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Agency Overview FY12 Budget Development MARC and Adjustments Key Assumptions Savings Proposals Medicaid Enrollment and Expenditure Trends Alliance Enrollment and Expenditure Trends FY11 Savings Initiatives Status Report
Agency Overview
Total Agency FY12 Budget: $2,129,260,361 Total Agency Local Fund FY 12 Budget: $609,441,494
Budget Adjustments
FY 2011 Revised Budget Adjustment for stimulus funding [ends 6/30/2011] Adjustment to PS and non-50 NPS for RMTS Align fixed costs to estimates Shift ICF/MR spending from Stevie Sellows Fund $529,623,529 $79,817,962 $2,104,339 ($53,695) $3,688,714 $10,449,619 $6,089,796 $1,445,348 ($23,724,118) $609,441,494
Budget Impact
$16.9M
Relevant History
Likely Resistance
N/A
No Rate Increases
$21.1M
FY11 Savings Initiatives include: holding nursing facility rates flat; reducing physician, hospital, DD waiver and adult dental rates; correcting non-physician rates; and lowering PCA benefit to 520 hours per year. See Slide 31 for details. This will require holding MCO rates flat for 2 consecutive years - 2011 & 2012.
MCOs may threaten to exit the program. Currently, there are only 2. Fed requires at least 2 for choice.
Maintaining EPD up to $7.3M In FY 2011 DHCF capped the state plan PCA Waiver cap at 3,940 benefit at 520 hours per year. Previously it was 1040 without a PA. Prediction is that many people will move to EPD waiver to continue PCA services. $7.3M figure is based on 140 people per month moving in FY 2011, and 100 per month moving in FY 2012. Current EPD enrollment allows for 1400 more people to enroll before hitting cap.
May not be able to demonstrate actuarial soundness for the MCO rates. If MCOs hold provider rates constant, this could adversely affect provider participation. If DHCF reaches cap, creates a waiting list, and this prevents a disabled beneficiary from leaving an institutional setting, it could aggravate the District's position in the current Olmstead lawsuit.
Relevant History
Likely Resistance
$2.8M
Current Alliance eligibility is up to 200% FPL for The Alliance has those not eligible for Medicaid. July 2010 never been approximately 35,000 beneficiaries up to 133% capped, so FPL transitioned to Medicaid as a result of Early resistance likely Option. December 2010 another 2,600 between from advocates. 133% - 200% FPL transitioned to Medicaid through a DSH waiver. Current Alliance enrollment is approximately 23,000, so closing enrollment and attriting down to 18,750 in FY 2011 is required. Increase due to revised MARC would be applied here. Increases cap to 21,500. Nursing home rates are being rebased in FY Nursing home 2011 retroactive to FY 2009 based on FY 2007. industry fought This change in treatment of therapies was this before. They attempted, but ultimately not implemented. claimed that Complaint was improper notice. Giving notice homes would go would be required. out of business, but when pressed could not say which one(s).
Relevant History
Likely Resistance
Nursing home industry will oppose this.
This savings is so substantial that it negates the industry's gains from rebasing the rates. The incentive payments explicitly pay homes more than their cost.
Replace $1.3M Average Wholesale Price (AWP) minus 10% in pharmacy pricing methodology with Wholesale Acquisition Cost (WAC) plus 3%
WAC is estimated to be roughly 82% of AWP, so Pharmacies will WAC+3% is roughly equal to AWP-15%. That's resist the rate cut. a 5% rate cut for drugs subject to this method -brand names without substitutes. AWP is being phased out at the end of FY 2011, so DHCF must change this methodology regardless.
Numerous audits and anecdotal reports have The industry will shown there is waste and abuse in this benefit. resist. The hours were limited to 520 per year in FY 2011. This initiative would do three things: 1) replace the existing assessment tool with one from another state with a proven track record, 2) selected real time monitoring of authorizations, so the wasteful spending is prevented rather than caught after the fact, and 3) promulgating new rules that strictly limit the use of staffing agencies.
$10,890
$8,059/yr 74%
Families w/ Children Pregnant Childless Institution Children Age (0-18)* Women* Adults and (Medicaid) Waiver
SSI
Non-SSI ABD
Notes: For all groups in red, eligibility cannot be cut due to maintenance of effort requirements from ARRA (stimulus funding) and the Affordable Care Act (health reform). Yellow denotes Medicaid programs whose eligibility can be changed, and green represents programs that are solely locally funded.
10
At Different Income Thresholds Medicare Beneficiaries Qualify For Some Medicaid Benefits
Income Eligibility Threshold As A Percent of Federal Poverty: $32,670/yr 2011 Federal Poverty Level (One Person) 300%
$21,780/yr 200%
$10,890/yr
$10,890
Medicare Eligibility Groups
100%
Notes: For all groups in red, eligibility cannot be cut due to maintenance of effort requirements from ARRA (stimulus funding) and 11 the Affordable Care Act (health reform). Yellow denotes Medicaid programs whose eligibility can be changed, and green represents programs that are solely locally funded. ).
Notes: Certified pediatric and family nurse practitioner services, midwife and nurse practitioner services, and rural health clinic services are also mandatory, but expenditure data were not available. Early and Periodic Screening, Diagnosis, and Treatment services are generally included in other categories of services above.
12
13
D.C. Public Schools OSSE/ Transportation Charter Schools Department of Mental Health Child and Family Services Administration Fire and Emergency Medical Services
Notes: FY11 and 12 Budget is based on Provider Agency Budget Submission. Expenditures represent the 70% FMAP only. FY10 budget for transportation for Special Needs children was allocated to D.C. Public Schools
14
197,624
200,000
150,000
160,665
100,000
50,000
Pre-SPA Post-SPA
2007 2008 2009 2010
Notes: D.C. fiscal year is October 1 through September 30; enrollment was averaged from October to September to create average monthly enrollment. The Department of Health Care Finance moved over 30,000 from the Alliance to the Medicaid program in July of 2010 while implementing a new coverage option state plan amendment. Data shown above for 2010 reflect October-June monthly average (pre-SPA) and July-September average (post-SPA). The Department transitioned over 2,700 people in December of 2010 while implementing an 1115 waiver for adult beneficiaries with incomes between 133 and 200 percent of the Federal Poverty Level.
15
Quarterly Enrollment
240,607
Notes: Enrollment projected using data from FY12 budget model. Childless Adult Expansion includes new coverage option state plan amendment, which covers childless adults from 0 to 133% FPL, and childless adult waiver, which includes childless adults from 133 to 200% FPL. Data labels shown are February 2011, October 2012, and September 2012. Projections assume EPD 16 waiver cap of 3,940 beneficiaries, and Alliance program cap of 18,750.
$1,343,625,101
$1,426,504,949
FY2009
FY2010
Notes: Total annual expenditures include local and federal share of spending, but excludes spending on the Alliance. Source: CFO$olve ad hoc report 1/28/2011. Date -of-payment basis including all object 50 spending.
17
160,000
140,000
120,000 100,000 80,000 60,000 40,000 20,000 0 FY2007 FY2008 64% 63% 36% 37%
37%
33%
63%
67%
Total Enrollment
FY2009
FY2010
Notes: D.C. fiscal year is October 1 through September 30; enrollment was averaged from October to September to create average monthly enrollment. Data were not available for managed care and fee for service enrollment prior to FY2007. Due to new coverage option state plan amendment and an 1115 waiver for childless adult beneficiaries with incomes between 133 percent and 200 percent of the Federal Poverty Level, over 30,000 individuals were moved from Alliance (not included in the data above) onto the Medicaid program. The net result is a rapid increase in managed care enrollment in FY2010 and FY2011, when looking at Medicaid enrollment data only.
18
29%
Children Aged
Adults
Notes: Distributions may not sum to 100% due to rounding effects. Distribution of beneficiaries by category is based on average Medicaid enrollment in FY10.
19
Aged
29% 73%
Blind & Disabled
Adults
Children
Adults Children
Notes: Distributions may not sum to 100% due to rounding effects. Source: Spending from ad hoc MMIS report 1/26/2011. FY 2010 date-of-service spending excluding DSH, cost settlements, Medicare premiums, and drug rebate.
20
The Cost of Serving the Elderly and Disabled Is Substantially Greater Than The Cost of Care For Children in Medicaid, FY10
$30,000
$27,129
$25,000
$20,000
$19,171
$15,000
$10,000
$9,920 $5,131
$5,000
$2,969
Source: Spending from ad hoc MMIS report 1/26/2011. FY 2010 date-of-service spending excluding DSH, cost settlements, Medicare premiums, and drug rebate.
21
39%
23% 16%
24%
21%
8%
9%
MCOs
Pharmacy
Nursing Facility
Source: Spending from ad hoc MMIS report 1/28/2011. FY 2010 date-of-service spending excluding DSH, cost settlements, Medicare premiums, and drug rebate.
22
Change in Expenditures for Medicaid Home and Community Based Waivers FY08-FY10
113%
79%
45%
18%
DD Waiver
Change in Total Expenditures
EPD Waiver
Change in Per Enrollee Expenditures
23
24
Comparison of District of Columbia Income Eligibility Levels for Medicaid and Alliance Programs
Income Eligibility Threshold As A Percent of Federal Poverty: 2011 Federal Poverty Level (One Person) $21,780/yr 200% $32,670/yr 300% $32,670/yr 300% $32,670/yr 300%
$21,780/yr 200%
$21,780/yr 200%
$10,890
Families w/ Children
Pregnant Women*
Local Funding
Notes: For all groups in red, eligibility cannot be cut due to maintenance of effort requirements from ARRA (stimulus funding) and the Affordable Care Act (health reform). Yellow denotes Medicaid programs whose eligibility can be changed, and green represents programs that are solely locally funded.
25
Inpatient Hospital Outpatient Hospital Laboratory & X-Ray Services Hospital Services
26
56,435
25,487
Pre-SPA Post-SPA
Notes: D.C. fiscal year is October 1 through September 30; enrollment was averaged from October to September to create average monthly enrollment. The Alliance program in its current form began enrolling beneficiaries in March of 2006. Average enrollment for FY06 is 27,193, but not shown above because due to high monthly variability as the program began. In July of 2010, the Department of Health Care Finance moved over 30,000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment. Data shown above for 2010 reflect October-June monthly average (pre-SPA) and July-September average (post-SPA). The Department transitioned over 2,700 people in December of 2010 while implementing 27 an 1115 waiver for childless adult beneficiaries with incomes between 133 and 200 percent of the Federal Poverty Level.
Female 55%
Male 45%
Notes: In July of 2010, the Department of Health Care Finance moved over 30,000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment. Pre-SPA enrollment above reflects OctoberJune monthly average, and post-SPA reflects July-September monthly average.
28
Hispanic 27%
Black 31%
Other 6%
Black 65%
White 2%
White 1%
Notes: Other includes Other Known Race (1% pre-SPA/2% post), Asian or Pacific Islander (1% pre-SPA/2% post), American Indian or Alaskan Native (<1% both pre and post-SPA), and Unknown (4% pre-SPA/7% post). In July of 2010, the Department of Health Care Finance moved over 30,000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment. Pre-SPA enrollment above reflects October-June monthly average, 29 and post-SPA reflects July-September monthly average.
Pre-SPA Post-SPA
9%
9% 3% 5% 3%
2% 1%
Notes: In July of 2010, the Department of Health Care Finance moved over 30,000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment. Pre-SPA enrollment above reflects October-June monthly average, and post-SPA reflects July-September monthly average.
30
Reduce DD Waiver provider rates Reduce rates for adult dental care to align with national average Correct certain nonphysician provider rates Lower cap on PCA state plan benefit to 520 hours per year
$3.98m
$3.98m