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DHCF Budget Review Team 2/17/11 - EMBARGOED

The Department of Health Care Finance

FY12 Budget Review Team Presentation

February 17, 2011

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DHCF Budget Review Team 2/17/11 - EMBARGOED

Table of Contents

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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

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DHCF Budget Review Team 2/17/11 - EMBARGOED

Agency Overview

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Total Agency FY12 Budget: $2,129,260,361 Total Agency Local Fund FY 12 Budget: $609,441,494


96% of budget spent on Provider Payments (Obj. Class 50)
Influencing Factors: – Eligibility – Benefits – Utilization – Provider Rates

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064.283 $4.796 $1.792 Waiver growth Fee-for-service growth Managed care growth Savings TOTAL 4 .962 $609.688.445.623.449.118) $609.623.348 ($23.441.724.339 ($53.817.817.529 $79.DHCF Budget Review Team 2/17/11 .089.619 $6.EMBARGOED FY12 Budget Development: MARC and Adjustments Maximum Allowable Request Ceiling FY 2011 Revised Budget Adjustment for stimulus funding [ends 6/30/2011] FY 2012 MARC $529.491 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 $529.441.695) $3.714 $10.962 $2.529 $79.104.494 February 1st Revision Revised Policy MARC Increase $614.622.

See Slide 31 for details.3M In FY 2011 DHCF capped the state plan PCA Waiver cap at 3. DD waiver and adult dental rates. This will require holding MCO rates flat for 2 consecutive years .DHCF Budget Review Team 2/17/11 . it could aggravate the District's position in the current Olmstead lawsuit. reducing physician. May not be able to demonstrate actuarial soundness for the MCO rates. hospital.940 benefit at 520 hours per year. and this prevents a disabled beneficiary from leaving an institutional setting.1M FY11 Savings Initiatives include: holding nursing facility rates flat. 5 . this could adversely affect provider participation.3M figure is based on 140 people per month moving in FY 2011. Current EPD enrollment allows for 1400 more people to enroll before hitting cap. Prediction is that many people will move to EPD waiver to continue PCA services. Previously it was 1040 without a PA.2011 & 2012. If DHCF reaches cap. correcting non-physician rates. and 100 per month moving in FY 2012. Currently. Maintaining EPD up to $7. $7.9M Relevant History Likely Resistance N/A Possible Unintended Consequences N/A No Rate Increases $21. MCOs may threaten to exit the program. creates a waiting list. Fed requires at least 2 for choice. If MCOs hold provider rates constant. there are only 2.EMBARGOED FY12 Budget Development: Key Assumptions Key Assumption FY11 Savings Initiatives remain in effect Budget Impact $16. and lowering PCA benefit to 520 hours per year.

out of business.8M Current Alliance eligibility is up to 200% FPL for The Alliance has those not eligible for Medicaid.000 beneficiaries up to 133% capped.DHCF Budget Review Team 2/17/11 .500. Nursing home rates are being rebased in FY Nursing home 2011 retroactive to FY 2009 based on FY 2007.EMBARGOED FY12 Budget Development: Savings Proposals Concept Estimated Local Savings $10. Capping Alliance enrollment at 18. Increase due to revised MARC would be applied here. Current Alliance enrollment is approximately 23.600 between from advocates. Increases cap to 21. claimed that Complaint was improper notice. but ultimately not implemented. Giving notice homes would go would be required.750 Change treatment of therapies in nursing home rate setting $2.750 in FY 2011 is required. July 2010 never been approximately 35. industry fought This change in treatment of therapies was this before. but when pressed could not say which one(s). 133% . so FPL transitioned to Medicaid as a result of Early resistance likely Option. 6 . They attempted.000. December 2010 another 2. so closing enrollment and attriting down to 18.200% FPL transitioned to Medicaid through a DSH waiver.6M Relevant History Likely Resistance Possible Unintended Consequences People waitlisted for the Alliance will show up at hospitals for charity care when they are sick enough or injured.

That's resist the rate cut.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.8M Relevant History Likely Resistance Nursing home industry will oppose this. so DHCF must change this methodology regardless. The incentive payments explicitly pay homes more than their cost.EMBARGOED FY12 Budget Development: Savings Proposals Concept Estimated Local Savings $7. a 5% rate cut for drugs subject to this method -brand names without substitutes. Possible Unintended Consequences Eliminate incentives in nursing home rate setting methodology This savings is so substantial that it negates the industry's gains from rebasing the rates. 7 .DHCF Budget Review Team 2/17/11 . Replace $1. so Pharmacies will WAC+3% is roughly equal to AWP-15%. AWP is being phased out at the end of FY 2011.

EMBARGOED FY12 Budget Development: Savings Proposals Concept Estimated Local Savings Relevant History Likely Resistance Possible Unintended Consequences Improved $1.DHCF Budget Review Team 2/17/11 .8M Savings Revised Policy MARC: $4. This initiative would do three things: 1) replace the existing assessment tool with one from another state with a proven track record. The hours were limited to 520 per year in FY 2011. resist. 2) selected real time monitoring of authorizations. and 3) promulgating new rules that strictly limit the use of staffing agencies.500) 8 .2M management of PCA services Numerous audits and anecdotal reports have The industry will shown there is waste and abuse in this benefit.792 Increase  Raise enrollment cap on the Alliance by 2.750 to 21. so the wasteful spending is prevented rather than caught after the fact.622. Total Estimated $23.750 (from 18.

DHCF Budget Review Team 2/17/11 .EMBARGOED Medicaid Enrollment and Expenditure Trends 9 .

and green represents programs that are solely locally funded.670/yr 300% 300% $24.890/yr 100% $580.80/m o 64% Medically Needy Income Limit Medicaid Eligibility Groups 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.059/yr 74% $10.DHCF Budget Review Team 2/17/11 .780/yr 200% $32. Yellow denotes Medicaid programs whose eligibility can be changed. eligibility cannot be cut due to maintenance of effort requirements from ARRA (stimulus funding) and the Affordable Care Act (health reform).EMBARGOED District of Columbia Eligibility Levels for Medicaid Groups Income Eligibility Threshold As A Percent of Federal Poverty: 2011 Federal Poverty Level (One Person) $21.176/yr $21.780/yr 200% 222% $10.670/yr $32. 10 .890 $8.

and green represents programs that are solely locally funded. Yellow denotes Medicaid programs whose eligibility can be changed.670/yr 2011 Federal Poverty Level (One Person) 300% $21.890 Medicare Eligibility Groups 100% Full Duals Medicaid Services & Medicare Premium Qualified Disabled & Working Qualified Medicare Beneficiaries Notes: For all groups in red. ).EMBARGOED At Different Income Thresholds Medicare Beneficiaries Qualify For Some Medicaid Benefits Income Eligibility Threshold As A Percent of Federal Poverty: $32.890/yr $10. eligibility cannot be cut due to maintenance of effort requirements from ARRA (stimulus funding) and 11 the Affordable Care Act (health reform).780/yr 200% $10. .DHCF Budget Review Team 2/17/11 .

619.383.187.DHCF Budget Review Team 2/17/11 .667 FY12 Proposed ($) 305.398 FY11 Budgeted ($) 297.576 14.112 43.996 43.666.742.064 15.497.947 13.838 20.582 11. but expenditure data were not available.266. and Treatment services are generally included in other categories of services above.187.597.930 24.980. and rural health clinic services are also mandatory.950 52.719.577 6.228.296 16.855 9.672.496 219.853 22.619.000 Notes: Certified pediatric and family nurse practitioner services.308.000.977.496 212. midwife and nurse practitioner services.790 14.EMBARGOED Mandatory Medicaid Services Expenditures FY10-FY12 (Proposed) FY10 Actual ($) Inpatient Hospital Outpatient Hospital Physician's Services Nursing Facilities Lab & X-Ray Transportation Private Clinic FQHC Cost Settlements 307.286.187.381 7.396 187.297.500 36. Source: FY10 Actual figures from CFO$olve ad hoc dated 1/28/11.165.258 12. Early and Periodic Screening.243 7.407.333 36. Diagnosis.496 35.055. 12 .311.630.572.339 8.339.

446 23.532 69.881.176.969 13.037 23.886.569.478.488 95.336 16.749.532 24.412.723.241.236 1.144 446.227 185. 13 .593 3.840 16.036 14.754 19.508.621 15.927.436 967.289.322 16.977.456 586.515.758.905 290.504 3.489 46.883 78.995 221.096.205 1.475 1.830.DHCF Budget Review Team 2/17/11 .573 9.573 428.143 133.075.636 17.773 19.755.398 FY11 Budgeted ($) 75.351 768.893.180.695 6.691 Source: FY10 Actual figures from CFO$olve ad hoc dated 1/28/11.000.459 27.585 58.837.605.828 3.572.275 262.763 617.155.484 1.203 14.000 14.929 569.303 FY12 Proposed Local ($) 21.070 723.258 59.946 672.632 101.246 805.256.102.119 69.727.398 4.563 1.958.862 FY12 Proposed Gross ($) 75.351.112.446 5.987.625 800.859 412.294.819 2.911 65.778 1.328 493.156.970.227 6.641.394.292 158.089 30.037.664.470.EMBARGOED Optional Medicaid Services Expenditures FY10-FY12 (Proposed) FY10 Actual ($) Inpatient DSH Day Treatment ICF/MR Residential Treatment Dental Optometry/Vision Optician Podiatry Durable Medical Equipment Hospice Rehab Services Mental Health Clinic Sterilization Home Health / Personal Care Aide Pharmacy Managed Care Services Medicare Buy In COBRA Waivers 71.204 7.126.462 20.315 6.456.793.198 58.133 239.247 226.122 49.233.682 33.126.812.989.081.852 4.451 4.522.533.490 75.154.383.015 69.787 614.

000. Public Schools Source: FY10 Actual figures from CFO$olve ad hoc dated 1/28/11 14 .000 2. Public Schools OSSE/ Transportation Charter Schools Department of Mental Health Child and Family Services Administration Fire and Emergency Medical Services 8.044 2.039.342. Expenditures represent the 70% FMAP only.500.047.500.854 21.000 8.000 2.C.C.253 7.784 1.176.000 9.312.000 3.DHCF Budget Review Team 2/17/11 .606 3.EMBARGOED Public Provider Expenditures FY10-FY12 (Proposed) FY10 Actual ($) FY11 Budgeted ($) FY12 Proposed ($) D.211 162.500.292.864 4.000.000 Notes: FY11 and 12 Budget is based on Provider Agency Budget Submission.000 4.612 297. FY10 budget for transportation for Special Needs children was allocated to D.531 1.050.050.780.

C. Data shown above for 2010 reflect October-June monthly average (pre-SPA) and July-September average (post-SPA). FY99-FY10 250.000 150. The Department of Health Care Finance moved over 30.700 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.665 100.EMBARGOED Average Monthly Medicaid Enrollment In The District of Columbia.44% Average Growth Pre-SPA Post-SPA 2007 2008 2009 2010 0 1999 2000 2001 2002 2003 2004 2005 2006 Notes: D. The Department transitioned over 2. fiscal year is October 1 through September 30.000 from the Alliance to the Medicaid program in July of 2010 while implementing a new coverage option state plan amendment.DHCF Budget Review Team 2/17/11 .000 160.000 Average Monthly Enrollment 197.624 200. 15 .000 . enrollment was averaged from October to September to create average monthly enrollment.000 50.

000 Fee-For-Service Managed Care Alliance Childless Adult Expansion Total Quarterly Enrollment 240.750. . and childless adult waiver.000 100.000 0 114.000 250.524 40. and September 2012.000 50. Projections assume EPD 16 waiver cap of 3. FY07-FY12 300.607 200.750 Notes: Enrollment projected using data from FY12 budget model.000 150. which includes childless adults from 133 to 200% FPL.940 beneficiaries. which covers childless adults from 0 to 133% FPL.260 18. and Alliance program cap of 18. Data labels shown are February 2011. October 2012.EMBARGOED Historical and Projected Quarterly DHCF Enrollment. Childless Adult Expansion includes new coverage option state plan amendment.DHCF Budget Review Team 2/17/11 .822 65.

but excludes spending on the Alliance.800.000 $1.825.625. FY06-FY10 $2.000 $1. 17 .000 $1.000.343.Increased PRTF placements FY2009 FY2010 Notes: Total annual expenditures include local and federal share of spending.DHCF Budget Review Team 2/17/11 .902 $1.456 $1.000. Date -of-payment basis including all object 50 spending.200.600.000.000.Medicaid MCO rate increase .000 $1.504.000.000.Alliance to Medicaid transition due to Health Reform .608.000 $600.506 $1.400.210.000 $800.000.000.000.513.000.679.101 $1.949 6% Average Annual Growth from FY06 to FY09 13% Annual Growth from FY09 to FY10 Nearly half of this increase due to: .000 $0 FY2006 FY2007 FY2008 $1.000.000 $1. Source: CFO$olve ad hoc report 1/28/2011.000.000 $200.426.653.Physician rate increase .000 $400.EMBARGOED Total Annual DC Medicaid Expenditures.

DHCF Budget Review Team 2/17/11 . fiscal year is October 1 through September 30.000 40.000 0 FY2007 FY2008 64% 63% 36% 37% 37% 33% Fee-ForService Managed Care (Medicaid) 63% 67% Total Enrollment FY2009 FY2010 Notes: D.000 120.C. over 30.EMBARGOED Managed Care Is A Growing Component of Medicaid in the District of Columbia 180. The net result is a rapid increase in managed care enrollment in FY2010 and FY2011. when looking at Medicaid enrollment data only. enrollment was averaged from October to September to create average monthly enrollment. 18 .000 100.000 60.000 Average Monthly Enrollment 160. Data were not available for managed care and fee for service enrollment prior to FY2007.000 individuals were moved from Alliance (not included in the data above) onto the Medicaid program.000 140.000 20.000 80. 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.

DHCF Budget Review Team 2/17/11 .EMBARGOED The Elderly And Disabled Represent 29 Percent Of Medicaid Program Beneficiaries Demographics Of Beneficiaries In The District of Columbia’s Medicaid Program Blind & Disabled 29% Children Aged Adults Notes: Distributions may not sum to 100% due to rounding effects. 19 . Distribution of beneficiaries by category is based on average Medicaid enrollment in FY10.

and drug rebate.DHCF Budget Review Team 2/17/11 . FY10 Aged Blind & Disabled Aged 29% 73% Blind & Disabled Adults Children Adults Children Notes: Distributions may not sum to 100% due to rounding effects. Medicare premiums.EMBARGOED …Yet They Account For 73 Percent Of Medicaid Program Spending. Source: Spending from ad hoc MMIS report 1/26/2011. 20 . FY 2010 date-of-service spending excluding DSH. cost settlements.

EMBARGOED The Cost of Serving the Elderly and Disabled Is Substantially Greater Than The Cost of Care For Children in Medicaid. and drug rebate.000 $10.131 $5.000 $19. FY 2010 date-of-service spending excluding DSH.000 $27. Medicare premiums. cost settlements.000 $9.000 $2.000 $20. FY10 $30.129 Average Annual Per Capita Spending $25.171 $15.969 $0 All Recipients Aged Blind & Disabled Children Adults Source: Spending from ad hoc MMIS report 1/26/2011. 21 .DHCF Budget Review Team 2/17/11 .920 $5.

cost settlements.DHCF Budget Review Team 2/17/11 . and drug rebate. 22 .EMBARGOED Change in Expenditures for Selected Medicaid Provider Types FY08-FY10 39% Expenditure Rate Increases for FeeFor-Service Episode-Based Care Expenditure Rate of Spending Increase for Fee-for-Service Long-Term Care 22% 23% 16% 24% 21% 8% 9% MCOs -3% -2% Inpatient Hospital Outpatient (includes ER Services) Pharmacy Nursing Facility Change in Total Expenditures Change in Per Enrollee Expenditures Source: Spending from ad hoc MMIS report 1/28/2011. FY 2010 date-of-service spending excluding DSH. Medicare premiums.

23 .DHCF Budget Review Team 2/17/11 .EMBARGOED 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 Source: Spending is date-of-payment from CFOSolve ad hoc report dated 1/28/2011.

EMBARGOED Alliance Enrollment and Expenditure Trends 24 .DHCF Budget Review Team 2/17/11 .

and green represents programs that are solely locally funded. eligibility cannot be cut due to maintenance of effort requirements from ARRA (stimulus funding) and the Affordable Care Act (health reform).EMBARGOED 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) $21.890 Medicaid & Alliance Eligibility Groups Families w/ Children Children Age (0-18)* Pregnant Women* Childless Adults (Medicaid) Childless Adults (Alliance) Immigrant Children’s Program Federal & Local Funding Local Funding Notes: For all groups in red.780/yr 200% $32.780/yr 200% $21. Yellow denotes Medicaid programs whose eligibility can be changed.DHCF Budget Review Team 2/17/11 .670/yr 300% $32. 25 .670/yr 300% $21.780/yr 200% $10.670/yr 300% $32.

EMBARGOED Covered Services in the Alliance Program Inpatient Hospital Outpatient Hospital Laboratory & X-Ray Services Hospital Services Pharmacy Services (Limited) Pregnancy Testing Routine and Emergency Contraception Family Planning Services Screening. Counseling. and Immunizations Emergency Services Specialist Services Primary Care Services Adult Wellness Services Dental (Limited) Nursing Home Care 26 .DHCF Budget Review Team 2/17/11 .

but not shown above because due to high monthly variability as the program began.884 56.000 0 2007 2008 2009 2010 53.000 20.DHCF Budget Review Team 2/17/11 .000 10. Average enrollment for FY06 is 27. In July of 2010. fiscal year is October 1 through September 30.000 30. The Alliance program in its current form began enrolling beneficiaries in March of 2006.193.EMBARGOED Average Annual Enrollment in the Alliance FY07-FY11 Average Monthly Enrollment 60. The Department transitioned over 2.C.894 48.000 50. enrollment was averaged from October to September to create average monthly enrollment. .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. Data shown above for 2010 reflect October-June monthly average (pre-SPA) and July-September average (post-SPA). the Department of Health Care Finance moved over 30.694 44.000 40.000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment.435 Enrollment shifted to Medicaid as a result of expanded eligibility due to health reform 25.487 Pre-SPA Post-SPA Notes: D.

by Gender.DHCF Budget Review Team 2/17/11 . Pre-SPA enrollment above reflects OctoberJune monthly average. 28 .EMBARGOED Distribution of Alliance Enrollment. FY10 Pre-SPA Post-Spa Female 42% Male 58% Female 55% Male 45% Notes: In July of 2010.000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment. and post-SPA reflects July-September monthly average. the Department of Health Care Finance moved over 30.

FY10 Pre-SPA Post-SPA Hispanic 27% Black 31% Other 6% Black 65% Hispanic 57% Other 11% White 2% White 1% Notes: Other includes Other Known Race (1% pre-SPA/2% post).DHCF Budget Review Team 2/17/11 . American Indian or Alaskan Native (<1% both pre and post-SPA). In July of 2010. and Unknown (4% pre-SPA/7% post). Pre-SPA enrollment above reflects October-June monthly average. the Department of Health Care Finance moved over 30. Asian or Pacific Islander (1% pre-SPA/2% post). .000 from the Alliance to the Medicaid program while implementing a new coverage option state plan amendment.EMBARGOED Distribution of Alliance Enrollment. by Race. 29 and post-SPA reflects July-September monthly average.

by Ward.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. FY10 40% 36% 35% 31% 30% 25% 20% 15% 10% 5% 0% Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 18% 13% 10% 12% 12% 13% 22% Pre-SPA Post-SPA 9% 9% 3% 5% 3% 2% 1% Notes: In July of 2010.DHCF Budget Review Team 2/17/11 . the Department of Health Care Finance moved over 30. and post-SPA reflects July-September monthly average. 30 .EMBARGOED Distribution of Alliance Enrollment.

1m $0. Budget assumed 10/1/2010 effective date.55M potential pressure assumes an April 1. 1/1/2011 is more likely.55m $3. Submitted to Council for passive approval 1/12/2011. $0.00m Public notice done. Reduce Medicaid physician payment to 80% of Medicare Reduce Hospital rates 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. $2. SPA submission to CMS planned after 30 day passive approval. SPA drafted.20m $0. This is on track.000 potential pressure assumes an April 1.20m $0. SPA pending CMS approval. $450.08M based on revised estimate and delay in implementation. SPA submission to CMS planned after 30 day passive approval. The savings estimate was based on a 10/1/2010 effective date. When approved. The budget assumed a 4/1/2011 effective date. 2011 implementation date. Public notice done. Submitted to Council for passive approval 1/12/2011.98m .50m $1.59m $0.55m SPA in development.90m $0.88m $0.51m Public notice done. Savings reduced to $2.00m Combined with physician SPA above.10m $3.35m $0. 2011 implementation date. the effective date will be 1/1/2011. SPA drafted.45m $0.45m Waiver amendment in development. $0. Budget assumed 10/1/2010 effective date. Submitted to Council for passive approval 1/12/2011. Savings reduced to $590K based on revised estimate and delay in implementation. $0. SPA submission to CMS planned after 30 day passive approval. $7. Budget assumed 1/1/2011 31 effective date.00m SPA in development.EMBARGOED FY11 Savings Initiatives Status Report Amendment Hold Medicaid nursing facility rates flat Budgeted Updated Spending Notes Savings Savings Pressure $1. $3. 1/1/2011 is more likely. $0. SPA drafted.63m Public notice done.35m $0.98m $3.DHCF Budget Review Team 2/17/11 .

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