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Expanded Access Coalition Meeting - Aug. 26, 2003

Extended discussion on changes in state low income health care programs. Clients need to think about how we can have input. There should be public meetings of "stakeholders" in cities around Oregon. -- Lynn
Oregon Health Access Project

3896 Beverly Ave NE, Bldg J, Suite 6, Salem, Oregon 97305-1374

Phone: (503) 581-6830 1-800-789-1599 Fax: (503) 370-7630 Email:  ohap@ohac.org Website: www.ohac.org

Promoting Affordable, Comprehensive, Quality, Universal Health Care in Oregon

Expanded Access Coalition Meeting

August 26, 2003, 10:15-12:10 p.m., Micah Bldg., Salem



Nancy Horn (OMAP) Kevin Earls (OAHHS)
Marcy Sugarman (Multnomah County Health Dept) Larry Gillespie (United Way)
Christine Talent (NARA Health Clinic) Kelly Harms ((IPGB)
Carol Simila (DCBS/Insurance Division) Tim Miller (OHAC)
Carlos Medina (Yakima Valley Farmworkers Clinic) LoriAnn Sheridan (OHAC)
Lupita Letscher (Yakima Valley Farmworkers Clinic) Ellen Pinney (OHAC)
Carlos Perez Medina (YVFWC) Jennie Hamilton (OPCA)
Angelica Ruppe (LCDV) Elsi Elkins (OCPH/OHP)
Tiffany Pahle (OCPH/OHP) Ann Strada (PHS)
Michele Wallace ((OHP Central) Linda Herman (OCPH/OHP)
Jim Edge (OMAP) Debbie Lamberger (OHSU)
Kaaren Driscoll (OHSU) Jacque Doney (SCHC)
Nora Lehnhoft (Central City) Luce Wendt (United Way)
Jan Morgan (NWHF) Rhonda Walker (OHAC)
Jere High (Virginia Garcia Medical Center) Elizabeth Byers (OHAC)
Peg Crowley (Rogue Valley CKF) Elena Garcia (Salud)
Lynn-Marie Crider (Oregon AFL-CIO) John Holmes (NAMI)
Katie Gauthier (Oregonians for Health Security) Kage Stainbrook (Chemawa Clinic)
Judi Cramer (RWJF NPO Southern Region Rep) Marisa Luera (RWJF-NPO Western Rep)
Bruce Goldberg (OHPPR) Laura Brennan (DHS)
Ellen Lowe (Oregon Law Center) Angie Newton (SCHC)
Diane Lund (OHF)

I. Call To Order: Jenny called the meeting to order at 10:15 a.m. Ellen Pinney briefly reviewed the handouts included in the EAC packets. (Listing of items is at end of the end of these mintues.

Oregon Health Plan Policy and Budget Update

A. Status of Medically Needy (Jim Edge) - Jim briefly addressed the Legislative session, then addressed HB 2511 - the restructuring of the Oregon Health Plan. He indicated the waiver request document will be sent to CMS within weeks and that the State is hoping for a January 2004 start date. If the state does not get a timely response from CMS, it will delay implementation and rock the budget. Medically needy will be re-defined as the low-income seniors (over 65) and disabled program. There was $21 million in the co-chair's budget for this program. This will be a spend down program just for prescription meds. Co-insurance may be as high as 30-50%. Out of the $21 million proposed, $16 million will be available January 1. The bill also addresses the possibility of a cap on populations served. Under the old medically needy program, there were 8,500 people receiving prescription meds, mental health, chemical dependency, transportation, etc. DHS will have to calculate and determine what co-insurance will be under the new program in an effort to maximize the numbers that can be served but keep the meds they receive affordable.

B. Status of OHP Standard (Jim Edge) - Jim pointed out HB 2511 includes a different benefits package than either that received currently by the Standard population or the package they had prior to January: physician services, lab, x-ray, medical supplies, emergency dental, mental health and chemical dependency. The hospital provider tax will provide for emergent hospital care, and if more money is available, include urgent dental care. The House passed a version of the bill with a cap on standard enrollment; however, the Senate pulled the cap and the final result is a bill without a cap on enrollment. In response to a question, Jim stated the hospital urgent and emergent codes have yet to be determined. He added retroactive eligibility will also be reinstated.

Jennie asked about OHP Standard reductions in populations this past year and how EAC members working in the field doing outreach and enrollment should best communicate with them. Jim stated there has been a reduction in the populations served, from 90,000+ to 65,000 in the past six months. This is due to a number of reasons: cost of premiums, reduced services, elimination of mental health and chemical dependency services (which are returning to coverage), limited hospital benefits, and co-pays. Jim suggested getting the information out that the services are coming back. Jennie stressed the need to identify Standard clients and notify them about their renewal dates if EAC members can get that information. Jim said Michele Wallace may be able to assist with this.

C. CHIP and FHIAP Expansions .Ellen Pinney added two positive inclusions in the waiver for CHIP and FHIAP is coverage up to 200% FPL for pregnant women and children, effective January 1. PLM stays at 185%. Jim confirmed these expansions proposed in the waiver.

D. Status of Premiums and Co-Pays (Jim Edge) - Jim said there will continue to be premiums and co-pays and it is the Legislature's intent for co-pays to remain the same as they are currently. He added there is a budget note requiring DHS to do a study on the impact of cost-sharing, including premiums, which will be taken to the emergency board in October 2004. The E-Board may determine if changes should be made in cost-sharing amounts and policies, and whether funding is available. He stressed the Legislature is retaining much more decision-making authority than in the past. He added if the revenue package goes to the voters and is voted down, there is a dis-appropriation bill, which will result in a huge hit on OHP and OHP Standard may be eliminated. If it is likely that the revenue package is voted down, Representative Bates has indicated he will call for a special session. Jennie Hamilton clarified that all the OHP changes are scheduled to take effect in January, but the vote will take place in February if the 50,000 signatures are secured, and cuts will take place in May. Jim stated there is a long and difficult negotiation process with the Federal government. He confirmed that if the revenue package fails, there will be significant reductions of populations covered under OHP in May 2004. Kevin Mannix is leading the charge to refer the revenue pacakge to voters and they have 90 days to gather signatures.

E. OHP Waiver Jim pointed out the waiver being submitted to the Feds includes a 30-line movement in the prioritized list of services, the largest line movement the Feds have ever allowed, moving from line 549 to 519. It's likely the Feds will not allow this movement. Oregon is requesting the line movement be allowed to continue OHP Standard enrollment with the revised benefits package. In addition, the waiver includes a replacement of the medically needy program (optional to the Feds). The ability of the State to fund these programs will depend on CMS approval of the provider tax, long-term care tax (nursing homes), managed care plan and hospital association-negotiated tax. He added Oregon could receive Federal match at a 60/40 ratio to pay for services and reimbursements, and it usually takes six months to get waiver when Oregon needs approval by January, creating significant challenges. Jim suggested if the EAC is interested in dealing with the waiver, it has to be submitted in the next two weeks and responses to Mary Greipp's letter need to happen quickly.

F. OHP PLUS Population. Jim said the OHP Plus package is composed of seven required services: Medicare/Medicaid, prescription drugs, lab, x-ray, medical supplies, mental health and chemical dependency. There's another six services the Legislature can either add or subtract to these services: emergency dental, non-emergency dental, optional provider services, emergency hospital services, outpatient services and inpatient services. The bill allows the Legislature to deal with these benefits in any order they choose.

G. Other Legislative Issues. In response to a question, Jim said general assistance was eliminated as part of the special session last year, and he did not think it was coming back. However, many of the individuals who were in the general assistance program have ended up in the OHP Plus population, so they are getting the richer benefits package. What they're not getting is the cash assistance. Ellen Lowe briefly addressed the DHS budget and SSI.

Jim stated the maternity case management was proposed by managed care plans with a small amount of money ($5 million savings), however there's no reduction in services. It's just a change in the way payments are made.

He addressed the OMAP handout with proposed increases in capitation enrollment for managed care. He further addressed HB 3624, which came out of Westlund's committee. He added the Legislature directed DHS to promote managed care. The bill was based on the premise there was a cost savings with managed care. But those projections of cost -savings became cost increases with required increases in capitation rates. Many believe managed care provides better access for enrollees. Unfortunately, managed care fell to a low of about 60% when the OHP Standard went into effect last year. This was primarily due to the fact that managed care was uncertain about the risks they were taking with the reduced benefits package for the Standard population and many managed care plans decided to drop OHP Standard clients. OMAP is now in the process of working to increase the percentage of OHP clients in managed care. Through negotiations, they decided the goal for 85% of OHP clients in managed care was over ambitious, settling for a new target of 70%. It was also realized that managed care does not operate throughout the state, with some areas not covered. Peg Crowley clarified that CareOregon serves the Jackson County area.

Jim addressed the preferred drug program, where OMAP implemented a process a few months ago, requiring providers to get prior authorization for prescribing drugs not on the preferred drug list. Legislators were not happy with this and removed OMAP's ability to continue this. There will be a rule change to discontinue this requirement, giving physicians more freedom to prescribe drugs. He pointed out the costs to OMAP was $15 million in losing prior authorization. Another bill proposed by Senator Minnis included language for requiring prior authorization for patients who have 15 or more prescriptions in a six-month period, which will have some cost-savings.

H. Status of Safety Net Funding - Ellen Pinney said there is a strong effort to secure $20 million (representing $20 per uninsured person per year), however there is no money for the safety net right now. Ellen Lowe encouraged everyone to contact Ways & Means about the Christmas Tree bill in an effort to get funding support for safety nets.

I. Senior Prescription Drug Assistance Program (Jim Edge) - Jim told the EAC the senior prescription drug assistance program and breast and cervical cancer programs will continue. Set up at the last Legislative session as a self-supporting program, the senior prescription drug assistance program provides seniors that meet certain income levels to get cards for $50 a year, enabling them to get prescriptions at Medicaid rates (15% savings). The program has not been real successful although well promoted, primarily due to other discounts offered through various pharmacies and people were expecting a greater savings. Only 300 people have enrolled in this program.

J. Status of FHIAP (Kelly Harms)- Kelly told the EAC FHIAP was not in the Governor's budget, but was included in the co-chair's budget with a $3 million cut. HB 5031 built in $15 million matched with $33 million in Federal funds for a total $48 million, so they will not be able to serve as many people as they planned on with the waiver. Now, based on trends, they will serve 10,000 people during this biennium. She addressed some housekeeping bills that went through: HB 2159 - allowing state agency to operate program where, in the past, a third party administered it; HB 2160 - allows FHIAP to start subsidizing dental premiums in the group market and allows them to directly reimburse providers for age-appropriate immunizations, which is part of the Federal requirement in the waiver; and HB-2189 - allowing the ability to get Federal match for assessment dollars being paid for the higher risk pool who go to OMIP. They will spend less money on these people, expand a little bit, and be able to do that without spending state general fund dollars. This will enable FHIAP to use Federal match and hopefully expand to the individual market. She pointed out there is political pressure to keep the individual market small because of the assessments. By having the language in the bill, they hope to overcome any political opposition. FHIAP has about 10,000 on the waiting list for the individual market and will continue to grow. She added HB 2189 removes the statutory requirement of the 50/50 split on group and individual market coverage, allowing the Legislature to direct FHIAP on how to spend the money. If FHIAP can prove there is a greater need in the individual market, FHIAP can tell the Legislature that's were they need to reallocate more money. In response to questions, Kelly said the ratio of FHIAP coverage is 37% group; the remainder in individual, and of the individual market, 24% are in the high-risk pool.

III. New Uninsurance Numbers for Oregon & their implication for OHP eligibility & enrollment (Bruce Goldberg) - Bruce addressed the 2002 Uninsured Report from OHPPR (attached in the packets), briefly discussing the findings from the Oregon Population Survey relative to uninsurance. He shared the rates of uninsurance: 1990 @ 16%, 1992 @ 18%, 1998 @ 11% and 2000 @ 12%, and declining to 14% in 2002. There were 19,000 uninsured children (10%) under 100% FLP and almost 30,000 children living between 100-200% FLP. He pointed out there's a disconnect between policy and practice as Oregon is supposed to cover children to 185% FPL. There were 113,653 uninsured adults living below 100% FPL and 124,000 uninsured adults living between 101-200% FLP in 2002. Ellen said OHAC is working with Susan Castillo, Superintendent of the Department of Education, pointing out the barrier is that there's a lack of awareness of the programs available. She suggested increasing outreach to kids, and this should be a discussion at the next EAC meeting. Bruce said he looks to groups like EAC to ensure qualified kids receive coverage and access to health care services they need.

IV. Status of Budget Deliberations on Hospital Tax and Other Revenue Options (Kevin Earls) - Kevin addressed the provider tax proposed by the Oregon Association of Hospitals & Health Systems and the current situation. He explained that in the co-chairs budget and the Governor's initial and revised budget, OHP Standard was not funded. Subsequently, OHP Standard hospital coverage was contemplated being dropped. The hospital tax was proposed to draw down Federal dollars as match and restore hospital benefits. OAHHS proposed the tax about three weeks ago in an effort to save hospital benefits as well as OHP Standard benefits at current levels. He said they have agreed upon a different provider tax as follows: $30 million net from hospital tax, $34 million net from Fully Capitated Healthcare Plans (FCHP) tax, $8 million as a result of maternity care case management changes, and $5.2 million general revenue for a total of $77 million to buy back for OHP Standard hospital benefits at approximately 70% of the funding level of the entire benefits for hospital services. He added he anticipates coverage for emergent, urgent, lab & x-ray services for inpatient and outpatient settings. He confirmed the $250 co-pay for hospital stays remain.

Kevin explained they are technically able, with the hospital tax, to pull down approximately $92 million, which would have fully funded the hospital benefit, rebate hospital payment levels to 73% of Medicare (of their costs or less), which is what physicians are currently paid. He added the Administration was concerned with two issues: (1) the ability to sustain that level of funding in the term and if the provider tax were to go away, would they be able to sustain that level of funding with just general fund appropriations, and (2) while the $92 million tax met every rule and regulation required under the Federal regs for a provider tax, it was of such a size that it could reasonably be anticipated that the approval process would be slow than for a smaller tax. In the end, OAHHS was told be the Administration that this is a tax they could support, and that was the line in the sand.

In response to a question from Peg Crowley, Kevin said the FCHPs changed maternity care in an effort to save money. He explained that FCHP's are fully capitated healthcare plans which provide OHP services through a managed care contract. He pointed out the hospital tax is tied to hospital benefits for OHP Standard. If the tax bill goes to the voters and fails, it is the common understanding the hospital tax will also go away. It will not go into the general fund.

Kevin addressed the items, which were restored as a result of negotiations: (1) all cuts made in March by OMAP have been restored (12% cut in hospital funding for OHP services for inpatient and outpatient care); (2) the Medicaid outlier program that pays hospitals a portion of the additional (high) costs related to high-risk Medicaid patients; (3) retroactive eligibility; (4) funding for small and rural hospitals (type A & B with 50 or fewer hospital beds); and (5) OHP Standard. He pointed out all these changes amount to several hundred million dollars in restored funding as a result of the package. He added it was to work of Governor's office, DHS, FCHP's, OMAP and OAHHS that made this possible. Jenny commended Kevin for all the work OAHHS has done.

Ellen addressed the revenue sources identified by the legislature and outlined in the AFL-CIO newsletter, questioning which of the new revenue proposals will be sent to the voters. Kevin said he did not think the hospital tax will be referred as all it does is pull down Federal funds. Jim Edge stated the taxes that would go to the voters come out of HB 2152, and that some or all of the bill can be repealed. None of the provider taxes would be referred. He added the bill started with a 10 cigarette tax, which partially funds OHP. If it is referred to the voters, they may lose the cigarette tax and DHS will take a hit. Kevin said Oregon is one of the only states not cutting optimal coverage populations during the budget crisis.

V. FHIAP Enrollment Numbers - handouts

VI. OHP Enrollment Numbers / Outreach Plans (Nancy Horn) - Nancy said she will send the current enrollment numbers to Ellen to get out to EAC. She pointed out there are 85 people in the breast/cervical cancer program. (At this writing, August numbers are not available. September numbers are attached.) Nancy told the EAC the next OHP2 training is September 17. She said they are getting a work group together soon to work on the OHP application, however, it's okay for the short term as no significant changes have taken place. They are emphasizing the distribution of preventive services brochures

In response to questions about Earhart, Nancy indicated they are not adding any more new lines and are working on a new contract. She referred to Nancy Rudolph as the contact. Jim Edge added they will be looking at recommendations from EAC as they deal with Earhart. In response to a question about premium payments at field offices, Nancy said there are liability issues with field staff if they don't get the payments in on time. Some attendees suggested having drop boxes in various areas. Jennie suggested including this on the next meeting's agenda. Nancy said they are open to any ideas.

Nancy added they are revisiting the idea of sending out a postcard reminder of reapplication date to clients as a cost-savings. If that idea carriers, OHP enrollees will no longer receive full re-application packages... .just a post card saying that if they want to re-apply they need to call and request an application. Thousands of people never respond to the opportunity for re-application. Some have moved. Nancy explained all letters returned to the prison have to be opened due to the prospect of contraband and the process is expensive.

Ellen Pinney addressed the calls OHAC receives about premium problems. She brought up the problem of people are having, receiving letters five days before their premiums are due, informing them they are being dumped because their premiums were not received on time. The most outrageous practice is when people are being dumped wrongly. Communications with Earhart are also difficult. She addressed various procedural suggestions that came out of EAC to make premium collection more equitable: use of credit cards, toll-free line, etc. They sent a letter and were told these could not take place. She suggested revisiting these suggestions. Marcy Sugarman pointed out there is a problem with posting too late after receipt of payment, and it was her understanding payments were suppose to be posted within 24 hours. Nancy suggested bringing Nancy Rudolph to the next EAC meeting to address these concerns.

VII. OHP Central Report (Michele Wallace) - Michele Wallace gave an update on OHP Central and told the EAC the good news is that they are processing applications five to 10 days after received by staff since they received increased staff. Now, because OHP2 has not grown as anticipate and, in fact, because OHP enrollment has declined, her office will have a 15% reduction in staff, 60 positions will be moved and they're not hiring. Although the Senior Drug Assistance Program continues, they do not have the staff to deal with it (2 FTE). At this month's processing time, they actually have workers waiting for the mail to come in as there's not enough work to do. Most staff are entry-level positions and they have a 15-20% vacancy rate. Carolyn Ross is now the Medicaid Program Manager. OHP Central has also grown with three additional fields: fraud investigations, SSI liaisons, and coordinating hearings. In response to a question from Tim Miller relative to outreach to grassroots organizations, Nancy said they will be doing outreach. She also addressed the regional meetings that have begun.

VIII. Upcoming Political Environment (Ellen Lowe) - Ellen stressed two slogans to push in light of the upcoming referendum: "DECLINE TO SIGN" and "THINK BEFORE YOU INK." She pointed out the Oregon AFL-CIO will be active in voter education, and encouraged everyone to get that note of caution out to the constituency. Addressing what will be referred, Ellen said the Republicans, led by Kevin Mannix, and Libertarians, led by Richard Burke, will be looking at the graduated income tax assessment as part of HB 2152 that will be referred. They will also be looking at the corporate minimum tax. The Oregon Business Association, led by Lynn Lundquist, will be actively supporting the three-year revenue tax, and she anticipates other business groups will support it. She addressed the number of unemployed who have worked in community-based services for the populations we serve. She encouraged everyone to read HB 2152 as it addresses how the income tax is graduated, the most progressive thing in tax proposals Oregon has done in 30 years. People making over $100,000/year will be the principle folks bearing the burden. These are the same folks benefiting from the Federal tax levy. She stressed thinking about the costs of not providing services when doing the long form for tax reporting. If the tax measure is not approved, it will be general fund dollars we'll have to use. She suggested looking at the Federal match for CHIP @ 72 for every dollar. She was told it is $244 million that will be lost for OHP if the measure goes down. She stated the non-match general fund for DHS is 13%.

Ellen said the hospital bill, which attached a number of bells and whistles, which would not fly through the Senate, was sent back to committee as HB 3393 (not HB 2747). She said she was hoping it would have enough money to help with the safety net. She stressed it is important for advocacy and encouraging local plans to have safety net clinics as an integral part of their delivery system.

Addressing premiums, Ellen said there's a budget note, which will be looking at by DHS. However, it may not be until November 2004 when they can deal with it. She suggested sharing concerns and information with legislators now since the date can be moved up. In thinking about the restorations for levels through #13, it's going to take some time. She stressed the need to get #14 included in the Christmas Tree bill.

IX. Enrollment Issues: Peg Crowley briefly addressed rural communities and provider access. She discussed the concerns with perceptions within the small community and how it affects enrollments, adding that through FHIAP, there is no outside knowledge of public health care subsidies. There was brief discussion on these issues. Jim suggested the EAC can help OMAP in understanding the implications of all the policy changes as they affect consumers and providers, including the reasons so many people have dropped off OHP. He added directing policy changes in response to problems in the system can take place.

Marisa Luera addressed the 20,000 applications OHP Central receives per month as well as the 17,000 calls. She said in other states, they have found the perception issue is a problem, but they're also finding administrative churning with workers understaffed and overworked. She questioned how they catch the applications with 20,000 coming in, how many are pended, how many are reapplications. Michele said many are reapplications, but they catch the duplicate applications through the bar-coding system. Marisa asked about the 65% enrollment rate from the applications received. Michele will confirm this tomorrow. She explained the main reasons for denials are over-income.

X. RWJF Orientation (Marisa Luera) - Marisa gave a brief overview of the Robert Wood Johnson Foundation, the nation's largest health care foundation, funding over 80 programs nationwide. 46 states are participating in the Covering Kids & Families Initiative. The mission is to reduce the number of uninsured adults and children. The EAC comes into play with its capacity to galvanize knowledge. The National Program Office is looking to simplify and coordinate health care delivery, provide technical assistance, and take back promising practices.

XI. Adjournment - 12:10 p.m.

NOTE: The next EAC Meetings will be at the normal dates and time:

4th Tuesdays 9:30 to 11:30.

Meetings are normally at the OHAC office (3896 Beverly Avenue NE, J-6, Salem). But increased numbers of participants may result in a change in meeting site. Please keep your eye on the EAC meeting notices or call the OHAC office for most current information re meeting location. 503-581-6830.

* Tuesday September 23rd

* Tuesday October 28th

* Tuesday November 25th

Recorded by LoriAnn Sheridan, OHAP

homepage: homepage: http://www.ohac.org