Joy Johnson Wilson, Health Policy Director at the National Conference of State Legislatures, looks at the coverage gaps at the Designing Healthcare in Texas June 4, 2014 conference.

1. Designing Coverage for All
“Closing the Coverage Gaps”
Joy Johnson Wilson
Health & Human Services Policy Director
Designing Healthcare in Texas
How the Past & Present Will Guide the Future
Houston, Texas
June 4, 2014

2. Overview
o How have states responded to the ACA?
o What is the current status of Medicaid expansion
and state marketplaces? What are the challenges
going forward?
o If not expansion, then what? What can be done to
increase health insurance coverage?
o What are the key issues for 2015 and beyond?

3. State Response to ACA
Federal Resources
o Planning Grants
o Enhanced Matching Payments for Eligibility Systems
o Increased Funding for Community Health Centers
o Innovation Grants
State Activities
o Decision-making regarding Medicaid expansion and marketplaces
o Comporting state laws with new federal requirements
o Applying for new federal grants

4. Medicaid Expansion Post SCOTUS Decision
o SCOTUS Decision - No penalty, no deadline, ….States can
go in and out of the expansion at will.
o Status of the Medicaid Expansion Today
• 26 states and the District of Columbia have decided to
adopt the expansion.
o Some states are addressing state priorities by using the
Section 1115 waiver process to expand Medicaid.
• The Centers for Medicare and Medicaid Services (CMS)
has approved waiver proposals from Arkansas, Iowa and
Michigan.

5. No Expansion…Then What?
• If a state decides not to implement the Medicaid expansion,
what happens?
o Individuals with income above 100% of FPL are eligible
to enroll in the state’s health insurance marketplace.
o Individuals with income below 100% of FPL are not
eligible for Medicaid and are not eligible to enroll in the
state’s exchange.
o These individuals will not be subject to the non-
coverage penalty provided for under the ACA individual
mandate provisions as they will qualify for an
affordability or hardship exemption.

6. Medicaid Expansion State Status Report - 2014
o Expansion States – Arizona, Arkansas, California, Colorado,
Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland,
Massachusetts, Michigan (April 2014), Minnesota, Nevada, New
Hampshire (July 2014), New Jersey, New Mexico, New York, North
Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, West
Virginia and the District of Columbia
o States not Expanding – Alabama, Alaska, Florida, Georgia, Idaho,
Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana,
Nebraska, North Carolina, Oklahoma, Pennsylvania, South Carolina,
South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming
o Waivers Pending – Indiana, Pennsylvania

7. Section 1115 Waivers
o Section 1115 of the Social Security Act allows the Secretary of the
U.S. Department of Health and Human Services (HHS) to waive
certain provisions of section 1902 of the Act for experimental,
pilot, or demonstration projects, and to provide federal financial
participation (FFP) for costs that would not otherwise be
considered as expenditures under the Medicaid state plan, when
the HHS Secretary finds that the demonstrations are likely to
assist in promoting the objectives of the Medicaid program. There
is a parallel provision in Title XXI of the Social Security Act
which authorizes the Children’s Health Insurance Program
(CHIP).

8. PPACA Waiver Transparency Provisions
o Section 10201(i) of the PPACA establishes transparency and public
notice procedures for 1115 waiver proposals related to Medicaid and the
Children’s Health Insurance Program (CHIP) and codifies the need to
seek advice from and consult with Indian health care providers and
urban Indian organizations.
o Final rules published in the February 27, 2012, established:
• State public notice and application requirements for new waivers and
for extensions of existing waivers;
• Federal public notice and comment requirements and a specific
timetable for the application process; and
• Ongoing reporting and evaluation components throughout the life of
the waiver.

9. State Waiver Process
o After the state has developed a proposal, the state must:
• Make a comprehensive description of the waiver proposal is available
to the public and provide a 30-day public notice and comment period;
• Establish a website to make the proposal and related materials
available to the public and provide a means for individuals to sign-up
for e-mail updates related to the proposal;
• Hold at least two public hearings in separate locations and on
separate days to receive feedback from the public related to the
proposal; and
• Include in the final waiver proposal a comprehensive description of the
proposal and documentation related to the public comment process
and the feedback that was received.

10. Federal Waiver Process
o The federal government (CMS) must:
• Send notice of receipt of the waiver proposal within 15 days of
receipt, which will then initiate a 30-day federal comment
period during which the general public will have an opportunity
to review a state’s proposal and comment on it;
• Publish the notice of receipt, the waiver application and
supporting materials on the CMS website so the public can
provide comment electronically; and
• Provide the public at least 45 days to comment before it makes
a decision on a waiver application.

11. Approved State 1115 Waivers
o Arkansas – Health Care Independence
Program (Private Option)
o Iowa – Iowa Marketplace Choice and Iowa
Wellness Plan
o Michigan – Healthy Michigan Plan

12. ARKANSAS
o Demonstration Period – October 1, 2013 – December 31, 2016
o Private Option Demonstration – State/federal partnership to
enroll individuals in the new Medicaid adult eligibility group
using premium assistance to purchase coverage from Qualified
Health Plans (QHPs) offering individual coverage in the
“Marketplace”.
o Private Option Beneficiaries – Childless adults ages 19 through
64 with income at or below 133% of FPL and parents or other
caretaker relatives ages 19 through 64 with incomes between
approximately 17%-133% of FPL. Medically frail individuals are
excluded unless they “opt-in”.

13. ARKANSAS cont.
o Objectives –
• Promote continuity of coverage for individuals;
• Improve access to providers;
• Smooth the “seams” across the continuum of coverage; and
• Further quality improvement and delivery system reform initiatives.
o Delivery System
• Provides integrated coverage for low-income people leveraging the
efficiencies of the private market to improve continuity, access and quality;
• Drives structural system reform and more competitive premium pricing by
doubling the number of people enrolling in the QHPs in the “Marketplace”.
o Enrollment – Estimates 200,000 in the first year.

14. IOWA
o Demonstration Period – January 1, 2014 – December 31, 2016
o Iowa Marketplace Choice – Will offer premium assistance to certain individuals in
the new Medicaid adult eligibility group to purchase coverage offered by Qualified
Health Plans (QHPs) in the Marketplace.
o Marketplace Choice Beneficiaries – Non-medically frail individuals ages 19
through 64 with incomes above 100% of FPL, except those with cost-effective
employer-sponsored insurance. Also special provisions for American Indians and
Alaskan Natives.
o Objectives – Promoting continuity of coverage for individuals who are near the
income eligibility threshold for individual coverage in the “Marketplace”;
Improving access to providers through the availability of payment for services by
QHPs at market rates; and Furthering quality improvement and delivery system
reform initiatives through incentives for beneficiaries to obtain preventive services
and engage in healthy behaviors.

15. IOWA cont.
o Iowa hopes to determine whether –
• Offering multiple plan options to the Marketplace Choice Plan population
that align with options available in the individual market will promote
continuity of coverage;
• The availability of third party payment for services at market rates will
improve access to needed services;
• Reduced premiums can be an incentive for beneficiaries to use
preventative services and engage in other healthy behaviors;
• Removing state responsibility to ensure that beneficiaries have needed
non-emergency transportation to and from providers will result in
decreased beneficiary access to covered services.

16. IOWA cont.
o Special provisions-
• Allows Iowa to align Medicaid timing requirements for prior authorization
for drugs with requirements applicable to QHPs;
• Beneficiaries under age 21 will continue to have access to early and
periodic screening and diagnostic treatment (EPSDT) services and all
beneficiaries in the demonstration will be able to access out-of-network
family planning services.
• Allows Iowa to impose premiums in the second year of the demonstration
on enrollees with incomes above 100% of FPL for the “incentive program”
that is intended to improve the use of preventive services and other healthy
behaviors. Enrollees who complete all required healthy behaviors in the
first year will have the premiums waived in the second year and will
continue to have them waived if they remain compliant. Premiums are
limited.

17. IOWA cont.
o Demonstration Period – January 1, 2014 – December 31, 2016
o Iowa Health and Wellness Demonstration – The Health and Wellness program
will promote healthy behaviors through education and engagement of beneficiaries
and providers, and includes an incentive component that is intended to promote
health behaviors. Covered services will be furnished in ways that promote
coordinated care, including the use of managed care and Accountable Care
Organizations (ACOs) under the state plan.
o Health and Wellness Beneficiaries – Individuals ages 19 through 64 with income
up to 133% of FPL; individuals with income above 100% of FPL, including 133%
of FPL who are medically frail, American Indian, Alaska Native, or have access to
employer-sponsored insurance coverage.
o Special Provisions – The state is not required to provide non-emergency
transportation for one year after which an evaluation must be conducted. State plan
cost-sharing rules apply and no premiums can be charged.

18. MICHIGAN
o Demonstration Period (pending approval) – April 1, 2014 –
December 31, 2016.
o Healthy Michigan Beneficiaries – Adults ages 19 through 64
who are not covered by or eligible for Medicaid at the time of
application, who have family incomes at or below 133% of FPL
and who are not eligible for or enrolled in Medicare. Includes
current enrollees in the Michigan Adult Benefits Waiver program
that provides coverage through an 1115 waiver to individuals with
incomes below 35% FPL (90,000 beneficiaries).
o Estimated Enrollment – 300,00 – 500,000 are estimated to be
eligible to enroll.

19. MICHIGAN cont.
o Healthy Michigan Plan – Individuals enrolled in the Healthy Michigan Plan
through a contracted Medicaid Health Plan will receive a MI Health Account into
which money from any source, including, but not limited to the beneficiary, their
employer, and/or public or private entities on the beneficiary’s behalf, may be
deposited for the beneficiary’s use in paying for incurred health expenses.
• The state will make contributions to the account: (1) in amounts varied based on
the beneficiary’s existing contributions and circumstances; (2) in a manner that
ensures beneficiaries can receive necessary services; (3) to assure providers are
paid for services provided; and (4) to ensure that cost transparency is
maintained for the beneficiary’s benefit. Beneficiaries will receive quarterly
statements. The program includes income-based cost-sharing, but will not
exceed 5% of the beneficiary’s annual income. Individuals exempt from cost-
sharing under federal law will be exempt from cost-sharing under the waiver
program.

20. If not expansion, then what?
State Woodwork Beneficiaries % Enrollment Increase
Georgia 98,800 5.8
Idaho 19,000 7.5
Indiana 45,000 4.0
Kansas 22,500 5.7
Mississippi 17,800 2.5
Montana 14,100 10.1
North Carolina 58,000 3.3
Tennessee 53,700 4.3
Virginia 36,600 3.2
Texas 3,200 .1
Source: Avalere Health, Medicaid Non-Expansion states experience up to 10% Enrollment Growth Due to Woodwork Effect, May
2014

21. If not expansion, then what?
o Be prepared for the 2015 open season.
o Continue and expand health insurance literacy activities.
o Increase focus on:
• Young adults
o Former Foster Care Children under age 26
o May be able to be added to parents health insurance
o Who turn 26 and lose parent coverage
• Older adults, not Medicare eligible
• Individuals for whom English is not their primary language
• Individuals with life changes---marriage, divorce, baby, adoption,
job loss, move to new area with different insurance carriers

22. State Marketplace Decisions
o Federally Facilitated – Alabama, Alaska, Arizona, Florida,
Georgia, Indiana, Louisiana, Maine, Mississippi, Missouri,
Montana, Nebraska, New Jersey, North Carolina, North Dakota,
Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas,
Utah, Virginia, Wisconsin, and Wyoming
o Partnership – Arkansas, Delaware, Illinois, Iowa, Michigan, New
Hampshire, and West Virginia
o State-Based – California, Colorado, Connecticut, Hawaii, Idaho,
Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New
Mexico, New York, Oregon, Rhode Island, Vermont and
Washington.

23. Key Issues for 2015 and Beyond
o Financial Sustainability of State-Based
Marketplaces/Marketplaces
o Insurer Participation
o Premium Rates
o Medicaid Expansion – State Fiscal Impact
o Improving the Health Care Infrastructure to Support More Patients
o Scope of Practice and Telemedicine Regulation
o Future of State Mandated Benefits/Essential Benefit Package
o Employer Issues/SHOP Exchanges

24. Joy Johnson Wilson
Health and Human Services Policy Director, NCSL
202-624-8689
Joy.Wilson@ncsl.org