Medicaid and the ACA

MEDICAID AND THE AFFORDABLE CARE ACTJANUARY 18, 2013

Betsy Aiello, Deputy Administrator, DHCFP

2

Key Points

• The ACA’s Medicaid Expansion to 138% FPL for newly eligible adults is expected to reduce the state’s uninsured population from 22.6% in 2011 to approximately 10.5% by the end of FY15. During this period nearly 146,000 additional Nevadans will enroll in Medicaid.

• Because of the ACA’s individual mandate, an estimated 68,000 additional Nevadans will enroll in Medicaid.

• Because of the expansion, an estimated 78,000 additional Nevadans will enroll in Medicaid.

• This Medicaid Expansion is estimated to cost Nevada’s State General Fund approximately $549 million between FY14-FY20. It will bring nearly $3.2 billion in federal funds to the state.

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Eligibility Changes under the ACA• No wrong door for applicants (lobbies, website, phone,

Silver State Health Insurance Exchange)• Simplified MAGI income test for eligibility• Federal hub for information verification (Social Security

Administration, Homeland Security, IRS, Treasury)• Note: Eligibility for Aged, Blind, and Disabled (ABD)

individuals is not simplified under the ACA

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Total Medicaid Caseload Projections

80,000

130,000

180,000

230,000

280,000

330,000

380,000

430,000

480,000

80,000

130,000

180,000

230,000

280,000

330,000

380,000

430,000

480,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Total Medicaid Actuals Leg. Approved

Projections (Nov. 2012) With ACA Mandatory Caseloads

With ACA Mandatory Caseloads & Optional Caseloads to 100% FPL With ACA Mandatory Caseloads & Optional Caseloads to 138% FPL

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Total Medicaid Caseload Projections, Fiscal Years 2012-15

275,000

325,000

375,000

425,000

475,000

525,000

275,000

325,000

375,000

425,000

475,000

525,000Ju

l-11

Sep-

11

Nov

-11

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

May

-15

Total Medicaid Actuals Projections (Nov. 2012)

With ACA Mandatory Caseloads With ACA Mandatory Caseloads & Optional Caseloads to 100% FPL

With ACA Mandatory Caseloads & Optional Caseloads to 138% FPL

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Total Medicaid Caseload and Projections with Expansion

Total Medicaid

Actuals with Retro

Total Medicaid

Actuals with Retro

Leg. Approved

Projections (Nov. 2012)

Total Medicaid

Actuals with Retro

Leg. Approved

Projections (Nov. 2012)

with ACA Mandatory Caseload

With ACA Mandatory

and Optional

Caseloads to 100% FPL

With ACA Mandatory

and Optional

Caseloads to 138% FPL

Jul-09 224,861 Jul-11 296,400 290,009 Jul-13 320,451Aug-09 230,258 Aug-11 298,213 291,802 Aug-13 321,841Sep-09 234,138 Sep-11 298,723 292,179 Sep-13 323,148Oct-09 238,338 Oct-11 300,178 292,929 Oct-13 324,618 329,094 329,094 329,094

Nov-09 241,463 Nov-11 300,337 292,908 Nov-13 325,466 334,417 334,417 334,417Dec-09 244,806 Dec-11 302,432 295,181 Dec-13 326,664 340,091 340,091 340,091Jan-10 249,668 Jan-12 304,850 295,986 Jan-14 327,693 349,528 368,350 378,514Feb-10 253,462 Feb-12 305,635 295,950 Feb-14 328,677 356,685 380,212 392,917Mar-10 258,741 Mar-12 306,161 297,184 Mar-14 330,084 364,265 392,498 407,744Apr-10 261,381 Apr-12 307,727 298,904 Apr-14 330,756 371,111 404,048 421,836

May-10 265,371 May-12 308,355 299,834 May-14 331,816 378,344 415,987 436,316Jun-10 268,415 Jun-12 308,954 300,513 Jun-14 332,765 385,467 427,816 450,685Jul-10 272,661 Jul-12 310,260 301,296 Jul-14 333,451 387,920 430,922 454,206

Aug-10 277,145 Aug-12 310,901 302,737 Aug-14 334,680 390,916 434,571 458,269Sep-10 279,264 Sep-12 310,172 303,075 Sep-14 335,771 393,775 438,084 462,195Oct-10 280,138 Oct-12 313,414 304,143 Oct-14 336,946 396,717 441,679 466,205

Nov-10 281,604 Nov-12 304,371 313,515 Nov-14 337,495 399,033 444,649 469,588Dec-10 283,335 Dec-12 306,590 314,360 Dec-14 338,413 401,719 447,987 473,341Jan-11 286,880 Jan-13 307,430 315,358 Jan-15 339,295 403,372 450,295 476,062Feb-11 288,187 Feb-13 307,373 316,198 Feb-15 340,151 405,037 452,612 478,794Mar-11 290,909 Mar-13 308,606 317,589 Mar-15 341,475 407,208 455,437 482,033Apr-11 292,432 Apr-13 310,413 318,199 Apr-15 342,048 408,614 457,496 484,506

May-11 295,866 May-13 311,190 319,093 May-15 343,007 410,388 459,924 487,347Jun-11 296,960 Jun-13 311,851 319,827 Jun-15 343,895 412,076 462,265 490,103

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Health Insurance Coverage with Medicaid Expansion to 138% FPL

Uninsured

FY 2013 22.4% FY 2014 12.6% FY 2015 10.5% FY 2016 10.5% FY 2017 10.5% FY2018 10.5% FY2019 10.5% FY2020 10.5%

Medicaid and Check Up

FY 2013 12.3% FY 2014 17.0% FY 2015 18.0% FY 2016 18.1% FY 2017 18.0% FY 2018 17.8% FY 2019 17.6% FY 2020 17.4%

Exchange


Employer-Sponsored, Direct Purchase,

Medicare, and Military


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Estimated and Projected Insurance Coverage in Nevada with Medicaid Expansion to 138% FPL

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000Ju

n-02

Jan-

03

Aug

-03

Mar

-04

Oct

-04

May

-05

Dec

-05

Jul-0

6

Feb-

07

Sep-

07

Apr

-08

Nov

-08

Jun-

09

Jan-

10

Aug

-10

Mar

-11

Oct

-11

May

-12

Dec

-12

Jul-1

3

Feb-

14

Sep-

14

Apr

-15

Nov

-15

Jun-

16

Jan-

17

Aug

-17

Mar

-18

Oct

-18

May

-19

Dec

-19

Employer-Sponsored, Direct Purchase, Medicare, and Military

Medicaid and Nevada CheckUp

Uninsured

Exchange

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Estimated and Projected Insurance Coverage in Nevada with Medicaid Expansion to 138% FPL

Employer-Sponsored,

Direct Purchase, Medicare, and

Military

Medicaid and CheckUp

Exchange Uninsured

Employer-Sponsored,

Direct Purchase, Medicare, and

Military

Medicaid and CheckUp

Exchange Uninsured

FY02 1,614,914 181,302 405,699 FY02 73.3% 8.2% 18.4%FY03 1,697,439 191,400 402,503 FY03 74.1% 8.4% 17.6%FY04 1,766,264 202,673 437,447 FY04 73.4% 8.4% 18.2%FY05 1,898,188 200,592 415,826 FY05 75.5% 8.0% 16.5%FY06 1,931,932 199,705 487,618 FY06 73.8% 7.6% 18.6%FY07 2,060,802 199,621 458,538 FY07 75.8% 7.3% 16.9%FY08 2,032,703 212,994 495,126 FY08 74.2% 7.8% 18.1%FY09 1,917,463 234,810 557,568 FY09 70.8% 8.7% 20.6%FY10 1,853,917 289,670 581,485 FY10 68.0% 10.6% 21.3%FY11 1,786,859 318,099 615,362 FY11 65.7% 11.7% 22.6%FY12 1,793,023 330,358 619,914 FY12 65.4% 12.0% 22.6%FY13 1,814,898 340,748 621,364 FY13 65.4% 12.3% 22.4%FY14 1,864,819 478,693 114,479 354,268 FY14 66.3% 17.0% 4.1% 12.6%FY15 1,897,109 514,334 139,703 299,106 FY15 66.6% 18.0% 4.9% 10.5%FY16 1,921,551 522,861 140,908 303,112 FY16 66.5% 18.1% 4.9% 10.5%FY17 1,952,307 525,722 141,293 307,099 FY17 66.7% 18.0% 4.8% 10.5%FY18 1,984,816 527,892 141,547 311,194 FY18 66.9% 17.8% 4.8% 10.5%FY19 2,016,717 528,887 141,424 315,037 FY19 67.2% 17.6% 4.7% 10.5%FY20 2,048,943 528,289 140,948 318,689 FY20 67.5% 17.4% 4.6% 10.5%

Note: The Current Population Survey (CPS) estimates the number of uninsured individuals and the share of the population that is uninsured. Because the CPS total state population estimates do not perfectly correspond with the offi cial population estimates produced by the Nevada State Demographer, the CPS share of population that is uninsured is applied to the State Demographer's population estimate to derive the number of uninsured Nevadans. For example, the CPS estimates that 607,000 Nevadans (22.6% of the population) were uninsured in 2010. Applying this percentage to the State Demographer's population estimate yields 581,485 uninsured Nevadans.

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Blended FMAP for State Fiscal Years 2003-2020State Fiscal Year FMAP Enhanced (CHIP) FMAP New Eligibles FMAP

51.79% 66.25%52.53% 66.77%54.30% 68.01%55.34% 68.74%

FY05 55.66% 68.96%FY06 55.05% 68.53%FY07 54.14% 67.90%FY08 52.96% 67.07%

50.66% 65.46%61.11% 72.78%50.12% 65.08%63.93% 74.75%51.25% 65.87%57.77% 70.44%

FY12 55.05% 68.54%FY13 58.86% 71.20%FY14 62.26% 73.58% 100.00%FY15 63.54% 74.48% 100.00%FY16 63.50% 74.45% 100.00%FY17 62.88% 74.02% 97.50%FY18 62.19% 73.53% 94.50%FY19 61.32% 72.93% 93.50%FY20 60.15% 72.10% 91.50%

NOTE: The green cells reflect a 2.95% increase for the period April 2003 through June 2004. The blue cells reflect the ARRA stimulus adjusted FMAP for October 2008 through December 2010. The FMAP values for FY14 through FY20 are projections.

FY03

FY04

FY09

FY10

FY11

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Increased FMAP for Newly Eligible Mandatory Individuals (ACA Section 2001)

‘‘(y) INCREASED FMAP FOR MEDICAL ASSISTANCE FOR NEWLY

ELIGIBLE MANDATORY INDIVIDUALS.—

‘‘(1) AMOUNT OF INCREASE.—[Replaced by section

1201(1)(B) of HCERA] Notwithstanding subsection (b), the

Federal medical assistance percentage for a State that is one

of the 50 States or the District of Columbia, with respect to

amounts expended by such State for medical assistance for

newly eligible individuals described in subclause (VIII) of section

1902(a)(10)(A)(i), shall be equal to—

‘‘(A) 100 percent for calendar quarters in 2014, 2015,

and 2016;

‘‘(B) 95 percent for calendar quarters in 2017;

‘‘(C) 94 percent for calendar quarters in 2018;

‘‘(D) 93 percent for calendar quarters in 2019; and

‘‘(E) 90 percent for calendar quarters in 2020 and each

year thereafter.

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Medicaid Expansion Eligibility and FMAP

138% 0% -100%

138%0% -75%

76% -138%

138%

101% -138% 200%

0%

50%

100%

150%

200%

250%

Children0 - 5

Children6-18

CHIP PregnantWomen

Parent /Caretaker

ChildlessAdults 19-

65

FPL

Regular FMAP 100% FMAP CHIP FMAP

FPL Household Size 1 Household Size 450% $5,585 $11,525100% $11,170 $23,050138% $15,415 $31,809150% $16,755 $34,575200% $22,340 $46,100250% $27,925 $57,625

2012 Federal Poverty Guidelines

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CHIP Caseload with Expansion

Age 0-18 between

139%-200% FPL

Current CheckUp

recipients below

138% FPL

TOTAL

Jul-13 0 0 0Aug-13 0 0 0Sep-13 0 0 0Oct-13 1,434 0 1,434

Nov-13 2,869 0 2,869Dec-13 4,303 0 4,303Jan-14 5,737 -953 4,784Feb-14 7,171 -1,906 5,265Mar-14 8,606 -2,859 5,747Apr-14 10,040 -3,812 6,228

May-14 11,474 -4,765 6,709Jun-14 12,908 -5,718 7,191Jul-14 13,073 -6,670 6,403

Aug-14 13,238 -7,623 5,614Sep-14 13,402 -8,576 4,826Oct-14 13,567 -9,529 4,038

Nov-14 13,732 -10,482 3,249Dec-14 13,896 -11,435 2,461Jan-15 14,061 -11,392 2,669Feb-15 14,225 -11,387 2,839Mar-15 14,390 -11,420 2,970Apr-15 14,555 -11,437 3,117

May-15 14,719 -11,438 3,281Jun-15 14,884 -11,424 3,460

CHIP FMAPACA Mandatory Caseload

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Medicaid/CHIP Administrative Costs• The State must cover the administrative costs at the

regular 50% Federal Match for the expansion population. This includes items such as:

• Eligibility processes• Utilization management and service prior authorization• Claims payment

• There are also information system costs that are at different match levels

• New benefit plan costs• Eligibility engine and link to Silver State Health Insurance Exchange• Data/recipient tracking

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Primary Care Physician Rate Increases • This proposed rule implements new requirements in sections 1902(a)(13),

1902(jj), 1905(dd) and 1932(f) of the Social Security Act as amended by the ACA requiring payment by State Medicaid agencies of at least the Medicare rates in effect in calendar years 2013 and 2014.

• Primary care specialties include:

• Family Medicine

• General Internal Medicine

• Pediatric Medicine

• Services to be included are all Evaluation and Management codes and vaccine administration codes.

• The average increase in primary care reimbursement is estimated at 36%.

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Other Significant Medicaid Issues

• Disproportionate Share Hospitals (DSH) – 50% reduction in national pool of federal dollars for this program

• Upper Payment Limit (UPL) – increase due to additional Medicaid bed days

• Care management for new eligibles and Aged, Blind, and Disabled (ABD) clients

• Presumptive eligibility –permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations

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Medicaid Eligible MHDS Clients

Not Medicaid, 49%

Current Medicaid, 27%

Currently Eligible but Not Served,

3%

New Eligibles under 100%

FPL, 12%

New Eligibles between

100%-138% FPL, 10%

FY14

Not Medicaid, 44%

Current Medicaid, 27%

Currently Eligible but Not Served,

3%

New Eligibles under 100%

FPL, 15%

New Eligibles between

100%-138% FPL, 11%

FY15 - FY20

% of Total MHDS Caseload on Medicaid FY14 FY15 FY16 FY17 FY18 FY19 FY20Medicaid Expansion to 138% FPL 51% 56% 56% 56% 56% 56% 56%Medicaid Expansion to 100% FPL 41% 45% 45% 45% 45% 45% 45%

Without Medicaid Expansion (Mandatory caseloads only) 30% 30% 30% 30% 30% 30% 30%

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Impact on County Medical Assistance

• Added insurance coverage through Medicaid would reduce the burden on Nevada’s counties to fund health care services to indigents.

• NACO has hired a consultant to estimate the impact of the Medicaid expansion on their medical assistance programs.

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Summary of State/Federal Impact through FY20

Federal, $1,063 million,

66%

$3.7 billion

$1.6 billion

MEDICAID EXPANSION TO 138% FPL MANDATORY CASELOADS ONLY


85%

State, $549 million,

15%


34%

MEDICAID EXPANSION TO 100% FPL

$3.0 billion


81%


19%

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Estimated Economic Impact FY14-FY20

• The economic impact analysis below corresponds to the total expenditures from a previous analysis and has not been updated with the re-estimated expenditures shown elsewhere in this presentation.

Total State Only

(Millions) (Millions)

Opt-In $3,454.40 $654.10 3,396 to 8,611 $3,608.50 to $6,216.10

Opt-Out $1,369.10 $487.00 1,354 to 3,434 $1,430.90 to $2,463.50

Difference $2,085.40 $167.10 2,042 to 5,177 $2,177.60 to $3,752.60

152% 34%

¹

NOTE: The opt-out values are computed from the opt-in amounts using the ratio of total opt-out spending to opt-in spending.

Lower limits computed by State Demographer Jeff Hardcastle using REMI model.

Upper limits computed by UNR Professor Tom Harris using IMPLAN model.

ACA Expenditures Cumulative Economic Impact¹

New Jobs Value of Goods & Services

(Millions)

Medicaid and the ACA

Health & Medicine

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