What State Medicaid Expansions May look like in 2014
This article reviews the draft model for one state’s answer to the
Medicaid Expansion under the Accountable Care Act. Washington State has posted
the preliminary benchmarks and plan design for accommodating this act.[1]
Warning to readers-this article may contain acronyms which are mind numbing,
but part of the lumbering vernacular, and wherever possible the full name is
cited.
Medicaid Eligibility
To start with there are a dozen
categories of “fast track” exemptions for Medicaid applicants and here is that
list:
- Health care for disabled workers
- Family planning extension (more on this later)
- Take charge family planning (whoa Nelly)
- Psychologically indigent inpatient program (example-homeless folks)
- Involuntary treatment act (hopefully this will apply to some of the nut-jobs who manage to obtain machine guns)
- Kidney disease program (for those on dialysis)
- ADATSA(Alcohol Drug Addiction Treatment Support Act)
- Social Security Income qualifiers based on their low income status
- Basic Health Plan qualifiers (subsidized medical insurance program for WA state residents with incomes no more than 200% of the Federal Poverty Level)
- Medical Care Services Program (This is a managed care program run by the WA State Health Care Authority)
- Medicaid qualifiers by virtue of low-income status
- Children’s Health Insurance Plan Enrollees (CHIP)
Benchmark Plan Coverage
Next up are the definitions of the benchmark plan for insurance
coverage mandates and here are those potential confounders:
- Essential health benefits,
- Essential health benefits reference plan
- Base benchmark plan, benchmark
- Alternative benefits plans
The benchmark plan must cover the following criteria in the benefit
design:
- BCBS-This refers to the bench mark equivalent coverage based on Blue Cross/Blue Shield plans
- EPSTD-Early and Periodic Screening, Diagnosis, and Treatment Program which applies to children under 21 who are covered by the state Medicaid program
- Non emergency transportation-What is this, a taxi to town?
- Family planning services & supplies-AKA birth control options
- Pregnant women
- Individuals who qualify for Medicaid based on being blind or disabled
- Dual eligible enrollees, which is a category of people on both Medicare and Medicaid plans
- Terminally ill hospice patients
- Inpatients in hospitals, nursing home and ICF (assisted living facilities) who must spend all but a minimal amount of their income for the cost of medical care
- TANF/Section 1931 enrollees, which is for parents and caretakers of incapacitated persons
- Medically frail individuals, including those with disabilities that impair ability in one or more activities of daily living
- Children in foster care
- Individuals who qualify for LTC (long term care) services based on their medical condition
- Individuals who only qualify for emergency care (?)
- Individuals who qualify based on the “spend down” of their total resources-such as senior citizens needing help with nursing home care.
Essential Health Benefits in 2014
The federal government has created ten essential health benefit plans
for the states to adopt. Each state may have more than one benchmark Medicaid
plan for eligible adults, which differs from the insurance exchange mandates,
which are slated to have only one benchmark plan. Also, under current law, the
mental-health-parity benefits for Medicaid only apply to Medicaid Managed Care
Plans, and not the general Medicaid plans, but this is changing in 2014. According
to federal mandates, essential health benefits must include the following
insurance benefits:
- Ambulatory services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
With regard to the habilitative services
and devices, this sounds like assistance for home living and a new word
invented by the government order.
Benchmarking the New Medicaid
Plan Design
Criteria which will be considered to establish a state benchmark for
the Medicaid expansion plans include any of the following factors: the largest
small group plan by enrollment (Blue Shield/Regence), the three largest state
employee plans by enrollment, the largest three federal employee plans, and the
largest commercial HMO in the state (Group Health Cooperative). The insurance
companies will need to determine if their plans comply with the new criteria if
they choose to participate in the Medicaid insurance offering, however, since
so many of the state’s children are enrolled on the Children’s Health Insurance
Plan (CHIP) it is expected that most carriers will. According to the Casey
Foundation, 23% of the children in the United States live in poverty and in
Washington State this metric was 18% in 2011.[2]
In 2009, 57% of Washington’s Medicaid enrollees were children and this is true
for other states as well.[3]
The state with the most children living
in poverty at that time was Mississippi at 32%.
Areas Not Affected by the
Accountable Care Rules (ACO)
The ACA rules still allow Medicaid cost sharing in co-payments,
deductibles, and contributions for services, which vary depending on the
enrollee category. Medicaid does have the demonstration waiver provision under
Section 1115, which allows states to petition for plan design changes which may
have higher cost sharing provisions. Families with incomes equal to or less
than the federal poverty level are allowed to have co-payments or cost sharing
up to 5% of their income without any premium payments. Allowable co-payments for 2012 are $3.80 for
most services and $7.60 for none-life threatening-emergency room visits, as
well as $3.80 for prescription drugs. There are also enrollees who are exempt
from these co-payment requirements and they are as follows:
- Pregnant women
- Terminally ill people in hospice care
- Medicaid enrollees who are already spending most of their income on health care costs during a hospitalization
- Family Planning Services and supplies
- Services provided by Indian Health Care entities for American Indians
- Emergency services
- All services are limited to one co-payment per service
Section 1115 Waiver Programs
under Medicaid
Currently, forty states require some co-payment from parents enrolled on
Medicaid and twenty-six states require co-payments for adults enrolled on their
Section 1115 waiver programs. According to the Kaiser Commission Survey on
Medicaid for the 2011 year, both Illinois and Wisconsin charge co-payments to
Medicaid enrollees with incomes in excess of 150% of the federal level.
Bottom line, even for states not adopting the Affordable Care Act
Medicaid expansion standards, there will still be an increase in their Medicaid
enrollment for the following four reasons:
- National insurance mandate requires insurance, so those who are of low income will become enrolled on Medicaid
- Federal Subsidies through the insurance exchanges
- Ease of enrollment process which integrates Medicaid and the insurance exchange offerings
- In plain English, there will continue to be growth in Medicaid enrollment as long as there are so many people who are poor in this country
And this is enough complexity and regulation analysis for a single setting
so the healthpolicymaven is signing off.
This article was written by Roberta E. Winter, MHA, MPA and may be freely
shared, with proper acknowledgement.
Additional sources for this article include the Center for Medicare and
Medicaid- Medicaid Overview dated September 11, 2012 and the Kaiser Family
Foundation Commission on Medicaid and the Uninsured report in November 2012.
