Medicaid



Senate Veto Overrides:
Implications for Ohio’s Medicaid Program 

Loren Anthes 
Fellow, Center for Medicaid Policy
August 23, 2017 

CONTEXT
On Tuesday, August 22, the Senate voted to override six of Governor Kasich’s Medicaid-related vetoes. In July, the House had overridden 11 of the governor’s vetoes, 10 of which dealt with Medicaid, meaning that the Senate can still act on four of those Medicaid-related provisions pushed forward by the House. Several of the veto overrides included provisions that would affect eligibility, rates, and the carve-in of certain Medicaid populations into managed care.






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JMOC Hears Testimony from ODM, ODMHAS, and Behavioral Health Providers as Redesign Implementation is Delayed
By Adam White
Graduate Assistant
June 29, 2017  

After over two years of preparing to carve new behavioral health benefits into Medicaid managed care plans and recode all Medicaid behavioral health services to align with national coding standards, the Ohio Departments of Medicaid (ODM) and Mental Health and Addiction Services (ODMHAS) had announced they were ready to go live with the Behavioral Health Redesign starting on July 1, 2017. The agencies filed rules implementing the changes with the Joint Committee on Agency Rule Review (JCARR) earlier this spring after the Common Sense Initiative Office ruled the rules would not have an adverse impact on business. However, after hearing from numerous small providers that were unprepared to go forward with the new system on July 1, the Ohio House of Representatives inserted a provision in the budget bill (H.B. 49) that would prohibit the new system from going live until January 1, 2018, and further delay the carve-in of alcohol, drug addiction, and other mental health services into Medicaid managed care until July 1, 2018. Correspondingly, JCARR requested that the administration place its proposed rules in “To Be Refiled” status to allow for further review.

On Thursday, June 22, the Joint Medicaid Oversight Committee (JMOC) of the Ohio General Assembly heard testimony regarding the status of the Behavioral Health Redesign from ODM Director Barbara Sears, ODMHAS Director Tracy Plouck, and representatives from various behavioral health providers. Directors Sears and Plouck testified that the administration is respectful of the budget deliberation process and that the agencies will not refile rules affecting community mental health providers nor propose an effective date for the rules until the budget process has concluded. However, Director Sears affirmed that the hospitals are prepared to move forward with the coding changes and make the new services available as soon as possible. Therefore, ODM has refiled a rule to increase access to services for children and multi-system youth with an effective date of August 1, 2017. Director Sears noted that ODM is able to accommodate these new services sooner because the billing methodology for hospitals in the Medicaid claims system is separate from the coding changes relating to community providers.



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Ohio Senate Medicaid Provisions Could Jeopardize Self-Reliance
By Emily Campbell
Associate Director, Williamson Family Fellow for Applied Research
June 23, 2017

Changes to the Medicaid program included in the Senate version of Ohio’s biennial budget would make it more difficult for some Ohio families to move toward self-sufficiency. By grandfathering individuals who are enrolled in Medicaid expansion at the end of the next fiscal year and closing all future enrollment in Group VIII (expansion), the Senate bill deepens the benefit cliff. This creates a disincentive for some workers to accept a raise or increased hours because even a small increase in pay would mean they could never qualify for Medicaid health coverage again, even if their financial circumstances change. This impact is especially great for low-income working adults without children.

Most harmful is the provision that essentially rolls back Medicaid expansion by closing Group VIII to new enrollees. The Senate version ends new enrollment in Group VIII after July 1, 2018, but allows Ohioans who are enrolled in Group VIII coverage on June 30, 2018 to maintain eligibility until they cease to meet eligibility requirements or federal reimbursement is reduced. When Medicaid reverts to pre-expansion income limits, parents would qualify only if they made less than 90 percent of the Federal Poverty Level (FPL), or $18,378 per year for a family of three. Non-disabled single adults would never again qualify, even if they had no income at all.



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JMOC: The Medicaid Group VIII Assessment Findings and Highlights on the Medicaid Portion of the Executive Budget

By Brie Lusheck
Public Policy Associate
February 23, 2017

Director Barbara Sears cemented her first 56 days as Director of the Department of Medicaid by briefing the Joint Medicaid Oversight Committee (JMOC), a committee she once chaired, on the Ohio Medicaid Group VIII Assessment (Expansion) report and Medicaid highlights from the executive budget, House Bill 49.

The Medicaid Group VIII Assessment report highlights key findings from an examination on Group VIII, otherwise known as the Medicaid expansion population in Ohio. A large sample size was used to gather data to examine, from a wide variety of sources and through biometric screenings, medical records, Medicaid records, focus groups and stakeholder interviews. 




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The Return on Investment of Medicaid Expansion:
Supporting Work and Health in Rural Ohio
By Loren Anthes, MBA

Fellow, Center for Medicaid Policy
January 4, 2017 

When debating the Medicaid expansion in 2013, the Ohio legislature appropriately questioned whether expanding the program to non-disabled adults would be done so efficiently, supporting the health, welfare, and economy of Ohio and its citizens. The subsequent policy process reflected this focus on program performance, including a legislative committee tour around Ohio to understand the potential impact of expansion, the creation of the Joint Medicaid Oversight Committee, legislative efforts to increase cost-sharing for participants, and an evaluation of the impact of the expansion due 2017. It is this last item, the “Ohio Medicaid Group VIII Assessment” evaluation, which is the subject of this blog.

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The Gift of the MAGI?
Sweating the Details of Obamacare Repeal
By Loren Anthes
Fellow, Center for Medicaid Policy
December 16, 2016

Medicaid is big and complicated. As I have written about before, the intertangled state and federal monies, processes, and policies that comprise the Medicaid program vary greatly from state to state and, as the saying goes, if you’ve seen one state Medicaid program, you’ve seen one state Medicaid program. With that said, Medicaid occupies a greater share of state and federal budgets, and it is a target of reform on both levels of government. Indeed, with an emboldened Congress and a new administration, changes are coming, and those changes create opportunities and challenges for policymakers. Given this complex relationship, federal policy cannot remain agnostic to the variation of state design.



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JMOC: Setting the Rate
By Loren Anthes
Fellow, Center for Medicaid Policy
October 25, 2016

            In September, the Joint Medicaid Oversight Committee (JMOC) met to discuss the preliminary report from the JMOC actuary, Optumas. During that meeting, Optumas laid out the basic process for determining the JMOC per member per month (PMPM) growth rate, and there was a review of the statutory obligations of JMOC when setting said rate. To learn more about the process and the discussion of that meeting, which may be helpful for this post, please see my blog post from September. On October 20, however, we saw JMOC officially establish their goal for the Medicaid Director at 3.3 percent. So what are the implications and how does this translate to the budget process?




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JMOC: Preliminary Report from the Actuary
By Loren Anthes
Fellow, Center for Medicaid Policy
September 28, 2016

               It has been a couple months since the last Joint Medicaid Oversight Committee (JMOC) hearing, and the latest meeting covered a lot of ground in a five-hour-plus session. The majority of JMOC dealt with the behavioral health redesign, including testimony from providers and the administration. If you want to learn more about what was shared during that portion, I recommend you read the following post from Kelly Smith of the Mental Health and Addiction Advocacy Coalition. For my blog, I will focus on the preliminary report from JMOC’s actuary, Optumas. While it may not have had the depth of content (or attendance) as the “redesign” section, the implications of what was shared may have a more significant impact in the next budget, generally.

            According to Ohio Law, at the beginning of every fiscal biennium, JMOC must contract with the actuary to provide a projected medical inflation rate, determine if it agrees with the projection, and submit a report on its findings to the Governor and the General Assembly (GA). If JMOC doesn’t agree with the projection, they must develop their own rate for the submission. This report will be submitted October 25th, to comply with the requirement to have it to the Governor 90 days before he submits a state budget proposal for the upcoming year (at least January 23, 2017).




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Census Review: 
The Impact of the Affordable Care Act on the Uninsured
By Loren Anthes
Fellow, Center for Medicaid Policy

September 15, 2016
 

The Center for Community Solutions team has been analyzing the implications of the latest U.S. Census information. To learn more about this data more broadly, please click here to see the blog post by Kate Warren. With that said, I wanted to dive a bit more deeply into one set of metrics around the uninsured and the policy underpinnings that have led to the current data measurements.

The census data revealed that Ohio’s uninsured rate continues to decrease, showing a reduction of the uninsured by over 500 thousand since 2013. In just five years, Cuyahoga County has seen its uninsured rate cut in half (12.5 percent uninsured in 2010 to 6.1 percent in 2015), and Cleveland’s uninsured rate has dropped nearly 10 percentage points over the same period. This decrease is attributable, in large part, to the passage of the Patient Protection and Affordable Care Act (ACA) which provided coverage through an optional Medicaid expansion and the creation of the Health Insurance Marketplace (Marketplace). The effects of these two aspects of the law, however, are not limited to their existence and, in fact, the two have shown to have significant influence on one another.



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Annual Checkup: Digging into Ohio Medicaid’s SFY16 Report
By Loren Anthes
Fellow, Center for Medicaid Policy
August 31, 2016
 

This month, the Ohio Department of Medicaid (ODM) submitted its Annual Report to the governor. The document, which has been released each year since State Fiscal Year (SFY) 2014, provides an overview of the initiatives (and the related messaging) behind some of the work of ODM. As we wait for the final budget from Governor Kasich’s administration, and as we contemplate what that may mean for the Medicaid program, I thought it would be good to dig a bit deeper into this report to garner some insights.


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A COLLABORATIVE REPORT ON THE UNINSURED IN NORTHEAST OHIO 

By

Loren Anthes, Fellow, Center for Medicaid Policy | The Center for Community Solutions
Tony Gutowski, Manager | Center for Health Affairs

Marketplace Take-Up Rates in Northeast Ohio:
Coverage Growth and Coverage Gaps






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Healthy Ohio Waiver Released
Loren Anthes, Fellow, Center for Medicaid Policy
July 8, 2016

On June 30, the Ohio Department of Medicaid (ODM) submitted its application for the legislatively required 1115 Demonstration Waiver known as “Healthy Ohio” to the U.S. Department of Health and Human Services (HHS). Throughout the state development process, we have written and posted about Healthy Ohio in order to address our concerns and questions regarding the potentially negative effects of the waiver on the Medicaid program. Now, as the state has its application reviewed by the federal government, we want to revisit the process associated with applying and discuss the potential next steps.

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JMOC: Redesign Update and Panel Discussion
Loren Anthes, Fellow, Center for Medicaid Policy
June 3, 2016

The Joint Medicaid Oversight Committee (JMOC) had a lengthy discussion on May 26th regarding alcohol and drug addiction. During the meeting, which featured a panel of experts in the field, there were two main points of conversation. First, there was a “status update” by Dr. Mark Hurst, Medical Director of the Ohio Department of Mental Health & Addiction Services (ODMHAS), on the Behavioral Health Medicaid Redesign. Second, there were presentations from a number of guests representing providers and the county ADAMHS Boards.


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An Update on the Extension of Medicaid
Loren Anthes, Fellow, Center for Medicaid Policy
May 18, 2016 

Ohio’s Medicaid extension has received a lot of scrutiny from the media, policymakers, and policy experts since its implementation in 2014. This scrutiny has only increased in the past few months during Governor Kasich’s Presidential run and as the Ohio Department of Medicaid (ODM) finalizes its statutorily required 1115 demonstration waiver, Healthy Ohio. While many have been extolling the value of the program, including the Governor, some have claimed that the costs associated with the extension are exorbitant, resulting in overspending in the Medicaid program. This post, then, tries to give a sense of where we are today by examining the performance of the extension geographically and in terms of enrollment and expenditures.

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Update on Disability Determination Redesign (DDR) 
Tara Britton, Fellow
May 13, 2016

As the state prepares to transition to a unified disability determination system, thus ending the Medicaid spend-down program, additional information about who will be affected by the transition, and the impact of these changes, has been released. The Governor’s Office of Health Transformation (OHT) published an overview of the changes. The impact of the state’s transition from a 209(b) state to a 1634 state (this means the state is implementing Section 1634 of the Social Security Act, rather than using Section 209(b)) will vary depending on an individual’s current eligibility status and income. Under the new eligibility criteria, those who meet disability under Supplemental Security Income (SSI) will also qualify for Medicaid. Medicaid income and asset limits will increase to match current SSI eligibility criteria at 75 percent of the Federal Poverty Level (FPL) or $743 of income and a $2,000 asset limit. The Center for Community Solutions has been following the implementation of these changes as part of a group of interested stakeholders working closely together, and with the Ohio Department of Medicaid (ODM) to help people who are impacted by these changes have accurate, timely, and clear information.

ODM has stated that all current Medicaid aged, blind, and disabled (ABD) enrollees will be automatically moved over to the new system and retain full Medicaid benefits, without spend-down. This automatic transition also applies to anyone who spent-down to Medicaid eligibility levels between July 1, 2015, and June 30, 2016, even if they do not fall into one of the previously mentioned ABD categories. This transition to the new system is planned for July, 2016. ODM is awaiting a response from the federal Centers for Medicare and Medicaid Services (CMS) to allow a waiver of ABD Medicaid renewals for July 1 – December 31, 2016. This will allow time to adjust to the new disability determination system. If approved, annual renewals will commence January 1, 2017, and the new eligibility criteria will apply moving forward. The new eligibility criteria will apply to anyone seeking new Medicaid coverage as of July 1, 2016.



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CMS Release Final Managed Care Rule
Loren Anthes, Fellow, Center for Medicaid Policy
April 26, 2016 

On April 25th, the Centers for Medicare and Medicaid Services (CMS) released the much anticipated final rule significantly updating regulations pertaining to managed care organizations (MCOs) participating in Medicaid and the Children’s Health Insurance Program or (CHIP). MCOs are private insurance companies that provide, or arrange the provision of, services for Medicaid enrollees in exchange for a set amount of money. Ohio has been a “managed care state” since the late 1970s and has increasingly used the model, with Ohio’s five plans covering 93 percent of the total Medicaid population as of March. As such, this rule has a significant impact on how Medicaid service is delivered and how providers are reimbursed.

SOME INITIAL HIGHLIGHTS



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JMOC Update and Healthy Ohio’s First Public Comment Hearing
Loren Anthes, Fellow, Center for Medicaid Policy
April 22, 2016
 

On April 21st, the Ohio Department of Medicaid was busy with Director John McCarthy offering testimony before the Joint Medicaid Oversight Committee (JMOC) in the morning as well as serving as host to the first of two required hearings for Ohio’s 1115 Demonstration proposal known as “Healthy Ohio” in the afternoon. During JMOC, the director provided a brief overview of the Department’s activities regarding Ohio’s Disability Determination Redesign, Ohio Benefits, and the Behavioral Health Redesign.

Director McCarthy affirmed the ongoing work with the Center for Medicare and Medicaid Services (CMS) around establishing a timeline for the new coverage via DDR. He outlined a request to CMS to delay the new coverage for existing participants until their redetermination in 2017. While the new coverage rules would still apply to any new applications starting July, 2016, this would allow county caseworkers, he explained, to learn the new rules between July of this year and January, 2017.



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Joint Medicaid Oversight Committee: Medicaid Budget Update

Loren Anthes, Fellow, Center for Medicaid Policy
March 29, 2016

On March 24th, the Joint Medicaid Oversight Committee (JMOC) received a Medicaid budget update from JMOC’s Executive Director Susan Ackerman and Policy Aide Gregory Craig. The update included a review of trends in enrollment and spending as well as a review of major policy initiatives in Ohio and across the nation. In part, this update sought to lay the groundwork for future Medicaid policy discussions in the next biennial budget. The major takeaway from the meeting was that Medicaid spending came in at $1.1 billion under initial budget estimates. The spending reduction was driven by a few key factors including structural aspects of how Medicaid dollars are spent, changes in caseloads, and reductions in Managed Care rates.

The most notable structural influence came from delayed payment in the Hospital Care Assurance Program (HCAP), Ohio’s Disproportionate Share Hospital (DSH) payment program. For background, HCAP provides regularly scheduled payments to hospitals that serve a large number of Medicaid and uninsured individuals. If this payment was made on time, Medicaid underspending would have been $816 million. Underspending also took place in administration through a delay in payment for Ohio’s Integrated Eligibility System vendor and a delay in Health Information Technology incentive payments. Mr. Craig underscored these points to highlight the importance of looking at monthly expenditures in the context of a given fiscal year.



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Updates on Changes to Disability Determination and Elimination of Medicaid Spend-down, now known as Disability Determination Redesign (DDR)
Tara Britton, Fellow
March 21, 2016

Earlier this year, a CCS blog post, and subsequent Common Ground, provided an overview of the State of Ohio’s plan to transition to a unified disability determination system thus ending the Medicaid spend-down program. Advocates have worked closely together, and with the Ohio Department of Medicaid (ODM), to learn about this change and how current spend-down enrollees will be impacted. ODM has named this transition the Disability Determination Redesign or DDR. The changes are on track to begin July 1, 2016. While no one will be grandfathered into the spend-down program, ODM is discussing with the federal government ways to avoid a “hard stop” or abruptly cutting people off of the program on July 1. ODM is considering aligning the transition with the enrollee’s normal redetermination date as an alternative. This is subject to federal approval, so nothing is certain yet.

ODM is developing educational letters to distribute in the spring of 2016 to people who will be impacted by the changes. The letters will contain information that is specific to the changes that each group of enrollees can expect, for example, people who are eligible to establish a qualified income trust, or Miller Trust, will receive a different letter than people who will transition to the health insurance marketplace. Advocates are working with ODM to ensure that there are resources included on the letters for people who will be expected to transition to the insurance marketplace, such as contact information for insurance navigators. ODM is also developing a list of frequently asked questions (FAQ) and educational videos. Specific information is also being prepared to share with county jobs and family services (JFS) agencies, who will undoubtedly receive requests for information from people impacted by DDR.



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Over 30,000 Ohioans Affected by the End of Medicaid “Spend-down” Eligibility 
By Jon Honeck, Edward D. and Dorothy E. Lynde Fellow
January 27, 2016

The Ohio Department of Medicaid (ODM) is preparing to change the program’s disability determination process. Starting in July, 2016, the program will have a unified disability determination system, so that individuals who qualify for Supplemental Security Income (SSI) will automatically qualify for Medicaid. (In legal terms, this means the state is implementing section 1634 of the Social Security Act, rather than using section 209(b)). This ends decades of practice in which applicants had to separately navigate a federal administrative process for SSI and a county administrative process for Medicaid. ODM has filed a state plan amendment with the federal Centers for Medicare and Medicaid Services (CMS) to raise the eligibility income threshold for disabled individuals to 75 percent of the federal poverty level, from the current 64 percent.

As part of the change, the current practice of allowing individuals with incomes above eligibility thresholds to use medical bills to “spend down” to achieve Medicaid eligibility will no longer exist. Spend-down takes place on a monthly basis. People can move in and out of eligibility as their income and expenses change. Spend-down can be used to access both institutional care, such as nursing homes, as well as waiver services, such as Home Care, PASSPORT, MyCare, and Assisted Living. With the change, individuals using institutional care or waivers can establish a qualified income trust (QIT), also known as a Miller Trust, in lieu of a spend-down process. The trust receives excess income above the eligibility threshold, and makes payments for medical care. Income left over in the trust after an individual dies is subject to estate recovery. ODM is contracting with a vendor, Automated Health Systems, to contact individuals currently in institutions or on waivers to help them establish a trust.

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