Iowa Health and Wellness Plan - National Health Policy Forum

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Iowa Health and Wellness Plan
National Health Policy Forum
March 28, 2014
Michael R. Bousselot, Policy Advisor
Office of Gov. Terry Branstad (R-IA)
CMS Approval
• Iowa agreement with CMS
• Approved plan will include premiums:
 50% FPL – 133% FPL
 Waived if complete healthy behaviors and
for Year 1
 No loss of coverage
2
Background
The Iowa Health and Wellness Plan
was enacted to provide comprehensive
health coverage for low-income adults
• State employee health benefits
• Iowans age 19 - 64
• Income up to and including 133% of the Federal Poverty Level (FPL)
• New, comprehensive program will replace the IowaCare program,
ending December 31, 2013
3
One Plan, Two Options
Iowa Wellness Plan – State Plan
• For adults age 19 - 64
• Income up to and including 100% of the Federal
Poverty Level
Marketplace Choice Plan – Exchange Based
• For adults age 19 - 64
• Income 101% to no more than 133% of the Federal
Poverty Level
4
Goals and Objectives
Quality:
Health/improved
outcomes
Investment: Incentives
for healthy behaviors
GOALS
Private Insurance: More
Iowans on Private
Insurance
Access:
Local access to care
5
Member Eligibility
Member
eligibility
12 months of
covered
benefits
Income reverified for
eligibility after
a 12-month
period
6
Iowa Wellness Plan: 0-100% FPL
Family of
one
$11,490
Individuals up
to
100% FPL
Family of
two
$15,510
7
Iowa Wellness Plan: 0-100% FPL
Administered by Iowa
Medicaid through
ACOs
Benefit Categories Covered
Physician services, including primary care
Outpatient services
Emergency room services and transportation
Provides
comprehensive
health services
Hospitalization
Mental health and substance use disorder
Rehabilitative and habilitative services and devices
Lab services, x-rays, imaging (MRI, CT, etc.)
Preventive and wellness services
Coverage is equal to
the benefits provided
to state employees
Home & community-based services
Prescription drugs
Dental services
8
Iowa Wellness Plan: 0-100% FPL
Access to the same
providers currently
available with Medicaid
Ability to choose
primary care physician
Primary care physician
coordinates care for
member
9
Iowa Wellness Plan Managed Care Map:
As of April 2014
Lyon
Osceola
Dickinson
Sioux
O’Brien
Clay
Emmet
Winnebago
Worth
Hancock
Cerro Gordo
Mitchell
Howard
Floyd
Chickasaw
Winneshiek
Allamakee
Fayette
Clayton
Kossuth
Plymouth
Cherokee
Palo Alto
Buena Vista
Pocahontas
Wright
Humboldt
Franklin
Butler
Bremer
Hardin
Grundy
Black
Hawk
Webster
Woodbury
Sac
Ida
Carroll
Crawford
Monona
Hamilton
Calhoun
Boone
Greene
Story
Marshall
Tama
Buchanan
Benton
Delaware
Dubuque
Jones
Linn
Jackson
Clinton
Harrison
Shelby
Audubon
Guthrie
Polk
Dallas
Jasper
Poweshiek
Iowa
Cedar
Johnson
Scott
Muscatine
Cass
Pottawattamie
Adair
Madison
Warren
Marion
Mahaska
Keokuk
Washington
Louisa
Mills
Montgomery
Adams
Union
Clarke
Lucas
Monroe
Wapello
Jefferson
Henry
Des Moines
Fremont
Page
Taylor
Ringgold
Decatur
Wayne
Appanoose
Davis
Van Buren
Lee
•
•
•
Counties in light blue are Iowa Wellness Plan Managed Care
Counties in dark blue can have Iowa Wellness Plan Managed Care or HMO
Counties in white are non-managed care (Fee-for-service)
Iowa Wellness Plan: 0-100% FPL
Out of Pocket Costs:
• No copayments except for using the emergency room
when it is not an emergency
• No monthly contributions during the first year (2014)
• No contributions for those with income below 50% FPL
• Costs cannot exceed 5% of income
11
Iowa Wellness Plan: 0-100%
FPL
Monthly contributions waived
beginning in 2015 if the member
completes wellness activities
First year (2014) members
need to complete health risk
assessment and wellness
exam (annual physical)
• 2015 and beyond will also
other wellness activities
12
Iowa Wellness Plan: 0-100% FPL
Program innovations include:
• Ensure coordination of care for members through
‘medical homes’
• Ensure health care providers are accountable for
achieving high quality and cost effective care that
is focused on the patient
Program innovations will continue to be developed
through a statewide planning process related to
the State Innovation Model* grant
*Go to http://www.ime.state.ia.us/state-innovation-models.html for more information
13
Iowa Wellness Plan: 0-100% FPL
Provider Incentives: Physician is contracted
similar to MediPASS (current managed care
program)
•
Primary Care Physician (PCP) is eligible to earn three
additional types of payments above the regular fee-forservice payment
Primary Care Case
Manager Monthly
Payment
Wellness Exam Incentive
Wellness Plan Medical
Home Value Index Score
Bonus
$4 Per Member Per Month
(PMPM)
$10 Per Member Annually
Up to $4 Per Member Per
Month (PMPM)
14
Marketplace Choice Plan: 101-133% FPL
Family of
one
$11,491$15,282
Family of
two
$15,511$20,628
Individuals
101% FPL
up to
133% FPL
15
Marketplace Choice Plan: 101-133% FPL
Members select a certain commercial health
plan available on the Health Insurance
Marketplace
Medicaid pays the premiums to the commercial
health plan on behalf of the member –
often referred to as “premium assistance”
16
Marketplace Choice Plan: 101-133% FPL
Commercial health plans available to members:
• CoOportunity Health
• Coventry Health Care of Iowa
Uses the commercial plan’s statewide provider
network – includes primary care, specialists,
hospitals
17
Marketplace Choice Plan: 101-133% FPL
Provides
comprehensive health
services
Benefit Categories Covered
Physician services, including primary care
Outpatient services
Emergency room services and transportation
Hospitalization
Mental health and substance use disorder
Coverage includes the
qualified health plan
required essential
health benefits
Rehabilitative and habilitative services and devices
Lab services, x-rays, imaging (MRI, CT, etc.)
Preventive and wellness services
Home & community based services
Prescription drugs
Dental services
18
Marketplace Choice Plan: 101-133% FPL
Out of pocket costs:
• No copayments except for using the emergency
room when it is not an emergency
• No monthly contributions during year one (2014)
• Costs cannot exceed 5% of income
19
Marketplace Choice Plan: 101-133% FPL
Innovation: Purchasing private
coverage
Allows individuals to stay
enrolled in their current plan
if their income changes
20
Plan Summaries
Wellness Plan
Marketplace Choice
0-100% FPL
101-133% FPL
Benefits equivalent to State
Employee Benefit Plan
Marketplace Plan benefits, at least
equivalent to State Employee Benefit
Plan
Plan managed by Iowa Medicaid
Plan managed by commercial insurer
Monthly member contributions
•Waived in 2014
•Waived beginning 2015 for
completing wellness activities
Monthly member contributions
•Waived in 2014
•Waived beginning 2015 for
completing wellness activities
Uses Medicaid provider network
Uses commercial insurer’s provider
network
21
Iowa Health and Wellness Plan
Accountable Dental Care Plan
•
Adequate reimbursement rates for dental services
•
Contracting with a commercial dental plan to cover
services
•
Population health approach
•
Member incentives: providing basic services, with ability
to earn higher cost restorative services
22
Medically Exempt
• Members who are considered ‘Medically Exempt’
must be given the option of enrolling in regular
State Medicaid Plan or Wellness Plan
‘Medically Exempt’ includes individuals with disabling mental disorders (including adults with
serious mental illness), individuals with chronic substance use disorders, individuals with serious
and complex medical conditions, individuals with a physical, intellectual or developmental
disability that significantly impairs their ability to perform 1 or more activities of daily living, or
individuals with a disability determination based on Social Security criteria
• Medicaid has a process to screen for Medically
Exempt members, both at enrollment, after
enrollment, and through provider referral
23
Medically Exempt
24
Enrollment Status Update
Member Enrollment To Date
•
•
•
42,000 current IowaCare
members transferred to
Iowa Wellness Plan
8,700 current IowaCare
members transferred to
Iowa Marketplace Choice Plan
Around 83,435 Iowans currently
enrolled on the Iowa Health and
Wellness Plan
Projected Enrollment
200,000
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
36,826
37,397
36,282
23,830
36,676
35,600
36,134
24,891
Employer
Sponsored
Insurance
Marketplace
Choice
115,869
93,968
114,156
Wellness Plan
117,608
25
Iowa Health and Wellness Plan Status
Member Enrollment
•
Member enrollment packets (primary care provider or
health plan selection) mailed in November- December
•
Iowa Wellness Plan members have 1,322 primary care
providers available, in addition to other contracted
Medicaid providers
•
All members have access to local primary care
physicians. In 88/99 counties, members will be
assigned to a primary care physician of their choice in
their county (where approx. 94% of members live).
26
Application Process
Federal Health
Insurance
Marketplace
www.HealthCare.gov
DHS website
dhsservices.iowa.gov
DHS Contact Center
1-855-889-7985
DHS Local Offices
APPLICATION
PROCESS
27
Information
Find up-to-date information on
the Iowa Health and Wellness Plan at:
http://www.ime.state.ia.us/iowa-health-andwellness-plan.html
28
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