Medicaid expansion-insurance pool.

WORKING DRAFT
2014
STATE OF
WYOMING
14LSO-0262

SENATE FILE
NO.
SF0088

Medicaid expansion-insurance pool.

Sponsored by:
Joint Labor, Health and Social Services Interim Committee

A BILL

for

AN ACT relating to Medicaid; creating the Health
c
are Independence Act of 2014; authorizing a private insurance option within the Medicaid program; authorizing payment or subsidy of health insurance premiums for Medicaid clients as specified; declaring legislative intent; providing definitions; providing eligibility criteria for clients and insurers; providing for a continuous appropriation; providing a sunset date; and providing for an effective date.

Be It Enacted by the Legislature of the state of Wyoming:

Section 1.

W.S. 42
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401 through 42
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40
8
are created to read:

ARTICLE 4
HEALTHCARE INDEPENDENCE ACT OF 2014

42
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4
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401.

Title.

This article shall be known and may be cited as the "Health
c
are Independence Act of 2014."

42
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4
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402.

Purpose
.

(a)

The department of health shall explore design options that reform the Medicaid program utilizing this act so that it is a fiscally sustainable, cost

effective, personally responsible and opportunity

driven program utilizing competitive and value

based purchasing to:

(i)

Maximize the available service options;

(ii)

Promote accountability, personal responsibility and transparency;

(iii)

Encourage and reward healthy outcomes and responsible choices; and

(iv)

Promote efficiencies that will deliver value to the taxpayers.

(b)

The purpose of this act is to:

(i)

Improve access to quality
healthcare
;

(ii)

Attract insurance carriers and enhance competition in the Wyoming insurance market;

(iii)

Promote individually owned health insurance;

(iv)

Strengthen personal responsibility through cost

sharing;

(v)

Improve continuity of coverage;

(vi)

Reduce the size of the state administered Medicaid program;

(vii)

Encourage appropriate care, including early intervention, prevention and wellness;

(viii)

Increase quality and delivery system efficiencies;

(ix)

Facilitate Wyoming's continued payment innovation, delivery system reform and market

driven improvements;

(x)

Discourage overutilization; and

(xi)

Reduce waste, fraud and abuse.

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3
.

Definitions.

(a)

As used in this act:

(i)

"Carrier" means a private entity certified by the department of insurance and offering plans through the health insurance exchange;

(ii)

"Cost sharing" means the portion of the cost of a covered medical service that must be paid by or on behalf of eligible individuals, consisting of copayments or coinsurance but not deductibles;

(iii)

"Eligible individuals" means individuals who:

(A)

Are adults between nineteen (19) years of age and sixty-five (65) years of age with an income that is equal to or less than one hundred thirty-eight percent (138%) of the federal poverty level, including individuals who would not be eligible for Medicaid under laws and rules in effect on January 1, 2014;

(B)

Have been authenticated to be a United
S
tates citizen or documented qualified alien according to the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. No. 104-193, as existing on January 1, 2014; and

(C)

Are not determined to be more effectively covered through the standard Medicaid program, such as an individual who is medically frail or other individuals with exceptional medical needs for whom coverage through the health insurance exchange is determined to be impractical, overly complex or would undermine continuity or effectiveness of care.

(iv)

"Healthcare coverage" means healthcare benefits as defined by certification or rules, or both, promulgated by the Wyoming department of insurance for the qualified health plans or available on the exchange;

(v)

"Health insurance exchange" means the vehicle created pursuant to P
.
L
.
111-148 known in federal regulations in effect on August 1, 2013 as the "health insurance marketplace";

(vi)

"Independence account" means individual financing structures that operate similar to a health savings account or a medical savings account;

(vii)

"Premium" means a charge that must be paid as a condition of enrolling in
healthcare
coverage;

(viii)

"Program" means the
healthcare
independent program established by this act;

(ix)

"Qualified health plan" means a department of insurance certified individual health insurance plan offered by a carrier through the health insurance exchange provided the carrier has agreed to manage the independence
account for any individuals enrolling as part of the Medicaid program and to continue to manage the independence account for at least two (2) years, if needed, after an individual leaves the Medicaid program;

(x)

"Wages" means any remuneration subject to social security taxes;

(xi)

"This act" means W.S. 42
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401 through 42
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8
.

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4
.

Administration of the
healthcare
i
ndependence
p
rogram.

(a)

The department of health shall:

(i)

Create and administer the
healthcare
independence program;

(ii)

Submit and apply for any:

(A)

Federal waivers necessary to implement the program in a manner consistent with this act, including
approval for a comprehensive waiver under Section 1115 of the Social Security Act, 42 U.S.C. § 1315; and

(B)

Medicaid state plan amendments necessary to implement the program in a manner consistent with this act.

(b)

The department of health shall submit only those Medicaid state plan amendments under this section that are optional and therefore may be revoked by the state at its discretion.

(c)

As part of its actions under subparagraph (a)(ii)(A) of this section, the department of health shall confirm that employers shall not be subject to the penalties, including an assessable payment, under Section 1513 of P.L. No. 111-148, as existing on January 1, 2014, concerning shared responsibility, for employees who are eligible individuals if the employees:

(i)

Are enrolled in the program; and

(ii)

Enroll in a qualified health plan through the health insurance exchange.

(d)

If the department of health is unable to confirm provisions under subsections (b) and (c) of this section, the program shall not be implemented. If the center for Medicare and Medicaid services does not approve the use of the independence account, a premium paid by individuals and the work requirement as set forth in this act, the program shall not be implemented.

(e)

Implementation of the program is conditioned upon the receipt of necessary federal approvals. If the department of health does not receive the necessary federal approvals, the program shall not be implemented.

(f)

The program shall include premium assistance for eligible individuals to enable their enrollment in a qualified health plan through the health insurance exchange.

(g)

The department of health is specifically authorized to use Medicaid funds to pay premiums and contributions to independence accounts and supplemental contributions to independence accounts directly to the qualified health plans for enrolled eligible individuals.
The amount of the contributions to independence accounts shall be determined by a formula set forth in rule and regulation, in the state plan or in the section 1115 waiver. The amount plus expected incentive contributions authorized by this act shall be enough to enable an ordinary individual to make required cost sharing payments. The intent of the payments under this subsection is to increase participation and competition in the health insurance market, intensify price pressures and reduce costs for both publicly and privately funded
healthcare
.

(h)

If an individual's independence account has insufficient funds to make a needed copayment, the department shall make a supplemental contribution to the independence account to enable the enrolled individual to pay required copayments. To the extent there are unrepaid supplemental payments, the individual's required premium contribution shall be increased by fifty percent (50%) and shall be entirely used to repay supplemental contributions. The repayment shall be on a first in, first out basis except that after a supplemental contribution has been outstanding for one (1) year, it's unpaid balance shall be forgiven. If the individual leaves the Medicaid program, any positive balance in that individual's independence
account shall be retained for use in paying the individual's further health insurance premiums and copayments and, if there are outstanding unrepaid supplemental contributions, the individual's required premium contribution shall be continued until the supplemental contributions are repaid or forgiven as provided by this subsection. If provided in the state plan or section 1115 waiver, the department shall continue to make supplemental contributions through the Medicaid program for up to one (1) year or until the individual's income exceeds the percentage of poverty level stated in the state plan or section 1115 waiver.

(j)

An individual who leaves the Medicaid program may retain the independence account for up to two (2) years and may, at any time during that period, transfer the balance of the independence account into a private health savings account or similar account. If an individual switches to a different carrier participating in the program, the individual may transfer the independence account to that carrier.

(k)

Individuals participating in the program established by this act shall pay a premium to the carrier
based on the individual's earnings. The carrier shall deposit the premium in the individual's independence account unless it is needed to repay a supplemental contribution, in which case the company shall forward the premium to the Medicaid program. The premium shall be set in accordance with department rules and regulations and shall be on a sliding scale according to income as authorized in the state plan or section 1115 waiver. The department shall not implement the program authorized by this act without further legislative authorization if the center for Medicare and Medicaid services does not approve a section 1115 waiver with a minimum premium of at
least
one-half of one percent (.5%) of income and an enhanced premium to repay supplemental contribution of at least fifty percent (50%) of the original premium, or demands a maximum premium, including base premium and enhanced premium, of more than five percent (5%) of income. The department may by rule and regulation require employers to deduct premium amounts from participating individuals' wages and forward the premium to the appropriate carrier.

(m)

Individuals participating in the program shall be required to work at least twenty (20) hours per week, averaged over a period to be specified in the state plan or
the section 1115 waiver. This requirement may be waived for good cause as provide
d
in the state plan or section 1115 waiver.

(n)

To the extent allowable by law:

(i)

The department of health shall pursue strategies that promote insurance coverage of children in their parents' or caregivers' plan, including children eligible for the child health insurance program pursuant to title 35,

chapter 25, article 1; and

(ii)

Upon the receipt of necessary federal approval, during calendar year 2015 the department of health shall include and transition to the health insurance exchange:

(A)

Children eligible for the child health insurance program; and

(B)

Populations under Medicaid from zero percent (0%) of the federal poverty level to seventeen percent (17%) of the federal poverty level.

(iii)

The department of health shall develop and implement a strategy to inform Medicaid recipient populations whose needs would be reduced or better served through participation in the health insurance exchange.

(o)

The program shall include allowable cost sharing for eligible individuals that is comparable to that for individuals in the same income range in the private insurance market and is structured to enhance eligible individuals' investment in their
healthcare
purchasing decisions.

(p)

The department of insurance and department of health shall administer and promulgate rules to administer the program authorized under this act on or before October 1, 2014.

(q)

The program authorized under this act shall terminate within one hundred twenty (120) days after a reduction in any of the following federal medical assistance percentages:

(i)

One hundred percent (100%) in 2014, 2015 or 2016;

(ii)

Ninety-five percent (95%) in 2017;

(iii)

Ninety-four percent (94%) in 2018;

(iv)

Ninety-three percent (93%) in 2019; and

(v)

Ninety percent (90%) in 2020 or any year after 2020.

(r)

An eligible individual enrolled in the program shall affirmatively acknowledge that:

(i)

The program is not a perpetual federal or state right or a guaranteed entitlement;

(ii)

The program is subject to cancellation upon appropriate notice; and

(iii)

The program is not an entitlement program.

(s)

The department of health shall develop a model and seek from the center for Medicare and Medicaid services all necessary waivers and approvals to allow nonaged,
nondisabled program eligible participants to enroll in a program that will create and utilize independence accounts that operate similar to a health savings account or medical savings account during the calendar year 2015. The independence accounts shall:

(i)

Allow a participant to purchase cost effective high deductible health insurance; and

(ii)

Promote independence and self sufficiency.

(t)

The department of health shall implement cost sharing and copays and, as a condition of participation, earnings shall exceed fifty percent (50%) of the federal poverty level. Participants may receive rewards based on healthy living and self sufficiency. At the end of each fiscal year, if there are funds remaining in the account, a majority of the state's contribution will remain in the participant’s control as a positive incentive for the responsible use of the
healthcare
system and personal responsibility of health maintenance. Uses of the funds may include rolling the funds into a private sector health savings account for the participant according to rules promulgated by the department of health.

(u)

State obligations for uncompensated care shall be projected, tracked and reported to identify potential incremental future decreases. The department of health shall recommend appropriate adjustments to the legislature.

(
w
)

On a quarterly basis, the department of health shall report to the joint labor, health and social services interim committee information regarding:

(i)

Program enrollment;

(ii)

Patient experience;

(iii)

Economic impact including enrollment distribution;

(iv)

Carrier competition; and

(v)

Avoided uncompensated care.

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5
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Standards of healthcare coverage through the
health insurance exchange
.

(a)

Healthcare coverage shall be achieved through a qualified health plan at the silver level as provided in 42 U.S.C. §§ 18022 and 18071, as existing on January 1, 2014, that restricts cost sharing to amounts that do not exceed Medicaid cost sharing limitations.

(b)

All participating carriers in the health insurance exchange shall offer healthcare coverage conforming to the requirements of this act.

(c)

A participating carrier in the health insurance exchange shall maintain a medical loss ratio of at least eighty percent (80%) for an individual and small group market policy and at least eighty-five percent (85%) for a large group market policy as required under P.L. No. 111-148, as existing on January 1, 2014.

(d)

To assure price competitive choice among healthcare coverage options, the department of insurance shall assure that at least two (2) qualified health plans are offered in each county in the state.

(e)

Health insurance carriers offering
healthcare
coverage for program eligible individuals shall participate
in and shall be reimbursed by Medicaid for payment improvement initiatives including:

(i)

Assignment of primary care clinician;

(ii)

Support for patient centered medical home;

(iii)

Access of clinical performance data for providers; and

(iv)

Additional payments to an individual's independence account for an initial visit with a primary care clinician which establishes the individual's patient centered medical home and for carrying out additional wellness activities recommended by the primary care clinician. The department shall specify in rules and regulations, the state plan or the section 1115 waiver the additional wellness activities that may be recommended and provided without cost to the individual by Medicaid.

(f)

The department may contract with participating carrie
r
s for the following third party administrative services:

(i)

A clinical team to assist individuals who have, or are likely to have, expensive medical problems in obtaining appropriate care or taking useful preventive measures; and

(ii)

Provision of health counselors or coaches to assist individuals in adapting to the requirements and opportunities of this program.

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Enrollment.

The department of insurance shall assure that a mechanism within the health insurance exchange is established and operated to facilitate enrollment of eligible individuals under this act. The enrollment mechanism shall include an automatic verification system to guard against waste, fraud and abuse in the program.

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7
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Healthcare
independent program account.

(a)

The
healthcare
independence program trust account is created. The account shall consist of mon
ies
saved and accrued
to the state
under this act including:

(i)

Increases in premium tax collections;

(ii)

Re
ductions in uncompensated care;

(iii)

Other spending reductions resulting from the Health
c
are Independence Act of 2014;
and

(iv)

Other funds
credited to the account as provided by law.

(b)

Funds in the
healthcare
independence program trust account
are continuously appropriated to the
department of health
to be used only for
purposes of

this act
.
The fund may be used by the department of health to pay for future obligations under the
healthcare
independence program created by this act.

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.

S
unset
.

W.S. 42
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are repealed effective June 30, 2017.

Section 2.

T
his act is effective immediately upon completion of all acts necessary for a bill to become law as provided by Article 4, Section 8 of the Wyoming Constitution.

(END)

1
SF0088