SPECIAL SESSION HB 1-FN-A

2013 SESSION

13-1029
01/10

SPECIAL SESSION HOUSE BILL 1-FN-A

AN ACT relative to access to health insurance coverage.

SPONSORS: Rep. Sherman, Rock 24; Rep. Rosenwald, Hills 30; Sen. Gilmour, Dist 12

COMMITTEE: Finance

ANALYSIS

This bill establishes the New Hampshire access to health coverage act to provide health insurance to the newly eligible population as provided under Section 1905(y) of the Social Security Act of 1935. The bill also deletes the prohibition on a state-based health benefit marketplace. The bill grants the commissioner of the department of health and human services rulemaking authority for the purposes of the bill.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

13-1029

01/10

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Fourteen

AN ACT relative to access to health insurance coverage.

Be it Enacted by the Senate and House of Representatives in General Court convened:

1 Statement of Findings, Purpose and Intent. The general court recognizes that:

I. Improving access to affordable health care for low-income New Hampshire citizens is essential to improving the health of the state's population and strengthening the state's economy. Health benefits for the newly eligible population should be provided in a manner that encourages personal responsibility, relies to the greatest extent possible on insurance offered by employers and private insurance companies, and improves the health outcomes and financial security of those receiving benefits. In establishing this subdivision under section 2 of this act, the general court has chosen to expand access to health coverage for individuals who are defined as newly eligible for medical assistance, as specified in section 1905(y) of the Social Security Act, 42 U.S.C. 1396d(y), in a manner that assures fiscal responsibility, safeguards the interests of New Hampshire taxpayers, and provides accountability and oversight.

II. Through expanding access to health coverage for the newly eligible population as provided in this law, the general court specifically intends to foster and promote the following:

(a) Access to affordable and quality health care coverage for the currently uninsured and underinsured populations in New Hampshire, by relying on innovative private models of care.

(b) Increased quality, efficiency, and improved clinical outcomes of the health care delivery system for low-income New Hampshire citizens, by strengthening the managed care system established under RSA 126-A:5, XIX, and by establishing a new managed care health plan for the newly eligible population offered by private managed care organizations under contract with the state that accepts full risk in providing care.

(c) Continuity of coverage for vulnerable populations, by phasing in a premium assistance coverage program that will substantially reduce the number of newly eligible persons who would lose coverage as a result of income fluctuations that cause their eligibility to change year to year, or multiple times throughout a year.

(d) Coordination of health care delivery for newly eligible individuals to address the entire spectrum of physical and behavioral health, by focusing on prevention and wellness, health promotion, chronic disease management, and long-term care.

(e) Competition and consumer choice by first increasing the number of insurance companies offering coverage on the New Hampshire health insurance marketplace then by implementing a premium assistance model that will enable newly eligible persons between 100 and 133 percent of the federal poverty level to obtain coverage through the marketplace.

(f) Access to federal funding during the period that the federal government will pay for 100 percent of the cost of the benefits provided to the newly eligible population.

(g) Increased provider reimbursement rates as a means of assuring sufficient provider capacity and equalizing reimbursement rates across health care payers in order to eliminate cost-shifting and to substantially reduce the burden of uncompensated care for medical providers and the state.

(h) Accountability of the program by providing effective oversight and audits.

2 New Subdivision; New Hampshire Access to Health Coverage Act. Amend RSA 126-A by inserting after section 66 the following new subdivision:

New Hampshire Access to Health Coverage Act

126-A:67 Short Title. This subdivision shall be known as the "New Hampshire Access to Health Coverage Act."

126-A:68 Definitions. In this subdivision:

I. "Centers for Medicare and Medicaid Services" or "CMS" means the federal agency responsible for overseeing the implementation of health coverage for the newly eligible population across the United States and is responsible for approval of state plan amendments and waivers under the Social Security Act of 1935, as amended.

II. "Commissioner" means the commissioner of the department of health and human services.

III. "Department" means the department of health and human services.

IV. "Eligible," "newly eligible," or "newly eligible population" means individuals who:

(a) Are defined under section 1902(A)(10)(A)(i)(VIII) of the Social Security Act of 1935, as amended (42 USC section 1902(A)(10(A)(i)(VIII)), for whom increased FMAP is provided for under section 1905(y)(2)(A) of the Social Security Act of 1935, as amended (42 USC section 1396d(y)(2)(A));

(b) Are residents of the state of New Hampshire; and

(c) Satisfy all applicable federal income, citizenship, and immigration requirements.

V. "Employer-sponsored insurance" or "ESI" means group health care coverage that is offered by a private employer to its employees.

VI. "Enhanced FMAP" means the federal medical assistance percentage for the newly eligible population as provided under section 1905(y)(1) of the Social Security Act of 1935, which is 100 percent reimbursement for calendar years 2014, 2015, and 2016.

VII. "Essential health benefits" means essential health benefits as defined in 42 USC section 18022(b).

VIII. "Federal funding" or "FMAP" means the federal medical assistance percentage for a state, including for the newly eligible population as provided under section 1905(y)(1) of the Social Security Act of 1935.

IX. "Health benefit marketplace" means the health benefit marketplace established for the state under 42 USC section 13031.

X. "Health insurance premium program" or "HIPP" means the program established by the department pursuant to section 1906 of the Social Security Act of 1935, as amended, (42 USC, section 1396e), to purchase employer-sponsored group health care coverage.

XI. "Insurance commissioner" means the commissioner of the department of insurance.

XII. "Managed care organization" means a managed care organization defined under RSA 126-A:5, XIX,(c)(3) that is under contract with the department.

XIII. "New Hampshire access to health coverage program" means the program established to provide health benefits to newly eligible through the health insurance premium program, qualified health plans on the New Hampshire health benefit marketplace, and the New Hampshire access to health plan as provided for in this subdivision.

XIV. "New Hampshire access to health plan" means a health insurance plan that is provided to the newly eligible population by a managed care organization under contract with the department in accordance with the terms and conditions of this subdivision.

XV. "Qualified health plan" or "QHP" means a health plan that meets the requirements of 42 USC section 18021 and is available for purchase on the New Hampshire health benefit marketplace.

XVI. "Wrap around benefits" means benefits that are required to be provided by the New Hampshire Medicaid program under the terms of a state plan amendment or waiver, but are not covered by a qualified health plan or private employer sponsored insurance.

126-A:69 New Hampshire Access to Health Coverage Program; Eligibility; Provision and Funding of Health Benefits.

I. The newly eligible may enroll and receive health benefits under the New Hampshire access to health coverage program provided that the individual:

(a) Provides all information regarding residency, financial eligibility, citizenship or immigration status, and insurance coverage to the department of health and human services in accordance with rules adopted under RSA 541-A; and

(b) Is determined to be eligible for participation in the program.

II. Newly eligible individuals who enroll in the program shall obtain health benefits in accordance with the following:

(a) Those newly eligible who have access to private employer-sponsored insurance on or after the effective date of this subdivision, either directly as an employee or through another individual such as a spouse, dependent, or parent who is eligible for employer sponsored coverage, shall be eligible for premium payments for the continued purchase of ESI through the employer, plus any required cost-sharing and wrap around benefits, if the department determines the ESI is cost effective in accordance with any waiver or state plan amendment approved by CMS. The newly eligible who have access to ESI that is determined to be cost effective shall not be eligible to receive benefits through a New Hampshire access to health plan offered by a managed care organization.

(b) Those newly eligible who do not have access to ESI or for whom ESI is not determined to be cost effective, shall be eligible to receive health benefits by selecting one of the private managed care organizations which contract with the department under the New Hampshire access to health plan. Covered services which shall consist of the health benefits provided under the Medicaid state plan plus any essential health benefits that are not included in the approved New Hampshire Medicaid state plan, as of the effective date of this subdivision.

(c) Those newly eligible who are determined to be medically frail in accordance with 42 CFR section 440.315(f) as determined through completion of a health questionnaire in the enrollment process may elect to receive health benefits directly from the department through its managed care program.

(d) Every newly eligible person who applies for health care coverage under this subdivision shall at the time of enrollment acknowledge that the New Hampshire access to health coverage program is subject to cancellation upon notice.

III. The health benefits provided to the newly eligible under the New Hampshire access to health coverage program shall be paid for by enhanced FMAP for calendar years 2014, 2015 and 2016, and with the maximum available amount of federal funding in any subsequent year for as long as the program is in effect.

IV. The New Hampshire access to health plan shall provide for reimbursement that is sufficient to ensure improved access to and quality of care. Payment incentives for providers may be based on such metrics as reduction of preventable readmissions, reduction of unnecessary emergency room visits, and other preventable health care events. Capitation rates to managed care plans shall be set at levels that enable plans to reimburse providers at rates sufficient to achieve New Hampshire's access and quality goals.

126-A:70 Mandatory Health Insurance Premium Program.

I. As part of the New Hampshire access to health coverage program, the department shall implement a mandatory health insurance premium program pursuant to 42 U.S.C. section 1396e upon approval by CMS.

II. Each applicant for the New Hampshire access to health coverage program shall provide to the department all information regarding eligibility for and access to employer sponsored health insurance and any other private health insurance in accordance with rules adopted under RSA 541-A by the department.

III. All newly eligible who have access to employer-sponsored coverage, either directly as an employee or through another individual such as a spouse, dependent, or parent who is eligible, which meets the definition of minimum essential coverage under the Internal Revenue Code, 26 USC section 5000(A)(f), and any regulation adopted thereunder, and for which the employer pays no less than 50 percent of the total cost of the employee's coverage, shall be required to participate in the health insurance premium program; provided that the department determines such participation to be cost effective.

IV. A determination of eligibility for the New Hampshire access to health coverage program is a qualifying event under the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.

V. If the department determines that it is cost-effective, the department shall pay the cost of premiums, co-payments, co-insurance and deductibles for the newly eligible and any spouse, dependent and parent, if applicable, with access to employer-sponsored insurance.

VI. A newly eligible individual is eligible for coverage under the expanded health insurance premium payment program effective the first day of the month following the month of application for enrollment; provided that enrollment is completed in time for enrollment in that month.

VII. Any newly eligible individual who receives health benefits from the HIPP program shall inform the department of any change in access or eligibility for ESI within 10 days of such change.

126-A:71 Department Administration; Waivers; State Plan Amendments.

I. The department shall submit and apply for such waivers and state plan amendments as are necessary to implement the requirements of this subdivision, including without limitation, a waiver and/or state plan amendment for the implementation of a health insurance premium program that requires participation of those newly eligible with access to employer-sponsored insurance that is determined to be cost effective. The department shall apply for and obtain the waiver for mandatory HIPP by January 1, 2014, or as soon thereafter as practicable.

II. The full cost of the purchase of a newly eligible employee's share of an ESI premium under HIPP, if determined to be cost effective, and the full cost of the purchase of the New Hampshire access to health plan, plus any additional required wrap around benefits, copayments, co-insurance and deductible shall be paid by the department.

III. The department shall negotiate and conclude an amendment to one or more of its existing contracts with managed care organizations to provide a new private managed care insurance plan known as the New Hampshire access to health plan for all newly eligible consistent with this subdivision. The following shall apply:

(a) Any private managed care organization that provides health benefits under this subdivision shall ensure that all newly eligible in a New Hampshire access to health plan have access to a qualified licensed primary care provider and are linked to a medical home.

(b) The department shall require by terms of the contract amendment that all newly eligible who enroll in a New Hampshire access to health plan be scheduled for an initial appointment with a qualified licensed primary care provider within 60 days of enrollment.

(c) The department shall work with contracted managed care organizations to create financial incentives for managed care plans that meet specified population health improvement goals for the newly eligible population.

126-A:72 Implementation of Individual Premium Assistance Program in the Marketplace.

I. Subject to the provisions of paragraph IV, the department shall implement a premium assistance program with coverage beginning January 1, 2017 to require all newly eligible between 100 and 133 percent of the federal poverty level who do not have access to cost effective ESI, and who are not determined to be medically frail in accordance with 42 CFR section 440.315(f), to enroll in a qualified health plan offered on the New Hampshire health benefit marketplace in order to receive health benefits under the New Hampshire access to health coverage program.

II. The department shall submit and apply to CMS for any waivers and/or state plan amendments necessary to implement a mandatory premium assistance program that allows the use of federal funds to purchase individual health coverage on the health benefit marketplace to the extent determined to be cost effective.

III. The full cost of the premium for purchase of a qualified health plan on the health benefit marketplace, plus any co-payments, co-insurance, deductible and wrap around coverage, as necessary, shall be paid by the department.

IV. The individual premium assistance program shall not commence until such time as the requirements of RSA 420-N:11 are satisfied and no fewer than 3 health insurance companies offer QHPs, at least one of which is a managed care organization.

126-A:73 Report Required.

I. The department shall apply its care management quality strategy program to the newly eligible population.

II. The department shall also report bi-annually, commencing June 1, 2014, to the oversight committee on health and human services, established in RSA 126-A:13, on the impact and effectiveness of the New Hampshire access to coverage program established in this subdivision.

126-A:74 Interim Rulemaking.

I. The commissioner of the department of health and human services shall be authorized to adopt interim rules, following a public hearing before the joint legislative committee on administrative rules, for the implementation of the New Hampshire access to health coverage program established in this subdivision, including without limitation, pertaining to:

(a) Eligibility and enrollment of newly eligible individuals.

(b) Implementation of an expanded health insurance premium program.

(c) Benefit and benefit design, including implementation of substance use disorder benefit.

II. The interim rules shall be effective for a period of one year, within which period the commissioner shall adopt rules pursuant to RSA 541-A.

126-A:75 Waivers; State Plan Amendments. Notwithstanding any provision of law to the contrary, the department is authorized to apply for and submit any waiver or state plan amendment to the Centers for Medicare and Medicaid relative to the implementation of this subdivision without prior review of the general court or by any committee, joint committee, oversight committee, or similar body of the general court.

126-A:76 Grants and Funds. Notwithstanding any law to the contrary, the department and the department of insurance may apply for, accept, and expend any grants and/or funds necessary to implement the provisions of this subdivision.

3 Audit Required. The commissioner of the department of health and human services shall select a qualified independent auditor to audit and evaluate the New Hampshire access to health coverage program established in section 2 of this act. The qualified independent auditor shall evaluate the program's costs, its impact to state revenue, the state general fund, the New Hampshire economy, the level of uncompensated care, the population health of the newly eligible population, and such other economic, financial, and health indicators that would meaningfully inform the governor and the general court regarding the impact of the program. The independent audit shall evaluate at least 2 years of operation of the program and shall be submitted to the governor, president of the senate, and speaker of the house of representatives no later than January 1, 2017.

4 Commencement of New Hampshire Access to Health Coverage Program; Termination for Reduction in Federal Medical Assistance.

I. Coverage for the newly eligible population under the New Hampshire access to health coverage program established in section 2 of this act shall commence on January 1, 2014 or as soon thereafter as practicable.

II. The New Hampshire access to health coverage program shall terminate no later than 180 days following a change in federal law to reduce the enhanced FMAP in any year as enacted under section 1905(y) of the Social Security Act of 1925, as amended (42 USC section 1396d(y)). The commissioner of the department of health and human services shall notify the secretary of state, the governor, the speaker of the house of representatives, the president of the senate, and the director of legislative services of any termination of the program under this paragraph. For the purposes of this paragraph, "enhanced FMAP" means the federal medical assistance percentage for the newly eligible population as provided under Section 1905 (y)(1) of the Social Security Act of 1935, which is 100 percent reimbursement for calendar years 2014, 2015, and 2016.

5 Study of Potential Innovations Required. No later than January 1, 2015, the department of health and human services and the department of insurance shall submit to the general court a detailed study of potential innovations that would support the goals of this chapter and further integrate coverage for the newly eligible population with that available on the marketplace and in private health insurance markets generally. The study shall address topics including, but not limited to:

I. Incentives for managed care organizations to participate in the health insurance marketplace.

II. Incentives for employers to continue offering coverage to newly eligible individuals.

III. The potential to develop a program that utilizes private market forces to address churn in the population above 133 percent of the federal poverty level.

IV. The potential to develop payment reform initiatives that are linked to improvements in health care delivery systems and improved efficiencies.

V. Options for implementing any recommended innovations, including potentially seeking an innovation waiver under 42 USC section 18052 for implementation of innovations that would begin on or after January 1, 2017.

6 Appropriation; Department of Health and Human Services.

I. A sum equal to 5 percent of premium tax revenue collected in accordance with RSA 400-A:32 is hereby appropriated to the department of health and human services in state fiscal years 2014 and 2015 to fund the costs of implementing and administering the New Hampshire access to health coverage program established in section 2 of this act. The governor is authorized to draw a warrant for said sums out of any money in the treasury not otherwise appropriated.

II. Any balance of the funds appropriated to the commissioner pursuant to 2013, 144:130 that were not used by the commission to study the expansion of Medicaid eligibility in New Hampshire may be used by department of health and human services in obtaining consulting services to implement the New Hampshire access to health care coverage established in section 2 of this act under the same terms and conditions as originally appropriated.

7 Department of Health and Human Services; Medicaid Breast and Cervical Cancer Program. Enrollment in the Medicaid breast and cervical cancer program, under 42 USC section 1396a(aa), shall be suspended 90 days following the commencement of the New Hampshire access to health coverage program, established in section 2 of this act. Any individual covered under the Medicaid breast and cervical cancer program prior to such date for suspension shall continue to be covered for the program unless his or her medical treatment has concluded, or until the next redetermination of his or her eligibility by the department, whichever event occurs later; whereas after, the individual's eligibility for the Medicaid expansion group shall be determined by the department pursuant to RSA 126-A:5, XXII. Commencing January 1, 2014, administrative rule He-W 641.09 shall be limited in its application to only those individuals enrolled in the Medicaid breast and cervical cancer program receiving treatment prior to the date of suspension of the program as provided herein.

8 New Section; New Hampshire Health Benefit Marketplace. Amend RSA 420-N by inserting after section 10 the following new section:

420-N:11 New Hampshire Health Benefit Marketplace. The health benefit marketplace established in New Hampshire under section 1311 of the Act shall have the functional capacity necessary to implement the provisions of RSA 126-A:67 – 126-A:76, including, but not limited to facilitating the sale of qualified health plans to qualified individuals and qualified employers in the state beginning with effective dates on or after January 1, 2016. New Hampshire state agencies and departments may plan for and take all actions necessary to establish the marketplace, including applying for, receiving, and expending grants, and contracting with any public or private entities. The commissioner shall adopt rules, under RSA 541-A, to implement this section.

9 Federal Health Care Reform; Purpose and Scope. Amend RSA 420-N:1 to read as follows:

420-N:1 Purpose and Scope. The intent of this chapter is to preserve the state's status as the primary regulator of the business of insurance within New Hampshire and the constitutional integrity and sovereignty of the state of New Hampshire under the Tenth Amendment to the United States Constitution and part I, article 7 of the New Hampshire constitution [and to create a legislative oversight committee to supervise the insurance commissioner's administration of the insurance reforms required under the Patient Protection and Affordable Care Act of 2009, Public Law 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Public Law 111-152, including any federal regulations, interpretations, standards, or guidance issued thereunder (hereinafter "the Act")].

10 Federal Health Care Reform; Authority of Commissioner. Amend the introductory paragraph of RSA 420-N:5 to read as follows:

[Only with such prior approvals from the oversight committee as are required under RSA 420-N:4,] The commissioner shall have authority to:

11 Federal Health Care Reform; Reference Deletion. Amend RSA 420-N:8, V to read as follows:

V. The commissioner may adopt rules, pursuant to RSA 541-A [and in accordance with RSA 420-N:4, II,] as necessary to perform the duties specified in this section and to protect against adverse selection by creating a level playing field between a federally-facilitated exchange and the commercial health insurance market.

12 Repeal. The following are repealed:

I. RSA 420-N:2, III, relative to an oversight committee.

II. RSA 420-N:3, relative to the joint health care reform oversight committee.

III. RSA 420-N:4, relative to implementation of the Act.

IV. RSA 420-N:7, I and IV, relative to prohibition on a state exchange.

V. RSA 161:11, relative to requiring the commissioner of health and human services to seek certain approval from the joint health care reform oversight committee.

13 Effective Date. This act shall take effect upon its passage.

LBAO
13-1029
Revised 11/14/13
12:30 PM

SS HB 1-FN-A FISCAL NOTE

AN ACT relative to access to health insurance coverage.

FISCAL IMPACT:
The Department of Health and Human Services and the Insurance Department state this bill, as introduced, will increase state expenditures by an indeterminable amount in FY 2014 and each year thereafter, and increase state revenue by an indeterminable amount in FY 2015 and each year thereafter. This bill may have an indeterminable fiscal impact on county and local revenue and expenditures.

This bill appropriates 5% of insurance premium tax revenue collected pursuant to RSA 400-A to the Department of Health and Human Services in FY 2014 and FY 2015 for the purposes of this act. Insurance premium tax revenue is currently deposited as state general fund unrestricted revenue.

METHODOLOGY:
The Department of Health and Human Services (DHHS) states this bill establishes the New Hampshire access to health coverage act to provide health insurance to the newly eligible population as provided under the Affordable Care Act (ACA), deletes the prohibition on a State-based health benefit marketplace, and grants the commissioner of DHHS rulemaking authority for the purposes of the bill. DHHS based their estimates upon the Lewin Group, Phase I, II, and III reports issued, respectively, in November 2012, January 2013, and September 2013. These impacts have been summarized below, along with estimated operating costs estimated by DHHS –

EXPENDITURES

Medicaid Expenditures

The table below summarizes the Department's estimates of the impact on Medicaid expenditures as a result of the proposed bill. (SUD = Substance Abuse Disorder/ HIPP =Health Insurance Premium Program/ BCCP = Breast and Cervical Cancer Program) -

Medicaid - State General Fund Impact

(In Millions)

Population FY14 FY15 FY16 FY17 FY18

Uninsured (<=138%) $0 $0 $0 $5.49 $14.15

Insured (<=138%) $0 $0 $0 $2.04 $5.25

SUD Benefits $0 $0 $0 $(0.04) $(0.15)

HIPP Expansion $0 $0 $0 $(0.55) $(1.42)

BCCP (<=138%) $(0.37) $(0.74) $(0.74) $(0.70) $(0.63)

BCCP (>138%) $(0.15) $(0.34) $(0.56) $(0.82) $(1.08)

Total – State $(0.52) $(1.08) $(1.30) $5.42 $16.12

Medicaid - Federal Fund Impact

(In Millions)

Population FY14 FY15 FY16 FY17 FY18

Uninsured (<=138%) $66.12 $206.39 $255.91 $269.23 $268.86

Insured (<=138%) $36.76 $96.01 $98.98 $99.88 $99.76

SUD Benefits $4.93 $12.33 $9.56 $(2.09) $(2.85)

HIPP Expansion $(10.11) $(25.25) $(26.72) $(26.97) $(26.93)

BCCP (<=138%) $0.37 $0.74 $0.74 $0.70 $0.63

BCCP (>138%) $(0.28) $(0.63) $(1.03) $(1.51) $(2.01)

Total – Federal $97.79 $289.59 $337.44 $339.25 $337.46

Start-Up/Implementation Costs

DHHS states the proposed bill will result in start-up/implementation costs (including first year IT system changes), and the need for 75 additional full-time equivalent employees (FTEs). Employees will be assigned to eligibility determination (60); training and supervision (5); client services unit (3); HIPP and Third Party Liability (3); appeals unit (2); and special investigations (2). Personnel and consulting costs will be ongoing, but indeterminable at this time, for purposes of this fiscal note FY 2015 costs were rolled forward to subsequent fiscal years.

The table below provides high range estimates from DHHS-

DHHS Start-Up/Implementation Costs - State General Fund Impact

(In Millions)
FY14 FY15 FY16 FY17 FY18

Personnel $1.15 $3.43 $3.43 $3.43 $3.43

IT/Systems Changes $0.67 $0.03 $0 $0 $0

Equipment $0.45 $0.35 $0 $0 $0

Consulting $0.87 $0.71 $0.71 $0.71 $0.71

Total – State $3.14 $4.52 $4.14 $4.14 $4.14

DHHS Start-Up/Implementation Costs - Federal Fund Impact

(In Millions)

FY14 FY15 FY16 FY17 FY18

Personnel $1.12 $3.31 $3.31 $3.31 $3.31

IT/Systems Changes $5.98 $0.24 $0 $0 $0

Equipment $0.37 $0.30 $0 $0 $0

Consulting $1.00 $0.84 $0.84 $0.84 $0.84

Total – Federal $8.47 $4.69 $4.15 $4.15 $4.15

SUMMARY OF TOTAL COSTS

Medicaid Expenditures and DHHS Start-Up Implementation Costs

(In Millions)

FY14 FY15 FY16 FY17 FY18

State $2.62 $3.44 $2.84 $9.56 $20.26

Federal $106.26 $294.28 $341.59 $343.40 $341.61

Total $108.88 $297.72 $344.43 $352.96 $361.87

Appropriation

The proposed bill appropriates a sum equal to 5% of insurance premium tax revenue collected in accordance with RSA 400-A to DHHS in FY 2014 and FY 2015 for the purposes of this act. The Insurance Department estimates 5% of insurance premium tax revenue will total approximately $3,765,000 in FY 2014, and $4,155,000 in FY 2015.

State Corrections

DHHS further assumes there will be state savings relative to coverage of inmates housed in state corrections who will be newly covered under Medicaid. These inmates will therefore be eligible for certain out of prison treatment costs to be paid entirely with federal funds. As a result of the federal fund offset, DHHS estimates state general fund savings of approximately $338,000 in FY 2014, and $675,000 in FY 2015 and each year thereafter.

The Department of Corrections (DOC) estimates these savings would be offset by the need for 3 additional staff to process an additional 904 applications. DOC estimated this cost at approximately $270,000.

Innovation Study

The Insurance Department states the bill calls for a study of potential innovations to be completed by DHHS and the Department. Study costs are estimated at approximately $200,000, and the bill allows for the application for federal funds to be used to pay for the study.

Consulting Services

The proposed bill also allows any balance of funds appropriated to DHHS for the Commission to Study the Expansion of Medicaid Eligibility in New Hampshire (2013, 144:130) to be used by DHHS in obtaining consulting services to implement the New Hampshire access to health coverage program, and extends the appropriation. This section will have no fiscal impact as it will utilize the balance of an existing appropriation.

County/Local Impact

The Department of Health and Human Services did not provide an estimate of any potential impact on county and local revenue or expenditures as a result of this bill.

Early Termination

In the event the federal medical assistance percentage (FMAP) for the New Hampshire access to health coverage falls below amounts stipulated in the ACA, the bill would terminate the program in six months. The Department states ACA FMAP percentages are assumed at 100% in FY 2014 through FY 2016, 98% in FY 2017, 95% in FY 2018, 94% in FY 2019, 92% in FY 2020, and 90% in FY 2021 and each year thereafter.

REVENUE

Insurance Premium Tax

DHHS estimates state insurance premium tax collections will increase by approximately $5,450,000 in FY 2015, $5,118,110 in FY 2016, $5,494,497 in FY 2017, and $5,660,192 in FY 2018. This information is based on data provided in the Lewin report.

The New Hampshire Insurance Department estimates premium tax collections will increase by approximately $6,000,000 in FY 2015, and $3,000,000 in FY 2016 and each year thereafter. The Department assumes premium tax returns reflecting the bills impact on insurance premium tax revenue will first be filed in March 2015 (FY 2015). These returns will include a true-up for CY 2014 premium tax payments (not received) and an estimated payment for the CY 2015 premium tax. As a result, FY 2015 premium tax collections will reflect a $3,000,000 payment relative to additional CY 2014 premiums plus a $3,000,000 payment relative to estimated additional CY 2015 premiums, for a total of $6,000,000. There will be no credit for CY 2014 premium tax payments received since they will not have been made. In FY 2016 and each year thereafter, premium tax collections will reflect a $3,000,000 payment relative to additional CY 2015 premiums, a $(3,000,000) credit for tax payments received in FY 2015, plus a $3,000,000 payment relative to estimated additional CY 2016 premiums, for a net tax payment of $3,000,000. The Department estimates an increase in premium tax revenue at $3,000,000 in FY 2017 and each year thereafter.

Medicaid Enhancement Tax

The Department of Health and Human Services estimates Medicaid Enhancement Tax (MET) revenue will be impacted as a result of increased Medicaid and Marketplace enrollments. DHHS estimates MET revenue will decrease by approximately $1,510,000 in FY 2016, and increase by $4,140,000 in FY 2017, and $4,190,000 in FY 2018.

For Immediate Release
November 13, 2013

Contact:
Communications Office
(603)271-2121

Governor Hassan and Speaker Norelli Announce Compromise Path Forward on Health Care Expansion

Compromise Proposal Incorporates Senate Ideas for Encouraging Private Coverage, Ensures Workable Timetables to Preserve Coverage for Families and Individuals, Promotes Competition and Cost-Effectiveness

CONCORD - In an effort to reach common ground and overcome differences between competing House and Senate bills to expand health coverage for tens of thousands of Granite Staters, Governor Maggie Hassan and Speaker of the House Terie Norelli today offered a compromise path forward that incorporates both Democratic and Republican ideas for increasing and preserving access to health insurance while promoting private coverage.

The compromise plan outlined by the Governor and Speaker would move health coverage forward and adopt the Senate proposal to shift the entire newly eligible population of individuals and families with incomes at 0-133 percent of federal poverty onto New Hampshire's health insurance exchange with premium assistance, but on a timeline that allows for workable, responsible and effective implementation, including increased competition to ensure cost-effectiveness on the exchange.  

"While I believe that the bill offered by the House, which reflects the recommendations made by a bipartisan study commission, offers an effective path forward for New Hampshire to expand coverage to tens of thousands of working families while encouraging private insurance, we are open to the Senate's ideas," Governor Hassan said. "However, the bill as written by the Senate simply will not work and will result in families losing their new bridge health coverage just in time for Christmas of 2014."  

The timeline in the Senate plan is unworkable for a number of reasons:

• It would require the state to implement a significant new exchange-based health care program in a matter of months, with little to no resources. This would require federal approval that is unlikely to be granted in such a short time period. Under the Senate bill, an extensive waiver would need to be developed and submitted in just six months, with approval and implementation in just five months after that.

• Arkansas, the only state in the country to pursue such a program, spent a full year developing its plan before it began negotiations with the federal government. In contrast, New Hampshire agencies have been essentially barred by law from doing much of the necessary groundwork to make the Senate exchange plan possible.

• The accelerated Senate timelines do not allow time for additional competition to develop on the marketplace, which currently only offers the Anthem narrow-network plan. Without additional competition, the Senate plan would hurt our insurance markets, be more expensive to taxpayers, and is not likely to meet the cost-effectiveness test required by the federal government.

• The Senate plan would undermine New Hampshire's efforts to manage the care provided to our low-income residents and would potentially violate the state's existing contracts with three private managed care companies.

Governor Hassan and Speaker Norelli also objected to the fact that the Senate bill does not include the necessary language to allow the state more control over the exchange, which would be necessary to ensure the increased competition required to making the Senate plan work. The Senate bill also includes provisions that give a few private entities - several with direct financial stakes - control over the program, even though New Hampshire taxpayers would be bearing the risk.

"We are willing to move toward the Senate's basic framework, but only if we have timelines and measures in place that are in the best interest of our people and families," Governor Hassan said. "We need to move forward quickly to maximize federal funds, and we should use the 100 percent federal match period to establish a New Hampshire plan that will work from day one and for the long-term. I thank Speaker Norelli and the House for their willingness to compromise, and I encourage Senate leadership to work with us to finalize a New Hampshire plan that can be implemented successful and responsibly."

"Through a long process the House has embraced new ideas and made compromises, and we continue to remain open to further innovation," Speaker Norelli said. "We must pass a plan that is designed for success from day one. It is important to deliver not just expanded access to needed care for tens of thousands of our neighbors, but also stability to all involved. The House plan provides security and improved health for those receiving coverage, and predictability for the providers, the private insurance carriers and the state."

"This compromise plan includes the ideas that were put forward in the Senate Republican plan, but makes them work for the people we are trying to cover," said Senate Democratic Leader Sylvia Larsen. "We can't support a plan that won't work in practice.  The Senate Republican plan unfortunately threatens to pull the rug out from under tens of thousands of Granite Staters by imposing an unworkable timeline. At the end of the day, we want a bipartisan solution that delivers all of the economic, budgetary, and health benefits of expanded Medicaid.  We believe this compromise can achieve that, and we look forward to working with Senate Republicans to pass it."

As proposed in both the House and Senate bills, the compromise path forward would expand the state's Health Insurance Premium Payment (HIPP) program, helping families and individuals with incomes at 0-133 percent of poverty to secure coverage through an employer if available.

For those without access to employer-provided insurance, the compromise offered today would make available a bridge plan operated by the state's Managed Care Organization partners for a period of time until New Hampshire's exchange has increased competition, additional state-level control, and plans with costs in line with the cost of providing coverage through the state's Managed Care program. Once those conditions are met, all newly eligible families and individuals without access to coverage through HIPP would then receive premium assistance to purchase private plans on the exchange.

House Finance
November 14, 2013

2013-2418h
01/05

Amendment to SS HB 1-FN-A

Amend subparagraph II (e) as inserted by section 1 of the bill by replacing it with the following:

                  (e)  Competition and consumer choice by first increasing the number of insurance companies offering coverage on the New Hampshire health insurance marketplace then by implementing a premium assistance model that will enable newly eligible persons between 0 and 133 percent of the federal poverty level to obtain coverage through the marketplace.

Amend RSA 126-A:72, I as inserted by section 2 of the bill by replacing it with the following:

            I.  Subject to the provisions of paragraph IV, the department shall implement a premium assistance program with coverage beginning  January 1, 2017  to require all newly eligible between 0 and 133 percent of the federal poverty level who do not have access to cost effective ESI, and who are not determined to be medically frail in accordance with 42 C.F.R. section 440.315(f), to enroll in a qualified health plan offered on the New Hampshire health benefit marketplace in order to receive health benefits under the New Hampshire access to health coverage program.

Amend section 2 of the bill by inserting after RSA 126-A:76 the following new RSA section:

      126-A:77  Health and Human Services Waiver Advisory Commission Established; Report. 

            I.(a)  There is established the health and human services  waiver advisory commission to advise the commissioner of the department of health and human services on the preparation of any Medicaid demonstration waiver under section 1115 of the Social Security Act of 1935, as amended, 42 U.S.C. section 1315, submitted by the department during the year 2014 to the CMS to improve population health, reduce health risks for the Medicaid and CHIP population, and  enhance the sustainability of the state's Medicaid financing system.  The members of the commission shall be as follows:

                        (1)  One public member appointed by the governor.

                        (2)  One public member appointed by president of the senate.

                        (3)  One public member appointed by the speaker of the house of representatives.

                        (4)  The commissioner of the department of health and human services, or designee.

                        (5)  A representative of a critical access hospital, nominated by the  New Hampshire Hospital Association and appointed by governor and council.

                        (6)  A representative of a non-critical access hospital that is not a member of the New Hampshire Hospital Association, nominated by joint agreement of the president of the senate and the speaker of the house of representatives and appointed by governor and council.

                        (7)  One member who is an executive director of a community mental health center, nominated by New Hampshire Community Behavioral Health Association and appointed by governor and council.

                        (8)  A representative of the community health centers, nominated by the Bi-State Primary Care Association and appointed by the governor and council.

                        (9)  One member who is an executive director of an area agency, appointed by the governor and council.

                  (b)  The commission shall:

                        (1)  Advise the department relative to how an 1115 Medicaid demonstration waiver could serve to integrate and align New Hampshire's Medicaid care management program, the provision of coverage to the newly eligible under this chapter, existing Medicaid waivered programs, and other department initiatives in a manner that improves public health, and improves the quality of care and access to care for all Medicaid and CHIP beneficiaries.

                        (2)  Advise the department relative to the manner in which a demonstration waiver could improve the sustainability of the state's Medicaid financing system, including through federal investment in service delivery and payment reform transformation initiatives.

                        (3)  Serve as a forum for the formal hearing and public comment on an 1115 Medicaid demonstration.

                        (4)  Create any subcommittees it deems necessary, which may include members of the public appointed by the chairperson, to assist with the research, analysis, or other work necessary to support its recommendations for a waiver application.

                        (5)  Provide recommendations to the commissioner on the implementation of any section 1115 waiver approved.

                  (c)  The members of the commission shall elect a chairperson from among the members.  The first meeting of the commission shall be called by the commissioner, or designee, and shall be held within 20 days of the effective date of this section.  Five members of the commission shall constitute a quorum.

                  (d)  The department shall provide administrative support to the commission and provide such information, data, testimony, and other assistance as requested by the commission.

                  (e)  The department of health and human services shall regularly update and consult with the commission throughout the process of preparing and submitting a waiver application and shall provide timely and detailed reports to the commission on the department's communications with the CMS during all phases of the waiver application and approval process.

            II.  On or before January 15, 2014, the commissioner shall make an initial report on the status of the department's work on an 1115 Medicaid demonstration waiver application to the fiscal committee of the general court, and shall report on the waiver application and approval process at each meeting of the fiscal committee thereafter until the waiver application is acted upon by CMS.

Amend the bill by replacing section 7 with the following:

      ­7  Department of Health and Human Services; Medicaid Breast and Cervical Cancer Program.

            I.  Enrollment in the Medicaid breast and cervical cancer program, under 42 U.S.C. section 1396a(aa), shall be suspended 90 days following the commencement of the New Hampshire access to health coverage program, established in section 2 of this act.  Any individual covered under the Medicaid breast and cervical cancer program prior to such date for suspension shall continue to be covered for the program unless his or her medical treatment has concluded, or until the next redetermination of his or her eligibility by the department, whichever event occurs later; whereas after, the individual's eligibility for the Medicaid expansion group shall be determined by the department pursuant to RSA 126-A:5, XXII.  Commencing January 1, 2014, administrative rule He-W 641.09 shall be limited in its application to only those individuals enrolled in the Medicaid breast and cervical cancer program receiving treatment prior to the date of suspension of the program as provided herein.

            II.  If a termination of the New Hampshire access to health coverage program occurs pursuant to paragraph II of section 4 of this act, the Medicaid breast and cervical cancer program shall be reinstated under the current Medicaid program.

Amend the bill by replacing section 8 with the following:

      ­8  New Sections; New Hampshire Health Benefit Marketplace.  Amend RSA 420-N by inserting after section 10 the following new sections:

      420-N:11  New Hampshire Health Benefit Marketplace.  The health benefit marketplace established in New Hampshire under section 1311 of the Act shall have the functional capacity necessary to implement the provisions of RSA 126-A:67 through 126-A:76, including, but not limited to facilitating the sale of qualified health plans to qualified individuals and qualified employers in the state beginning with effective dates on or after January 1, 2016.  New Hampshire state agencies and departments may plan for and take all actions necessary to establish the marketplace, including applying for, receiving, and expending grants, and contracting with any public or private entities.  The commissioner shall adopt rules, under RSA 541-A, to implement this section.

      420-N:12  Ambulatory Services.  Each health plan offered on a federally-facilitated or state based exchange shall, as a condition of participation in such exchange, offer to each federally-qualified health center, as defined in section 1905(I)(2)(B) of the Social Security Act 42 U.S.C. section 1396d(l)(2)(B), providing services in geographic areas served by the plan, the opportunity to contract with such plan to provide to the plan's enrollees all ambulatory services that are covered by the plan that the center offers to provide and shall reimburse each such center for such services as provided in the act.  Provider payments, under this section shall be no less than before the effective date of this section.

Amend the bill by replacing sections 12 and 13 with the following:

      ­12  Repeal.  The following are repealed:

            I.  RSA 420-N:2, III, relative to an oversight committee.

            II.  RSA 420-N:3, relative to the joint health care reform oversight committee.

            III.  RSA 420-N:4, relative to implementation of the Act.

            IV.  RSA 420-N:7, I and IV, relative to prohibition on a state exchange.

            V.  RSA 161:11, relative to requiring the commissioner of health and human services to seek certain approval from the joint health care reform oversight committee.

            VI.  RSA 126-A:77, relative to the health and human services waiver advisory commission.

      ­13  Effective Date.

            I.  Paragraph VI of section 12 of this act shall take effect December 31, 2014.

            II.  The remainder of this act shall take effect upon its passage.

New Hampshire Senate

News Release

For Immediate Release

November 18, 2013

Contact:
Tom Cronin 603.264.5659

Senate President Morse: "Governor's Comments Detrimental to Progress on Health Care"

Concord, NH – Senate President Chuck Morse issued the following statement this morning regarding Governor Hassan's troubling comments on Saturday evening at a Democratic Party fundraiser that a compromise deal on health care reform would be worse than no deal at all:

"The Governor's suggestion that the health care plan offered by Senate Republicans, one that would increase access to private insurance while protecting taxpayers, would be worse than leaving nearly 60,000 New Hampshire citizens without insurance is detrimental to the progress Democrats and Republicans in the legislature are making towards a compromise.

"The flaws of ObamaCare are becoming more apparent every day. Regardless, Governor Hassan is asking lawmakers to ignore them and simply adopt a key component of President Obama's health care law in New Hampshire with no safeguards in place. Senate Republicans will not take that chance with the taxpayer's dollars or put the long term financial well being of the state of New Hampshire at risk.

"Instead, we continue to work towards a compromise that protects New Hampshire from the obvious flaws of the federal health care law while seeking to take advantage of federal funding available to help us extend insurance coverage to thousands of New Hampshire residents that lack it today. We'd argue those hardworking men and women who would benefit from our plan would agree that it is unquestionably better than no solution at all.

"Governor Hassan's all or nothing approach is not how laws are made in New Hampshire, that's the mindset of how laws are made in Washington. New Hampshire deserves better. In the days ahead, we hope the Governor will focus less on press conferences and partisan rhetoric and more on being here in the State House working with us to create a piece of legislation that will improve the lives of thousands of Granite State citizens."

During a Democratic Party fundraiser on Saturday evening, Governor Hassan was quoted as saying, "The bad deal senate republicans are offering is worse than no deal at all." Source: https://twitter.com/joshrogersNHPR/status/401877296883437568

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@GovernorHassan: "The bad deal senate republicans are offering is worse than no deal at all," she says on Medicaid expansion. #nhpolitics

— Josh Rogers (@joshrogersNHPR) November 17, 2013

For Immediate Release
November 20, 2013

CONTACT:
Mario Piscatella
(603) 271­-3664
mario.piscatella@leg.state.nh.us

Speaker Norelli's Statement on Senate Ending Talks to Achieve Expanded Health Care Access

CONCORD—­ Speaker Terie Norelli issued the following statement on the state of negotiations with the Senate regarding expanding access to health care for low income Granite Staters:

"I'm disappointed the Senate has closed the door to finding a workable compromise that would provide health care access to 58,000 low income working men and women across the state."

"After the House made numerous compromises, our plan adopts many of the ideas the Senate proposed including privatizing coverage, expanding the HIPP program, and transitioning the entire expansion population to a fully private, competitive marketplace. The key difference is doing so on a workable timeline, rather than on a plan designed for failure. One of the objectives of expanding access to healthcare is introducing stability and security for providers, insurers, our most vulnerable citizens, and our economy."

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