Posts Tagged ‘Medi-Cal’

Growing Medicaid enrollment poses potential fiscal threat to state health benefit exchanges

June 24th, 2015 Comments off

The biggest threat to the future financial sustainability of the state health benefit exchange marketplace may be declining economic prosperity and the resulting polarization of household income strata, particularly in the states that have elected to expand Medicaid eligibility to households earning up to 138 percent of federal poverty and to single adults.

The reason? Low income households that qualify for Medicaid generally cannot purchase qualified health plans (QHPs) offered on state health benefit exchanges. If the growing Medicaid eligible population isn’t able to purchase QHPs, the exchanges don’t derive fees assessed on health plan issuers – their main source of revenue as federal establishment grant funds dwindle — that are based on a percentage of premium or set amount for each “effectuated” enrollee. (In states that have opted not to expand Medicaid eligibility, households earning at least 100 percent of federal poverty are eligible to purchase exchange QHPs.)

A Rand Corporation analysis of 2013-15 health coverage enrollment trends issued in June 2015 reported 6.5 million newly enrolled in Medicaid as of February 2015, outpacing by 58 percent the 4.1 million that enrolled in exchange QHPs. According to federal data, 71.1 million Americans were enrolled in Medicaid and the Children’s Health Insurance Program as of April 2015, 12.3 million more than the average for July to September 2013.

While exchanges realize no revenue from Medicaid enrollments, they do incur expense in handling them. Under the Patient Protection and Affordable Care Act’s “no wrong door” policy, exchanges are required to process eligibility and enrollment for both state insurance programs like Medicaid as well as QHPs. It’s also easier to enroll in Medicaid coverage. Unlike exchange QHPs that limit enrollment to part of the year during open enrollment periods, those eligible for Medicaid can enroll at any time of the year.

In California, an expansion state with the nation’s largest Medicaid program serving 12.2 million or about 1 in 3 Californians, enrollment grew by 41.4 percent between December 2013 and January 2015, according to the state’s Medicaid administrator, the Department of Health Care Services. Before that, a severe economic downturn added about 1 million new eligibles to the Golden State’s Medicaid rolls between 2007 and 2010.

Enrollment in California’s Medicaid program – known as Medi-Cal – far outstrips that of QHPs sold through the state’s health benefit exchange, Covered California. According to the federal Department of Health and Human Services, there were 1.4 million enrolled in Covered California plans as of February 2015 — about the same number for plan year 2014. To put that in perspective, there are roughly 61 Medi-Cal enrollees for every 7 enrolled in a Covered California QHP.

Colorado, a Medicaid expansion state that operates a state-based exchange, has seen burgeoning Medicaid enrollment tax the finances of its exchange. The state enrolled 1.2 million in Medicaid — an increase of 433,172 or 55 percent — between late 2013 and February 2015. For 2015, the state’s exchange, Connect for Health, enrolled 27,465 people in Medicaid or CHIP. That’s nearly twice the 15,566 enrolled in commercial plans, blowing a $7 million hole in its budget for increased call center costs handling complex Medicaid enrollments and prompting the exchange to seek reimbursement from the federal government, according to The Denver Post.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Burgeoning enrollment in California’s Medicaid program raises tensions between administration, lawmakers over access to care, provider reimbursement rates

March 5th, 2015 Comments off

California Gov. Jerry Brown took a cautious approach on expanding Medicaid eligibility under the Patient Protection and Affordable Care Act. It was well into 2013 and not long before the start of the new fiscal year (July 1) and the October 1, 2013 launch of open enrollment in that state’s exchange marketplace, Covered California, before Brown approved legislation authorizing the Medicaid expansion. Even though the federal government would initially be covering most of the cost of the expansion, Brown was concerned about the overall growth of the state’s Medicaid program, Medi-Cal.

With good reason. Kim Belshé, who served as Health & Human Services Agency secretary in the previous administration of Gov. Arnold Schwarzenegger, warned in 2009 that even with a $10 billion infusion of supplemental federal cost share funding provided by the American Recovery and Reinvestment Act of 2009, “California cannot afford the Medicaid program as currently structured and governed by federal rules and requirements.” In other words, it’s a budget buster.

In 2013, Brown was at odds with his fellow Democrats in the Legislature who wanted to increase reimbursement rates paid to medical providers unhappy with low reimbursement rates. Since providers can opt not to accept Medi-Cal, they argued, it’s critical that they have sufficient incentive to do so to allow Medi-Cal enrollees adequate access to health care. Brown didn’t go along with boosting provider reimbursement rates that year, reasoning the state was still on the road to recovering its fiscal health after tax revenues were severely crimped in the 2008-09 recession.

Now two years later, Medi-Cal enrollment has jumped to more than 12 million, covering nearly 1 in 3 Californians and following the pattern seen in other states where Medicaid enrollments are outpacing by 2 to 1 sign ups for subsidized commercial health plans sold though state health benefit exchanges. The burgeoning enrollment has heightened the pre-existing tensions between Brown and legislative Democrats over increasing Medi-Cal provider reimbursement rates, as the Los Angeles Times reports in this story on two measures that would reverse the recession-era cuts in provider reimbursement rates.

As The Times reports, those tensions surfaced in this blunt exchange between the chair of the Senate Health Committee, Ed Hernandez (D-West Covina), and Jennifer Kent, director of the state Department of Health Care Services, at a hearing this week. Hernandez asked Kent to respond directly as to whether Medi-Cal patients have the same access to doctors as presumably more affluent Silicon Valley workers covered by commercial health plans.

“Yes or no?” he said.

“Yes,” Kent said.

“I don’t think so,” Hernandez replied.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Top health care issue shifts from coverage in 2014 to provider access in 2015

February 26th, 2015 Comments off

For implementation of the Patient Protection and Affordable Care Act, 2014 was the year of increasing medical coverage. The rate of those lacking coverage in 2014 fell to its lowest level in seven years, driven in large part by states that have fully implemented the law, California Heathline reported this week. States that fully implemented the ACA saw their uninsured rates decline by almost twice the rate as states that did not do so, according to the story.

For 2015, the focus is shifting to how well expanded coverage ensures access to and payment for care. In California – a state that has fully implemented the Affordable Care Act by establishing its own state health benefit exchange and expanding Medicaid eligibility – these issues are coming into full play.

Underlying them are economic tensions in both commercial individual coverage and Medicaid. In the former, they arise from the tradeoff of narrow provider networks in commercial individual health plans in order to keep premium rates down, particularly in exchange qualified health plans that must offer standardized benefits. (Narrow networks have also increased patients’ risk of medical bankruptcy due to “balance billing” when they receive care and particularly emergency care from providers outside of their plan’s network as Kaiser Health News reports). Provider resistance to the high volume/lower reimbursement model of these networks is manifesting in complaints from those enrolled in exchange plans that their coverage is being declined when they seek care amid provider network volatility and churn. That has drawn attention in all three branches of government as California Healthline reported earlier this month:

California has addressed the issue on all fronts, from consumer groups launching suits against insurers over allegedly inadequate provider networks, lawmakers taking legislative action and state regulators implementing immediate policy changes.

In October 2014, Gov. Jerry Brown (D) signed a bill (SB 964) that increased oversight of insurers’ provider networks by authorizing the state Department of Managed Health Care to review insurers’ annual report on timeliness compliance. More recently, state Sen. Ed Hernandez (D-West Covina) has proposed a bill (SB 137) that would require insurers to update their provider directories on a weekly basis, among other requirements.

Meanwhile, Insurance Commissioner Dave Jones (D) released regulations on Jan. 5 that his office said were designed “to address the deficiencies in the market we have been seeing.”

Department of Insurance officials noted that they have received complaints from consumers about difficulty getting doctor appointments, traveling long distances to access in-network care and encountering erroneous provider directories. Relatedly, multiple suits have been launched against Anthem Blue Cross and Blue Shield of California over the issue.

In the Medicaid segment that covers about 1 in 3 California residents, burgeoning enrollments are outstripping available providers. As with commercial individual coverage, provider dissatisfaction with reimbursement rates is widely considered a key contributing factor. A California Healthcare Foundation study issued in August 2014 found the ratio of primary care physicians to Medi-Cal enrollees in 2011 and 2013 (35 to 49 per 100,000 enrollees) fell well short of the federal Health Services and Resource Administration’s guidelines of 60 to 80 per 100,000 enrollees. “Without a large increase in the number of primary care physicians participating in Medi-Cal or another means of increasing efficiency in primary care, such as greater use of nonphysician clinicians or phone and electronic visits, Medi-Cal beneficiaries are likely to have difficulty accessing primary care,” the study concludes.

While low Medi-Cal reimbursement rates are linked to the lack of access to PCPs, the study notes it did not find an association with unmet health care needs or preventative services. It also suggested a greater role for community health centers since they receive higher Medi-Cal reimbursement rates than private practice physicians.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Rapid Growth in Wisconsin’s Medicaid Program Could Cause Strain on State Budget | MacIver Institute

October 1st, 2014 Comments off

[Madison, Wisc…] The Department of Health Services (DHS) has requested a $2.78 billion increase in funding for the 2015-17 biennium. The new dollars would grow the agency’s total budget to nearly $23 billion, or roughly one-third of the entire state budget.

Almost half of the new money, $1.25 billion, would come from the federal government, which already provides $10.5 billion to the agency for federally sponsored programs. Another $831.5 million would come from Wisconsin’s General Fund, made up of state tax dollars paid by the average Wisconsinite.

What is driving such an increase in costs for the agency? The answer lies mostly in its massive Medicaid program.

Of the $831.5 million in additional state dollars requested by DHS, $760 million would be added to Wisconsin’s Medicaid program and its outcrop, BadgerCare.

via Rapid Growth in Wisconsin’s Medicaid Program Could Cause Strain on State Budget | MacIver Institute.

This is likely to become a major budgetary issue in the states. This summer, California had to appropriate more than $2 billion in increased tax revenues in its fiscal year 2014-15 budget toward offsetting rising Medicaid cost sharing.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Lingering recession fallout: Medicaid grows to cover nearly one third of Californians

August 20th, 2014 Comments off

Enrollment in California’s Medicaid program, Medi-Cal, is projected to grow in the new fiscal year that began July 1 to cover about 30 percent of the state’s population, with total enrollment expected to rise from 7.9 million before implementation of the Patient Protection and Affordable Care Act to 11.5 million in fiscal 2014-15, according to a summary of the budget.

The growing importance of Medi-Cal was highlighted in the release today of results of a California Field Poll of registered voters showing respondents assigning growing importance to Medi-Cal. Twenty-nine percent of voters surveyed rated the program as “very important” in a 2011 Field Poll; that number rose to 40 percent this year. “This is a safety net program (for the poor) that has now reached the masses,” noted Mark DiCamillo, senior vice president of the Field Research Corporation, calling the increase “very significant.”

The high percentage of Californians covered by Medicaid appears to coincide with the 2007-09 recession. As the downturn began to bite, data compiled by Kaiser Family Foundation show California having about the same percentage of its population in Medi-Cal in 2010 – 31 percent that year – and among the highest proportion of its population in Medicaid compared to other states. Only Maine and Vermont equaled California’s 31 percent in 2010 and those three states were exceeded only by the District of Columbia at 35 percent, according to the Kaiser Family Foundation. (Comparative year to year data are not available)

The growth in Medi-Cal spending all but wiped out an unanticipated surge in state tax revenues, the Ventura Star quoted Gov. Jerry Brown as saying. Consequently, Brown’s revised $107.8 billion general fund budget proposal contains little new spending beyond covering the additional costs of providing health care to 307,000 more low-income residents than anticipated when the 2014-15 budget was released in January, the newspaper reported. Another account appearing in The Sacramento Bee quoted Brown as saying California faces $1.2 billion in unanticipated costs in expanded Medi-Cal enrollment in the new fiscal year.

As Medi-Cal grew to cover 1 in 3 Californians in 2010 as tax revenues declined in the recession, the administration of then-Gov. Arnold Schwarzenegger bluntly declared the state could no longer afford to fund the program as it sought cost relief though program reductions and federal rule waivers. The heavy fiscal burden of program clearly continues to vex the current Brown administration. “As we are paying for this that will be at the expense of other government priorities,” said Health and Human Service Secretary Diana Dooley at today’s Sacramento briefing on the Field Poll results.

A final takeaway worth pondering: With more people being covered by Medicaid, might California and eventually the United States as a whole be moving toward the German “Kaiser system” where the government provides a safety net of basic health coverage for all?


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

California’s continuing Medicaid woes

August 14th, 2014 Comments off

Five years ago as California stared down a severe budget gap as the economy cratered, the state drew up plans to cut $1.2 billion from its Medicaid program, Medi-Cal, through program reductions and federal rule waivers.

At the time, then-California Health & Human Services Agency Secretary Kim Belshé warned that even with a $10 billion infusion of supplemental federal cost share funding provided by the American Recovery and Reinvestment Act of 2009, “California cannot afford the Medicaid program as currently structured and governed by federal rules and requirements.”

Now with the budget crisis in the past amid an uneven economic recovery, the Golden State faces renewed concerns that it can fund a sustainable Medicaid program given its acceptance of expanded family status and income eligibility guidelines under the Patient Protection and Affordable Care Act. As a result of the expansion, a staggering 3 in 10 California residents are expected to obtain health coverage though the program. In addition to budgetary concerns, there is also the practical matter of whether Medi-Cal beneficiaries will have adequate access to providers given the state’s low reimbursement rates.

Kaiser Health News provides an analysis of the situation here.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Jump in Medi-Cal enrollment will consume most of California’s tax windfall » Ventura County Star

May 13th, 2014 Comments off

Jump in Medi-Cal enrollment will consume most of state’s tax windfall » Ventura County Star.

The Ventura County Star’s Timm Herdt reports the majority of higher than projected tax receipts is being directed by the administration of Gov. Jerry Brown to cover also higher than expected enrollment in the state’s Medicaid program, Medi-Cal.

One year ago, Brown delayed approving legislation that expanded Medicaid eligibility under the Patient Protection and Affordable Care Act, concerned over the fiscal impact of a program the prior administration of Gov. Arnold Schwarzenegger deemed a budget buster during the recession.

With a staggering 3 in 10 Californians reliant on the public health insurance program, Medi-Cal continues to be a budget threat. Only this time, a revenue windfall staved off a shortfall for upcoming fiscal year that begins July 1.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Achieving single, integrated marketplace for individual, Medicaid health plans faces initial difficulties

April 14th, 2014 Comments off

Section 1413(c)(1) of the Patient Protection and Affordable Care Act requires each state to “develop for all applicable State health subsidy programs a secure, electronic interface allowing an exchange of data …that allows a determination of eligibility for all such programs based on a single application.” That means state health benefit exchanges must operate as integrated marketplaces offering both commercial insurance plans (referred to as Qualified Health Plans or QHPs) as well as Medicaid coverage for those whose household incomes meet their state’s Medicaid eligibility guidelines. The policy rationale – known as “no wrong door” and “one touch and you’re done” – is to reduce the ranks of the medically uninsured by simplifying the process of getting health coverage and removing roadblocks to enrollment.

Implementing that Affordable Care Act mandate, however, has been challenging from IT integration standpoint given the variety of legacy state computer systems that manage their Medicaid programs and state rules governing them, including those of the three dozen states using the federal marketplace,

That’s also been the case in California, where enrollment elegance has proven elusive. “I think we’ve oversold simplicity,” said Frank J. Mecca, executive director of the County Welfare Directors Association of California. Mecca made that observation today at a California Healthcare Foundation (CHCF) briefing in Sacramento on early consumer experiences with enrollment in the Golden State’s exchange, Covered California.

Mecca described the IT interface between the California Healthcare Eligibility, Enrollment and Retention System (CALHEERS) and the IT system that manages Medicaid eligibility and enrollment, the Statewide Automated Welfare System (SAWS) as a “clogged highway.” Consequently, Mecca noted, a large backlog of potential Medicaid enrollees remain stuck in the system. Mecca credited Covered California and the California Department of Health Care Services (DHCS), the state’s Medicaid administrator, for their efforts to remedy the backlog and improve the interface between the two IT systems. “It’s not an easy thing to fix,” Mecca added. “Things have improved tremendously, but we still have a long way to go.”

Both Mecca and another panelist at the briefing, Sonya Vasquez, policy director of the community-based health advocacy and policy organization, Community Health, said greater emphasis should be placed on marketing both Covered California QHPs as well as Medi-Cal, the state’s Medicaid program, particularly given Medi-Cal does not have set enrollment periods. They also said more effort should be made to make consumers aware in-person assistance is available for those seeking to enroll in coverage, including welfare department staff who can sign up applicants for either Covered California QHPs or Medi-Cal. (California is among those states have expanded Medicaid eligibility to 138 percent of federal poverty guidelines).

Consumers participating in focus groups conducted in early 2014 by PerryUndem Research/Communication were mostly uninsured and had substantial knowledge gaps for both Medi-Cal and QHP coverage and advance tax credit subsidies for the latter for households with incomes between 138 and 400 percent of federal poverty. (Click here for the full report on the findings presented at today’s CHCF briefing.)


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

California could opt to offer Medicaid “bridge plans” on exchange rather than expand Medicaid eligibility

May 11th, 2013 Comments off

Despite the assumption that California would opt to expand Medicaid eligibility to households with incomes between 100 and 133 percent of federal poverty guidelines as permitted under the Patient Protection and Affordable Care Act, the policy question remains open in the Golden State.  A number of sticking points remain as detailed in this story in today’s Los Angeles Times. Chief among them is Gov. Jerry Brown’s expectation that since counties would benefit from the expansion through a reduced burden of caring for indigents not currently eligible for Medi-Cal as it’s called in California, they should help Sacramento shoulder the state’s future federal Medicaid cost share.

According to The Times, the Brown administration is also concerned that allowing people to enroll in Medi-Cal online could encourage fraud.  California is rushing to ready an online enrollment system, the California Eligibility, Enrollment and Retention System (CALHEERS), to implement the Affordable Care Act’s mandate that individuals and families be offered enrollment for both government insurance programs like Medi-Cal and private coverage offered through its health benefit exchange thorough a single, streamlined application process.  The unresolved policy question of whether to expand Medi-Cal eligibility poses significant potential to complicate an already complex process to prepare the online system and to provide enrollees what state officials expect to be a customer-friendly “no wrong door” experience.  Problems integrating the state’s legacy Medi-Cal eligibility computer software with CALHEERs have already delayed plans to have it functional by the October 1 pre-enrollment date for 2014 coverage until January 1, 2014.

While the Brown administration’s concerns over expanding eligibility for Medi-Cal have stalled legislation that would do so, the administration is sponsoring pending legislation, SBX1-3, that would authorize commercial Medicaid managed care “bridge plans” per federal guidance issued in December, 2012 for those earning up to 200 percent of federal poverty.  The plans would be available through the state’s exchange marketplace, Covered California.

Since the Affordable Care Act deems households with incomes of at least 100 percent of federal poverty eligible to buy coverage through the exchange marketplace, the bridge plan option provides policymakers an alternative to expanding Medi-Cal eligibility to 133 percent of federal poverty.  Some states that have declined to expand Medicaid eligibility including Tennessee, Arkansas and Oklahoma are negotiating with the federal Center for Medicare and Medicaid Services to obtain waivers to allow their Medicaid eligibles to purchase commercial coverage on their exchanges. Absent a near term political agreement to expand Medi-Cal eligibility, California could soon be among them.

If the trend continues, it could lead to a bifurcated Medicaid system: basic, legacy Medicaid for those households with incomes below 100 percent of federal poverty guidelines and a “super Medicaid” system of federally subsidized coverage for households with incomes above the poverty line that wouldn’t otherwise qualify for Medicaid.  It would also have fiscal implications for the states electing to “expand” Medicaid eligibility via Medicaid bridge plans sold on their health benefit exchange marketplaces since it would reduce their future federal Medicaid cost share burden, shifting subsidization fully to the federal government in the form of advance income tax credits.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

California bill aimed at deterring large employers from placing low wage workers on part time status to avoid ACA coverage mandate

May 7th, 2013 Comments off

California employers with 500 or more workers would be required to pay the state a penalty based on the average cost of coverage provided by large employers for those employees that enroll in Medicaid (Medi-Cal in California) coverage under advancing legislation.

According to an analysis of AB 880 prepared by the Assembly Health Committee, the bill is aimed at deterring large employers with sizable numbers of low wage workers from reducing their hours to less than 30 hours per week in order to avoid the Patient Protection and Affordable Care Act requirement to offer coverage to all workers employed at least 30 hours per week. “The author states this bill is designed to ensure that the largest employers in the state do not evade their responsibilities under the ACA by cutting hours and eliminating benefits so that their employees qualify for Medi-Cal,” the analysis states.  “This shifts costs onto the public and threatens the fiscal solvency of the state.”

As AB 880 moves forward, legislation stating intent to expand California’s Medicaid eligibility under the Affordable Care Act to households earning up to 133 percent of federal poverty level has bogged down over the extent to which counties should share in the cost and the Brown administration’s concern over the long term fiscal impact of the expansion and specifically whether California will remain obligated to honor it if federal cost share funding is cut in the future. Anxiety over Medicaid remains high among the state’s budget writers.  They viewed the state’s Medicaid cost share as a budget buster during years of fiscal shortfalls following the economic downturn that began in 2008.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

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