MA by leader6


									                                                  State Coverage Reform Matrix
     Prepared for the Florida Hospital Association by Health Management Associates
Massachusetts Health Care Reform
Comprehensive, multi-pronged strategy to reach near universal coverage based on bi-partisan support.

      Key                Description                            Pros                              Cons                    Considerations for FL
Individual           As of July 2007, all          Greatly reduces number of          May be considered                 There has been little interest
Mandate               adult residents must           uninsured, free care,               government intrusion:              and no serious debate about
                      obtain coverage if             unnecessary ER utilization, &       requiring private purchase         individual mandates in the
                      determined affordable          cost-shift to insured; and          of coverage, monitoring            Florida legislature
                      for income bracket;            improves access to early,           employment status and             In-synch with emphasis on
                      otherwise, granted a           preventive care enhancing           income                             individual responsibility
                      waiver                         productivity                       Effectiveness depends on          But could require large state
                     Penalty for non-              Stabilizes risk pools by            definition of “affordability,”     investment in subsidies to
                      compliance: in 2007,           including younger, healthier        adequate subsidies to low          ensure affordability of a plan
                      loss of person                 people who would otherwise          income individuals, and            that provides real protection
                      exemption (nearly              opt out                             on insurers to offer low-         Further, individual mandates
                      $3,600); 2008 and later,      Allows free care and penalty        cost plans                         work best as “add-on” to fairly
                      half the cost of lowest        funds to be used to subsidize                                          comprehensive publicly
                      premium for an                 private insurance                                                      subsidized coverage for most
                      “acceptable” plan             Promotes individual                                                    low-income adults as well as
                                                     responsibility and greater role                                        kids; Florida has major gaps in
                                                     in health care                                                         adult coverage

  Additional components of MA reform include: establishment of Disparities Council, Quality and Cost Council, Advisory Council for Community Health
Worker Outreach, and Consumer Health information website; restoration of $20m for public health prevention; allocation of $3m for outreach to community
  Mandates were discussed by the Governor’s Task Force, but were not recommended.

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Employer Fair         Employers with 11+            Establishes the principle of         May be viewed as                Talk of an employer mandate in
Share                  FTEs who don’t                 “employer responsibility”             government intrusion             Florida—even a limited one—
Contribution &         contribute at least 33%        without large financial burden       Adds new financial               could be a deal-breaker. Unlike
Free Rider             of individual premium,        Enhances fairness, reducing           burden to firms, may get         MA and CA, Florida has not
Surcharge              with at least 25%              the cost shift from non-              shifted to workers as            had a strong push for any type
                       worker participation,          offerers to employers who             reduced compensation or          of “pay or play” system
                       must pay up to $295 per        provide coverage as well as           job loss (the latter is less    May be less sense of employer
                       worker annually                pay premium tax into                  likely given the modest          responsibility for health
                      Employers must offer           Uncompensated Care Pool               contribution level)              contributions in FL than in MA
                       cafeteria plans that          As number of uninsured               Fair Share contribution          and some other states
                       allow pre-tax purchases        declines, assessment (based           too small to encourage          FL has less participation in ESI
                       through Connector              on total uncompensated care           most non-offering                than MA; 21% of people in
                      Non-offering employers         used by workers in non-               employers to begin               home of a FT worker are
                       with frequent free care        offering firms) will decline          providing coverage               uninsured vs. 10% in MA
                       pool users are charged         below $295                           Need to track free care
                       up to 100% of costs           Assessments are used to help          use of
                       over $50k                      finance coverage expansion            workers/dependents in
                                                                                            non-offering firms may be
                                                                                            cumbersome and
                                                                                            considered invasion of
Commonwealth          Independent quasi-            Potential for efficiencies by        Adds a layer of                 The “Connector” concept may
Health                 public entity to               central linking of purchasers         bureaucracy with many            fit well with Florida’s emphasis
Insurance              “connect” individuals to       and suppliers (reducing               complex responsibilities,        on market forces combined
“Connector”            affordable health plans        administrative and marketing          with risk of not attaining       with growing feeling that more
                      Authorizes and offers          costs to insurers), and               the efficiencies envisioned      than small tinkering is required
                       private insurance plans        collecting/ transmitting of          Does not allow firms with        to address the nearly one of
                       to businesses with up to       premiums                              more than 50 workers to          five people without insurance
                       50 workers and                Not subject to executive office       participate                     Requires expansion of
                       individuals                    control                                                                government role in health care,
                      Workers and families          Promotes access to                                                     and this could incur some
                       purchase plans with            individuals without access to                                          opposition in Florida

  To monitor offerings, employers must sign a “Health Insurance Responsibility Disclosure” that certifies they have purchased insurance.
  Employers must offer IRS Section 125 Plans (cafeteria plans) that give employees the opportunity to pay for eligible medical and dependent care expenses on a
tax-free basis. Contributions to these plans are made before federal income taxes, Social Security taxes, and most state income taxes are calculated.
  Deposited into Commonwealth Care Trust Fund to be used for Commonwealth Care and other coverage programs.

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                       pre-tax dollars                ESI by offering a menu of                                             But would support new Gov’s
                      Sets affordability             plans, and reducing cost                                               discussion of letting small
                       standards for individual       through use of pre-tax dollars                                         businesses purchase together
                       mandate and subsidy           Promotes consumer-driven                                              Connector concept, based on
                       levels for                     market by making the                                                   individual ownership and
                       Commonwealth Care              consumer the purchaser, and                                            portability, would accelerate
                      Evaluates affordability        offering greater choice of                                             drive toward consumer-driven
                       and quality of health          health plans to workers in                                             health care system
                       plans, collects                firms purchasing through
                       premiums from                  Connector
                       employers and                 Promotes competition among
                       individuals, remits            health plans
                       premiums to health            Allows portability if each
                       plans, determines              employer purchases through
                       eligibility for premium        Connector
                       assistance                    Promotes affordability for PT,
                                                      seasonal, contract workers by
                                                      allowing multiple employers to
                                                      contribute to premiums, and
                                                      allows these workers to pay
                                                      premiums with pre-tax dollars
                                                      through cafeteria plans
Commonwealth          Offers subsidies for          Provides coverage option to          If insurers do not offer        FL does not have federal
Care -                 private health coverage        people ineligible for Medicaid        “affordable” plans, state        promise of $385m/year, would
Premium                to uninsured individuals       but who cannot afford private         must expand subsidies            need to tap other state/federal
Assistance             with income below              insurance                            Subsidies will rise as           sources to finance subsidies;.
                       300% FPL                      Supports private insurance            health care costs outpace       Concept of a sliding scale
                      Currently using 4              market                                inflation                        subsidy outside of Medicaid to
                       Medicaid MCOs                 Promotes early intervention          Rising costs may lead to         support private coverage may
                      Premiums fully                 and prevention, while                 enrollment cap if funds          be supportable in Florida if
                       subsidized if below            discouraging unnecessary              (primarily federal               financing can be secured.
                       100% FPL, sliding scale        and inefficient use of ERs            Medicaid payments of

  In September 2006, the Connector set the following affordability standards for individuals between 100-300% FPL: premiums 1.8% to 4.7% of income ($18 to
$106/month for individuals, $36 to $112/month for couples); copays range from $20 per specialist visit to $250 per hospital stay. Individuals who maintain that
they can not afford these amounts may appeal to avoid penalties.

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                      subsidy if income is                                             $385m/year) do not meet
                      100-300% FPL                                                     needs
                     No deductibles                                                  Insurance may remain
                     Copayments for                                                   unaffordable for some
                      services including non-                                          individuals/families with
                      emergency use of ERs                                             income above 300% FPL

Medicaid             Expands MassHealth          Ensures comprehensive              May crowd out private          FL starts with much lower FPL
Expansion             coverage to children         coverage to more low-               insurance for newly             eligibility levels than MA for
                      from 200% to 300%FPL         moderate income children            covered populations             adults so has longer way to go
                     Raises MassHealth           Restores critical coverage and                                      to reach MA eligibility
                      enrollment caps for          necessary services to very                                          standards
                      unemployed                   vulnerable populations                                             Similar starting point for
                      (“Essential”), people       Costs of coverage expansion                                         children (200% FPL)
                      with disabilities            offset by less need for                                            Florida may want to consider
                      (“CommonHealth”), and        Commonwealth Care                                                   covering the very poorest
                      HIV programs, expands        subsidies                                                           adults without children (e.g.
                      “Insurance Partnership”                                                                          incomes below half of FPL) as
                      (incentives for small                                                                            part of a reform package; but
                      employers)                                                                                       the state could take several
                     Reinstates Medicaid                                                                              other important steps even if it
                      benefits cut in 2002 for                                                                         does not take any action on
                      adults (dental,                                                                                  public program expansion
                      eyeglasses, others)
Insurance            Merges small group and      Expected to reduce individual      Does not eliminate current     Strong insurance market
Market Reforms        individual insurance         premiums by 25%                     mandated benefits,              reform may sell in Florida
                      markets                     Low-cost plans should be            making it harder to create     FL individual and small group
                     Reduced benefit, low-        attractive to young adult           affordable health plans         markets less heavily regulated
                      cost plans created for       cohort most likely to be                                            than MA
                      individuals aged 19-26       uninsured                                                          Merging the markets requires
                      without access to ESI                                                                            major regulatory and statutory

 On October 1, 2006, the Connector began enrolling adults with income less than 100% FPL; enrollment for those with income between 100-300% FPL is
planned to begin January 2007.
8 Elibility for Non-working parents: 23.Parents: 22% FPL, working parents: 60%, pregnant women: 185% FPL, aged/blind/disabled: 74% FPL, with some
exceptions and higher for NF and HCBS waivers.

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                 Health plans must offer                                                                        change, and would only work
                  family coverage to                                                                             with an individual mandate
                  young adults up to age                                                                         (otherwise, adverse selection
                  25 (or for 2 years after                                                                       would drive up small group
                  losing dependent status                                                                        costs)
                  if earlier)                                                                                   Florida could reform the non-
                 No new mandated                                                                                group market to promote
                  benefits pending                                                                               affordable coverage even if it
                  assessment of current                                                                          chooses not to merge it with
                  mandated benefits                                                                              small-group market
                                                                                                                Waiving mandates benefit to
                                                                                                                 promote affordable plan for
                                                                                                                 young adults (and other
                                                                                                                 populations) should be
                                                                                                                 politically palatable, part of new
                                                                                                                 Gov’s platform
Provider         Medicaid                    Reduces cost shift to private    Raises Medicaid costs          As in MA, provider rate
Reimbursement     reimbursement to             sector                            further                         increases may be needed to
Increases         hospitals and               Encourages provider                                               gain provider and insurer
                  physicians increase          participation in Medicaid                                         support for reform
                  from about 80% to 95%       Should promote quality of                                        Helpful to hospitals that serve
                  of costs (additional         care                                                              Medicaid patients
                  $90m each year)             Reduces burden on providers
                 Higher rates contingent      of payment shortfalls.
                  on hospitals/physicians
                  meeting quality
Financing        Uncompensated Care          Funds for free care should       FY 2007 commitments            FL does not face “use it or lose
                  Pool becomes Health          decline as insurance              include grandfathered           it” on federal dollars, so needs
                  Safety Net Trust Fund        coverage increases                existing commitments and        other financing sources
                  (October 2007), funding     MA has tried to maintain its      new spending, requiring        FL starts with higher levels of
                  free care with remaining     commitment to a strong safety     an additional $400 million      uninsurance, requiring more in
                  year-end balances            net even as it expands            to be split between federal     subsidies to assure coverage
                  transferred to               coverage.                         and state shares               Spending per uninsured likely
                  Commonwealth Care                                             Cost growth in 2008 and         much lower in FL (MA spends
                  Trust Fund to finance                                          beyond expected at              about $1,500 per uninsured)
                  subsidies and other                                            $100+ million/year, split      Getting state investment a

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             programs                       between federal and state        challenge; Bush administration
            Prior DSH and                  shares, offset by $48            Task Force “message” was that
             supplemental MCO               million in employer              any coverage expansion could
             payments, comprised of         assessments                      not tap public funding
             state and federal             Without controlling health      This argues for leveraging by
             Medicaid matches,              care costs, the state costs      (1) relying on private market
             along with additional          will continue to rise,           sources with private financing;
             Medicaid spending for          threatening the viability of     (2) developing a dedicated
             under-and uninsured,           the program                      source of public financing for
             will be redeployed to                                           limited new public spending;
             fund subsidies, Trust                                           and (3) drawing in new federal
             Fund, and Medicaid                                              dollars where possible.

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Illinois’ Covering All Kids Health Insurance Act
Illinois is the first state to provide access to affordable, comprehensive insurance coverage to all uninsured children in the state, by
allowing parents to buy into the SCHIP program.9

  Key                             Description                                      Pros                               Cons                  Considerations
Compon-                                                                                                                                         for FL
Comprehen-          Beginning July 2006, state offers All             Provides critical access to care    Opponents argue that            Florida may garner
sive coverage        Kids coverage for all residents through            for children unable to get           public funds should not          support for coverage
                     age 18 – including undocumented                    private coverage because it is       subsidize immigrants             expansion limited to
                             10                      11                 unaffordable or because of           ineligible for Medicaid          children
                     children --who are uninsured or who                preexisting conditions
                     meet income requirements
                                                 12                                                          due to citizenship              However, for the
                                                                       Should improve immunization
                    The benefit package is virtually identical         rates and encourage                  status; this group               large numbers of
                     to KidCare, the state's Medicaid-SCHIP             preventive care                      comprises about 16,000           children in FL
                     program; includes doctor visits, hospital         Benefits to the state include        children or 58% of the           ineligible for
                     stays, prescription drugs, vision care,            improved attendance rates in         newly insured                    Medicaid due to
                     dental care, and medical devices such              schools, easing burden on                                             citizenship status;
                     as eyeglasses and asthma inhalers                  emergency rooms, & reducing                                           state would not
                    Families select a primary care physician           uncompensated care costs,                                             receive federal
                                                                        which are passed along to                                             match; also politically
                     to provide regular check-ups and                   consumers
                     immunizations                                                                                                            risky
                                                                       Addresses providers’ dilemmas
                                                                                                                                             Growing interest in
                                                                        re: serving one child in family

  Illinois has an estimated 250,000 uninsured children.
   The state is able to accept these children because it foregoes the Medicaid funding match for the children whose families don't meet federal guidelines on
immigration status or income.
11 In 2006, a child needed to be uninsured since January 1, 2006; beginning in 2007, this uninsured period will be lengthened to one year, in an effort to avoid

families dropping their private coverage in favor of the government program
   Children in families with income up to approximately 200% of FPL (i.e., Medicaid/SCHIP eligibility levels) are eligible even if they are currently insured.
13State officials counter that while the newly eligible immigrants make up a large portion of new enrollees, they account for less than 2 percent of the 1.3 million
children now receiving health insurance through the state. (Source: The Courier News, Blagojevich's All Kids program is outpacing enrollment targets, November 19,

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                                                                  while the others are not eligible                                  this model by other
                                                                                                                                     states; e.g., PA, TN
Sliding Scale      Monthly premiums, copayments, and             Promotes “mainstream”               Despite requirement         FL could structure
Subsidies           maximum total copays vary based on             program, while tying                 that child is uninsured      the subsidies
                    family income, with rates for middle-          contributions to ability to          for one year, some fear      differently to control
                    income families lower than in private          pay                                  that program will draw       expenditures;
                    market plans                                                                        people who would             subsidies could be
                                                                                                        otherwise enroll in          lower proportion of
                                                                                                        private insurance, and       total premium or
                                                                                                        discourage employers         phase down more
                                                                                                        from providing coverage      steeply with higher
                                                                                                       Opponents argue that a       incomes; but this
                                                                                                        state-subsidized             could lower take-up
                                                                                                        program should be            rates
                                                                                                        closed to higher income
                                                                                                        families, who should
                                                                                                        have the means to
                                                                                                        purchase private
                                                                                                       Others argue the
                                                                                                        opposite; they fear that
                                                                                                        not enough higher
                                                                                                        income families will
                                                                                                        enroll, resulting in a
                                                                                                        program for poor and
Outreach           $4.2 million outreach effort                  Early enrollment has                Reports of focusing         FL could learn from
Campaign           All Kids Training Tour held nearly 20          surpassed expectations; as           outreach to lower-           successful outreach
                    events statewide to make sure over             of November 2006, the                income families could        strategies, and
                    1,500 community leaders, services              state enrolled 52,044                hurt effort to create        should restore full
                    providers, and social service agencies         children in the program and          mainstream program           effort, even if exact
                    were informed about the new/expanded           expect to reach 130,000 by                                        coverage model
                    program                                        the end of the program's                                          differs

  A family of four with an annual income between $40,000 and $60,000, for example, will pay a $40 monthly premium per child and a $10 copayment per
physician visit. Families with income up to 150% of FPL pay no premiums. Sliding scale premiums apply for families with income above 150% FPL, with
highest level for families at and above 800% FPL, where premium per child is $300 per month.

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              State partnered with hospitals, schools,      first year
               multi-ethnic community organizations,        Outreach effort results in
               religious organizations, radio and TV         enrollment of children
               stations, shopping malls to inform and        previously eligible for
               enroll eligible children                      Medicaid/SCHIP, as well as
              Incentives to parents who pre-registered      newly eligible
Prior         Builds on recent HIFA waiver                 Proponents agree with            Opponents object to           To maximize federal
Medicaid/      Medicaid/SCHIP expansion to children          greater government role in        growing government             contributions, FL
SCHIP          up to 200% FPL, parents to 133% FPL,          providing coverage to             role in health coverage        would need to raise
Expansions     and KidCare Rebate (premium                   vulnerable populations                                           eligibility in Medicaid/
               assistance and wrap-around benefits to                                                                         SCHIP, possibly
               eligible children with access to ESI)                                                                          through waiver
Financing     The state already enrolled more than         State financing plan             Physicians are                Under waiver, FL is
               50k children, exceeding expectations          provides way to cover most        concerned that state           already transferring
              Children under 200% FPL who meet              costs of new program will         reimbursement will be          Medicaid groups to
               citizenship requirements will be funded       potentially improving quality     inadequate, and ability        managed care but
               by SCHIP dollars                              and coordination of care          to cost-shift will decline     does not plan to use
              Subsidies for other children enrolled are    Improved coordination of          if private insurance           “savings” for
               expected to cost the state $45 million        care and strong disease           decreases                      coverage expansion
               the first year, funded from an expected       management should further        Concerns that state           FL does have
               $56 million in savings from                   reduce health costs in the        savings from PCCM              unused SCHIP funds
               implementing a primary care case              long term                         and disease                    it can tap
               management and chronic disease                                                  management will be
               management model for most Medicaid                                              inadequate to finance
               participants.                                                                   state costs,
              Approximately 204,000 children are                                              endangering program or
               expected to be enrolled in All Kids by                                          requiring additional
               the fifth year at an annual cost                                                state dollars that could
               estimated at $96 million, countered by                                          go to education,
               savings of $93 million (from PCCM)                                              transportation, etc.
              State also expects reduction in
               expensive hospitalizations
              Premiums paid by higher-income
               families so far have paid 74 percent of
               the cost of expanding All Kids access
               beyond Medicaid's levels

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Healthy NY Reinsurance Program
HMO basic benefit plans available to lower-income uninsured individuals and small firms, at premiums made more affordable
because the state provides reinsurance to the health plans.

  Key                        Description                             Pros                   Cons             Considerations
Compon-                                                                                                          for FL

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Basic health        All licensed HMOs must offer a standard                    Builds upon and               Government forces            In-synch with
plan offered         insurance product to ‘low-income’ small                     supports private               private plans to offer        preference to build on
by all HMOs          businesses, self-employed, and individuals                  insurance                      a product it may              private sector for
                    Benefits include hospital & physician services,            Complements public             otherwise not offer           coverage expansion
                     maternity care, preventive services, diabetes               coverage expansions           Concerns that limited
                     management, x-ray & lab, ER services, others;               for children and               benefits do not
                     limited prescription drug benefit is optional               families                       provide adequate
                    Premiums are lower due to: reduced benefit                 Combination of cost-           protection or raise
                     package (exempt from some state mandated                    reducing factors result        costs in long run
                     benefits ); prescription drug coverage optional,            in lower premiums             Equity issue: does
                     closed network of providers w/copays; state-               Targets populations in         not allow employers
                     funded reinsurance (see below):                             most need of coverage          or individuals who
                    Rates below commercial market - about half for                                             had struggled to buy
                     individuals, 1/3 to half for families                                                      coverage to take
                                                                                                                advantage of more
                                                                                                                affordable, state-
                                                                                                                subsidized coverage
Reinsurance:        State pays 90% claims between $5k-75k                      Allows state to               Requires ongoing             Flexibility in
Stop Loss           Stop loss spending about $40m in 2005, est.                 subsidize coverage             state contributions           reinsurance corridor
Mechanism            $71m in 2006 with about $110m allocated                     indirectly, maintaining       You get more bang             parameters and
                    6% enrollees reached stop loss corridor in 2004             private insurance              for the buck by               benefit structure
                    Most plans have profit margin between 1-20%                 focus                          subsidizing                   would allow FL to
                     after stop loss; average $179 pmpm costs                   State costs have been          individuals who are           experiment and adjust
                     before stop loss; adjusted med loss ratio 82%               below amounts                  uninsured, not                to control state costs
                                                                                 allocated, reflecting          employers; the               Florida may find

   Small business owners may participate if: firm did not offer insurance during past 12 months or did not contribute more than $50 per employee per month,
there are no more than 50 employees, 30% of workers earn $35,500 or less/year, willing to contribute 50% of HealthyNY premium for FT employees, plan is
offered to all employees working at least 20 hours/week and earning $35,500 or less/year, and at least half of employees offered coverage enroll (with at least
one earning $35,500 or less). Individuals may participate if: the person or spouse worked some time in the past year or person is a sole proprietor, person has
been uninsured for at least 12 months and is ineligible for employer coverage or Medicare, person’s household income is no more than 250% FPL (e.g., $33,375
for a family of two).
   The benefit plan does not include mental health or substance abuse treatment, home health or hospice care, physical therapy, dental or vision care, or
chiropractic services.
   Premiums are community-rated, do not vary by eligibility category (i.e., small employer, sole proprietor, individual), and are divided into four tiers: one adult,
two-adult, one parent with child(ren), and family. Rates vary by county and by HMO.
   For example, hospitalization is covered but follow-up rehabilitative care is not, forcing some extended hospitalizations in order to receive needed therapy.

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                                                                        relatively healthy         research shows that      proportionately more
                                                                        population                 a 30% reduction in       poor and near-poor
                                                                       Reinsurance set to         premium will cause       adults line up to enroll
                                                                        allow profits to HMOs,     only 15% of small        due to gaps in
                                                                        securing cooperation       employers to newly       Medicaid coverage
                                                                                                   offer coverage, and
                                                                                                   then the number of
                                                                                                   employees who are
                                                                                                   newly covered is only
                                                                                                   5% of those who
                                                                                                   were uninsured and
                                                                                                   work for small
Adjustments    State continually adjusting as needed, after slow      Flexibility crucial to    Small businesses         FL may consider pilot
                uptake in early years                                   best meet needs of         continue to comprise      in certain counties,
               Changed stop-loss corridor due to lower-than-           target population and      small portion of          make adjustments as
                expected claims                                         participating HMOs         members; even             needed
               Made drug coverage optional to reduce                  Steady enrollment          reduced cost plan is
                premiums                                                increase, to reach         a hard sell to
               Will offer high deductible plan for HSAs in 2007        120,000+ active            employers
                                                                        members; 26% in
                                                                        small businesses, 18%
                                                                        sole proprietors, 56%
                                                                        working individuals/
                                                                        spouses (2005)
Financing      Health Care Reform Act of 2000 established             Stop loss fund            Requires ongoing         FL could explore with
                program with stop loss fund, along with                 sufficient to support      financial commitment      CMS the feasibility of
                Medicaid/SCHIP expansions for children and              program growth             by state                  federal contributions
                families                                                through 2007+                                        to a reinsurance
               The state budgeted $44m for 2005, $117m for                                                                  program through
                2006                                                                                                         waiver or other
               Some of the subsidy is funded through tobacco                                                                mechanism
               State is exploring feasibility of obtaining federal
                financing through a HIFA waiver

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New Mexico State Coverage Insurance (SCI) Program
SCI is a public-private health plan launched in 2005 designed for low-income working adults, with blended funding from employee,
employer, and state/federal governments.

   Key                            Description                                    Pros                            Cons                   Considerations
Component                                                                                                                                   for FL
3-Share Type           Part of Insure New Mexico!                    Employer based to extent         May be too complicated         Builds on private
Premium                 initiatives                                    possible; also available to       and administratively            insurance, which is in-
Assistance             Private MCOs offer basic,                      those without access to           burdensome for small            synch with FL political
                        standardized commercial plan                   ESI (unemployed, self-            firms to offer different        climate
                       Open to low-income uninsured adults            employed, workers w/o             coverage to low-income         Like NM, FL has high
                        (up to 200% FPL) purchasing                    ESI offer)                        workers vs. higher              portion of small
                        individually or through their employers       Heavy early enrollment            income workers (those           employers, low rates of
                        of small firms (50 or fewer workers)           (individuals)                     ineligible for SCI)             ESI, and high rates of
                       Began in 2005 to individuals, 2006 to                                           Individuals without             adult uninsurance
                        small firms                                                                      employer participation         Florida communities
                       3-share premium: $75/mo for                                                      may not afford employer         have implemented
                        employer, $0-35/mo for employee                                                  and employee shares             variations on this
                        based on income, remainder public                                               Challenges re: public           model (Jacksonville, St
                        share                                                                            and private operational         Pete, etc.)
                       Individual purchasers must pay the                                               differences, information

   New Mexico also recently began the Small Employer Insurance Program (SEIP), a state administered health insurance pool that is available for employers with
fewer than 50 employees; the benefit design is similar to SCI but there is no low-income subsidy; i.e., cost sharing is more similar to the commercial market..
SEIP is currently taking applications from employers (about 30 firms are interested as of December 2006), but has not yet reached a critical mass for the pool, so
no one is officially “enrolled” yet. The state is screening all employees for the SCI program when they apply for SEIP and many of them qualify; so most of the
employers who originally thought they would apply for SEIP are now on SCI.(correspondence with Mari Spaulding-Bynon, 12/06).
 NM has expanded its Health Insurance Alliance (HIA), and simplified enrollment for the state’s high risk pool for individuals with preexisting conditions and
others who are “uninsurable.” NM is also exploring broader coverage expansion options.
   Managed care coverage is offered by three private health plans selected through a competitive bid process (MCOs were not required to participate or bid), and
premiums/copays are identical under the 3 plans. A $100,000 annual benefit limit applies. Medicaid benefits not included in SCI are non-emergency
transportation, vision and dental, chiropractic care, hearing aids, skilled nursing, pulmonary rehabilitation and hospice. Out-of-pocket cost sharing limited to 5%
of annual income.

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                         employer and employee portion                                                  interfaces, protocols
                        Co-pays on sliding scale, with total                                          Need to monitor
                         out-of-pocket limited to 5% income                                             enrollment trends for
                        Employers must not have dropped                                                adverse selection
                         coverage during the prior 12 mos.;
                         individuals must not have dropped
                         coverage in past 6 mos.
Financing               Based on 2002 HIFA waiver approval             Spreads burden across         Funds and therefore           FL also has unused
                         allowing NM to use unspent federal              different parties              enrollment are capped          SCHIP funds; may
                         SCHIP funds to provide managed                 Taps federal dollars at                                       consider HIFA waiver
                         care coverage for adults up to 200%             high match rate                                               to utilize federal funds
                        Plan to cover 40,000 over course of
                         waiver, with annual enrollment caps;
                         as of December 2006, SCI has about
                         4,000 enrollees
                        Financed with employee & employer
                         premiums; public share funded with
                         federal SCHIP match (82%), and
                         state match from general funds
                        State will assess potential for
                         expansions using county and tribal
                         funding, and alternative sources

   Employers can, however, add SCI to existing commercial coverage for workers who could not afford to participate; this allows easier transition to commercial
coverage if the worker’s income rises.
   For example, under the Medicaid waiver, SCI meets Medicaid eligibility and reporting requirements; but enrollment processes and interfaces with employers
must mirror commercial products.
   Despite SCHIP coverage to children up to 235% FPL, state has not spent all of its SCHIP funds. Meanwhile, NM has high rates of uninsured adults: over 42%
of adults below 200% FPL are uninsured.
   According to a state administrator, enrollment in SCI has dropped significantly in the past quarter from about 5,000 in August due to the challenges faced as
current members recertify eligibility and try to meet the rigorous citizenship requirements for Deficit Reduction Act.
     State plans to use Medicaid funds when SCHIP funds are used up.

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Blue Cross Blue Shield of Massachusetts Foundation, Massachusetts Health Care Reform Bill Summary, 2006.

The Courier News, Blagojevich's All Kids Program is Outpacing Enrollment Targets, November 19, 2006,,3_1_EL19_A1ALLKIDS_S1.article)

Gallagher, Christy. From New England to the Golden Gate Bridge: A Look at Creative Coverage Expansions at the Sate and Local Levels, New
America Foundation, November 2006.

Health Policy Institute of Ohio, Massachusetts Health Care Reform of 2006: an Analysis of the Pros and Cons, September 2006

Health Policy Institute of Ohio, Universal Health Care in Massachusetts: Implications for Ohio, September 2006.

Kaiser Commission on Medicaid and the Uninsured, Massachusetts Health Care Reform Plan, April 19 2006,

New Mexico State Coverage Insurance website,

Report on the Healthy NY Program 2005, Prepared for State of New York Insurance Department by EP&P Consulting, Inc., December 31, 2005,

Silow-Carroll, Sharon and Fouad Pervez, The Commonwealth Fund, Snapshots: Short Takes on Promising Programs: Illinois: Universal
Coverage for Children,” States in Action: A Quarterly Look at Innovations in Health Policy, March 2006,

Silow-Carroll, Sharon and Tanya Alteras, Stretching State Health Care Dollars: Building on Employer-Based Coverage, Prepared for the
Commonwealth Fund, 2004.

State Coverage Initiatives, Profiles in Coverage: Healthy NY, January, 2005,

State Coverage Initiatives, Profiles in Coverage: New Mexico State Coverage Insurance, 2006,

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State of New York, Healthy NY website,

2006 Interactive New York Consumer Guide to HMOs: Healthy NY,

12-11-06                                                            17                           Health Management Associates

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