,636 $6,682 </li></ul></ul><ul><ul><li>Annual Change (2004-2005) 7.2% 7.4% </li></ul></ul><ul><ul><li>Average Annual Change (1995 -2005) 7.9% 7.0% </li></ul></ul><ul><ul><li>Share of Gross State/Domestic Product 15.2% 16.2% </li></ul></ul><ul><li>Over 60,000 Vermonters are uninsured, and the number is growing </li></ul><ul><li>An estimated 50% of Vermonters with chronic conditions account for 70% of health care spending, but only 55% get the right care at the right time </li></ul>
  4. 4. Vermont Context – The Insured 91.2% of Vermonters, 95.1% of Vermont children <ul><li>Private Health Insurance </li></ul><ul><ul><li>59.4% (370,000) have private insurance as primary coverage </li></ul></ul><ul><ul><ul><ul><li>91% receive employer-sponsored insurance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>5% purchase their own coverage in the individual market </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Remaining covered by higher education, COBRA, etc. </li></ul></ul></ul></ul><ul><li>Medicaid: </li></ul><ul><ul><li>14.5% (90,350) have Medicaid as primary coverage </li></ul></ul><ul><ul><ul><ul><li>Traditional Medicaid – up to 125% FPL </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dr. Dynasaur – Children in households up to 300% FPL (41% of Vermont’s children) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vermont Health Access Plan (VHAP) – Adults up to 150% FPL and caretakers of dependent children up to 185% FPL </li></ul></ul></ul></ul><ul><ul><li>Largest Insurer in Vermont (9,000 Enrolled Providers) </li></ul></ul><ul><li>Medicare: 14.5% (90,100) </li></ul><ul><li>Military Insurance: 1.7% (10,500) </li></ul>
  5. 5. Vermont Data 2005 – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children <ul><li>An 1.4% increase in the rate of uninsured since 2000 (8.4%) </li></ul><ul><li>51% are eligible for Medicaid programs but not enrolled </li></ul><ul><ul><li>79% of uninsured children; 49% of uninsured adults (18 – 64) </li></ul></ul><ul><ul><li>87% are interested in enrolling; 57% believe they are not eligible </li></ul></ul><ul><li>27% have household income between 150-185% and 300% FPL and are not eligible for a Medicaid program but cannot afford private insurance </li></ul><ul><li>69% have been without insurance for more than a year </li></ul>
  6. 6. Vermont Data 2005 – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children <ul><li>77% reported cost as the main reason for being uninsured </li></ul><ul><li>30% of uninsured children and 40% of uninsured adults did not see a health care professional in past year </li></ul><ul><li>45% of uninsured children did not see a physician for routine care (compared to 7% of insured children) </li></ul><ul><ul><li>Much more likely to go to ER or urgent care (8.6% vs .7%) </li></ul></ul><ul><li>25% of uninsured adults reported not seeking needed medical care due to cost </li></ul>
  7. 7. Vermont’s Response <ul><li>2006 Legislation </li></ul><ul><ul><li>Health Care Affordability Acts (Acts 190, 191) </li></ul></ul><ul><ul><li>Common Sense Initiatives (Appropriations Bill) </li></ul></ul><ul><ul><li>Sorry Works! (Act 142) </li></ul></ul><ul><ul><li>Safe Staffing and Quality Patient Care (Act 153) </li></ul></ul><ul><li>2007 Legislation </li></ul><ul><ul><li>Corrections and Clarifications to the Health Care Affordability Acts of 2006 (Act 70) </li></ul></ul><ul><ul><li>An Act relating to Ensuring Success in Health Care Reform (Act 71) </li></ul></ul><ul><li>Joint Legislative Commission on Health Care Reform </li></ul><ul><li>Administration Director of Health Care Reform Implementation </li></ul>
  8. 8. Health Care Reform Goals Increase Access Improve Quality Contain Costs 35+ Initiatives
  9. 9. Goal: Increase Access to Affordable Health Care Coverage <ul><li>Enhance Private Insurance Coverage </li></ul><ul><li>Catamount Health Plan for the Uninsured </li></ul><ul><li>Non-Group Market Reform </li></ul><ul><li>Promotion of Employer-Sponsored Insurance </li></ul><ul><li>Local Health Care Coverage Planning Grant </li></ul><ul><li>Potential Individual Insurance Mandate </li></ul><ul><li>Improve Outreach to </li></ul><ul><li>Uninsured </li></ul><ul><li>Aggressive Marketing </li></ul><ul><li>Dedicated Web-site, 1-800 # </li></ul><ul><li>Application Simplification </li></ul><ul><li>Assist with Affordability </li></ul><ul><li>Premium Assistance (ESI, Catamount) </li></ul><ul><li>Reduction in VHAP Premiums </li></ul>
  10. 10. Goal: Improve Quality of Care <ul><li>Chronic Care Management </li></ul><ul><li>Blueprint for Health </li></ul><ul><li>OVHA Chronic Care Management Program </li></ul><ul><li>State Employee Health Plan </li></ul><ul><li>ESI Premium Assistance plan approval, cost-sharing </li></ul><ul><li>Catamount Health coverage, cost-sharing </li></ul><ul><li>Care Coordination </li></ul><ul><li>Payment Reforms </li></ul><ul><li>Increase Provider Access </li></ul><ul><li>to Patient Information </li></ul><ul><li>Health Information Technology </li></ul><ul><li>Electronic Medical Records </li></ul><ul><li>Master Provider Index </li></ul><ul><li>Multi-payer Database </li></ul><ul><li>Promote Quality Improvement </li></ul><ul><li>Consumer Health Care Price & Quality System </li></ul><ul><li>Adverse Events Monitoring System </li></ul><ul><li>Hospital-acquired Infections Data </li></ul><ul><li>Safe Staffing Reporting </li></ul><ul><li>SorryWorks! </li></ul><ul><li>Advanced Directives </li></ul><ul><li>Increase Provider Availability </li></ul><ul><li>Loan Repayment Program </li></ul><ul><li>Loan Forgiveness Program </li></ul><ul><li>FQHC Look-alike Funding </li></ul><ul><li>Promote Wellness </li></ul><ul><li>Immunizations </li></ul><ul><li>CHAMPPS Grants </li></ul><ul><li>Catamount Health Coverage, cost-sharing </li></ul><ul><li>Healthy Lifestyles Insurance Discounts </li></ul><ul><li>AHS Inventory of Health and Wellness Programs </li></ul>
  11. 11. Goal: Contain Costs Increase Access to Coverage and Care  Decrease Uncompensated Care  Lower Premium Costs <ul><li>Decrease Cost Shift </li></ul><ul><li>Increase Medicaid Provider Rates </li></ul><ul><li>Cost Shift Task Force </li></ul><ul><li>Standardize Policy for Hospital </li></ul><ul><li>Uncompensated Care and Bad Debt </li></ul><ul><li>Hospital Cost Shift Reporting Reforms </li></ul>Improve Quality of Health Care  Appropriate Care, Better Information  Lower Costs <ul><li>Simplify Administration </li></ul><ul><li>Common Claims and Procedures </li></ul><ul><li>Uniform Provider Credentialing </li></ul>
  12. 12. Health Care Coverage
  13. 13. Why is Coverage Important? <ul><li>Un-reimbursed care increases private insurance premiums </li></ul><ul><ul><li>Makes insurance less affordable </li></ul></ul><ul><ul><ul><li>Fewer people are covered </li></ul></ul></ul><ul><ul><ul><li>Benefits are decreased and/or people choose non-comprehensive plans to make plans affordable </li></ul></ul></ul><ul><li>People with comprehensive insurance coverage are more likely to participate in preventive care </li></ul><ul><ul><li>Increases quality of life </li></ul></ul><ul><ul><li>Decreases cost of health care overall </li></ul></ul>
  14. 14. Catamount Health <ul><li>A non-group insurance product for uninsured Vermont residents </li></ul><ul><li>Offered as a preferred provider organization plan by two private insurers, beginning October 1, 2007 </li></ul><ul><li>Is required to be a comprehensive insurance package covering: </li></ul><ul><ul><ul><li>Primary care </li></ul></ul></ul><ul><ul><ul><li>Preventative care </li></ul></ul></ul><ul><ul><ul><li>Acute episodic care </li></ul></ul></ul><ul><ul><ul><li>Chronic care </li></ul></ul></ul><ul><ul><ul><li>Hospital services </li></ul></ul></ul><ul><ul><ul><li>Pharmaceutical coverage </li></ul></ul></ul><ul><li>Individuals may choose which insurer they would like to use. </li></ul>
  15. 15. Catamount Health <ul><li>LEGISLATIVELY-MANDATED COST-SHARING </li></ul><ul><li>Deductibles: In-Network: Out-of-Network: </li></ul><ul><li>$250/individual $500/individual </li></ul><ul><ul><ul><li>$500/family $1,000/family </li></ul></ul></ul><ul><li>Co-Payment: $10/office visit </li></ul><ul><li>Prescription Drugs: No deductible Co‑payments: $10 generic drugs </li></ul><ul><li>$30 drugs on preferred drug list </li></ul><ul><li>$50 non-preferred drugs </li></ul><ul><li>Preventive Care & </li></ul><ul><li>Chronic Care*: $0 Not subject to deductible, co-insurance, co-payments </li></ul><ul><li>Out-of-Pocket Maximum: In-Network : Out-of-Network: </li></ul><ul><li>(excluding Premium) $800/individual $1,500/individual </li></ul><ul><ul><ul><li> $1,600/family $3,000/family </li></ul></ul></ul><ul><ul><ul><li>* For people enrolled in Chronic Care Management Program </li></ul></ul></ul>
  16. 16. Catamount Health Costs <ul><li>The cost will depend on individual / household income </li></ul><ul><li>Cost for Individual Coverage with Premium Assistance: </li></ul><ul><li>Individual Income by federal poverty level Monthly premium cost * </li></ul><ul><li>(1 person/annual in 2007) </li></ul><ul><ul><ul><li>Below 200% FPL ($20,420) $60.00 </li></ul></ul></ul><ul><ul><ul><li>200-225% ($20,421 – 22,973) $90.00 </li></ul></ul></ul><ul><ul><ul><li>225-250% ($22,974 – 25,525) $110.00 </li></ul></ul></ul><ul><ul><ul><li>250-275% ($25,526 – 28,077) $125.00 </li></ul></ul></ul><ul><ul><ul><li>275-300% ($28,078 – 30,630) $135.00 </li></ul></ul></ul><ul><ul><li>* Cost for two-person coverage will be double these amounts </li></ul></ul><ul><ul><li>Estimated Full Cost for Individuals/Households over 300% FPL: </li></ul></ul><ul><ul><ul><li>Single $ 390 / month </li></ul></ul></ul><ul><ul><ul><li>Two Person $ 780 / month </li></ul></ul></ul><ul><ul><ul><li>Family $1,750 / month </li></ul></ul></ul>
  17. 17. Catamount Health Eligibility <ul><li>You can purchase Catamount Health if you are an uninsured Vermont resident, are 18+, and are not eligible for an Employer-Sponsored Insurance (ESI) plan *. </li></ul><ul><li>Uninsured means: </li></ul><ul><ul><ul><li>You have insurance which only covers hospital care OR doctor’s visits (but not both) </li></ul></ul></ul><ul><ul><ul><li>You have not had private insurance for the past 12 months </li></ul></ul></ul><ul><ul><ul><li>You had VHAP or Medicaid but became ineligible for those programs </li></ul></ul></ul><ul><ul><ul><li>You had private insurance but lost it because you: </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Lost your job </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Got divorced </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>No longer have COBRA coverage </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Had insurance through someone else who died </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Are no longer a dependent on your parent’s insurance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Graduated, took a leave of absence, or finished college or university and got your insurance through school </li></ul></ul></ul></ul></ul>
  18. 18. Catamount Health Eligibility <ul><li>You can purchase Catamount Health even if you are eligible for an Employer-Sponsored Insurance (ESI) plan IF you have an income under 300% FPL, AND </li></ul><ul><ul><li>Your ESI plan is not approved by the state as comprehensive and affordable (with state assistance) </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>It is more cost effective to the state to provide premium assistance for you to enroll in a Catamount Health plan than providing premium assistance for you to enroll in your ESI </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>It is more cost effective to the state to provide premium assistance for you to enroll in your ESI than providing premium assistance for you to enroll in Catamount Health, but you must wait until the next open enrollment period for your ESI (at which point you must switch to your ESI to receive premium assistance) </li></ul></ul>
  19. 19. Key Dates: CATAMOUNT HEALTH PLANS <ul><ul><li>September 8, 2006 Rules filed with Secretary of State </li></ul></ul><ul><ul><li>October 7, 2006 Carriers submitted Letters of Intent </li></ul></ul><ul><ul><li>(BCBS-VT, MVP, CDPHP) </li></ul></ul><ul><ul><li>Mid-March, 2007 Carriers file forms and rates </li></ul></ul><ul><ul><li>July, 2007 Final MVP rates approved </li></ul></ul><ul><ul><li>September, 2007 Final BCBS-VT rates approved </li></ul></ul><ul><ul><li>October 1, 2007 Catamount Health Insurance available to uninsured Vermonters </li></ul></ul><ul><ul><li>October 1, 2009 Legislative review re: cost effectiveness; may trigger a self-insured plan </li></ul></ul>
  20. 20. Premium Assistance <ul><li>Catamount Health </li></ul><ul><ul><li>Vermonters who qualify for Catamount Health with income less than or equal to 300% of Federal Poverty Level (FPL) ($30,630 for one person) may receive premium assistance from the state </li></ul></ul><ul><li>Employer-Sponsored Insurance (ESI) </li></ul><ul><ul><li>Uninsured Vermonters with income less than or equal to 300% FPL may apply for ESI premium assistance </li></ul></ul><ul><ul><li>ESI plans must offer comprehensive benefits and be affordable in order for the individual to receive premium assistance </li></ul></ul><ul><ul><ul><li>Affordable = maximum individual in-network deductible of $500 </li></ul></ul></ul><ul><ul><ul><li>Comprehensive = covers physician, inpatient care, outpatient, prescription drugs, emergency room, ambulance, mental health, substance abuse, medical equipment/supplies, and maternity care </li></ul></ul></ul><ul><ul><ul><li>Employers do not have to contribute to the plan for it to qualify </li></ul></ul></ul>
  21. 21. Premium Assistance Cost Effectiveness Test <ul><li>VHAP Applicants (under 150 -185% FPL) </li></ul><ul><ul><li>If providing premium assistance to the individual to enroll in their ESI plan is more cost-effective to the state than enrollment in VHAP, the applicant will be required to enroll in their ESI plan to get state assistance. </li></ul></ul><ul><li>Catamount Health Applicants (at or under 300% FPL) </li></ul><ul><ul><li>If providing premium assistance to the individual to enroll in their ESI plan is more cost-effective to the state than providing premium assistance for the Catamount Health Plan, the applicant will only receive state assistance to enroll in their ESI plan. </li></ul></ul>
  22. 22. How will Premium Assistance be Paid? <ul><li>Catamount Health Premium Assistance </li></ul><ul><ul><ul><li>Beneficiary will pay his or her share to state </li></ul></ul></ul><ul><ul><ul><li>State will pay total premium to carrier </li></ul></ul></ul><ul><li>ESI Premium Assistance </li></ul><ul><ul><ul><li>Employee will pay total premium to employer through payroll deduction </li></ul></ul></ul><ul><ul><ul><li>State will pay employee prospectively for premium assistance </li></ul></ul></ul><ul><ul><ul><li>Employers will not have to modify payroll or accounting systems </li></ul></ul></ul><ul><ul><ul><li>Employers may have to provide information on the plan’s cost to the employee to assist with enrollment in the premium assistance program </li></ul></ul></ul>
  23. 23. Key Dates: PREMIUM ASSISTANCE FOR ESI / CATAMOUNT <ul><ul><li>September, 2006 Waiver Amendment Request submitted to CMS for approval of premium assistance programs </li></ul></ul><ul><ul><li>November, 2006 Report to Legislative Committees on fiscal implications (estimated costs and savings) </li></ul></ul><ul><ul><li>April, 2007 Draft Rules for Premium Assistance Eligibility Determination </li></ul></ul><ul><ul><li>July, 2007 Finalize Rules for Premium Assistance Eligibility Determination </li></ul></ul><ul><ul><li>August, 2007 CMS decision to only approve up to 200% FPL </li></ul></ul><ul><ul><li>October 1, 2007 Premium Assistance available for ESI and Catamount to eligible Vermonters </li></ul></ul>
  24. 24. Outreach and Enrollment <ul><li>Integrated Medicaid, Catamount Outreach and Enrollment Strategies </li></ul><ul><ul><li>Aggressive Marketing and Education Campaign in Fall 2007 </li></ul></ul><ul><ul><li>1-800 number </li></ul></ul><ul><ul><li>New web-site </li></ul></ul><ul><ul><li>Pro-actively assist with eligibility screening and applications (complete forms for people at key junctures) </li></ul></ul><ul><ul><li>Using state and local staff, partners and volunteers </li></ul></ul><ul><ul><li>Delayed Hard Launch (1 month) to identify and resolve implementation issues </li></ul></ul><ul><li>New Over-arching Brand: </li></ul><ul><li>Green Mountain Care – a healthier state of living </li></ul><ul><li>Re-tooling of Existing Application and Enrollment Processes </li></ul><ul><li>Phased-in New IT systems </li></ul>
  25. 28. Coverage Implementation Issues <ul><li>Estimating costs for new coverage plans </li></ul><ul><li>Estimating eligibles, take-up rates  managing political expectations </li></ul><ul><li>Getting CMS approval for expansions </li></ul><ul><li>Administrative complexity, ERISA barriers for premium assistance programs </li></ul><ul><li>Motivating state bureaucracy change </li></ul><ul><li>Competing agendas  reducing the uninsured versus managing state budget (enrollment, IT) </li></ul>
  26. 29. FOCUS ON CHRONIC CARE
  27. 30. Blueprint for Health <ul><li>State’s Plan for Better Management and Prevention of Chronic Illnesses across All Payers and Providers </li></ul><ul><li>Vision: Vermont will have a standardized statewide system of care that improves the lives of individuals with and at risk for chronic conditions. </li></ul><ul><li>To achieve this vision, the Blueprint is: </li></ul><ul><ul><li>Statewide system reform based on the Chronic Care Model </li></ul></ul><ul><ul><li>A public-private collaborative </li></ul></ul><ul><ul><li>Recognizes the central role of the patient and community </li></ul></ul><ul><ul><li>Designed around “Core System Competencies” rather than disease programs </li></ul></ul><ul><ul><li>Is the state’s mandated standard for chronic care management across all payers and providers </li></ul></ul>
  28. 31. Public Policy Public Health Health Systems Community Health Provider Team Patients and Families <ul><li>Policies </li></ul><ul><li>Infrastructure </li></ul><ul><li>Financing </li></ul><ul><li>Resources </li></ul><ul><li>Advocacy </li></ul><ul><li>Regulation </li></ul><ul><li>Info. Systems </li></ul><ul><li>System Policy </li></ul><ul><li>Quality Care </li></ul><ul><li>Service Development </li></ul><ul><li>Reimbursement </li></ul><ul><li>Financing </li></ul><ul><li>Continuity </li></ul><ul><li>Coordination </li></ul><ul><li>Info. Systems </li></ul><ul><li>Built Environment </li></ul><ul><li>Programs and Services </li></ul><ul><li>Health Awareness </li></ul><ul><li>Healthy Options </li></ul><ul><li>Info. Systems </li></ul><ul><li>Practice Standards </li></ul><ul><li>Info. Systems </li></ul><ul><li>Decision Support </li></ul><ul><li>Office Systems </li></ul><ul><li>Coaching/Support </li></ul><ul><li>Health Knowledge </li></ul><ul><li>Self-Management </li></ul><ul><li>Skill and Practice </li></ul><ul><li>Supportive Home </li></ul><ul><li>Environment </li></ul><ul><li>Info. Systems </li></ul>Blueprint for Health Model Healthier V e r m o n t e r s
  29. 32. Examples of Blueprint Components <ul><li>Insurance company collaboration </li></ul><ul><li>Required payment reform in 2 pilots in 2008 </li></ul>Health Systems <ul><li>Consensus treatment standards—Diabetes and Asthma </li></ul><ul><li>Physician coordination—dedicated medical director </li></ul><ul><li>6 Communities (HSAs); 200 primary care practices </li></ul>Health Care Practice <ul><li>Practice based disease registries </li></ul><ul><li>EMRs </li></ul>Information Systems <ul><li>Healthier Living Workshop—All conditions </li></ul><ul><li>Over 40 statewide; 500+ enrolled </li></ul><ul><li>+60% reduction in MD and ED visits post at one year </li></ul>Self-Management <ul><li>Blueprint physical activity opportunities </li></ul><ul><li>Walking maps, walking programs </li></ul>Community <ul><li>Blueprint legislation and funding </li></ul><ul><li>Executive Director at Governor’s Office level </li></ul><ul><li>Integration of health disparities/minority health </li></ul><ul><li>Internal coordination—Chronic Disease </li></ul>Public Policy
  30. 33. Other Chronic Care Strategies To Be Aligned with the Blueprint <ul><ul><li>Medicaid Chronic Care Management Program </li></ul></ul><ul><ul><li>State Employee Health Benefit Programs </li></ul></ul><ul><ul><li>State-approved Employer-Sponsored Insurance (ESI) Plans for Premium Assistance </li></ul></ul><ul><ul><li>Catamount Health Plans </li></ul></ul>
  31. 34. Blueprint Alignment Topics Across Chronic Care Programs <ul><li>Coordination of care across the multiple programs working with the same providers and patients </li></ul><ul><li>Agreement on best practices for all chronic diseases </li></ul><ul><li>Use of a consistent health risk assessment </li></ul><ul><li>Referrals to patient self-management resources </li></ul><ul><li>Coordination of IT initiatives to improve access and support clinical decision making </li></ul><ul><li>Use of consistent metrics for provider feedback, profiling and measurement </li></ul><ul><li>Changing and aligning payer fee structures to provide incentive to reward quality (e.g., pay-for performance, payment reforms) </li></ul>
  32. 35. Blueprint Impact on Health Care Costs <ul><li>It will not SAVE money – but it will reduce the rise in cost of care </li></ul><ul><li>We do expect to reduce the cost per case for chronic illness by: </li></ul><ul><ul><li>reducing hospitalizations </li></ul></ul><ul><ul><li>reducing complications </li></ul></ul><ul><ul><li>reducing specialist visits </li></ul></ul><ul><li>So why doesn’t that save money? </li></ul><ul><ul><li>Because when we take better care of chronic illness we prolong productive life </li></ul></ul><ul><ul><li>Because more people are developing chronic illness, especially with the obesity epidemic </li></ul></ul><ul><ul><li>That means more people in Vermont with chronic illness </li></ul></ul><ul><ul><li>More cases at less cost per case still means more total health care cost for the population </li></ul></ul>
  33. 36. Health Information Technology <ul><li>VITL = Statewide Regional Health Information Organization (RHIO) </li></ul><ul><ul><li>State Health Information Technology Plan </li></ul></ul><ul><ul><li>Medication History Pilot Project </li></ul></ul><ul><ul><ul><li>Implemented at 2 Hospital Emergency Rooms in April, 2007 </li></ul></ul></ul><ul><li>Chronic Care Information System (Disease Registry) </li></ul><ul><ul><li>First community site (Mt. Ascutney) for diabetes will be implemented in December, 2007 </li></ul></ul><ul><li>Electronic Health Records supported statewide </li></ul><ul><li>Master Provider Index, Multi-payer Database </li></ul>
  34. 37. Blueprint, IT Implementation Issues <ul><li>Private Payer Resource Commitments </li></ul><ul><li>Provider Belief, Vision </li></ul><ul><li>Provider Costs for IT Implementation </li></ul><ul><li>IT Privacy Issues </li></ul>
  35. 38. Reform Financing
  36. 39. Financing of Reforms <ul><li>Based on the principle that everybody is covered and everybody pays: </li></ul><ul><ul><li>Catamount Health Plan: individuals pay sliding scale premiums based on income </li></ul></ul><ul><ul><li>Employers pay an assessment based on number of uncovered employees </li></ul></ul><ul><ul><li>Increases in tobacco taxes </li></ul></ul><ul><ul><li>VHAP savings due to Employer-Sponsored Insurance (ESI) enrollment </li></ul></ul><ul><ul><li>Cost avoidance due to better chronic care management </li></ul></ul><ul><ul><li>Matching federal dollars via Global Commitment 1115 waiver </li></ul></ul>
  37. 40. Employer Contribution <ul><li>Assessment for “uncovered FTEs” </li></ul><ul><ul><li>Employers without a plan that pays some part of the cost of insurance of its workers must pay the health care assessment on all employees. </li></ul></ul><ul><ul><li>Employers who offer coverage * must pay the assessment on: </li></ul></ul><ul><ul><ul><li>Workers who are ineligible to participate in the plan </li></ul></ul></ul><ul><ul><ul><ul><li>New amendment: If the employer offers insurance to all full time employees, they do not have to pay the assessment on seasonal or part-time employees who have coverage from another source (unless it is Medicaid or VHAP). </li></ul></ul></ul></ul><ul><ul><ul><li>Workers who refuse the employer’s coverage and do not have coverage from some other source. </li></ul></ul></ul><ul><li>Assessment does NOT enroll employees in Catamount Health! </li></ul><ul><li>* Employers plan must include hospital and physician coverage to qualify </li></ul>
  38. 41. Employer Contribution <ul><li>Employee = any individual 18 years or older on employer’s unemployment insurance filing </li></ul><ul><ul><li>Based on the unemployment insurance definition of employee; excludes the following: </li></ul></ul><ul><ul><ul><li>Workers on small farms </li></ul></ul></ul><ul><ul><ul><li>Full time college students working at the college in a program designed to provide financial assistance </li></ul></ul></ul><ul><ul><ul><li>Elected officials </li></ul></ul></ul><ul><ul><ul><li>Emergency volunteers such as volunteer fire fighters </li></ul></ul></ul><ul><ul><ul><li>Licensed insurance and real estate sales </li></ul></ul></ul><ul><ul><ul><li>Foreigners temporarily in Vermont on cultural exchange (J-1) visas </li></ul></ul></ul><ul><ul><ul><li>Foreigners in Vermont on temporary foreign agricultural (H-2A) visa </li></ul></ul></ul><ul><li>$ 365 / year Fee per Uninsured FTE (2007) </li></ul><ul><ul><ul><li>Assessed quarterly - $91.25 / FTE / Qtr </li></ul></ul></ul><ul><ul><ul><li>FTE = number of employee hours worked during a calendar quarter divided by 520 (based on 40 hour work week maximum) </li></ul></ul></ul><ul><ul><ul><li>Exempts 8 FTEs in 2007 & 2008; 6 FTEs in 2009; 4 FTEs thereafter </li></ul></ul></ul><ul><li>Annual Fee indexed to Catamount Health premium increases </li></ul><ul><li>* </li></ul>
  39. 42. What about ERISA? <ul><li>Employee Retirement Income Security Act of 1974 </li></ul><ul><ul><li>Regulates private sector pension programs and employee benefit programs, including health coverage </li></ul></ul><ul><ul><li>Prevents states from regulating the benefit plans of any employer </li></ul></ul><ul><ul><li>Does not prevent states from regulating insurers </li></ul></ul><ul><ul><li>Courts have used 2 prongs to determine whether a state law is in violation of ERISA: </li></ul></ul><ul><ul><ul><li>Does the state law relate to ERISA plans (i.e., private sector, employer-sponsored plans) because it: </li></ul></ul></ul><ul><ul><ul><ul><li>Directly refers to ERISA plans (by imposing obligations or treats them differently)? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Regulates areas ERISA addresses (such as reporting, disclosure, or remedies)? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Regulates an ERISA plan’s benefits, structure or administration? and/or </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Imposes substantial costs on ERISA plans? </li></ul></ul></ul></ul><ul><ul><ul><li>Is it a law that regulates insurance (which is allowed)? </li></ul></ul></ul>
  40. 43. What about ERISA? <ul><li>We do not believe that Vermont’s Employer Assessment law does not meet the standards to be in violation of ERISA: </li></ul><ul><ul><li>Overall: It is a funding source and is not a mechanism intended to, or is likely to, affect change in an employer’s decision about whether to offer coverage or type of coverage </li></ul></ul><ul><ul><li>Specifically, </li></ul></ul><ul><ul><ul><li>It does not directly refer to ERISA plans by imposing obligations or treating them differently </li></ul></ul></ul><ul><ul><ul><ul><li>Nothing in our law dictates that 1) employers offer coverage or 2) anything about the coverage offered by employers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>The law is neutral about whether employers choose to offer coverage or pay the assessment </li></ul></ul></ul></ul><ul><ul><ul><li>It does not contain any areas of regulation that are contained in ERISA (such as reporting, disclosure, or remedies) </li></ul></ul></ul><ul><ul><ul><li>It does not regulate ERISA plans’ benefits, structure or administration </li></ul></ul></ul><ul><ul><ul><li>The $91.25 / FTE quarterly assessment does not meet the standard for “imposing substantial costs” </li></ul></ul></ul>
  41. 44. Key Dates <ul><li>EMPLOYER CONTRIBUTION </li></ul><ul><ul><li>September, 2006 Draft Rules Distributed for Public Comment </li></ul></ul><ul><ul><li>December 13, 2006 Final Rules Approved </li></ul></ul><ul><ul><li>January 15, 2007 Report on Inclusion of Seasonal Employees </li></ul></ul><ul><ul><li>April 1, 2007 Assessment Implemented (to be paid at end of 4th Quarter – June 30, 2007) </li></ul></ul>
  42. 45. Employer Contribution Implementation Issues <ul><li>ERISA barriers to good revenue estimates </li></ul><ul><li>As of October 2nd, received 78% of estimated 1 st Quarter (due July 31 st ) revenue ($1.37 m of $1.75 m) </li></ul><ul><ul><li>406 (of 20,833 total) employers did not submit a UI/HC report at all (typical 2% delinquency rate at this point in the process) </li></ul></ul><ul><ul><li>350 employers left HC portion of UI reporting form blank or used old UI-only forms </li></ul></ul><ul><ul><li>3,000 employers reported zero FTEs </li></ul></ul><ul><ul><ul><li>Use intermediaries (e.g., payroll services) </li></ul></ul></ul><ul><ul><ul><li>Have out-of-state headquarters </li></ul></ul></ul><ul><ul><ul><li>Have 40 or more employees </li></ul></ul></ul>
  43. 46. Reform Oversight <ul><li>Joint Legislative Commission on Health Care Reform </li></ul><ul><ul><li>Monthly meetings </li></ul></ul><ul><li>Reports on Reform Progress </li></ul><ul><ul><li>Five-year plan for Health Care Reform Implementation, including recommendations for administration or legislation (December 1, 2006) </li></ul></ul><ul><ul><li>Annual Administration Reports on Reform Progress (January 15) </li></ul></ul><ul><ul><li>Multiple Reports on Enrollment, Costs </li></ul></ul><ul><li>Universal Coverage/Individual Mandate - 2011 </li></ul><ul><ul><li>If Vermont has less than 96% of the population insured in 2010, the Health Care Reform Commission must submit a plan to increase health care coverage to ensure universal access, including individual mandates </li></ul></ul>
  44. 47. <ul><li>For more information </li></ul><ul><li>Vermont Health Care Reform Web-site: </li></ul><ul><li>www.hcr.vermont.gov </li></ul><ul><li>Health Care Coverage Information: </li></ul><ul><li>www.GreenMountainCare.org </li></ul><ul><li>1-800-250-8427 </li></ul>

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