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Claims Expenditure Assessment: A Proposal to Replace the Provider Tax

Issue After examining more than a dozen different


The provider tax, a controversial source of funding options, a claims expenditure assessment was
for Medical Assistance (MA), MinnesotaCare and identified.
several other long-standing health access programs
since 1992, is scheduled to sunset December 31, Claims Expenditure Assessment Mechanics
2019. Although the Health Care Access Fund A claims expenditure assessment would be applied
(HCAF), the fund into which the provider tax is to all non-federal adjudicated health care claims for
deposited, is solvent through FY 2021, replacement a Minnesota resident processed by a health plan,
funding is needed to maintain health care coverage insurer, or third-party administrator (TPA). Unlike
for low-income Minnesotans. the provider tax, it would not apply to patient out-
of-pocket spending, including co-pays, deductibles,
Approach cosmetic, or non-covered services.
Given the scheduled provider tax sunset, the MMA
recognized the need to identify potential Assessment Rate
alternative sources of revenue. To guide its review Financial modeling conducted by SHADAC
of potential alternatives, the MMA established estimated that a claims expenditure assessment of
three guiding principles: 1.67% to 1.99% would generate sufficient revenue
(see Methodology section, below, for additional detail).
• Preserve Coverage: Any alternatives must
provide ongoing funding for current Advantages
MinnesotaCare and MA coverage and A claims expenditure assessment preserves MA
historic HCAF programs. and MinnesotaCare coverage and will generate
• Modernized: Any alternatives must sufficient revenue to support other ongoing HCAF
generate revenue that reflects current spending.
spending needs and recognizes post-ACA
federal and state financing dynamics. A claims expenditure assessment is based on health
• Sustainable: Any alternatives must be care spending, which will allow revenue to keep
sufficient to meet future spending needs pace with health care inflation. A claims
and qualify for appropriate Medicaid expenditure assessment also meets Centers for
matching funds. Medicare and Medical Services requirements for
federal matching funds.
The MMA engaged experts to assist it in its
work – Harbage Consulting, a national health A claims expenditure assessment is broad based, as
policy and communications consulting firm; it would be applied to all non-federal claims for
and, the State Health Access Data Assistance health care services provided to Minnesota
Center (SHADAC), a health policy research residents. The assessment is also permissible under
center affiliated with the University of ERISA and supported by federal case law.
Minnesota School of Public Health.
A claims expenditure assessment reflects current Methodology
spending needs and recognizes federal and state SHADAC was engaged to estimate the assessment
financing dynamics enacted since the Affordable rate that would be necessary to generate the
Care Act. following 2020 revenue targetsi:
• Low Target: $501 million
A claims expenditure assessment is less regressive o Enough to cover all existing projected
than the provider tax, because it is not applied to Health Care Access Fund expenditures
patient out-of-pocket spending, non-covered and transfers [$628 million]
services, or charity care. ▪ Minus projected existing
ongoing Health Care Access
A claims expenditure assessment, unlike the Fund revenue (i.e., 1% gross
provider tax, does not put Minnesota border premium tax and MinnesotaCare
community health care facilities or national centers enrollee premiums) [$127
of excellence at a competitive disadvantage. million]
• High Target: $596 million
A claims expenditure assessment results in a $100 o Enough to cover all existing projected
million tax cut compared to the current provider Health Care Access Fund expenditures
tax. [$628 million]
▪ Minus projected MinnesotaCare
A claims expenditure assessment is more efficient enrollee premiums [$32 million]
than the provider tax as fewer entities will collect • This assumes the 1%
and pay it compared to the number of providers gross premium tax is
paying the provider tax. It will also reduce either repealed or
administrative expenses for all health care rededicated.
providers.
To complete these estimates SHADAC built an
A claims expenditure assessment will not increase Excel spreadsheet model based primarily on 2016
health care costs as insurers and employers already data, which was projected to 2020 and used to
account for the cost of the provider tax via the tax calculate what assessment rates would be needed
pass-through. to hit both the low and high revenue targets.

A claims expenditure assessment allows legislators Additional detail about the SHADAC data sources
to maintain their 2011 commitment to the provider and key assumptions are as follows:
tax repeal.
Claims for the Fully-Insured Market
Potential Disadvantages • Claims for the fully-insured market are
A claims expenditure assessment is new and would based on net-incurred claims after
require new Department of Revenue processes. reinsurance (excluding pharmaceutical
rebates).
Despite support from federal case law, a claims • Primary Data Source: 2016 National
expenditure assessment may nevertheless be Association of Insurance Commissioners
challenged in court on the question of ERISA (NAIC) Supplemental Health Care Exhibit
preemption. Report Volume I.ii
• We adjusted the 2016 fully-insured claims
expenditure totals to:
o Exclude TRICARE expenditures Claims for MinnesotaCare and Medical
(assumes 1% of the Minnesota Assistance
population is enrolled in • Claims data for MinnesotaCare and Medical
TRICARE).iii,iv,v Assistance are based on DHS forecast data
o Exclude Federal Employee Health for 2020.xii
Benefit Plan expenditures (assumes
the FEHBP per member claims Results (in 000s)
profile is the same as the fully 2016 Actual (Adjusted) and 2020 Projected Claims
insured large group market).vi
Claims 2016 2020
o Adjust the final total claims
expenditure upwards by 6% in order
to account for the inclusion of
Minnesota
standalone dental claims, which are
Commercial
not included in the NAIC data.vii $4,840,000 $5,150,000
Business - Fully
• To project 2016 claims to 2020 for the large
Insured
and small group market, we applied the
National Health Expenditure Trend
Projection growth rate calculated by the
Minnesota
Office of the Actuary in the Centers for
Commercial $8,320,000 $9,980,000
Medicare & Medicaid Services.viii
Business - Self
• To project 2016 claims to 2020 for the
Insured
individual market, claims were adjusted to
reflect the 40% decline in claims between MinnesotaCare n/a $490,000
2016 and 2017ix and the National Health
Expenditure Trend projection was used to Medical Assistance n/a $14,350,000
predict growth between 2017 and 2020.viii
Total Claims n/a $29,980,000
Claims for the Self-Insured Market
• The most significant data gap for
SHADAC’s analysis is related to the self- Based on a total projected claims expenditure of
insured market. $29.9 billion in 2020:
• To estimate the size of this market, we used • In order to raise $501 million in revenue, a
2016 data from the Minnesota Department health care claims assessment rate would
of Health’s Health Economics Program.x,iv need to be: 1.672%
• To estimate 2016 claims expenditures of the • In order to raise $596 million in revenue, a
self-insured market we assumed claims health care claims assessment rate would
experience would be the same as with the need to be: 1.989%
fully-insured market (see above) and that
95% of enrollees in this market were in large
firms.xi
• As with fully-insured claims, we applied
the National Health Expenditure Trend
Projection growth rate to project 2016 claims
December 2018
to 2020.
i Minnesota Department of Management and Budget (MMB). xi Estimate based on SHADAC analysis of the Medical
(2018, February 28). Health Care Access Fund: February 2018 Expenditure Panel Survey - Insurance Component.
Forecast Update. Retrieved from xii Minnesota Department of Human Services, Reports and

https://mn.gov/mmb/assets/feb18fcst-hcaf_tcm1059-327960.pdf Forecasts Division. (2018). Background Data Tables for February


ii National Association of Insurance Commissioners (NAIC). 2018 Forecast [Excel Table Spreadsheet]. from
(2017). 2016 Supplemental Health Care Exhibit Report Volume I. https://mn.gov/dhs/general-public/publications-forms-
Retrieved from resources/reports/financial-reports-and-forecasts.jsp
https://www.naic.org/documents/prod_serv_statistical_hcs_zb.
pdf
iii Minnesota Department of Health (MDH). (2018). Chartbook

Section 2: Trends and Variation in Health Insurance Coverage.


Retrieved from
http://www.health.state.mn.us/divs/hpsc/hep/chartbook/sectio
n2.pdf
iv U.S. Census Bureau, Population Division. (2018). Annual

estimates of the resident population: April 1, 2010 to July 1, 2016.


[Table. Release Date: December 2016]. Retrieved from
https://factfinder.censusd.gov/faces/tableservices/jsf/pages/pro
ductview.xhtml?pid=PEP_2017_PEPANNRES&src=pt
v Defense Health Agency, Decision Support Division. (2016,

February 24). Evaluation of the TRICARE Program: Access, Cost,


and Quality [Fiscal Year 2016 Report to Congress]. Washington,
DC: Office of the Assistant Secretary of Defense. Retrieved
from https://health.mil/Reference-
Center/Reports/2016/05/19/Evaluation-of-the-TRICARE-
Program-Fiscal-Year-2016-Report-to-Congress
vi Governing: The States and Localities. (2018, January 18).

Federal Employees by State. Retrieved from


http://www.governing.com/gov-data/federal-employees-
workforce-numbers-by-state.html
vii Estimate based on SHADAC analysis of the Medical

Expenditure Panel Survey - Insurance Component as well as


National Health Expenditure data and information from the
Minnesota Department of Health, Health Economics Program.
viii Centers for Medicare & Medicaid Services, Office of the

Actuary; U.S. Department of Commerce, Bureau of Economic


Analysis; and U.S. Bureau of the Census. (February 2018). Table
1 National Health Expenditures and Selected Economic Indicators,
Levels and Annual Percent Change: Calendar Years 2010-2026.
Baltimore, MD: CMS. Retrieved from
https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/Downloads/Proj2017Tabl
es.zip
ix National Association of Insurance Commissioners (NAIC).

(2018). 2017 Supplemental Health Care Exhibit Report Volume I.


Retrieved from https://www.naic.org/prod_serv/HCS-
ZB_2017.pdf
x Minnesota Department of Health (MDH). (2018). Chartbook

Section 2: Trends and Variation in Health Insurance Coverage.


Retrieved from
http://www.health.state.mn.us/divs/hpsc/hep/chartbook/sectio
n2.pdf