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AAHAM
Music City Chapter Conference
September 26, 2013
Tennessee Plan for Payment Reform
• State hired Mckinsey and Company
• Modeling program after Arkansas Health Care
Payment Improvement Initiative
– Retrospective bundled payments
– Primary care medical home
• Will begin with TennCare and State employees
• Goal to have majority of “healthcare spend”
based on episodes and population-based
payments within next three to five years
Tennessee Plan for Payment Reform
• Episode based payments
– Reward one or more providers for total performance,
specific event, procedure or treatment of condition
– Episodes will cover a specific pre-defined period
during which patients receive care from multiple
providers
– Each episode has a “quarterback”
• Leads and coordinates all providers involved in care
• Helps drive improvement
• Pre-determined with episode definition and may be physician
or hospital
– Episodes are “triggered” by hospital inpatient or
outpatient procedure or encounter
Tennessee Plan for Payment Reform
• Retrospective episode-based payments
– Providers receive reimbursement from payers based
on usual negotiated rates as they currently do
– Quarterback receives rewards or penalties based on
overall cost of episode
• Commendable and acceptable levels of cost determined based on
retrospective cost data
• Calculate risk-adjusted average cost per episode for the total
patient population served during the performance period for the
episode
• Share savings if average cost below commendable level
• No change in payment if average cost between commendable and
acceptable
• Pay portion of excess costs if costs exceed acceptable
Tennessee Plan for Payment Reform
• Three initial episodes selected
– Total Joint Replacement
• Greatest impact for state employee population
• Orthopedic surgeon will be quarterback
– Asthma Exacerbation
• Hospital will be quarterback
– Perinatal
• Obstetrician or Family Practice physician will be
quarterback
Tennessee Plan for Payment Reform
• MCOs to start providing data to
quarterbacks January 2014
• Additional episodes rolled out in batches
every 3 to 6 months
• Within 3 to 5 years episodes and
population based payment models
account for majority of healthcare spend
Year 2 TennCare Rate Variation
• Aon on track to complete the analysis by October
– New data could result in minor changes to bands for Year 2 in
order to maintain budget neutrality
• When final percentages are available, TennCare will host
a webinar for all hospitals
– THA will send impact information to all hospitals
• TennCare bureau will review MCO contract amendment
language and contract negotiations should begin in
November
• No changes will be implemented until all contract
amendments have been signed
– Amendments will be retroactive to July 1, 2013
Transition of CoverKids to TennCare
• On July 30, Blue Cross notified providers CoverKids and
pregnant women in HealthyTNBabies would be using
the TennCare Select network, effective October 1
– These groups previously used the state employee network
• Contract amendment placed providers serving those
populations into the TennCare Select network at existing
TennCare Select rates
• Change was automatic unless provider notified Blue
Cross in writing of rejection prior to August 29
Transition of CoverKids to TennCare
• The Blue Cross communication states “CoverKids program
and HealthyTNBabies program members are not TennCare
Select Members”
• THA requested clarification from the TennCare bureau on
several issues not communicated by Blue Cross
– Kids age 6 through18 under 138% of poverty required by the
ACA to be moved into Medicaid
• Will be implemented beginning January 2014
• Still discussing with CMS whether move will be all at once or at time of
recertification
• Unclear if they will stay in TennCare Select or be auto-assigned to MCO
Transition of CoverKids to TennCare
• Women in HealthyTNBabies who were pregnant and under the care
of an OB on October 1, 2013 could stay with that OB
– OB would be reimbursed under the previous rate
• 100 percent Medicare bump will be implemented for doctors that
saw kids age 6 through 18 under 138 percent of poverty
– Will receive increased payment for selected E&M codes
• State does not have spending authority to fund interim payment
increase for physicians or hospitals
– Agreed to increase all TennCare Select rates effective July 1, 2014
funded by hospital assessment
TennCare Benefit Changes
• Beginning October 1, 2013
– TC won’t cover
• Facets injections
• Allergy medicine of any kind
• TENS services for chronic lower back pain
– These will have limits:
• Trigger point injections – only pay for 4 trigger
point injections in each muscle group every 6
months
TennCare Benefit Changes
• Limits, con’t:
– Epidural Injections – only pay for 3 epidural
shots every 6 months
– Urine Drug Screenings – Only pay for 12
urine drug screenings per year
• All of above apply to add adults 21 or older
TennCare Benefit Changes
• Starting October 1
– There will be a $1.50 co-pay for generic
prescriptions
• Applies if member currently pays a $3 co-pay for
brand name prescriptions
• Does not apply if member is in CHOICES Group 1
or CHOICES Group 2
– For drugs within member’s monthly limit,
won’t pay co-pay for
TennCare Benefit Changes
• For drugs within member’s monthly limit, won’t
pay co-pay for:
• Birth control
• Medicine received in hospice care
• Medicine received in a medical emergency (in the
ED)
• Medicine member takes while pregnant (ex. vitamins)
Insurance Exchange
Insurance Exchange Enrollment
Opportunity
Three-fourths
of the uninsured
live in 16 states
CA
TX
FL
NY
GA
IL
NC
OH
PA
NJ
MI
AZ
VA
TN
WA
IN
Data provided by Baptist Healing Trust
16
Expansion Population
• Because Medicaid has not been expanded
in Tennessee, there will be a donut hole
• Those below 100% of federal poverty level
AND who do not qualify for Medicaid today
are NOT ELIGIBLE FOR THE
EXCHANGE
• They will have not have access to any
health insurance
17
Affordable Care Act includes:
• Insurance requirements & regulatory
changes
• Tax credits and cost-sharing subsidies
• Individual mandate/penalties
• Establishes essential health benefits
18
QHP Plan Levels of Coverage
Levels of
Coverage
Plan Pays
On Average
Enrollees Pay
on Average*
(In addition to the
monthly plan premium)
Bronze
60%
40%
Silver
70%
30%
Gold
80%
20%
Platinum
90%
10%
*Based on the aggregate cost under the plan when benefits are provided to a standard
population. This may not be the same for every (or any specific) enrolled person.
19
Enrollment Periods
• Initial open enrollment period: October 1, 2013
through March 31, 2014
• Annual open enrollment periods will be October
15 – December 7 in succeeding years
• Special enrollment periods available in certain
circumstances during the year
20
Initial Open Enrollment Period
for the Individual Market
October 1, 2013 – March 31, 2014
Enroll during the initial open
enrollment period
• On or before December 15,
2013
• Between the 1st and 15th day of
January – March
• Between the 16th and the last
day of December - March
Coverage is effective
• January 1, 2014
• First day of the following
month
• First day of second following
month
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Apply Online, By Phone or
In Person
1. Enter basic information
Healthcare.gov has checklist
2. Choose level of coverage
3. Compare health plans
4. Confirm plan selection
5. Apply for coverage
Exchange verifies information/determines eligibility
6. Pay first month’s premium
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New Rules
• Cannot be denied coverage
• Modified community rating (only can adjust
premium for age, tobacco & geography;
cannot adjust for gender or health status)
• Mandated coverage of 10 essential health
benefits determined by HHS
23
Essential Health Benefits
–
–
–
–
–
–
–
–
–
–
Ambulatory patient services
Emergency services
Hospitalization, maternity and newborn care
Mental health & substance use disorder services,
including behavioral health treatment
Prescription drugs
Rehabilitative & habilitative services & devices
Laboratory services
Preventive & wellness services
Chronic disease management
Pediatric services (including oral & vision care)
24
Exchange Eligibility
• Marketplace eligibility requires consumer
to:
– Live in its service area AND
– Be a U.S. citizen or national OR
– Be a non-citizen who is lawfully present in the
U.S. for the entire period for which enrollment
is sought
– Not be incarcerated
25
Consumer Assistance
• Applicant may be eligible for two forms of
assistance to afford coverage in the health
insurance marketplace:
– Premium tax credits
– Cost-sharing subsidies
26
Premium Tax Credit
• Eligibility for the premium tax credit is
based on:
– Household income and family size (previous
year end)
– Income between 100% to 400% of the federal
poverty level
• $23,550 - $94,200 for family of four in 2013
– Not eligible for government-sponsored
coverage or affordable employer-sponsored
insurance
27
Premium Tax Credit
• Amount of the premium tax credit depends
on:
– Actual household income as a percentage of
the federal poverty level and family size
– The premium for the second lowest cost
silver level qualified health plan, adjusted
for the age of the covered person
– A sliding scale that increases the taxpayer’s
own contribution towards the premium cost as
income increases
28
Cost-Sharing Reduction
• Cost-sharing subsidies for those that
receive premium tax credit
– People with income between 100% and
250% of federal poverty level
• Federal government shares in cost of
co-pays and deductibles
• Silver plans only
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Resources & Training
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National Consumer Information
• Provider-focused website
– www.marketplace.cms.gov
• CMS consumer-focused website
• www.HealthCare.gov
• 24-hour CMS consumer call center for the
individual exchange
•
•
•
•
800-318-2596
1-855-889-4325 (TTY)
Now providing general information
Starting 10/1/13 – eligibility & enrollment assistance
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Outreach Efforts for Enrollment
• Important terms to understand:
– Navigators receive funding from CMS to conduct outreach.
• There are two in Tennessee:
– Structured Employment Economic Development Corporation
(SEEDCO)
– Tennessee Primary Care Association
– Certified application counselors (CACs) are trained individuals
who provide consumer enrollment assistance. They are
accredited by CMS, but are not funded by CMS.
– Certified Enrollment Entity (CEE) is a designation hospitals must
apply for and be granted by CMS before their employees can be
trained and accredited CACs.
http://marketplace.cms.gov/help-us/cac-apply.html
32
CAC Training
• CAC training modules are posted online at
the health insurance marketplace
• Remember, your organization must first be
a registered CEE in order for employees to
complete the training
• Modules are available at:
http://marketplace.cms.gov/training/get-training.html
CAC Training
• CMS backlog with CAC application responses
• CMS Consumer Support team has established the
following email address for CAC-related questions:
[email protected].
– Include the organization name
– and topic in subject line
– and be sure to include contact info with email
•
TDCI Emergency Rules
• Last week, the Tennessee Department of
Commerce & Insurance (TDCI) released
emergency rules
(http://state.tn.us/sos/rules_filings/09-29-13.pdf)
requiring registration for navigators and
certified application counselors for the new health
insurance exchange.
TDCI Emergency Rules
• The department also has released:
– FAQ 1 Offering educational information
• (http://www.tn.gov/insurance/documents/9_20NavigatorFAQ1.pdf)
– FAQ 2 Application forms, fingerprinting and background check requirements
(http://www.tn.gov/insurance/documents/9-20NavigatorFAQ2.pdf)
- Registration requirements and application for navigator or certified application
counselor (CAC) ENTITY
(http://www.tn.gov/insurance/documents/navigator_entity_packet_2013.pdf)
- Registration requirements and application for navigator or certified application
counselor INDIVIDUAL
(http://www.tn.gov/insurance/documents/navigator_individual_packet_2013.pdf)
Insurance Exchange Enrollment
• Enrollment of uninsured critical issue for hospitals
• CMS navigator grant for Tennessee exchange
enrollment only $1.4 million
• Tennessee hospitals saw 345,000 uninsured
individuals in EDs in 2011 (out of 889,000
uninsured statewide)
• THA will make $3 million of grant funds available
to hospitals
– Grant amounts will be based on the level of uninsured
each member facility serves in the ED
– The minimum grant amount would be $10,000
37
THA Grants
• $3 million in grants available to acute care and
research hospitals who are THA members
• Grant amounts will be based on 2011 JAR
uninsured ED volume
• Deadline for application is Oct. 31, but
applications will be funded as they are received
• Criteria and details in package emailed to CEOs
• Questions: email [email protected]
THA Grants
• Grant information/application sent to hospital
CEOs
– Acute care hospitals
– Hospital systems containing acute care
hospitals OR
– Research hospitals
• System hospitals may apply individually or as a
system
• Approved grant uses will be flexible so they can
be tailored to your community
39
THA Grants
• Include (but not limited to):
– Salary/benefit costs of hospital staff (or
temporary staff) to become certified as CACs
(explain health coverage options to uninsured &
assist with enrollment)
– Independent contractor fees to provide or assist
with community education
– Cost to print educational materials
– Cost to analyze hospital data for a targeted
campaign effort
40
THA Grants
• Partnering with not-for-profit organizations
that specialize in working with populations
that lack insurance. Examples include:
– Project Access
– Tennessee Health Care Campaign
• Partner with local insurance
agents/brokers to work with uninsured
individuals
41
THA Grants
• Quarterly reports will be required to include
successes & obstacles so hospitals can
learn from each other
• THA will provide exchange resource
materials
• Questions: email
[email protected]
42
THA Resources
• THA website
– Resource guide for Tennessee hospitals
– List of Tennessee agents/brokers who have
committed to assist individual exchange
applicants
– THA grant information
– Sample hospital application
– THA grant application
– Webinar/audio recording
43
THA Resources
• Materials hospitals can customize and use
locally
– Brochures
– Posters
– Tent Cards
– Stickers
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Questions?
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