Basic Health Program Workgroup
- Presentation also available in Portable Document Format (PDF)
July 31, 2013
One Commerce Plaza Albany, New York
Office of Health Insurance Programs Department of Health
Agenda
- Introductions
- Workgroup Charge
- BHP Overview
- Informing New York´s Decision on a BHP
- Impact on NYS – Studies to Date
- Open Discussion
- Next Steps
BHP Workgroup Charge
- 2013–14 Enacted Budget established the BHP Workgroup:
- §16–a. (a) The Commissioner of Health shall convene a workgroup to consider issues pertaining to the federal option to establish a basic health program for individuals who are not eligible for medical assistance under title eleven of article five of the social services law.
(b) The workgroup shall: evaluate federal guidance related to basic health programs; discuss fiscal, consumer, and health care impacts of a basic health program; and consider benefit package, premium and cost–sharing options for a basic health program.
- §16–a. (a) The Commissioner of Health shall convene a workgroup to consider issues pertaining to the federal option to establish a basic health program for individuals who are not eligible for medical assistance under title eleven of article five of the social services law.
BHP Workgroup Membership
- Chair:
- Judith Arnold, Division of Health Reform and Exchange Integration
- Members:
- Elisabeth Benjamin, Community Services Society
- Kate Breslin, SCAA
- Lauri Cole, NYS Council for Community Behavioral Healthcare
- Jeffery Gold, HANYS
- Assemblyman Richard N. Gottfried, Assembly Majority
- Senator Kemp Hannon, Senate Majority
- Trilby de Jung, Empire Justice Center
- Joseph Maldonado, Jr., MSSNY
- Bertram Scott, Affinity Health Plan
- Kathy Shure, GNYHA
- Richard Winsten, Meyer Suozzi English and Klein
- Robert Wychulis, AMERIGROUP NY, LLC
- Paul Zurlo , EmblemHealth
BHP Overview
- ACA gives states the option to establish a Basic Health Program for:
- Individuals with incomes between 138–200% FPL who are ineligible for Medicaid or CHIP, and do not have access to affordable employer coverage.
- Individuals with incomes below 138% of FPL who are ineligible for Medicaid due to immigration status.
- Federal government gives states 95% of what would have been spent on APTC in the marketplace.
- Health plans must include essential health benefits.
- Monthly premiums and cost sharing cannot exceed the amount the individual would have paid for coverage in the marketplace.
How BHP Fits Into Health Coverage Eligibility Levels
![Chart of How BHP Fits Into Health Coverage Eligibility Levels](/health_care/medicaid/redesign/images/bhp_fit.jpg)
Who is Eligible for BHP?
- To be eligible for coverage under the BHP, individuals must meet the following requirements:
- Below age 65 at the beginning of the plan year;
- Resident of the State;
- Not eligible for Medicaid or CHIP;
- Not eligible for affordable minimum essential coverage;
- Income between 133% FPL – 200% FPL or < 133% and ineligible for Medicaid due to immigration status; and
- Individuals eligible for BHP are ineligible for Marketplace coverage.
Potential Advantages and Disadvantages of a BHP in NY
- Potential Advantages
- State cost savings
- Greater consumer affordability
- Reduction in uninsured
- Reduction in provider bad debt
- Potential Disadvantages
- Impact on the size of the Marketplace
- Impact on premiums in the Marketplace
- Increase in uninsured
Decisions Needed From CMS
Financing
- How will BHP financing work?
- How will CMS calculate the value of APTC and cost sharing subsidies that would have been provided to the individual in the Marketplace?
- How will CMS implement annual reconciliation?
- Will states be given 100% of the value of cost sharing reductions?
- Will CMS permit states to use 90% FMAP to fund IT System modifications to implement a BHP?
Impact on Marketplace
- Will CMS allow states to pool risk between BHP and the Marketplace?
- Will CMS require the BHP to mirror Medicaid rules or Marketplace rules or give states flexibility to decide?
Eligibility and Enrollment
- Whether to have open or rolling enrollment?
- Whether eligibility rules always follow tax filer rules or whether non–filer rules can apply in special exceptions?
- Will CMS permit states to provide 12–month continuous coverage for BHP enrollees?
Other Logistics
- Rules around notices and administrative hearings.
- Network adequacy rules.
- Essential community providers.
- Health plan accreditation.
State Decisions
Financing and Administration
- Does the Federal financing for the BHP fully fund the program with no new state dollars?
- Is the funding sustainable?
- What is the value of potential state savings?
- How will program administration be funded?
- How will QHP enrollees be transitioned if BHP is adopted?
Cost–Sharing
- What level of cost–sharing should BHP adopt?
- Premium contributions.
- Co–payments to providers.
- An individual in Medicaid at 138% of FPL pays no premiums.
- An individual in a QHP at 180% of FPL ($20,700) pays about $90 a month in premiums.
Benefits and Health Plan Selection
- The Benefit package must be at least the Standard Silver Essential Health Benefit.
- Does the State want to add any benefits?
- How will BHP plans be selected?
Provider Reimbursement Rates
- Should provider reimbursement rates be set at Medicaid rates, Medicaid plus, or Commercial rates?
- Will the funding levels support higher rates than Medicaid?
Impact on NYS: Studies to Date
Open Discussion/Comments
Next Steps
- Next Meeting
- September 9 or October 8 from 10 AM – 1 PM.
- Meeting Date dependent on CMS regulations.
- New York City, NYS Department of Health Metropolitan Area Regional Office 90 Church Street, 4th Floor, Conference Room A/B, Manhattan.
- Questions? Please contact: Kalin Scott, kid01@health.state.ny.us or (518) 474–8141
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