Tag: Medicaid Reform

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The bill that would cover kids who don’t have citizenship documentation was modified to not give politicians running for re-election issues.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Gov. Phil Murphy announced his intention to expand New Jersey’s Medicaid program to cover the state’s nearly 90,000 uninsured children — including those who are undocumented — as part of his budget address in February. He highlighted his “cover all kids” pledge again in late March at an event in Passaic with U.S. Rep. Bill Pascrell (D-9th) and a half-dozen state legislators and administration staff.

Last Tuesday, Murphy privately signed a revised “cover all kids” bill — which eliminates waiting periods and out-of-pocket costs for most families and provides $20 million to help cover the state’s additional costs — with no statement or fanfare. It was one of eight spending measures that officials said needed his OK before he approved the state’s $46.4 billion spending plan for the 2022 fiscal year, which began Thursday.

While the changes to Medicaid, also known as NJ FamilyCare, will benefit tens of thousands of low-income families, it is not clear how much — or how soon — it will truly help immigrant children. Advocates estimate there are at least 53,000 uninsured kids in New Jersey who qualify for the program economically but are not enrolled, and more than 18,000 of those children are undocumented. Advocates say the number of undocumented children could be much higher because no one is exactly sure how many are living in New Jersey.

No reference to undocumented kids

Unlike previous versions of the bill, the one passed almost unanimously by the Senate and Assembly and signed by Murphy does not mention undocumented or immigrant children. According to several people involved with the process, the language was changed so that lawmakers — who are all up for reelection this year, along with the governor — did not have to be on record voting for a measure that uses public dollars to fund health insurance for undocumented individuals.

Longtime legislative champions of expanding the Medicaid program to include undocumented youngsters said in a statement that the COVID-19 pandemic underscored the importance of insurance coverage and access to proper medical care. They also suggested their work was not done.

“We must keep working towards our goal of providing New Jersey families with quality, affordable health insurance if we want as many residents as possible to receive the care they both need and deserve,” read the statement from Sen. Joe Vitale (D-Middlesex) and Assembly Democrats Yvonne Lopez (Middlesex), Dan Benson (Mercer) and Gordon Johnson (Bergen). “Eliminating wait times and premiums while further promoting this important program will help us achieve this goal.”

Cumbersome process

Some stakeholders said that parents will now be able to enroll children who lack legal residency, but the new process is cumbersome for both the family and state regulators. Under the changes, parents of undocumented children would need to sign them up through a revised FamilyCare Advantage program, in which they are required to pay the full cost of the coverage, and then could apply for a “hardship waiver” to excuse these expenses after they were enrolled.

Administration officials said providing health insurance to undocumented children remains a priority for Murphy and noted the plan was proposed in two phases, with the second — focused on immigrant youngsters — still pending. Participation in Medicaid, which now covers nearly 2 million New Jerseyans, grew 17% between March 2020 and March 2021, according to state figures.

The state Department of Human Services (DHS), which oversees Medicaid, did not issue a formal statement on Murphy’s signing of the bill, but acting Commissioner Sarah Adelman added her support on Twitter. Adelman, who previously worked with the New Jersey Association of Health Plans, praised the 15-year effort of sponsors and advocates and noted “We will #CoverAllKids.”

‘This new expansion of NJ FamilyCare puts New Jersey one big step closer to universal coverage for all, starting with our kids.’

In a written response to questions from nonpartisan legislative staff about spending on Medicaid, DHS officials said this spring that state officials will begin planning how to include undocumented children this year, but coverage for these families may not be available until the start of fiscal year 2023 next summer. The department also estimated the cost of this year’s changes could reach nearly $70 million, far more than the $20 million provided in the new budget.

No immediate access?

The DHS timeline squares with the expectations of Maura Collinsgru, the health care policy leader at New Jersey Citizen Action, one of several groups that have long fought to expand Medicaid access, especially for children. A plan unveiled in 2018 by New Jersey Policy Perspective (NJPP), another advocate for expansion, outlined mechanisms similar to those Murphy approved and predicted the changes would cost less than $70 million annually.

“This new expansion of NJ FamilyCare puts New Jersey one big step closer to universal coverage for all, starting with our kids,” something now in place in seven other states, Collinsgru said. “If the pandemic taught us anything, it is having access to health care is essential to our health and economic well-being. By increasing access to coverage, New Jersey can help close the health and wealth gaps that persist in communities of color.”

The new law (S-3798) eliminates a 90-day waiting period for some children to access Medicaid and ends the use of premiums or copays for families who earn less than 350% of the federal poverty level, or less than $6,400 a month for a family of three. It also calls for state officials to enhance and coordinate public outreach around Medicaid and the state’s health insurance exchange, which sells subsidized commercial plans to those who earn too much to qualify for Medicaid but aren’t covered through work.

How it would work

The changes also restart the FamilyCare Advantage program, which allows those who earn more than 350% of the poverty level to purchase this state coverage for their children at cost. This part of Medicaid, which had been unfunded for years, could be used to insure undocumented children, some stakeholders said, but the cost could also be prohibitive for some immigrant families. A “hardship waiver” process was also added to the law, but applying for this option requires additional time and paperwork.

While it does not mention undocumented children in the way previous versions of the legislation did, the law Murphy signed clearly notes: “No child who applies for enrollment in the program who otherwise meets the eligibility criteria for enrollment shall be denied immediate enrollment for any reason.”

That brings hope to many of those who have long advocated to provide undocumented children better insurance options. “All kids in New Jersey deserve access to affordable, high-quality health coverage,” said Brittany Holom-Trundy, an NJPP senior policy analyst. She praised the state for making “an important investment in the state’s future and the long-term health of New Jersey families,” and said she looks forward to working with the administration and health care leaders on “building the best health care system possible for all children in the Garden State.”

Clipped from: https://www.njspotlight.com/2021/07/without-saying-so-nj-expands-medicaid-to-undocumented-children/

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Indiana lawmakers sent a letter to HHS Secretary Becerra requesting documentation and correspondence related to the decision to nullify the approved Indiana waiver.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

SOUTHERN INDIANA — All of Indiana’s Republican members of Congress signed off on a letter delivered Thursday opposing Democratic President Joe Biden’s administration’s block of the state’s work requirements for Medicaid recipients.

The U.S. Department of Health and Human Services informed state officials last week that the Indiana Gateway to Work Program, which includes an employment mandate, risks “significant coverage losses and harm to beneficiaries” and does “not promote the objectives of the Medicaid program,” according to the Associated Press.

Those requirements are included in Gov. Eric Holcomb’s 2019 Healthy Indiana Plan program, which was approved by former President Donald Trump’s administration.

But the program was halted during the pandemic after a challenge through a federal lawsuit.

According to the AP, the agency’s response referenced the time and paperwork required for Medicaid recipients to receive coverage. The agency stated the Gateway to Work program would “influence the behavior of a very small number of individuals, while risking coverage loss for many.”

The letter sent Thursday by the Republican lawmakers and dispersed via a news release was addressed to Xavier Becerra, secretary for the agency.

“We write today to express our dismay that, under your watch, the Centers for Medicare & Medicaid Services (CMS) withdrew authorities enjoyed by the State of Indiana through its Healthy Indiana Plan (HIP) that permit our state to determine appropriate work and community engagement requirements for its Medicaid recipients,” Indiana’s Republican Congressional members wrote in the letter.

Those who signed the letter include Sen. Todd Young and Sen. Mike Braun, as well as Rep.Trey Hollingsworth.

“Indiana’s Gateway to Work program aims to require Healthy Indiana Plan members to report 20 hours of work, volunteer, school and other activities every month,” the members of Congress wrote in the letter. “CMS has not allowed the state of Indiana to fully implement the program, even while our state’s Governor has noted that the Gateway to Work program has the potential to ‘help many Hoosiers.'”

The Republicans go on to infer that it’s “curious” that the Biden administration is resorting to fear tactics by “prematurely” rescinding the program before the U.S. Supreme Court issues a decision.

They focus on a part of the agency’s response stating that the pandemic and its aftermath would make the work or volunteer requirements “infeasible.”

“As of May, Indiana’s unemployment rate stands at 4 percent – well below the national average – despite the challenges associated with the pandemic’s recovery,” they state in the letter. “Our state has low unemployment, employers looking to hire, educational and training opportunities abound, and yet your agency is making decisions to curtail our state’s ability to connect our Medicaid recipients to a network of community engagement that makes sense to Hoosiers.”

The letter concludes with a request for a response by July 12 to include documentation and communications regarding the decision.

Indiana’s plan included exemptions for people 60 or older, those with medical problems and people who are primary caretakers of young or disabled children.

According to the AP, more than 130,000 Hoosiers were predicted to be affected by the requirements as of 2019. Other states have attempted to implement similar restrictions, which were blocked by federal court orders.

Clipped from: https://www.newsandtribune.com/news/indiana-republicans-oppose-biden-administrations-block-of-medicaid-work-rules/article_1fdd2ab8-dabc-11eb-a936-0b05bc6e0a93.html

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The plaintiffs who lost their bid to force the state to expand despite no funding for it will get their chance before the Missouri Supreme Court.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Clipped from: https://www.kshb.com/news/local-news/missouri-supreme-court-to-hear-medicaid-expansion-lawsuit

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The Biden HHS is now de-authorizing individual components it doesn’t like from waivers that were approved years ago.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

— CMS has told four states their 1115 waivers no longer apply

WASHINGTON — The Biden administration’s decision to repeal Medicaid work requirement waivers in four states is getting mixed reviews from the health policy community.

Work requirements “definitely can be a barrier to access, and that is something that we definitely have to avoid at all costs,” said Ada Stewart, MD, president of the American Academy of Family Physicians, in a phone interview. “They could end up doing harm to patients who are at most need of Medicaid.”

Nina Schaefer, senior research fellow in health policy at the Heritage Foundation, a right-leaning think tank here, disagreed. “The whole purpose of a waiver is for states to experiment with different approaches on how they want to administer the Medicaid program,” she said in a phone interview. “There has been a lot done with work requirements on other welfare programs, so why not Medicaid? … The idea of welfare is not to have a life of permanent welfare, but as a ladder to move out of the welfare hole. Working and getting higher income — those types of things should be rewarded, not be seen as a negative.”

Last week, CMS officials notified Medicaid directors in Arizona and Indiana that they were withdrawing approval for Medicaid work requirements in those states. The administration also took similar action in New Hampshire and Arkansas in March, although those states are both appealing that action in a case now before the Supreme Court, according to Bloomberg Law.

The waivers, which were granted by the Trump administration under the 1115 waiver program, generally mandate that Medicaid enrollees show that they are participating in “community engagement” activities, which could include employment (at least 80 hours per month), job training, school enrollment, or volunteer work. The policies also come with exemptions — in Arkansas, for example, the requirement exempted students, the disabled, persons responsible for full-time care of a child or other family member, and pregnant women.

In her June 24 letter to Arizona Medicaid director Jami Snyder, CMS administrator Chiquita Brooks-LaSure noted that per federal law and regulations, “CMS may withdraw waivers or expenditure authorities if it ‘find[s] that [a] demonstration project is not likely to achieve the statutory purposes.'”

After noting the effects that the pandemic has had on the Medicaid program — including the increased unemployment and lack of economic opportunities as well as the long-term effects of COVID infection that require ongoing medical care — she continued, “At a minimum, in light of the significant risks and uncertainties described above about the adverse effects of the pandemic and its aftermath, the information available to CMS does not provide an adequate basis to support an affirmative judgment that the community engagement requirement is likely to assist in promoting the objectives of Medicaid.”

“Accordingly, CMS is hereby withdrawing its approval of that portion of the January 18, 2019 amendment that permits the state to require work and community engagement as a condition of eligibility under the [Medicaid] demonstration.”

The CMS letter to Indiana Medicaid director Allison Taylor contained similar sentiments. “We do not have evidence before us that suggests that the state has measures in place that are likely to reduce the risks of Indiana’s demonstration project resulting in substantial coverage losses at a time when losing access to healthcare coverage would cause significant harm to beneficiaries,” Brooks-LaSure wrote.

“CMS has determined that, on balance, the authorities that conditionally permit Indiana to require community engagement as a condition of continued eligibility are not likely to promote the objectives of the Medicaid statute. Therefore, we are withdrawing the community engagement authorities that were conditionally approved in the October 26, 2020, extension approval of the HIP [Healthy Indiana Plan] demonstration.”

This withdrawal of permission occurring after the waiver has already been approved opens a real Pandora’s box, according to Schaefer. “What is a precedent is that the government would now reopen what was an agreed-to contract between the federal government and the state regarding the provision of the waivers,” she said. “Is this a way that waivers are going to move in future administrations, where new administrations now reopen the Biden administration’s waivers and say, ‘OK, we don’t agree with these policies and we’re going to stop them again?’ That will have a real chilling effect on innovation at the state level.”

But Gary Rosenfield disagreed. “It could open a Pandora’s box, but when it’s bad policy, that is a Pandora’s box that needs to be opened,” said Rosenfield, senior vice president at ConsejoSano, a healthcare technology company specializing in culturally-aligned outreach to Medicaid plan members. “It’s targeting people who don’t necessarily have voices, and it’s taking the wrong approach … The whole notion that someone is sitting around saying, ‘I want to be on Medicaid so I’m not going to work’ is, in my opinion, a ridiculous thing. Statistics show that people who aren’t aged, blind, or disabled — the vast majority of them are working.”

“As long as the Biden administration makes it clear why they’re reversing the policy, and why it was bad policy to begin with, and sells it and justifies why they’re doing it … they could do it in a way that would make it defensible,” Rosenfield said, speaking during a phone interview at which a public relations person was present.

Thomas Johnson, executive director of the Population Health Alliance, a trade organization for groups interested in population health management, said in an email that although his organization has not taken a position on work requirements, “I haven’t seen any evidence from any state that has resulted in any goals being reached from supporters of such requirements.” In addition, “I think there were a number of challenges for enrollees around the country. In Arkansas, the state was solely reliant upon an online system for enrollees entering required information, and that state has the largest gap for access to the internet in the country.”

Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

Clipped from: https://www.medpagetoday.com/publichealthpolicy/medicaid/93348

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The proposed use of community engagement requirements to get Medicaid managed care (vs fee for service) is being targeted by opponents as a violation of the equal access clause of SSA.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

For the most part, Arkansas has been successful in navigating state politics and the federal waiver process to expand Medicaid coverage for its residents, albeit with that navigation resulting in some dubious policy choices. Arkansas intermittently added waiver features such as work and community engagement requirements, premium obligations for enrollees with household incomes above 100 percent of the federal poverty level, and health independence accounts (a swiftly discontinued feature that was operationally flawed) to achieve the required supermajority vote in both state legislative chambers to continue funding authorization for Medicaid expansion.

However, the major and most innovative feature of the state’s Medicaid expansion has been the use of “premium assistance”—a long-standing option for Medicaid but made feasible by standardization of the essential health benefit. Instead of enrolling eligible individuals in the Medicaid fee-for-service program or managed care organizations, Arkansas used Medicaid dollars to purchase individual market qualified health plans (QHPs) available on the Affordable Care Act’s newly established health insurance Marketplace. By doing so, the state unquestionably met the Medicaid “equal access” requirement—the requirement that payments are “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area” for the expansion population.

Arkansas’ expansion program is currently undergoing another facelift with the passage of enabling legislation for Arkansas Health and Opportunity for Me, or ARHOME . This version of Medicaid expansion still sits on the chassis of premium assistance, but it incorporates incentives for “full-time work and attainment of economic independence” and “encourages personal responsibility for individuals to demonstrate that they value healthcare coverage and understand their roles and obligations in maintaining private insurance coverage.” Failure to participate in so-called “economic independence incentives,” including work and community engagement, does not result in loss of coverage as it did before. Courts and the Biden administration have closed that door. Instead, as initially proposed in the enabling legislation and as previously stated by supporters in remarks to the news media, an ARHOME enrollee in a QHP could be moved into Medicaid fee-for-service for failure to participate.

Evaluating The Premium Assistance Model

Being moved from a QHP to the Medicaid fee-for-service program could certainly be viewed as a penalty. After all, the stigma of Medicaid has been documented and is among the many reasons that Arkansas opted for a premium assistance model in the first place. The federally required evaluation of the Health Care Independence Program—the first iteration of expansion in Arkansas that was also known as the “Private Option”—showed that Medicaid enrollees in QHPs experienced better access—both perceived and actual—and higher-quality care than enrollees in fee-for-service. This is not at all surprising: It follows the mantra, “You get what you pay for.” The evaluation found that physician payment rates for outpatient services were about 95 percent higher in each of the three years under study for enrollees in a QHP compared to their Medicaid fee-for-service counterparts. For inpatient stays, there was a 53 percent difference in payment rates per discharge, inclusive of supplemental payments above the base rates.

These cost-related findings from the evaluation have been used by some Arkansas legislators to argue that the state should save its money by ending the premium assistance approach and moving all of the enrollees into Medicaid fee-for-service. In fact, a group of legislators filed a bill to do exactly that. Fortunately, the majority of the Arkansas General Assembly has not been tempted to move in that direction, confident that the premium assistance approach has not only improved quality and access for expansion enrollees but has also benefitted the individual insurance market by promoting enhanced competition and stabilizing premiums. Equally if not more attractive are the fiscal benefits to the state budget and providers from higher QHP reimbursement rates, which have shored up the state’s rural hospitals (only one has closed in Arkansas in recent years, compared to 57 in surrounding states that did not expand).

Medicaid Premium Assistance Versus Fee-For-Service

The ARHOME waiver application appears to have walked back on “reassignment” of QHP enrollees to Medicaid fee-for-service for failure to participate in economic independence incentives as originally proposed. The application indicates both a delay in implementation until 2023 and a regulatory process for defining what it means to be an “inactive” beneficiary for purposes of reassignment. Regardless, the waiver feature as originally proposed has sparked a debate about the Medicaid “equal access” requirement and whether compliance is in question.

Evaluation of the premium assistance model in Arkansas established that the QHPs provided beneficiaries with enhanced access and quality. Ideally, state officials would have used the evaluation findings to acknowledge and address what led to the disparities in access and quality—that is, the insufficiency of Medicaid fee-for-service payments. Instead, the ARHOME waiver application now proposes to evaluate “whether beneficiaries enrolled in a QHP recognize and value the health coverage as insurance above and beyond Medicaid medical assistance.” Federal officials should vigilantly examine compliance with Medicaid “equal access” requirements before considering waiver proposals from any state that would reassign a beneficiary to a care delivery strategy with lower provider payments.

To be fair, Arkansas Medicaid officials have launched a systematic review of reimbursement rates in response to a 2019 executive order issued by the governor, and the review must consider “the availability and access to care in each area of the state.” Prior to the executive order, there was no schedule or standardized process for rate review, despite the state’s being subject to a consent decree that requires court review of rate changes. In place since 1993, the consent decree is the result of a lawsuit brought by provider groups, and, while intended to ensure sufficient Medicaid payment rates, rates have actually stagnated under court oversight, with some providers not seeing rate increases in more than a decade.

Consent decrees resulting from “equal access” lawsuits have been at risk of being dissolved since the US Supreme Court held in 2015 that health care providers have no right to sue to enforce the terms of the federal Medicaid statute. To date, Arkansas Medicaid officials have not moved to dissolve the consent decree, but recent legislation passed by the Arkansas General Assembly requires the state to seek reconsideration of the consent decree in light of the 2015 Supreme Court decision.

Back And Forth On “Equal Access” Monitoring

Following the 2015 decision, the Obama administration issued regulations requiring states to regularly submit reports documenting their monitoring of access for Medicaid enrollees and to prospectively submit for federal review any proposed rate reductions or changes that could result in diminished access. However, as documented in this Health Affairs blog post, in 2019 the Trump administration proposed regulations that would have abandoned efforts to ensure some level of state-based monitoring. What is more, the proposal fully retreated from prospective federal review of Medicaid provider payment reductions. Interestingly, the Trump administration’s proposed regulations were never finalized, which means that the Biden administration could rescind the proposed rule and reexamine whether the Obama-era regulations are effective at ensuring access.

Such an examination should consider the following questions at minimum:

Are State-Based Assessments Of Payment Rates And Monitoring Of Access Rigorous Enough To Determine Compliance With The Law?

As has been the case with demonstration waiver evaluations, the administration should be clear about the data collection, methodological, and measurement expectations for state reporting. It should also consider requiring an independent assessment.

How Do Medicaid Rates Compare To Both Medicare And Commercial Insurance Payment Rates?

Data to enable these types of comparisons are increasingly available. Both states and the federal government have invested in state-based all-payer claims databases, and they should use them as an available tool to enhance the assessment.

Should The Administration Establish A Standard Rate-Setting Methodology And Network Adequacy Requirements For Medicaid, Irrespective Of The Care Delivery Strategy?

Clearly Arkansas’ fee-for-service rates fall short of meeting the Medicaid “equal access” provision, and many other states report similar disparities, despite federally required access monitoring and reporting requirements. While offering the opportunity for more comprehensive measuring and stringent monitoring of access and quality contractually, managed care strategies similarly disappoint on the payment front. State requirements for managed care plans to offer minimum provider reimbursement—if there are requirements—are often tethered to Medicaid fee-for-service rates. The use of Medicaid premium assistance through QHPs by definition meets the “equal access” standard. Should we not expect more of other Medicaid delivery strategies?

The “equal access” quandary might not be at the top of the Biden administration’s policy priorities, but Arkansas’ waiver proposal is certain to provoke questions about how the administration can possibly square approval of a reassignment feature while advancing broadly applicable equal-access regulations. As the administration negotiates with states on one-off waiver features, it should be careful not to send mixed messages and erode long-established—albeit ill-defined and tepidly enforced—beneficiary protections engrained in Medicaid law.  

Clipped from: https://www.healthaffairs.org/do/10.1377/hblog20210624.640822/full/