Medicaid Changes from the Accountable Care Act-Whether or Not Your State Adopted the Revised Eligibility Guidelines

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:

1. Health care for disabled workers
2. Family planning extension (more on this later)
3. Take charge family planning (whoa Nelly)
4. Psychologically indigent inpatient program (example-homeless folks)
5. Involuntary treatment act (hopefully this will apply to some of the nut-jobs who manage to obtain machine guns)
6. Kidney disease program (for those on dialysis)
7. ADATSA(Alcohol Drug Addiction Treatment Support Act)
8. Social Security Income qualifiers based on their low income status
9. Basic Health Plan qualifiers (subsidized medical insurance program for WA state residents with incomes no more than 200% of the Federal Poverty Level)
10. Medical Care Services Program (This is a managed care program run by the WA State Health Care Authority)
11. Medicaid qualifiers by virtue of low-income status
12. 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:

1. Essential health benefits,
2. Essential health benefits reference plan
3. Base benchmark plan, benchmark
4. Alternative benefits plans

The benchmark plan must cover the following criteria in the benefit design:

1. BCBS-This refers to the bench mark equivalent coverage based on Blue Cross/Blue Shield plans
2. EPSTD-Early and Periodic Screening, Diagnosis, and Treatment Program which applies to children under 21 who are covered by the state Medicaid program
3. Non emergency transportation-What is this, a taxi to town?
4. Family planning services & supplies-AKA birth control options

People who are Exempt from the Benchmark Criteria and Eligible for Standard Medicaid Benefits include:

1. Pregnant women 
2.  Individuals who qualify for Medicaid based on being blind or disabled
3. Dual eligible enrollees, which is a category of people on both Medicare and Medicaid plans 
4.  Terminally ill hospice patients
5. 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 
6.  TANF/Section 1931 enrollees, which is for parents and caretakers of incapacitated persons
7. Medically frail individuals, including those with disabilities that impair ability in one or more activities of daily living
8. Children in foster care 
9.  Individuals who qualify for LTC (long term care) services based on their medical condition
10. Individuals who only qualify for emergency care (?) 
11.  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:

1. Ambulatory services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. 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:

1. Pregnant women
2. Terminally ill people in hospice care
3. Medicaid enrollees who are already spending most of their income on health care costs during a hospitalization
4. Family Planning Services and supplies
5. Services provided by Indian Health Care entities for American Indians
6. Emergency services
7. 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:

1. National insurance mandate requires insurance, so those who are of low income will become enrolled on Medicaid
2. Federal Subsidies through the insurance exchanges
3. Ease of enrollment process which integrates Medicaid and the insurance exchange offerings
4. 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.

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[1] http://www.hca.wa.gov/me/documents/Bnchmrk_Benefit_Cost_Sharing_December_2012.pdf

[2] http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=43

[3] http://www.statehealthfacts.org/profileind.jsp?cat=4&sub=52&rgn=49