Implementing State Health Reform: Lessons for

Policymakers

Webinar for State Officials

April 8, 2010

Overview Introductions Overview of Reform Initiatives in Featured States Key Questions and Takeaways

– Eligibility and Enrollment– Use of Health Insurers– Marketing and Outreach– Staffing and Coordination of Reforms– Employer Assessment and Section 125 Policy Considerations– Reporting and Evaluation

Questions

Introductions

Moderator: Enrique Martinez-Vidal, State Coverage Initiatives

Gwyn Volk, Navigant Consulting Anne Jacobs, Navigant Consulting Laurie Lee, Tennessee Susan Besio, Vermont Jim Jones, Wisconsin

Relevance for National Reform

State governments responsible for implementing substantial changes to Medicaid and CHIP programs.

National reform affects each state differently and policies must vary accordingly.

Overview of Reform Initiatives in Featured States

Tennessee’s

CoverTN

New Mexico’s

State Coverage Insurance

Wisconsin’s

BadgerCare Plus Vermont

Massachusetts

CHIP/Medicaid Expansion

New State-Sponsored Insurance Product(s)

Premium Subsidies

Employer Assessment

Individual Mandate

Eligibility and Enrollment

Eligibility and Enrollment Eligibility and enrollment processes are one of the

most important pieces of an expansion. Flexible information systems are critical but limited

by state funding constraints. Involvement of federal funding brings additional

layers of compliance. States often use health insurers to assist with

enrollment.

Eligibility and Enrollment (cont’d)

Key Questions– What are the primary pathways and information

system requirements?– Will the state consolidate public coverage options

under one program?– Will employers enroll in the new offering?– Are current information systems equipped to handle

coverage expansion?

Eligibility and Enrollment (cont’d)

Key Takeaways– Assess ability of current information systems to

meet new requirements. – Support information system flexibility.– Think creatively about how to exchange data with

employers and health insurers– Consider using:

• Web-based processes• “One-stop shopping” contact for employers• Centralized processing center

Eligibility and Enrollment (cont’d) Key Takeaways (cont’d)

– Streamline consumer premium determination process.– Assess contractor information system capacity.– Standardize eligibility and enrollment -- initially time-

consuming but increases efficiency.– Proactively address administratively burdensome

federal requirements and maintain flexibility to respond to changes in federal requirements.

Use of Health Insurers

Use of Health Insurers Insurers can take on numerous responsibilities as part

of expansion:– Provision of managed care delivery system– Claims payment– Enrollment– Premium Collection

Using insurers may reduce state administrative burden. Insurer experience with public programs varies widely

by state.

Use of Health Insurers (cont’d) Key Questions

– Does expansion require the state to assume responsibilities that have not been part of other public insurance programs?

– Are state’s current contracts with insurers similar or different than those required for expansion?

– What is the capacity of the exiting health insurance market?

– How can the state create contractual relationships that provide flexibility while maintaining appropriate oversight?

Use of Health Insurers (cont’d) Key Takeaways

– Conduct in-depth assessment of state’s health insurer market.– Consider reducing state’s administrative burden by using

insurers’ expertise and delivery systems.– Do not make assumptions regarding insurers’ systems and

processes.– States that currently involved MCOs with CHIP and Medicaid

may find expansion easier.– Craft contracts with insurers that best meet state’s needs --

requires state staff and resources.

Marketing and Outreach

Marketing and Outreach

Success of expansion depends on eligibles and employers believing that they benefit from enrollment.

State funding for marketing and outreach is typically very limited.

Structure of marketing and outreach for expansion depends on the targeted population(s).

Marketing and Outreach (cont’d) Key Questions

– What modifications to current outreach efforts are needed?

– To what extent can current CHIP and Medicaid outreach activities be modified?

– How will the state need to strengthen or change relationships and marketing approach with community organizations and the business community?

Marketing and Outreach (cont’d) Key Takeaways

– Establish relationships with business organizations when marketing insurance reforms targeted to employers.

– Develop focused, low-cost outreach strategies aimed at the target population.

– Dedicate staff time and resources to establishing or expanding relationships with community-based organizations.

– Marketing and outreach approaches should be flexible.

Staffing and Coordination of Reforms

Staffing and Coordination of Reforms

Reform initiatives require coordination of multiple agencies and contractors.

Limited funding and need to establish new relationships among agencies and contractors can be challenging.

Identifying and empowering a lead agency and the roles of other agencies is critical.

Staffing and Coordination of Reform (cont’d)

Key Questions– Is one agency a natural fit for overseeing reform initiatives?– Does the lead agency have sufficient authority?– What staff background and experience are needed to

implement reform?– What current state contracts could be modified to include

work on reform?– What components of reform could state contract out if staff

resources or experience are insufficient?

Staffing and Coordination of Reform (cont’d)

Key Takeaways– Using existing state agencies is very effective

although far-reaching reforms may require a new state agency.

– Work with legislature to provide lead agency with sufficient authority.

– Maximize existing state and contractor staff resources including developing flexible contracts.

Staffing and Coordination of Reform (cont’d)

Key Takeaways (cont’d)– Use of independent agency may allow for greater

flexibility in hiring staff.

– Establish formal, ongoing communication among key senior agency staff.

– Provide training and education to state staff to develop understanding of employer-related insurance options.

– Structure staffing approaches assuming that reform will be implemented over several years.

Employer Assessment and Section 125 Policy

Considerations

Employer Assessment/Section 125

Data needs and involved agencies for Employer Assessment and Section 125 programs go beyond those of traditional expansions.

Communicating policies to the public regarding these programs is particularly challenging.

Employer Assessment / Section 125 (cont’d)

Key Questions– What types of data are needed for

implementation? To what extent is that data collected now?

– What new information system or data sharing capacities are required?

– What agency is best suited for implementation and monitoring?

Employer Assessment / Section 125 (cont’d)

Key Takeaways– Understand that substantial information system changes

will likely be required.– Involve state departments other than the department of

health and social services.– Determine if web-based data collection can reduce

administrative burden.– Carefully consider how Section 125 plans -- particularly

difficult for a layperson to understand -- are communicated to stakeholders.

Reporting and Evaluation

Reporting and Evaluation

Reform initiatives are subject to intensive scrutiny.

Federal requirements and state legislation often drive reporting and evaluation activities.

Reporting and evaluation activities are one tool to build stakeholder support for an expansion.

Reporting and Evaluation (cont’d)

Key Questions– Will reform require federal waiver approval?

– Has state legislature mandated specific reporting and evaluation requirements?

– Do reform initiatives include “hot button” issues that require proactive monitoring?

– How will stakeholders assess whether programs achieve their goals?

Reporting and Evaluation (cont’d) Key Takeaways

– Consider contracting with neutral third party to evaluate “hot button” issues.

– Assess reporting and evaluation requirements prior to implementation to identify where additional data collection and systems changes are required.

– Explore alternative funding sources.– Identify reports that will be needed from insurers or

other contractors and reports that may vary from standard industry practices.

Questions?

Report Available at: www.statecoverage.org/node/2242