Demonstration projects to study the effect of allowing states to extend Medicaid to pregnant women and children not otherwise qualified to receive Medicaid benefits : [interim report to Congress]

9 Pages·2002·0.41 MB·English

by  Shalala, Donna E

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THESECRETARYOFHEALTHANDHUMANSERVICES
WASHINGTON.O.C.20201
JUL 2 1393
TheHonorableAlbertGore,Jr.
PresidentoftheSenate
Washington,D.C. 20510
DearMr.President:
Iampleasedtoprovideyouwiththisinterimreporton"DemonstrationProjectstoStudythe
EffectofAllowingStatestoExtendMedicaidtoPregnantWomenandChildrenNot
OtherwiseQualifiedtoReceiveMedicaidBenefits." Itwaspreparedinresponsetosection
6O4B07RAof8t9heprOomvniidebsusfoBruddegmeotnsRtercaotnicoinlsiaitniosnevAecratloSfta1t9e8s9,to(sOtBudRyAth8e9)ef(fPe.cLt.s1o0f1e-2x3t9e)n.ding
benefitsundertitleXIXoftheSocialSecurityActtopregnantwomenandchildrenunderthe
ageof20wholiveinfamilieswithincomesbelow185percentoftheFederalpovertyleveland
whoarenototherwiseeligibletoreceivesuchbenefits. Foreachofthemandated
demonstrations,anevaluationisrequiredontheeffectoftheprojectwithrespectto:accessto
healthcare,privatehealthcareinsurancecoverage,costsforhealthcare,andfeasiblepremium
andcost-sharingpolicies.
Thisletterreportfocusesonthedevelopmentactivitiesconductedthusfarinpursuitofthe
goalsofthelegislativemandateandthestatusofeachdemonstration. Aninterimreport
containingasummaryoftheevaluationsconductedundersection6407wasduetoCongress.
SincethetimerequiredtoensureStatefunding,developtheoperationalprotocols,and
preparethewaiverdocumentationextendedconsiderablybeyondtheoriginalprogram
implementationtargets,thisreportwassimilarlydelayed
BACKGROUND
UnderOBRA89,Congressspecifiedthedemonstrationsshouldbeoperationalforupto
3years(FiscalYears(FYs)1990,1991,and1992). TheHealthCareFinancingAdministration
issuedasolicitationforproposalstoeachoftheStatesinJune1990. InSeptember1990,three
oftherespondingsevenStates-Florida,Maine,andMichigan-werecompetitivelyawarded
cooperativeagreementstoconductthedemonstrations.
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Page2-TheHonorableAlbertGore,Jr.
Eachprogramincludesadevelopmentalphase,a3-yearoperationalperiod,anda3-month
phase-downperiod. TheFederalshareoftitleXIXadministrativeandserviceexpendituresfor
thecombinedprojectsisrestrictedbythelegislationtoatotalof$10millionperyearforeach
operationalyear. EachStateissubjecttoanannualcapinordertoensurethatthetotal
Federalmatchingfundsdonotexceedthestatutorylimit. Separateresearchand
demonstrationfundshavebeenprovidedforevaluation-relatedactivitiestofacilitatefull
cooperationwithdatagatheringrequirements,includingduringthedevelopmentalandphase-
downperiods. Atotalof$483,150inresearchanddemonstrationmonieswasmadeavailable
forallawardeesforthefirst18months,andatotalof$500,000willbeavailableforeachof
theremainingyears.
AfinalreporttoCongressisdueonJanuary1,1994. Thedelaysininitiatingeach
demonstrationhaveresultedinafundingproblembecausetheoriginallegislationspecifiedthat
fundingwasauthorizedonlyforFYs1990,1991,and1992. Becausethedemonstrationswere
notoperationalfortheentirefiscalyear1992,sufficientfundsremaintocoverthecostsof
servicesandadministrationthroughSeptember1993. Thedemonstrationswillnotcontinue
beyondSeptember1993withoutadditionalCongressionalauthorization. Withoutsuchfurther
authorizationaswillallowthedemonstrationstocontinue,thevalueofthesedemonstrations
asresearchtoolswillbeseverelydiminished Thiswillaffectourabilitytoproducea
meaningfulfinalevaluationofthedemonstrationsinthefinalreporttoCongress. Wehave
informedmembersofCongressaboutthissituation.
DESCRIPTION
Auniquestrategyforextendinghealthcoveragetoeligibleindividualswillbeemployedineach
ofthethreedemonstrationsites. TheMaineprogramcomprisesthechildren'sbenefitsportion
ofthestatewideMaineHealthProgram,enactedin1989,whichprovidesMedicaid-like
coveragetoallresidentsoftheStatemeetingincomeeligibilitycriteria. Thedemonstration
containsaprovisionforsubsidizingthepurchaseofcomparableprivate,employer-basedgroup
coverage,wheresuchinsuranceisavailabletoworkers'dependentsandisshownbytheState
tobecosteffective.
Floridaisimplementing,inVolusiacounty,aschool-basedinsurancepackageemploying
income-relatedsubsidiestoprovidepreventiveandcomprehensiveservicesthroughamanaged-
carenetwork. Michiganwilltesttheeffectivenessofapublic-privatepartnershipbetweenthe
StateandBlueCrossBlueShieldofMichiganinwhichprivatelydonatedfundswillcontribute
totheunderwritingofacommercialoutpatientinsuranceproduct. Wehaveencloseda
descriptionofthedesignandcurrentstatusofeachdemonstration.
--J tu
Page3-TheHonorableAlbertGore,Jr.
Thisletterreporthaspresentedkeyelementswithregardtothedesignanddevelopmentof
theMedicaidExtensionDemonstrationsmandatedbyOBRA89. Althoughitistooearlyto
arriveatanyconclusionsabouttheeffectivenessofthealternativeprogramsinmeetingthe
statedgoals,itisclearthattheStatesinvolvedareattemptingtoestablishviablesystemsfor
providingbasichealthcarecoveragetopreviouslyuninsuredpregnantwomenandchildren.
Moreover,duetothecarefulplanningoftheresearchdesign,theevaluationoftheprograms
shouldyieldimportantinformationregardingtheabilityofsuchcoverageexpansionsto
enhanceaccess,reduceinappropriateutilization,ensureadequateproviderparticipation,
controlcosts,andimprovehealthoutcomesofprogramenrollees.
WelookforwardtoworkingwithCongresstoachieveabetterunderstandingoftheseissues.
Sincerely,
Enclosure
MAINEDEMONSTRATION
ThedemonstrationbuildsupontheMaineHealthProgram,enactedin1989,whichprovides
Medicaid-likebenefitstoalladultresidentsoftheStatewhosehouseholdincomeisator
below95percentoftheFederalpovertylevel(FPL)atthetimeofapplication,andallchildren
belowage18inhouseholdsatorbelow125percentoftheFPLatthetimeofapplication.
Onceenrolled,ifthehouseholdincomerisesabove125percentoftheFPL,individualsand
familiesremaineligiblefortheprogramduringa2-yeartransitionperiod,aslongasthat
incomedoesnotexceed185percentoftheFPL. Maine'spresentMedicaidcoverageextends
eligibilitytopregnantwomenandinfantsinfamilieswithincomesupto185percentofthe
FPL.
ThedemonstrationmakesavailableFederalfinancialparticipationforallMaineHealth
Programbenefitstoincome-eligiblechildrenbetweentheagesof6and19. Benefitsinclude
inpatientandoutpatienthospitalservices,prescriptiondrugs,laboratoryandradiologyservices,
mentalhealthcare,dentalhealthcare,visioncare,andspeechandhearingservices. The
demonstrationisdesignedtoenhanceoutreachefforts,coordinateservicedeliveryandpay-
ment,and,wherefeasibleandcosteffective(asdeterminedbytheState),toencouragetheuse
ofemployer-basedcoveragefordependentsofemployedworkers. Forthosewithemployer-
basedinsurance,thedemonstrationwillprovidewrap-aroundcoverageforanyMedicaidbenef-
itsnotavailablethroughtheprivateplan. Specialmarketingstrategiestargetadolescents,
employerswhohavenotprovidedcoveragepreviously,andhealthcarepractitioners. Anewly
augmentedMedicaidfeeschedulefeaturingaresource-basedrelativevaluescaleisexpectedto
encouragephysicianparticipation.
Individualsfromfamilieswithincomesunder100percentoftheFPLpaynopremiumcosts,
whilethosewithhouseholdincomesbetween100percentand185percentoftheFPLare
requiredtopayanincome-relatedpremium. Forthosewithfamilyincomesbetween
100percentand125percentoftheFPL,thecostsharingapproximates1.5percentofincome,
whileattheuppereligibilitylimits,a3percentincomecapisimposed. Eligibilityrulesimpose
nolimitsonassetsandprovidefora20percentdisregardonearningsplusachild/dependent
personcaredeductionofupto$250perindividualpermonth.
TheStatewillmakeavarietyofprogramdataoneligibility,enrollment,utilization,andcost,as
wellasinformationonproviderandemployerparticipationavailablefortheevaluationupon
request. TheHealthCareFinancingAdministration(HCFA)awardedMaine$294,153in
researchanddemonstration(R&D)moniestosupporttheevaluation-relatedactivitiesduring
theperiodfromSeptember1990throughSeptember1993. TheStatewasalsoawarded
$256,144inFederalfundsfordemonstrationadministrativecostsand$4,481,586forservice
costsduringthisperiod.
STATUS
ProgramwaiverswereapprovedinNovember1991andmaderetroactiveto
June14,1991.
ServiceexpendituresfortheperiodJune1991throughApril1993totaled$4,337,701.
EnrollmentinMarch1993was6,500. Othermajorserviceexpenditurecategoriesand
theirapproximatedistributionofthetotalwere:(a)generalinpatient,16percent;
(b)physician,14.5percent;(c)dental,13percent;and(d)prescriptiondrugs,8percent.
FLORIDADEMONSTRATION
FloridahasdesignedaSchoolEnrollment-BasedHealthInsurance(SEBHI)Programto
providelowcostcomprehensivehealthinsurancetoschoolagechildrenoffamilieswithlow
incomeswhodonototherwisehaveaccesstocomparableindividualorgroupinsurance.
SEBHIisacollaborativeeffortoftheFloridaMedicaidProgram,theFloridaDepartmentof
Insurance(DOI),theFloridaDepartmentofEducation,theFloridaHealthyKidsCorporation
(FHKC),theUniversityofFlorida'sInstituteforChildHealthPolicy,MedimetrixConsulting
Group,andtheFloridaHealthCarePlan(FHCP). Throughatri-partyagreementamongthe
FloridaMedicaidProgram,FloridaDOI,andFHKC,FHKCholdsleadresponsibilityfor
operatingtheSEBHIproject. FHKCisaprivate,not-for-profitcorporationsetupbythe
Floridalegislaturetopromotechildren'saccesstopreventivecareservicesandtoprovide
comprehensivehealthinsurancecoveragetochildrenandtheirfamilies. FHKCwillcontract
withseveralentitiestoadministertheproject.
Usingaformalsolicitationprocess,VolusiaCountyschooldistrictwasselectedasthe
demonstrationsite. Onthebasisofdemographicsimilarities,PascoCountywassubsequently
chosenasacontrolsite. EligibilityforSEBHIislimitedtoVolusiaCountyschoolchildren
withfamilyincomesupto185percentoftheFPL. Childreninfamilieshavingincomes
between101percentand130percentoftheFPLareeligibleforapartialpremiumsubsidyof
about95percent. Childreninfamilieswithincomesbetween131percentand185percentof
theFPLareeligibleforabouta72percentpremiumsubsidy.
Itisestimatedthatoftheapproximately15,000uninsuredchildreninVolusiaCountyeligible
toenrollinthedemonstration,7,400willactuallydoso. FHKChascontractedwithCSX
Technologytodetermineeligibility,aswellasmaintainamastereligibilityfile. FHCP,amixed
modelhealthmaintenanceorganizationselectedcompetitivelyasthedemonstrationinsurer,
willmaintainaprovidernetworksufficienttomeettheserviceandqualityassuranceneedsof
programenrollees. Themonthlypremiumof$58.98submittedbyFHCPwithitswinningbid
fellsomewhatundertheactuarialrateestimate($6239)baseduponprivateinsurancecosts.
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Theprimarycarecasemanagedbenefitpackageiscomparabletocommercialgrouphealth
insuranceproducts. UnlikeFloridaMedicaidcoverage,someSEBHIbenefitsrequireminimal
co-paymentsmeanttodiscourageunnecessaryuseofdiscretionaryservices. Thebenefit
packageincludesalifetimemaximumforallmedicalandmentalhealthservicesbutimposes
nolimitoneitherthenumberofphysicianvisitsperdayorprescriptionsfilledpermonth.
Rehabilitationbenefitsarelimitedtoshort-terminterventions.
HCFAawardedFlorida$316,549inR&Dmoniestosupportevaluation-relatedactivities
duringtheperiodfromSeptember1990throughSeptember1993. TheStatewasalsoawarded
$795,083inFederalfundsfordemonstrationadministrativecosts,and$3,545,235forservice
costsduringthisperiod.
STATUS
TheStateoriginallyintendedtoimplementtheoperationalphaseofthecooperative
agreementonApril1,1991. Duetoseveralchangesintheprojectdesign,however,the
periodofdevelopmentwassignificantlyextended. Theoperationalprotocolwas
finalizedinNovember1991.
AlthoughHCFAapprovalforwaiverstoimplementthedemonstrationhadnotbeen
obtained,theStatedecidedtopermitenrollmenttobeginonFebruary1. However,
FederalfundswerenotavailableuntilthewaiverswereapprovedonMarch1,1992.
ServiceexpendituresfortheperiodMarch1992throughApril1993totaled$2387,000.
EnrollmentasofApril1993was5,200.
MICHIGANDEMONSTRATION
TheMichiganCaringProgramforChildren(CPC)willfocusonprovidingcoveragefor
otherwiseuninsuredchildrenandadolescentsthroughage18. Usingapublic-private
partnershiparrangementbetweentheStateofMichiganDepartmentofSocialServices
(MDSS)andBlueCrossBlueShieldofMichigan(BCBSM),alimited-benefitcommercial
insuranceproducthasbeencreatedtocoverthehealthneedsofchildrenwhoarelivingin
householdswithincomesupto185percentoftheFPL.
MDSSwillexerciseStateoversightoftheCPCandserveasliaisonwithHCFA. TheMichigan
HealthCareEducationandResearchFoundation(MHCERF),aresearchsubsidiaryof
BCBSM,hasresponsibilityfortheprivate-sideoversightoftheprogram. MHCERFhas
contractedwithBCBSMtoadministertheprogram. MHCERFwillworkincooperationwith
BCBSMtoraisefunds,willbetheholderofsuchfundstransferredfromBCBSM,andwill,on
amonthlybasis,forwardtoMDSSamountsneededtocovertheStateshareofpremiumcosts.
Inadditiontouseofitsstatewidenetworkofprovidersfordeliveryofcare,BCBSMwillhave
primaryresponsibilityfortheoperationalaspectsoftheCPC,includingeligibility
determination,enrollments,marketing,benefitscoordination,claimsprocessing,quality
assurance,andmaintenanceofutilizationandmanagementinformationdata. Themainthrust
oftheoutreacheffortswillbethroughtheMichiganDepartmentofEducationandthe
MichiganDepartmentofPublicHealth.
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•FundingoftheStateportionofservicecostsoftheprogramwillcomewhollyfromprivate
dollarscontributedbyvariousindividuals,foundations,corporations,andagencies. BCBSM
willusetheirregularphysicianfeescheduletoreimburseparticipatingphysicians,thus
enhancingenrolleeaccesstocare. MDSSwillpayanactuariallydeterminedpremiumof
$29.50permemberpermonthtopurchaseCPCcoverage. Michiganhaselectedtowaiveout-
of-pocketpremiumcostsforallenrollees,notonlythosewithfamilyincomesbelowtheFPL.
TheStatereasonsthatfamilieswithmarginalincomesmaybeunabletopurchaseevena
subsidizedproduct. Federalmatchingfundswillbeclaimedonlyforthatportionofthe
premiumwhichexceedsthedeterminedincome-relatedcontributionforfamilieswithincome
abovetheFPL.
Thebenefitpackagewillincludecoverageofpreventiveandoutpatientservices,including
substanceabusetreatmentandprescribeddrugs. Inpatientservicesarenotincludedsincethe
programassumesrapidspend-downtoMedicaideligibilityintheeventofhospitalizationby
individualparticipants. ABCBSMpreferredproviderorganizationwillbeusedforthe
prescriptiondrugbenefit. EnrolleeswillbeissuedaBCBSMidentificationcard,thuslessening
anystigmaattachedtotheMedicaidprogram.
Thedemonstrationwillbestatewide. Thegeneralenrollmentstrategywillbefirstcome,first
servedwithineachofninestatehealthserviceareas(HSAs). EachHSAwillbeassignedan
initialallotmentofslotsbasedontheirprojectedproportionofthestatewideserviceneed
Concomitantly,someenrollmentswilloccurinclustersasaresultofaprovisionallowingfor
thededicationofprivatedollarstospecifiedmultiplesof10ormorepersons. Familiesin
whichonechildisenrolledwillberequiredtoenrollalladditionaleligiblesiblings.
HCFAawardedMichigan$115,000inR&Dmoniestosupportevaluation-relatedactivities
duringtheperiodfromSeptember1990throughSeptember1993. Fundsforevaluation
activitieswillbeusedtodevelopandmaintainanauxiliarydatasystemtocapturedemographic
informationnotpreviouslycollectedbyBCBSM,suchasfamilyincomeandprogrameligibility
status. Allreportsgeneratedbythemanagementinformationsystemwillbemadeavailableto
theevaluationcontractor,aswillcostandutilizationdata(retrievableattheindividual
encounterlevel). TheStatewasalsoawarded$145,400inFederalfundsfordemonstration
administrativecostsand$1319,126forservicecostsduringtheperiodSeptember1990through
September1993.
STATUS
MichiganoriginallyintendedtoimplementtheCPCinApril1991. Thedevelopment
periodrequiredalongertimethananticipated,however,largelyduetofiscalproblems
intheStatewhichnecessitatedchangesinthedemonstrationdesign. Thefinal
operationalprotocolwasreceivedinMarch1992,andtheStatebeganimplementation
inSeptember1992.
TheStateandBCBSMbeganoperationoftheCPCprogramonOctober1,1991,using
onlyprivatelycontributedmoniestofundserviceandservice-relatedadministrative
costs. ThefirstchildwasenrolledNovember1,1991. Currentenrollmentsare1,500.
Therearepresentlyabout3,000childrenontheprogramwaitinglist. Enrollmentsare
lowerthanexpectedbecauseprivatelydonatedfundsarelowerthanexpected.
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EVALUATION
.
HCFAcompetitivelyawardedacontractinJune1991toAbtAssociates,Inc.(Abt),toconduct
anindependentevaluationofthethreedemonstrations. Theevaluatorwilldescribeeach
projectseparately,specifytheconceptualandoperationaldifferencesamongthem,identify
dataneededfromeachtomeetthestudyobjectives,conductaprocessanalysisofeach
program,andfieldsurveysineachStateofparticipatingfamilies,controls,providers,and(in
Maine)employers. Resultsobtainedfromthesestudieswillbeusedinpreparingthereportto
Congress,dueJanuary1,1994. Uponconclusionofthedemonstrations,afinalevaluation
reportwillbesubmittedtoHCFAgivingoverallfindingsanddiscussingtheirpolicy
implications. Takingintoaccountthedistinctivenessofthethreedemonstrations,the
objectivesoftheevaluationareto:
determinetheeffectofthealternativeinterventionsonvariousoutcomeandprocess
measuresofaccesstocare,marketpenetration,healthstatus,serviceuseandtreatment
costs,andprogrameffectiveness;and
determinewhetherand/orhowtheavailabilityofsuchcoveragealtersthebehaviorof
consumers,employers,providers,andprivateinsurancemarkets.
Primarydatacollectionwilluseasampleframecomposedofapplicationsforthenational
schoollunchprogramineachState. Foursamplesofrespondentswillbedrawnforeachof
thethreesites: (1)across-sectionalsampleofschoollunchenrolleesfromthegeographic
regionexposedtotheprogramasstratifiedbyincomerequiredforeligibility;(2)across-
sectionalsampleofschoollunchenrolleessimilarlystratifiedbyincomefromschooldistrictsin
ageographicareanotexposedtothedemonstrationtoserveascontrolgroups;(3)thecensus
ofprogramenrolleesineachofthethreedemonstrations;and(4)asampleofprogram
enrolleesineachdemonstrationstratifiedbyyearofintakeforlongitudinalanalysis.
Telephoneinterviewsand,inthecaseofthelongitudinalsamples,twoannualfollow-upsurveys
oftherespondentswillcaptureresponsesonvariousmeasuresofsatisfactionwiththeprogram.
Caregiversatisfactionwillalsobecapturedthroughsurveysofproviders,andselected
employerswillbequeriedabouttheprovisionofprivateinsuranceproducts. Secondarydata
fromtheclaimsprocessingsystemswillbeusedtolinkinformationonservicecostand
utilizationwiththecapturedprimarydata.
STATUS
AbtconducteditspreliminarysitevisitfortheMainedemonstrationinJanuary1992
andfortheFloridaandMichigandemonstrationsinApril1992.
Abtiscurrentlycollectingclaimsinformationforallthreedemonstrationsitesand
preparingfortheadministrationofasurveytoprogramparticipantsandcontrol
recipientscoveringtheinitialperiodofthedemonstration.
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CnSLIBRARY
3 6015 D0014141