Med­i­caid cost-shar­ing could re­duce en­roll­ment, ex­perts warn

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Ea­ger to get Repub­li­can-led states to ex­pand Med­i­caid, the Obama ad­min­is­tra­tion seems in­creas­ingly will­ing to al­low them to im­pose new pre­mi­ums and cost-shar­ing on very low-in­come adults. But some ex­perts say those costs likely will de­ter el­i­gi­ble peo­ple from sign­ing up and seek­ing needed health­care. In ad­di­tion, they warn the added ad­min­is­tra­tive costs will ex­ceed ben­e­fi­ciary pay­ments.

Last De­cem­ber, the CMS al­lowed Iowa to im­pose a monthly pre­mium of up to $5 a month for adults with in­comes as low as 50% of the fed­eral poverty level, although it barred the state from can­cel­ing cov­er­age for fail­ure to pay. In May, In­di­ana’s Repub­li­can Gov. Mike Pence pro­posed charg­ing a monthly “con­tri­bu­tion” rang­ing from $3 to $15 for peo­ple un­der the poverty line; those who don’t pay would lose vi­sion and den­tal ben­e­fits and would be li­able for co­pay­ments out of pocket. A CMS decision on In­di­ana’s waiver pro­posal is pend­ing.

Arkansas, which pre­vi­ously adopted a Med­i­caid ex­pan­sion model us­ing pri­vate plans, now has asked the CMS if it can re­quire peo­ple with an­nual in­comes be­tween 50% and 99% of the fed­eral poverty level to con­trib­ute $5 a month to health sav­ings ac­counts. Fail­ure to pay would trig­ger co­pays. That waiver re­quest is pend­ing as well.

The trend is trou­bling to con­sumer ad­vo­cates and health­care providers. “En­rollees might not un­der­stand that they won’t be dis­en­rolled or that they can get a hard­ship ex­emp­tion,” said Dee Ma­han, Med­i­caid pro­gram di­rec­tor at Fam­i­lies USA.

Providers in Arkansas are wor­ried that re­quir­ing co­pays for low-in­come Med­i­caid pa­tients could hurt care and jeop­ar­dize the suc­cess the state has seen in re­duc­ing its unin­sured ranks. With nearly 200,000 Arkansans gain­ing Med­i­caid cov­er­age, hos­pi­tals say their bot­tom lines have im­proved. “Th­ese are such low-in­come fam­i­lies (that) cost-shar­ing is go­ing to be a bar­rier to care,” said Dr. Rox­ane Townsend, CEO of the Univer­sity of Arkansas for Med­i­cal Sciences Med- ical Cen­ter in Lit­tle Rock.

“We’re al­ready see­ing in those el­i­gi­ble for sub­si­dized ex­change cov­er­age that when they have to pay a co­pay, even if it’s just a lit­tle bit, they are not sign­ing up,” said Daniel Ri­ley, UAMS’ chief fi­nan­cial of­fi­cer.

Other ex­perts ques­tion the wis­dom of hav­ing states col­lect and track pre­mium and health sav­ings ac­count con­tri­bu­tions. “Pre­mium col­lec­tion costs and mon­i­tor­ing out-of-pocket caps may ex­ceed the value of pre­mi­ums,” Tri­cia Brooks, a se­nior fel­low at Ge­orge­town Univer­sity’s Cen­ter for Chil­dren and Fam­i­lies, wrote in an anal­y­sis last De­cem­ber.

Vir­ginia pre­vi­ously im­posed a $15 per child monthly pre­mium on fam­i­lies with in­comes be­tween 150% and 200% of poverty. The state later elim­i­nated the pre­mi­ums be­cause fam­i­lies strug­gled to pay them and be­cause it was spend­ing $1.39 for ev­ery dol­lar it col­lected, ac­cord­ing to Brooks’ re­port.

Sim­i­larly, a decade ago, Med­i­caid en­roll­ment in Ore­gon plum­meted 77% in less than 3 years after the state re­quired ben­e­fi­cia­ries to make pre­mium con­tri­bu­tions, in­creased co­pay­ments and im­posed penal­ties for non­pay­ment.

An of­fi­cial in Michi­gan, which ex­panded Med­i­caid, ac­knowl­edged her state will in­cur ad­di­tional ad­min­is­tra­tive costs from charg­ing monthly pre­mi­ums worth up to 2% of an­nual in­come for ben­e­fi­cia­ries earn­ing be­tween 100% and 138% of the poverty level. “There will be ad­di­tional ad­min­is­tra­tive ex­penses beyond what the costs would have been had we sim­ply ex­panded Med­i­caid,” said An­gela Minicuci, a spokes­woman for the Michi­gan Depart­ment of Com­mu­nity Health.

In May, In­di­ana’s Repub­li­can

Gov. Mike Pence pro­posed

charg­ing a monthly

“con­tri­bu­tion” rang­ing from

$3 to $15 for peo­ple un­der

the poverty line; those who

don’t pay would lose vi­sion

and den­tal ben­e­fits and would

be li­able for co­pay­ments

out of pocket.

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