Earlier this year, we blogged about health insurance exchanges, a major provision of the federal health care reform law, the Affordable Care Act (ACA).  In a nutshell, states have been tasked with setting-up online insurance marketplaces, or “exchanges,” for selling private coverage and determining eligibility for premium subsidies or public health insurance programs.  The online exchanges envisioned by the Affordable Care Act institute robust consumer protections, simplify plan and premium comparisons, and facilitate competition.  The deadline for states to gain approval for their exchange plans from the federal government is January 2013, and the deadline for having their online insurance marketplace up and running is January 2014.

The federal government has repeatedly assured the states “flexibility” in instituting the health law’s new programs and regulations.  When the Department of Health and Human Services recently issued its proposed regulations governing health insurance exchanges in early July, state flexibility once again took center stage.  So does all of this emphasis on flexibility mean that HHS intends to let states slide if their exchanges fall short of federal requirements or run behind schedule?  Not so, says a representative from the Centers for Medicaid and Medicare Services (CMS), part of the Department of Health & Human Services.

Laurie McWright, from the Office of Health Insurance Exchanges at CMS, spoke in late July to a meeting I attended that was hosted by the National Academy for State Health Policy.  Her message was clear:  States have the flexibility to design and implement an exchange that best suits their needs, but not the flexibility to miss deadlines or skirt compliance with minimum federal requirements.  If a state isn’t making a timely and good faith effort to comply with federal rules for insurance exchange operation, their efforts will be preempted by a federally-run exchange.  This means that the federal government will implement, operate, and monitor their own standardized exchange ‘template’ in the states that aren’t ready, willing or compliant by 2014.

Oklahoma’s plan for implementing a health insurance exchange is due in less than a year and a half, yet so far planning efforts are stuck in the earliest stages.  Ever since Governor Fallin and legislative leaders decided to give back the $54 million competitive grant Oklahoma had been awarded to design a state-of-the-art exchange, the nascent planning process has come to a virtual halt.  The Oklahoma Insurance Department, which seem to have assumed responsibility for the planning process, canceled meeting after scheduled meeting of stakeholder work groups in May and June, while the intricate blueprints and timelines developed for putting an exchange in place by the deadline are gathering dust.  Meanwhile, both of the bills introduced this past session attempting to authorize Oklahoma’s Health Insurance Exchange failed to pass, and seemed to fall well short of federal standards designed to ensure an affordable and consumer-friendly exchange.

A special interim committee to study the health care law was announced in early August.  The committee will hold a series of public meetings this fall and eventually make recommendations on how the state should address components of the federal health care law.  Every month that goes by draws us nearer to the January 2013 deadline for producing a blueprint for Oklahoma’s Health Insurance Exchange.  Swift and serious attempts to reach out to stakeholders, hold regular public planning meetings, and address minimum requirements are crucial at this juncture to avoid federal intervention.

To learn more about how states compare with each other in implementing key aspects of the health reform law, including exchanges, visit www.statereforum.org.  To learn more about health care reform in Oklahoma, visit the health care page on our website.

share this post

I was at a national conference of health care policy experts and advocates last month when the morning’s plenary speaker, Cindy Mann, Medicaid Director for the Centers for Medicare and Medicaid Services, posed that ominous question. “Uh-oh. What have we done this time?”, I wondered, as I tentatively lifted my hand.  But this time, Oklahoma was being singled out for major praise, not ridicule. What Oklahoma had done that had Mann and several others at the conference gushing was launch a new streamlined enrollment system for the Medicaid program that may be the most user-friendly in the nation – and that positions Oklahoma at the front of the pack as states face the challenges and opportunities of implementing health care reform in the coming years.

Until the launch of the new enrollment system, applicants for SoonerCare health insurance coverage, the state’s Medicaid program, submitted a paper application to the Oklahoma Department of Human Services (DHS) during regular office working hours. In most cases an eligibility determination would be made 20 to 30 days later after information was entered into the agency’s legacy mainframe computer and verified. Policies and procedures were handled at least slightly differently in each county office and by each caseworker, and the client numbering and tracking system was prone to errors.

The new online enrollment system, which is now operated by the Oklahoma Health Care Authority (OHCA), simplifies, standardizes, and expedites the process. Individuals can apply at any time from any computer, either on their own or with the assistance of trained community or state agency partners (For the computer-shy, paper applications may still be submitted). As with an online tax return, the process is logic-driven and rules-based, ensuring that applicants provide all required information on family members, income, health status, and the like needed to make a determination. After the application is completed and submitted, eligibility is determined in real-time and those found to be eligible are enrolled in the program immediately and automatically (contingent on some follow-up verification of information). Once they are enrolled, applicants can review their status and update their information online at any time, in many cases doing away with the need for the state to send out annual eligibility redetermination letters. This process empowers and equips the applicants/members to control their own household data.

The online enrollment system has been in development since late 2007; after data on all current recipients – some 700,000 individuals – was transferred over from the old system, the new system launched September 7, 2010. When I spoke with Richard Evans, OHCA’s Eligibility Automation and Data Integrity Manager (a title itself in need of some streamlining), he reported that since the system’s launch, more than half of new applications have come directly through the online enrollment system; the remainder are part of a common benefits application submitted to the Oklahoma Department of Human Services. One limitation of the new system: While SoonerCare applicants are informed that they may be eligible for benefits administered by DHS, such as food stamps or child care subsidies, and provided information on how to apply, OHCA and DHS are not directly sharing and transferring data.

The new system moves Oklahoma towards a single comprehensive application for public medical programs. Currently, the online enrollment system is able to process SoonerCare applications for children, families, and pregnant women, as well as for adults who may be eligible only for family planning or behavioral health services in a single application. The scheduled Phase II  online enrollment would expand the application to include the Oklahoma Care program, which provides coverage for Breast and Cervical Cancer, the Insure Oklahoma premium assistance program, and the WIC nutrition program administered by the state Health Department.

As the national attention at my conference indicates, the new system puts Oklahoma out in front among states in creating a simplified, integrated and consumer-controlled enrollment process. It should also put Oklahoma in an ideal situation for moving forward with health care reform. Under the Affordable Care Act, states will have primary responsibility for creating integrated, consumer-focused systems to determine whether low- and moderate-income families are eligible for coverage under Medicaid (which will be expanded to include all adults up to 133 percent of the federal poverty level) or for tax credits to purchase private policies through the new Health Insurance Exchanges beginning in 2014. As Tricia Brooks discussed in this recent blog post, the federal government is committing significant resources to helping states develop enhanced eligibility systems that will be up to the task. Soon the federal government will select five states for Innovator Grants to design and implement the IT  infrastructure needed to operate Health Insurance Exchanges – bolstered by 100 percent federal funding. Based on the progress the state has already made with online enrollment, Oklahoma is believed to be a leading candidate to be one of the five successful states – assuming the new Governor and her administration sign off on the application. If Oklahoma does become a model for integrated and simplified enrollment across health care programs, many more of us may be quicker to raise our hands when Oklahoma is mentioned in national meetings in the years ahead.

share this post

I’m not big on rules. When I ran New Hampshire’s Children’s Health Insurance Program  and had to talk with a family who was unhappy about some bureaucratic rule, I often diffused the conversation by saying “I don’t make the rules, if I did there wouldn’t be any.” I know, that was a cop-out but it worked. Now I take those words back. This is one rule I might love!

The Centers for Medicaid & Medicare Services (CMS) has published a proposed rule in the federal register that would broaden the definition of “claims” to include “claims of eligibility” in regard to Medicaid management information systems. What does this really mean? It means that eligibility systems may qualify (assuming the rule is adopted) for a 90 percent federal financial participation to support the design, development, testing and implementation of new or enhanced eligibility systems capacity through 2015. Systems could also qualify for an ongoing 75 percent federal match once they are operational.

Is this a big deal? Indeed it is. States have been severely encumbered by a lack of resources to make system innovations or replace decades old legacy systems that, quite frankly, have outlived their usefulness due to a lack of major overhauls. Moving forward on streamlining efficiencies and the use of data matching to verify eligibility helps both states and real people but requires the latest in systems architecture and performance to achieve the innovations that we know are possible. These kinds of system transformations, along with seamless integration with Exchange IT systems, require major investments and the enhanced federal funding will be welcome news to cash-strapped states.

So, we commend CMS leadership for rightly justifying this rule change to ensure that Medicaid eligibility systems are as efficient and effective as possible and ready to fulfill the promise of coverage for millions of low- and moderate-income people envisioned by the Affordable Care Act. It is worth emphasizing that this is a time-limited opportunity (through 2015) and, given the time required to build these systems, states should get to work quickly.

The proposed rule was accompanied by new guidance for Exchange and Medicaid Information (IT) Systems that establishes a framework and approach for Exchange IT systems developed through the new Innovator Grants and for Medicaid IT systems supported by the 90 percent funding proposed in the rulemaking.  The Office of Consumer Information and Insurance Oversight (OCIIO) teamed up with CMS to issue the guidance.  It  will be updated over time, requiring states to comply with future iterations as well.

Coupled with last week’s announcement of 100 percent  funding for five model Exchange IT systems through the Innovator Grants, this is big news and cause for celebration. Without getting into the really technical requirements (which I’m not qualified to do), here are a few provisions that warm my heart:

1) The guidance requires IT systems to support a first-class customer experience, as well as seamless coordination between the Medicaid and CHIP programs and the Exchanges and between Exchanges and plans, employers and navigators.

2) The guidance also confirms that systems must comply with new standards developed by the National Office of the Coordinator for Health Information Technology, which envision consumer-focused systems that interface across multiple assistance programs.

3) In the proposed rule, CMS anticipates additional standard federal requirements for more timely and detailed reporting of eligibility and enrollment statistics. The proposed rule goes on to indicate that CMS will develop a range of data and performance metrics on which states would be required to report on an ongoing basis. (This is where “like” turned to “love” for me!)

4) Like the Innovator Grants, states will be encouraged to share and reuse Medicaid technologies and systems within and among states.

5) Interoperability goes further than interfacing with Exchange IT systems and includes public health agencies, human service programs, and my favorite – community organizations providing outreach and enrollment assistance services.

All in all, the Innovator Grants, the proposed 90 percent funding for Medicaid IT systems, federal IT guidance with more to come, technical assistance from CMS and ICIIO and incentives for states to share and learn from one another will go a long way to bring the use of technology into the 21st century for our public coverage programs. There’s a lot of work to be done but no longer are we waiting for guidance and the extra resources to get started. Up first on our list is to make sure the proposal becomes the final rule. CCF will be working with our partners to draft supportive comments and to ensure the final rule is as strong for beneficiaries as possible. So stay tuned.

share this post

The Oklahoma Legislature has made several efforts in recent years to chip away at the number of uninsured by expanding eligibility for Insure Oklahoma, a program that provides public subsidies towards the purchase of employer-sponsored coverage for employees of small businesses or a public product for those without access to employer coverage. Eligibility for Insure Oklahoma goes up to 200 percent of the federal poverty level ($44,000 for a family of four) and is available to employees of businesses with up to 250 employees.

Back in 2007, the Oklahoma Legislature passed the All Kids Act (SB 424), that aimed to expand access to health insurance coverage for children in low- and moderate-income working families.  The bill offered subsidized coverage in the Insure Oklahoma program for children 18 years of age or younger with family income between 185 percent of the federal poverty level – the current income threshold for the Medicaid program – and 300 percent .  The bill included an $8 million  set-aside from Insure Oklahoma revenues to help pay for coverage for an estimated 20,000 children. In 2007 and 2008, the Legislature also approved expansions of Insure Oklahomans to new categories of adults, including those with incomes up to 250 percent of poverty, employees of businesses up to 500 employees, and foster parents regardless of the size of their employer.

All that was left to do was for the Oklahoma Health Care Authority secure federal approval for the amendments to the state’s SoonerCare and Insure Oklahoma waivers that would allow for the expanded coverage. How long could that take, right? As it turned out, it wasn’t until this past December, after two-and-a-half long years of negotiations, discussions, revisions, and waits,  that CMS (the Centers for Medicare and Medicaid Services) finally informed OHCA that the amendments had been approved to the applications for both children and adults.

Despite the delays associated with the lengthy approval process, OHCA has indicated that it intends to implement the expansion slowly and gradually.  Beginning in October, enrollment in Insure Oklahoma will be opened to children between 185 and 200 percent of the federal poverty level whose parents are already enrolled in Insure Oklahoma. OHCA estimates that 3,000 children could gain coverage during this initial phase.  No date has been set to open up enrollment for children above 200 percent of poverty or to those with parents not enrolled in Insure Oklahoma. Similarly, OHCA has not set a timeline for expanding enrollment for adults in categories that have now received federal approval for coverage in Insure Oklahoma.

The cautious approach is explained as due to both systems implementation issues and to uncertainty about the ongoing availability of funding to cover the expansion. Insure Oklahoma is funded through a portion of the increased tobacco tax collections approved by voters in 2004. In FY ’09, OHCA was allocated $45 million for Insure Oklahoma. For several years, the program accumulated large surpluses as enrollment lagged. However, enrollment nearly doubled in 2009; with 30,314 participants as of February 2010, the program is approaching the level where annual revenues will only match expenditures on an ongoing basis. At that point, OHCA anticipates imposing a cap and waiting list on new enrollment.

The agency’s cautious approach to expanding eligibility without additional revenues is understandable, especially given the fraught fiscal outlook for the state as a whole, and the Medicaid program in particular, over the next few years.  The problem is really one only the Legislature can resolve. Expanding coverage to new categories of uninsured children and adults was the right commitment to make. Now it’s time to fund the commitment.

share this post

Oklahomans and their families prefer in-home supports over institutionalization and we know these supports offer marked savings with much better outcomes. Over two decades, Oklahoma developed five in-home support Medicaid programs (i.e., 1915C Waivers) now serving 31,000 eligible citizens, and 2 more are in the works. Yet, in-home programs are increasingly squeezed by nearly eight years of stagnant reimbursement.

One way to generate new funds is through Medicaid provider assessments. Through assessments, fees levied on “classes” of services generate revenues matched with federal funds to help cover provider costs. Provider assessments on institutions like nursing facilities allow them to average annual 10% increases even while operating at 65% occupancy.

To investigate in-home provider assessments, the Home and Community-Based (H&CB) Services Council joined Representative Peters to organize an Interim Study (2009H-080) on Provider Assessment Options for Home & Community-Based 1915C Waiver programs. In-home support recipients, advocates, and providers endorsed the study in the belief that Oklahoma should lead through stewardship and prevention across the lifespan for disabled and aging populations, and with measures that assure cost-effective, quality-proven programs. In-home programs save Oklahoma nearly half of a billion dollars annually by preventing costly institutionalization, promoting individual responsibility, self-determination, and full participation in the community –all with better outcomes, including help with employment and a full life in the community no matter how complex the disability.

Medicaid experts spoke with legislators and agency heads on implications for in-home programs if assessments are not passed. According to consultants, CMS (the federal agency overseeing Medicaid), has not updated assessment classes since 1981, preventing states from assessing fees on in-home programs like other providers. National advocacy is underway to change this omission. Missouri and Texas passed bills pursuing in-home assessments, Kentucky has an assessment with the knowledge of CMS, Michigan created an in-home assessment in managed care, and Maine adopted an assessment through allowed taxation. Clearly, preventive, cost-saving opportunities through in-home programs are motivating states to pursue assessments. Conversely, as California cut citizen choice for in-home programs, families/advocates filed a lawsuit under the Olmstead Supreme Court Decision, one that mandates services in the most integrated setting possible.

Additional considerations:

• Oklahoma’s in-home programs support citizens, ages 3 through late adulthood and all are deemed “nursing-facility-level-of-care.” Without in-home programs, these Oklahomans are forced into more costly options, including emergency rooms, nursing and intermediate institutions;

• Oklahoma’s legislated Rate Review recommends a rate adjustment to sustain in-home services.

• Estimates suggest that over 100,000 Oklahomans are employed in in-home programs providing a range of proprietary and non-profit supports. Experts agree that rate stagnation lowers preventive, quality services, and employment for Oklahoma citizens.

• Oklahoma’s Health Care Authority received Oklahoma’s 2nd Freedom Initiative grant for over $45M to bring over 2,000 citizens out of institutions due to recognized benefits of community living. With CMS ‘ strong encouragement, the state is writing two additional waivers for children and adults with disabilities and seniors to advance use of in-home supports.

With the age wave upon us, increasing numbers of Oklahomans with disabilities across the lifespan, and when recognizing the place Medicaid holds in state budgets–the chief funding for long-term care–it seems logical to endorse in-home support programs to save Oklahoma substantial dollars, assure better outcomes, and serve individuals and families as desired–in their own homes and communities.

share this post

But what does this situation mean for the agencies, departments, and school districts that operate public services? We usually don’t hear stories about the impact of underfunding unless and until there is a crisis. Yet the reality is that many public agencies at all levels of government, especially regulatory and administrative agencies, are perpetually underfunded.  Resources are always scarce, and even in good budgetary times, most legislators prefer to fund programs that provide direct benefits to their constituents than those that do the unglamorous work of  licensing, inspecting, investigating, and adjudicating. This is especially true here in Oklahoma, where we are among the bottom five states in the amount we spend per person on state and local government

Recently, the journal Health Affairs published an interview with Kerry Weems, who served as Interim Director of one of those unheralded but vital regulatory agencies, the Centers for Medicare and Medicaid Services (CMS), during the last 18 months of the Bush Administration. CMS is charged with overseeing expenditures of almost $700 billion annually in the two major public health care programs. In particular, it has the responsibility for preventing and investigating waste, fraud and abuse in these programs. But in Weems’ view, one that is shared by many others, CMS is not staffed at levels necessary for it to fulfill its mission. Here’s how he describes the impact that a shortage of resources has on his former agency:

And in many ways, right now CMS behaves like a resource-starved agency, which it is. The staff feels a sense of fatalism when they begin complicated tasks that carry out the law. The sense develops because while the agency will do its best, we don’t have enough resources to do all of these tasks well, so our final products are not always 100 percent…

CMS is a weakened organization. It has the capacity to pay bills and prepare the annual payment notices. But after that, there is little capacity, much less time, left to develop innovative approaches to health care, to think through what a system of higher quality would look like.

There is a widely-held belief that cutting budgets, or keeping funding levels flat over an extended stretch, is healthy for government by forcing it to trim the fat and become leaner and more efficient. In reality, “starving the government beast” has similar effects to starving an individual. Before long, that which is being starved becomes weak, lethargic, and dispirited. As Weems discusses for CMS, underfunded agencies become less efficient because they lack the resources to do their job well. Operating on a shoestring also means being unable to invest the time and resources needed to innovate and think creatively.  And in overworked, understaffed agencies, staff suffers from fatigue and declining morale, which tends to lead to rapid turnover among the better employees and a critical loss of experience and expertise.

The Health Affairs article was titled “Doing More With Less”. That is what we are demanding of many of our public agencies, nationally and in Oklahoma, especially but not only in a time of declining revenues. We need to be asking whether this a reasonable expectation, and if not, how we are going to get our expectations of  governments back in alignment with the resources we provide them.

share this post

As health care reform heats up, it is clear that the Medicaid program will be one of the pillars upon which a new system providing health insurance coverage to all Americans will be built.  While Medicaid faces many significant challenges in the years ahead, it will without question benefit from Cindy Mann’s strong leadership.

share this post