Proposals in Health Care Reform Molina Healthcare Supports

House Tri-Committee Bill

Positives

• Effective 2013, individuals under age 65 with family incomes at or below 133% of poverty ($14,400 for an individual in 2009) would be eligible for Medicaid. The cost of care for those newly enrolled in Medicaid as a result of this policy would be primarily paid by the federal government.  An Energy and Commerce Committee amendment would replace full federal financing for Medicaid coverage expansions with 100% federal financing through 2014 and 90% federal financing beginning in year 2015.
  
• State Medicaid programs would continue to cover those with incomes above 133% of poverty using the eligibility rules that states now have in place.
  
• Medicaid payments to primary care physicians and practitioners for primary care services would be increased from 80% of Medicare fee-for-service rates in 2010, to 90% in 2011, and 100% in 2012 and thereafter. The costs of raising these rates would be paid by the federal government.
  
• The Medicaid drug rebate program would be extended to Medicaid managed care organizations.  The language ensures that states will collect the rebates.
  
• Medicaid-eligible individuals would generally be enrolled in Medicaid, not the Health Insurance Exchange (Exchange), which is a clearinghouse for private and public coverage options. An exception is made for childless adults with incomes under 133% of poverty ($14,400 per year for an individual) who had other qualifying coverage within the previous six months. They have the choice to obtain coverage through Medicaid or the Exchange.
  
• Babies born without health insurance would be deemed eligible for Medicaid. The initial Medicaid eligibility is for up to 60 days while a determination is completed to enroll the newborn in appropriate insurance.
  
• States would be prohibited from adopting Medicaid or CHIP program eligibility standards, methodologies, or procedures that are more restrictive than those in effect as of June 16, 2009.
  
• State Medicaid programs would be required to allow adults to apply for Medicaid coverage at DSH hospitals, FQHCs, and locations other than welfare offices (requirement already applies to pregnant women and children), effective July 1, 2010.
  
• State Medicaid programs would be mandated to cover all preventive services that the Secretary determines are recommended by the U.S. Preventive Services Task Force and appropriate for Medicaid beneficiaries.
  
• State Medicaid programs would be prohibited from excluding tobacco cessation products from coverage.
  
• State Medicaid programs would be allowed to cover home visits by trained nurses to families with a first-time pregnant woman or child under 2 eligible for Medicaid.
  
• State Medicaid programs would be allowed to cover low-income women who are not pregnant for family planning services and supplies without obtaining a waiver. These services would be covered during a presumptive eligibility period.
  
• State Medicaid programs would be allowed to cover individuals with HIV with incomes and resources below state eligibility levels for individuals with disabilities. The costs of coverage of such individuals would be matched at an enhanced rate. Sunsets on January 1, 2013.
  
• A 75% federal matching rate is provided for the costs of translation or interpretation services for Medicaid-eligible adults for whom English is not the primary language.
  
• When a provider or supplier, MA or Part D plan (but not a beneficiary) becomes aware of a Medicare or Medicaid overpayment, he or she would be required to report and return it within 60 days.
  
• The minimum manufacturer rebate for brand-name drugs purchased by State Medicaid programs would be increased from 15.1% of average manufacturer price to 22.1% of average manufacturer price, and the additional Medicaid rebate would be applied to new formulations of brand-name drugs.
  
• The Special Needs Plans (SNP) program would be extended through 2012.
  
• The study of Medicare Advantage risk adjustment would be expanded to include additional populations (low-income and chronically ill) and CMS would be required to improve the risk adjustment system by taking into account results from such study.
  
• CMS would establish a dedicated office to improve coordination of benefits and other policies for beneficiaries dually eligible for Medicare and Medicaid.
  

 

Negatives

• The bill includes a contractually-required minimum 85% medical cost ratio for Medicaid health plans, and extends the provision to CHIP plans, which was not in the original draft House bill.  This provision would apply to contracts entered into or renewed on or after July 1, 2010.
  
• CMS would be required to publish standardized information on Medicare Advantage plan medical cost ratios and other plan information. Plans with medical cost ratios below 85% would be required to give rebates and would be subject to increasing penalties over time, including eventual termination of contracts.
  
• The House bill allows CHIP to expire on its next reauthorization date (2013), after which time children receiving, or eligible for, CHIP would be covered through Exchange plans.  However, the Energy and Commerce Committee passed an amendment requiring the Secretary to submit a report to Congress by Dec. 31, 2011, that compares CHIP to coverage offered through the Exchange. If the Secretary cannot certify that the coverage in the Exchange is at least comparable to CHIP coverage regarding benefits, cost-sharing, and provider networks, then CHIP would continue and no CHIP-eligible child could be enrolled in an Exchange plan until the Secretary certifies the coverage is comparable. 
  
• A public health insurance option would be offered starting in 2013 as a plan choice within the Exchange.
  
• Medicare Advantage benchmarks would be reduced over three years, reaching equality with the fee-for-service system by 2013.
  
• The MA Regional Plan Stabilization Fund would be eliminated.