GOP-led ex­pan­sion states test CMS’ flex­i­bil­ity on Med­i­caid waivers

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Repub­li­can-led states that have al­ready ex­panded Med­i­caid now are com­ing back to the Obama ad­min­is­tra­tion with re­quests to make their ex­pan­sion pro­grams more con­ser­va­tive, in­clud­ing higher cost-shar­ing, work re­quire­ments and cov­er­age time lim­its. Th­ese moves may test the lim­its of the ad­min­is­tra­tion’s flex­i­bil­ity and could lead to roll­backs in Med­i­caid ex­pan­sion across the coun­try.

Forth­com­ing waiver re­quests from Ari­zona, Michi­gan, Ohio and Iowa are rais­ing red flags for the ad­min­is­tra­tion. Even Repub­li­can sup­port­ers of th­ese pro­pos­als ac­knowl­edge that the pro­vi­sions are likely to dis­cour­age thou­sands of low-in­come peo­ple from sign­ing up for Med­i­caid cov­er­age.

Th­ese moves come as Repub­li­can gov­er­nors and law­mak­ers face grow­ing po­lit­i­cal pres­sure from con­ser­va­tives to ei­ther make their ex­pan­sion pro­grams tougher on ben­e­fi­cia­ries or end them en­tirely.

A CMS spokes­woman de­clined to com­ment on the emerg­ing pro­pos­als, say­ing only that the re­quests have not been for­mally sub­mit­ted.

In Oc­to­ber, Ari­zona plans to sub­mit a pro­posal re­quir­ing pre­mium con­tri­bu­tions for ben­e­fi­cia­ries both above and be­low 100% of the fed­eral poverty level, a job search re­quire­ment and the ter­mi­na­tion of Med­i­caid benefits for “able-bod­ied adults” af­ter they have re­ceived cov­er­age for five years. Ari­zona’s new Repub­li­can gover­nor, Doug Ducey, who op­posed Med­i­caid ex­pan­sion be­fore be­com­ing gover­nor, signed the lit­tleno­ticed law in March.

So far, the CMS has not given per­mis­sion to im­pose pre­mi­ums on peo­ple be­low the poverty line with the threat of cut­ting off cov­er­age. It has not ap­proved any ben­e­fit time lim­its, and it has re­jected work re­quire­ments. Most peo­ple on Med­i­caid al­ready are em­ployed or are part of work­ing house­holds.

But Ari­zona’s Repub­li­can law­mak­ers de­cided to seek the work re­quire­ment and time lim­its any­way. “They want to keep it in front of the fed­eral gov­ern­ment as an is­sue,” said Mon­ica Higuera Coury, an of­fi­cial in the state’s Med­i­caid agency.

Ad­vo­cates for the poor in Ari­zona are ner­vous. “Forc­ing some­one to look for a job, or kick­ing them out of the pro­gram af­ter five years un­der­cuts the whole pur­pose of the pro­gram, which is to en­sure ac­cess to health­care,” said Ellen Katz, direc­tor of the Phoenix-based Wil­liam E. Mor­ris In­sti­tute for Jus­tice.

In Michi­gan, a 2013 law au­tho­riz­ing the Med­i­caid ex­pan­sion re­quired that the state must re­ceive a CMS waiver by Dec. 31, 2015, to boost ben­e­fi­ciary cost-shar­ing to as much as 7% of in­come af­ter they have been in the pro­gram for four years.

If the CMS does not grant the waiver, the state must ter­mi­nate its Med­i­caid ex­pan­sion, which has ex­tended cov­er­age to 600,000 Michi­gan­ders.

Un­der the cur­rent ex­pan­sion pro­gram, dubbed Healthy Michi­gan, ben­e­fi­cia­ries with in­comes be­tween 100% and 138% of the fed­eral poverty level pay 3% to 5% of their in­come for pre­mi­ums and cost-shar­ing.

The state law also says that low­in­come peo­ple who choose not to pay the higher pre­mi­ums, and thus have to leave the pro­gram, could sign up for cov­er­age through the fed­eral in­sur­ance ex­change.

Fed­eral of­fi­cials have told the state that low-in­come peo­ple can’t af­ford to pay 7% of their in­come for cov­er­age.

“The first year of the Healthy Michi­gan Plan demon­strated the suc­cess of the pro­gram, and we will con­tinue con­ver­sa­tions with CMS to reach pos­i­tive out­comes for our res­i­dents,” a spokes­woman for Michi­gan’s Med­i­caid agency said.

Kim Si­bil­sky, CEO of the Michi­gan Pri­mary Care As­so­ci­a­tion said it’s im­por­tant to pre­serve the ex­pan­sion. “Our great­est con­cern is that with­out CMS’ ap­proval of the sec­ond waiver, the pro­gram cur­rently cov­er­ing nearly 600,000 Michi­gan res­i­dents could go away,” she said. “We strongly urge CMS to ap­prove the waiver and al­low this crit­i­cal pro­gram to con­tinue.”

In Ohio, the GOP-led House has pro­posed that ben­e­fi­cia­ries with in­comes be­tween 100% and 138% of poverty be re­quired to put 2% of their in­come into health sav­ings ac­counts or lose cov­er­age.

It also pro­posed job search and train­ing pro­grams. The pro­posal is now be­ing con­sid­ered by the Se­nate. About 500,000 Ohioans have re­ceived cov­er­age through the state’s ex­pan­sion.

Ad­vo­cates for the poor are alarmed. “Pro­pos­als that rec­om­mend cost­shar­ing would most cer­tainly dis­rupt con­ti­nu­ity of care,” said Deanna Moore, a spokes­woman at the Cen­ter for Health Af­fairs, which ad­vo­cates for Ohio hos­pi­tals.

“We’ve seen in the lit­er­a­ture that even sur­pris­ingly small cost-shar­ing re­quire­ments, like $5 per visit, can de­ter some­one with a low in­come from seek­ing nec­es­sary care,” Moore said.

Ari­zona Gov. Doug Ducey in March

signed a bill to tighten state

re­quire­ments for Med­i­caid el­i­gi­bil­ity,

lim­it­ing the ex­panded health in­sur­ance

pro­gram to fewer res­i­dents.

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