Tag Archives: Medicaid Eligibility

1115 Medicaid Waivers: From Care Delivery Innovations to Work Requirements

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

http://www.commonwealthfund.org/publications/explainers/2018/apr/1115-medicaid-waivers#/utm_source=1115-medicaid-waivers-explainer&utm_medium=Facebook&utm_campaign=Health%20Coverage

After months of debate, the Medicaid program emerged from efforts to repeal and replace the Affordable Care Act (ACA) without major legislative changes. Now, however, the Trump administration is encouraging states to apply for waivers that place new conditions on Medicaid eligibility as well as additional costs on beneficiaries in the form of premiums and copayments at the point of service.

To better understand the continuing controversy over Medicaid, let’s take a look at the waiver program’s objectives and how states have used waivers in the past. Are recently proposed state waivers consistent with Medicaid’s underlying mission? And are federal and state authorities appropriately evaluating them for their impact on Medicaid populations?

What is a Medicaid Section 1115 waiver?

Medicaid grants states autonomy in how they run their programs. Under a provision of the Social Security Act, Section 1115, the U.S. Secretary of Health and Human Services (HHS) can waive federal guidelines on Medicaid to allow states to pilot and evaluate innovative approaches to serving beneficiaries. Most waivers are granted for a limited period and can be withdrawn once they expire.

States seek 1115 waivers to test the effects of changes both in coverage and in how care is delivered to patients. The Centers for Medicare and Medicaid Services (CMS), a government agency, reviews each waiver application to ensure not only that it furthers the core objective of Medicaid — to meet the health needs of low-income and vulnerable populations — but also that the proposed demonstration does not require the federal government to spend more on the state’s Medicaid program than it otherwise would.

However, a recent General Accountability Office (GAO) review found that, because of significant limitations, evaluations of 1115 demonstrations often do not provide enough information for policymakers to understand the waivers’ full impact.1 The GAO recommended that CMS establish procedures to ensure that all states submit final evaluation reports at the end of each demonstration cycle, issue criteria for when it will allow limited evaluations of demonstrations, and establish a policy for publicly releasing findings from federal evaluations.

How have 1115 waivers been used in the past?

States have been granted waivers throughout the 53-year history of Medicaid. Most waivers were small in scope until the 1990s, when states started to use them for a wide range of purposes, including to: expand eligibility, simplify the enrollment and renewal process, reform care delivery, implement managed care, provide long-term services and supports, and alter benefits and cost-sharing. Some states have used 1115 waivers to change the way care is delivered to Medicaid patients, like encouraging investments in social interventions. Oregon, for example, used its waiver to establish Coordinated Care Organizations — partnerships between managed care plans and community providers to manage medical, behavioral health, and oral health services for a group of Medicaid beneficiaries.

With the ACA’s enactment, a new category of low-income adults became eligible for Medicaid. After the Supreme Court ruled in 2012 that this eligibility expansion was optional for states, eight states applied for 1115 demonstration waivers from the Obama administration to test different approaches to expanding eligibility, including the introduction of premiums and copayments that exceeded federal guidelines. One of those states, Arkansas, has used Medicaid funds to purchase private health insurance for marketplace enrollees.

How are 1115 waivers changing?

With encouragement from the Trump administration, many states are applying for waivers to make employment, volunteer work, or the performance of some other service a requirement for Medicaid eligibility. The administration has also encouraged waivers to impose premiums and increases in cost-sharing.

States can take different approaches to work or service requirements. Some might require them only for the Medicaid-expansion population (working-age adults with incomes up to 138 percent of the federal poverty level), while other states might also require employment of the traditional Medicaid population.

As of early April 2018, three states — Kentucky, Indiana, and Arkansas — have received approval for work- or service-requirement waivers. Seven others have pending waivers for new applications, amendments to existing waivers, or requests for renewals or extensions.

In Kentucky — the first state to have its work-requirement waiver approved — affected beneficiaries must complete 80 hours per month of community-engagement activities, such as employment, education, job skills training, or community service. Documentation of meeting this requirement is required to remain eligible for coverage. Exemptions are granted to pregnant women, people considered medically frail, older adults, and full-time students. Indiana and Arkansas have received approval for similar waivers.

Shortly after Kentucky’s waiver was approved, attorneys representing 15 Medicaid beneficiaries sued the HHS secretary in federal court (Stewart v. Azar), arguing that the objective of promoting work is not consistent with Medicaid’s core purpose of “providing medical assistance (to people) whose income and resources are insufficient to meet the cost of necessary medical services.”2 The lawsuit’s outcome will affect whether some of the state demonstrations will be able to proceed.

What’s the bottom line?

The 1115 demonstration waiver program is intended to fulfill the primary purpose of Medicaid: to provide health care protection to poor and disabled Americans. The new waivers seeking to impose work or service requirements, as well as others that would impose lifetime coverage limits or premiums, should be fully and carefully evaluated to determine whether they meet this goal. In addition to state and federal evaluations, independent assessments of state demonstrations will be important to informing policymakers and the public about the waivers’ full impact.

 

Here’s how states are trying to overhaul Medicaid — without Congress

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , • Leave a comment

http://money.cnn.com/2018/01/18/news/economy/medicaid-state-waiver-requirements/index.html

Image result for Here's how states are trying to overhaul Medicaid -- without Congress

Work requirements are only the beginning.

Mandating Medicaid recipients work in order to receive benefits is in the spotlight right now, but states are seeking to make a host of other changes to their programs. These include requiring enrollees to pay premiums, limiting the time they can receive benefits, testing them for drugs and locking them out if they fail to keep up with the paperwork.

Many provisions would apply to working age, non-disabled adults who gained coverage under the Affordable Care Act’s Medicaid expansion. But several states also would require some who qualify under traditional Medicaid — very low-income parents, mainly — to meet these new rules.

Trump administration and state officials say these measures will help people gain independence and prepare them to purchase health insurance on their own. Critics, however, argue states are putting additional hurdles in place to winnow down their rolls.

“The practical impact of all these proposals is that it will knock people off of coverage,” said Patricia Boozang, a managing director at Manatt Health Solutions, a consulting firm.

Republicans have long wanted to overhaul the 53-year-old Medicaid program, which covers nearly 75 million mainly low-income children, parents, elderly and disabled Americans. The broadening of Medicaid to low-income adults under Obamacare — roughly 11 million have gained coverage under the health reform law’s Medicaid expansion provision — has further spurred GOP efforts.

Congress attempted last year to revamp the safety net program, hoping to sharply curtail federal support and turn more control over to the states. Studies showed that millions would lose coverage, helping to sink the measure in the Senate.

States, however, are undeterred. They are ramping up efforts to customize their Medicaid programs through the federal waiver process.

States have long had this power, but the Obama administration rejected any waivers with work requirements and only sparingly granted requests to tighten eligibility. Many of the states that used waivers tied provider payments to performance goals or expanded mental health and substance abuse services and eligibility, for instance. A few turned to waivers to implement alternative Medicaid expansion models that include charging premiums or enrolling recipients in private insurance and covering the premiums, for example.

Indiana, for example, broke new ground in 2015 by getting permission to levy premiums on some traditional Medicaid enrollees, such as very low-income parents, and to lock out expansion recipients above the poverty line for six months if they don’t keep up with their payments.

But the Trump administration has taken a different approach. Seema Verma, who leads the Centers for Medicare & Medicaid Services, sent a letter to governors hours after she was confirmed in March asking them to file waivers that promote a path to self-sufficiency. At least 10 states have responded with waivers that include work requirements and a host of other provisions. Last week, CMS granted Kentucky’s waiver to implement work requirements, marking the first time ever a state can mandate recipients work for their benefits.

Kentucky also can start charging its Medicaid enrollees monthly premiums ranging from $1 to $15, depending on income, and suspend some of those who fall behind on payments. The state will also provide recipients with a high-deductible health savings account, which it will fund, and offer incentives to purchase additional benefits, such as dental and vision coverage.

And the state can lock recipients out of the program for up to six months if they don’t renew their paperwork on time or promptly report changes in income that could affect their eligibility — the first time the federal government has granted such a request.

All told, Kentucky is expecting about 95,000 fewer people to be in its Medicaid program by the end of its five-year waiver period.

Kentucky joins Indiana, Michigan, Arizona, Montana and Iowa in gaining permission to charge premiums. However, states such as Maine and Wisconsin — that didn’t expand Medicaid — are also looking to levy premiums on certain enrollees, primarily low-income parents or childless adults.

Wisconsin also wants to implement additional changes, including drug testing and a 48-month time limit, after which the recipient loses coverage for six months. Months during which the enrollee works or participates in training programs wouldn’t count toward the limit. Utah, meanwhile, wants to impose a lifetime limit on coverage of 60 months. Arizona, Kansas and Maine also want to set caps on the length of time residents can be on Medicaid.

Other states want to reduce the income threshold for Medicaid expansion eligibility. Arkansas and Massachusetts have asked to cover adults only up to 100% of the poverty level, or roughly $24,600 for a family of four, rather than 138%, but the states would still get the enhanced federal match. Those who would fall off would be able to sign up for subsidized policies on the Obamacare exchanges, though consumer advocates say that coverage would be too pricey for most low-income Americans.

Each of these provisions is complicated and having to comply with multiple requirements could prove too much for some recipients, said MaryBeth Musumeci, an associate director at the Program on Medicaid and the Uninsured at the Kaiser Family Foundation.

“There’s a very real risk that eligible people can lose coverage,” she said.

Understanding the Intersection of Medicaid and Work

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/?utm_campaign=KFF-2018-The-Latest&utm_source=hs_email&utm_medium=email&utm_content=59811229&_hsenc=p2ANqtz–JERFINvucriGGpU1rflJEeJxuQPVDm8Wxcl7b-PGXeAoVUch8Oz-J5zdRyTzl09wIqr9zHKJO6Lrp-P6xvIdaGh3oKQ&_hsmi=59811229

Image result for medicaid

Medicaid is the nation’s public health insurance program for people with low incomes. Overall, the Medicaid program covers one in five Americans, including many with complex and costly needs for care. Historically, nonelderly adults without disabilities accounted for a small share of Medicaid enrollees; however, the Affordable Care Act (ACA) expanded coverage to nonelderly adults with income up to 138% FPL, or $16,642 per year for an individual in 2017. As of December 2017, 32 states have implemented the ACA Medicaid expansion.1 By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. While many have gained coverage under the expansion, the majority of Medicaid enrollees are still the “traditional” populations of children, people with disabilities, and the elderly.

Some states and the Trump administration have stated that the ACA Medicaid expansion targets “able-bodied” adults and seek to make Medicaid eligibility contingent on work. Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states are seeking waiver authority to do so.  These types of waiver requests were denied by the Obama administration, but the Trump administration has indicated a willingness to approve such waivers. This issue brief provides data on the work status of the nearly 25 million non-elderly adults without SSI enrolled in Medicaid (referred to as “Medicaid adults” throughout this brief) to understand the potential implications of work requirement proposals in Medicaid.  Key takeaways include the following:

  • Among Medicaid adults (including parents and childless adults — the group targeted by the Medicaid expansion), nearly 8 in 10 live in working families, and a majority are working themselves. Nearly half of working Medicaid enrollees are employed by small firms, and many work in industries with low employer-sponsored insurance offer rates.
  • Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work including illness or disability or care-giving responsibilities.
  • While proponents of work requirements say such provisions aim to promote work for those who are not working, these policies could have negative implications on many who are working or exempt from the requirements. For example, coverage for working or exempt enrollees may be at risk if enrollees face administrative obstacles in verifying their work status or documenting an exemption.

Data Findings

Among nonelderly adults with Medicaid coverage—the group of enrollees most likely to be in the workforce—nearly 8 in 10 live in working families, and a majority are working themselves. Because policies around work requirements would be intended to apply to primarily to nonelderly adults without disabilities, we focus this analysis on adults whose eligibility is not based on receipt of Supplemental Security Income (SSI, see methods box for more detail). Data show that among the nearly 25 million non-SSI adults (ages 19-64) enrolled in Medicaid in 2016, 6 in 10 (60%) are working themselves (Figure 1). A larger share, nearly 8 in 10 (79%), are in families with at least one worker, with nearly two-thirds (64%) with a full-time worker and another 14% with a part-time worker; one of the adults in such families may not work, often due to caregiving or other responsibilities.

Because states that expanded Medicaid under the ACA cover adults with family incomes at higher levels than those that did not, adults in Medicaid expansion states are more likely to be in working families or working themselves than those in non-expansion states (Table 1). Adults who are younger, male, Hispanic or Asian were more likely to be working than those who are older, female, or White, Black, or American Indian, respectively (Figure 2 and Table 2). Not surprisingly, adults with more education or better health were more likely to work than others (Figure 3 and Table 2). Perhaps reflecting job market conditions, those living in the South were less likely to work than those in other areas, though similar rates of enrollees in urban and rural areas were working (Table 2). 

Most Medicaid enrollees who work are working full-time for the full year, but their annual incomes are still low enough to qualify for Medicaid. Among adult Medicaid enrollees who work, the majority (51%) worked full-time (at least 35 hours per week) for the entire year (at least 50 weeks during the year) (Table 3).2Most of those who work for only part of the year still work for the majority of the year (26 weeks or more). By definition (that is, in order to meet Medicaid eligibility criteria), these individuals are working low-wage jobs. For example, an individual working full-time (40 hours/week) for the full year (52 weeks) at the federal minimum wage would earn an annual salary of just over $15,000 a year, or about 125% of poverty, below the 138% FPL maximum targeted by the ACA Medicaid expansion.

Many Medicaid enrollees working part-time face impediments to finding full-time work.  Among adult Medicaid enrollees who work part-time, many cite economic reasons such as inability to find full-time work (10%) or slack business conditions (11%) as the reason they work part-time versus full-time. Other major reasons are attendance at school (14%) or other family obligations (14%).

Nearly half of working adult Medicaid enrollees are employed by small firms, and many work in industries with low employer-sponsored coverage offer rates.  Working Medicaid enrollees work in firms and industries that often have limited employer-based coverage options. More than four in ten adult Medicaid enrollees who work are employed by small firms with fewer than 50 employees that will not be subject to ACA penalties for not offering coverage (Figure 4). Further, many firms do not offer coverage to part-time workers. Four in ten Medicaid adults who work are employed in industries with historically low insurance rates, such as the agriculture and service industries. A closer look by specific industry shows that one-third of working Medicaid enrollees are employed in ten industries, with one in 10 enrollees working in restaurants or food services (Figure 5). The Medicaid expansion was designed to reach low-income adults left out of the employer-based system, so, it is not surprising that among those who work, most are unlikely to have access to health coverage through a job.

Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work.  Even though individuals qualifying for Medicaid on the basis of a disability through SSI were excluded from this group, more than one-third of those not working reported that illness or disability was the primary reason for not working. SSI disability criteria are stringent and can take a long time to establish. People can have physical and/or mental health disabilities that interfere with their ability to work, or to work full-time, without those impairments rising to the SSI level of severity. Other analysis indicates that nearly nine in ten (88%) non-SSI Medicaid adults who reports not working due to illness or disability has a functional limitation, and more than two-thirds (67%) have two or more chronic conditions such as arthritis or asthma.3

30% of non-working Medicaid adults reported that they did not work because they were taking care of home or family; 15% were in school; 6% were looking for work and another 9% were retired (Figure 6). Women accounted for 62% of Medicaid enrollees who were not working in 2016, and parents with children under the age of 6 accounted for 17%.

Policy Implications

Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility. As with other core requirements, the Medicaid statute sets minimum eligibility standards, and states are able to expand coverage beyond these minimum levels. Prior to the ACA, individuals had to meet not only income and resource requirements but also categorical requirements to be eligible for the program. These categorical requirements provided coverage pathways for adults who were pregnant women or parents as well as individuals with disabilities, but other adults without dependent children were largely excluded from coverage. The ACA was designed to fill in gaps in coverage and effectively eliminate these categorical eligibility requirements by establishing a uniform income threshold for most adults. States are not allowed to impose other eligibility requirements that are not in the law.

Some states have proposed tying Medicaid eligibility to work requirements using waiver authority that may be approved by the Trump Administration. Under Section 1115 of the Social Security Act, the Secretary of HHS can waive certain provisions of Medicaid as long as the Secretary determines that the initiative is a “research and demonstration project” that “is likely to assist in promoting the objectives” of the program. The Obama administration did not approve waivers that would condition Medicaid eligibility on work on the grounds that they did not meet the waiver test to further the purpose of the program which is to provide health coverage. The Trump Administration has indicated a willingness to approve waivers to require work.

Research shows that Medicaid expansion has not negatively affected labor market participation, and some research indicates that Medicaid coverage supports work. A comprehensive review of research on the ACA Medicaid expansion found that there is no significant negative effect of the ACA Medicaid expansion on employment rates and other measures of employment and employee behavior (such as transitions from employment to non-employment, the rate of job switches, transitions from full- to part-time employment, labor force participation, and usual hours worked per week). In addition, focus groups, state studies, and anecdotal reports highlight examples of Medicaid coverage supporting work and helping enrollees transition into new careers. For example, individuals have reported that receiving medication for conditions like asthma or rheumatoid arthritis through Medicaid is critical in supporting their ability to work.  Addressing barriers to work requires adequate funding and supports.  While TANF spending on work activities and supports is critiqued by some as too low, it exceeds estimates of state Medicaid program spending to implement a work requirement.

Implementing work requirements can create administrative complexity and put coverage at risk for eligible enrollees who are working or who may be exempt.  States can incur additional costs and demands on staff, and some eligible people could lose coverage.  While work requirements are intended to promote work among those not working, coverage for those who are working could be at risk if beneficiaries face administrative obstacles in verifying their work status or documenting an exemption.  In addition, some individuals who may be exempt may face challenges in navigating an exemption which could also put coverage at risk.

Medicaid is GOP target in 2018

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

http://thehill.com/policy/healthcare/366728-gop-could-push-medicaid-cuts-in-2018

Image result for medicaid target

Medicaid could face crucial tests in 2018 at both the federal and state levels.

Republicans in Congress failed in their attempts earlier this year to impose drastic cuts to the program as part of ObamaCare repeal, but GOP lawmakers could try again next year.

The tax bill that President Trump recently signed into law is projected to add $1 trillion to the federal deficit, making cuts to Medicaid an even more tempting target for some conservatives.

“Medicaid is front and center in any budget exercises, and now that deficits have increased, it puts Medicaid squarely in the bull’s-eye,” said Joan Alker, the executive director of the Georgetown University Center for Children and Families.

Speaker Paul Ryan (R-Wis.) has said he wants to bring down entitlement spending, saying in December that “health-care entitlements such as Medicare and Medicaid are the big drivers of debt.”

Any entitlement cuts from Ryan will likely face pushback from members of his own party, including Senate Majority Leader Mitch McConnell (R-Ky.). McConnell has said he doesn’t expect to see entitlement reform on the agenda next year ahead of the midterms.

“The sensitivity of entitlements is such that you almost have to have a bipartisan agreement in order to achieve a result,” McConnell told reporters in late December.

Medicaid covers nearly 75 million people, and the program has proven resilient in the face of conservative opposition.

Cindy Mann, a consultant at Manatt Health who ran Medicaid under former President Obama, said attacks on Medicaid have made it more popular.

“Medicaid has always been supported by the people closest to it,” Mann said.

Some Republican senators have recognized the political risks of Medicaid cuts, too. The GOP’s ObamaCare repeal push failed in part because of senators opposed to the Medicaid cuts.

“The Medicaid program is starting to get a politically powerful status,” said Eliot Fishman, the senior director of health policy at Families USA, an advocacy group.

Fishman noted that Maine, Arizona and Alaska are all Medicaid expansion states represented by Republican senators who have shown a willingness to protect the expansion funding.

Over 16 million people have enrolled in Medicaid since states began expanding coverage under ObamaCare. The program could continue to grow in the near future, as more states could seek to take advantage of the additional federal money offered by the health law.

Future Medicaid expansions could be especially likely if a Democratic wave in November’s midterms gives Democrats control in more statehouses.

In Virginia, Gov.-elect Ralph Northam (D) has promised to expand Medicaid, something Democrats in the state have been unable to accomplish in the last four years in the face of a GOP-controlled legislature. But with a 50-50 split in the House or even a 51-49 Democratic minority, depending on the results of a recount, Northam has much better odds than current Gov. Terry McAuliffe (D).

In Maine, voters approved a ballot initiative allowing the state to expand Medicaid. Gov. Paul LePage (R) has refused to implement it, but a new governor replacing LePage after he leaves office in the face of term limits could be more willing to accept the results.

If even a few more states choose to expand Medicaid, “it starts to get to be enough critical mass nationwide that I would hope it just makes it a permanent part of the Medicaid program,” Fishman said.

But advocates worry that unprecedented flexibilities offered by the Trump administration will allow states to completely change the nature of Medicaid.

Administration officials have said they will allow governors to add work requirements, time limits and lockout periods for people who can’t pay their premiums on time.

Advocates say adding such provisions would further the Republican case that Medicaid is a welfare program, instead of health insurance.

“Whether you support them or not, those activities are not the function of a Medicaid program,” Mann said. “People can differ as to the efficacy of those efforts, but few people can accurately say that’s what health insurance ought to be doing.”

In the coming months, the Trump administration could approve waivers allowing states like Arkansas, Arizona, Indiana and Kentucky to impose work requirements on Medicaid beneficiaries.

Arizona also wants to impose a five-year limit on Medicaid eligibility for the “able-bodied.”

States that want work requirements have acknowledged that tens or even hundreds of thousands of people would lose Medicaid coverage under the proposals.

Prior to ObamaCare, Medicaid mainly covered children, the disabled and pregnant women. The law’s optional expansion allowed many more low-income people to become eligible, leading to criticisms from conservatives that “able-bodied” beneficiaries were essentially freeloading off the government.

Alker said that’s the wrong way to look at it.

“[Medicaid is] predominantly run by managed care insurance companies, so that kind of rhetoric is a gross oversimplification,” Alker said. “But people who want to cut it, they tend to focus on one population.”

GOP states move to cut Medicaid

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

GOP states move to cut Medicaid

GOP states move to cut Medicaid

Republican governors are working with the Trump administration to do something Congress couldn’t accomplish: fundamentally alter their state Medicaid programs.

At least six states with GOP governors— Arkansas, Kentucky, Arizona, Maine, Wisconsin and Indiana — have already drafted plans meant to introduce new rules people would have to meet to be eligible for Medicaid, which provides healthcare to low-income Americans and those with certain disabilities.

Some want to add work requirements or introduce drug testing for recipients. Others want to raise premium prices.

The Trump administration has to approve the plans. Some approvals could come in weeks.

Critics say the proposed changes will leave fewer people on Medicaid and hurt the poor and vulnerable.

“There are limits on what’s allowable, and tying eligibility to work or drug testing or some of these other things is not consistent with what should be allowed,” said Judith Solomon, vice president for health policy at the liberal-leaning Centers on Budget and Policy Priorities.

“That said, we know we now have an administration that likely thinks differently, and we could see some changes in that regard,” she said.

Proponents argue the changes, which would waive federal requirements under Medicaid, are an important tool in trimming the fast-rising costs of the program.

They say Medicaid recipients should have some “skin in the game” — an incentive to transition from government support to full-time employment.

“Medicaid is Pac-Manning state budgets right now. It’s taking money away from education, transportation, in expansion and non-expansion states alike. It is eating their budgets,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.

In the past, waivers have been granted to test new ways of delivering care and expanding Medicaid coverage. The only real requirements are that the waivers be budget neutral and promote the objectives of the Medicaid program.

Health and Human Services Secretary Tom Price, a former Republican congressman from Georgia and a vocal ObamaCare critic, has enormous flexibility in deciding what that means.

In March, Price and Seema Verma, who helms the Centers for Medicare and Medicaid Services, sent a letter to governors saying the administration would allow work requirements, larger premiums and other waiver provisions.

It was a dramatic departure from the Obama administration and “an open invitation” for states, said Robin Rudowitz, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured.

“By and large, Obama let states use waivers to expand the number of people in the Medicaid program,” Archambault said.

The Trump administration seems poised to do the opposite.

Critics say the proposed requirements go beyond the authority of the executive branch, but Archambault said the statute on what’s allowed is extremely broad, meaning the administration has the authority to approve most, if not all of the proposals.

Republicans in Congress have been deeply divided over Medicaid, with conservatives seeking to cut spending on the program but centrists from states where it was expanded under ObamaCare pushing back.

The House and Senate’s ObamaCare repeal bills sought to drastically cut back Medicaid spending by capping federal financing and ending ObamaCare’s enhanced federal funding for coverage expansion. The bills also would have given states the option of imposing work requirements.

Medicaid waivers can’t change the program’s financing the way a federal law could, but several state waivers filed months ago include a work requirement as a way to trim spending.

Work requirements “will have the result of cutting state Medicaid costs because fewer people will be on Medicaid,” said Deborah Bachrach, a partner at Manatt Health and former Medicaid director of New York.

To date, no state has received an approval for a waiver requiring people to work to be eligible for Medicaid. If the Trump administration approves of one, most experts think other states will get similar requirements approved quickly.

“If and when Kentucky and Arizona get approval … you’ll see a bunch of other Republican states copycat,” Archambault said.

Other changes, if approved, include lowering the eligibility levels for coverage and a time limit for being on Medicaid.

Arkansas recently filed a waiver request to lower the Medicaid eligibility level while still receiving extra federal money as a Medicaid expansion state. It’s the first state to make such a request of the Trump administration; some states tried similar requests during the Obama administration and were denied.

Wisconsin would like to screen all and test some applicants for drugs. Those who test positive for drugs would be required to receive treatment; those who refuse to be screened or take a test would be ineligible for Medicaid benefits.

The state also wants to impose a 48-month limit on Medicaid eligibility, unless the person is working.

“My biggest concern is that the state is going to create a lot of new red tape and expense that is going to suppress Medicaid participation and increase total healthcare costs by putting greater reliance on hospital and emergency departments,” Jon Peacock, research director for Wisconsin-based Kids Forward, said.

Experts warn certain controversial provisions, if implemented, could be targets for lawsuits.

“Some of these waivers are pushing the boundaries of what has been approved before, and that could lead to potential litigation,” Rudowitz said.

Ten Ways That the House American Health Care Act Could Affect Women

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , , • Leave a comment

Ten Ways That the House American Health Care Act Could Affect Women

Women have much at stake as the nation debates the future of coverage in the United States. Because the Affordable Care Act (ACA) made fundamental changes to women’s health coverage and benefits, changes to the law and the regulations that stem from it would have a direct impact on millions of women with private insurance and Medicaid. On May 4, 2017, the House of Representatives passed the American Health Care Act (AHCA), to repeal and replace elements of the ACA (Appendix Table 1). It would eliminate individual and employer insurance mandates, effectively end the ACA Medicaid expansion, cap federal funds for the Medicaid program, make major changes to the federal tax subsidies available to assist individuals who purchase private insurance, and ban federal Medicaid funds from going to Planned Parenthood. It would also allow states to waive the ACA’s Essential Health Benefits requirements and permit health status as a factor in insurance rating for individuals who do not maintain continuous coverage with the goal of reducing insurance costs.1 The Senate will now take up legislation to repeal and replace the ACA and may consider several elements that the House has approved in the AHCA. This brief reviews the implications of the AHCA for women’s access to care and coverage.

Understanding the Intersection of Medicaid and Work

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

http://kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/

Figure 3: Industries with largest number of workers covered by Medicaid, 2015

Issue Brief

Medicaid is the nation’s public health insurance program for people with low incomes. Overall, the Medicaid program covers more than 70 million Americans, or 1 in 5, including many with complex and costly needs for care. Historically, nonelderly, non-disabled adults accounted for a small share (27%) of Medicaid enrollees; however, the enactment and implementation of the Affordable Care Act (ACA) has expanded coverage to nonelderly adults with income up to 138% FPL, or $16,394 for an individual in 2016. As of January 2017, 32 states have implemented the ACA Medicaid expansion. By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. With the expansion to more “able-bodied” adults, questions have arisen about tying work to eligibility.

President Trump may consider waiver proposals with a work requirement, and the Administration and leaders in Congress are considering proposals to repeal the ACA and to transform Medicaid from an entitlement program with guaranteed federal matching dollars for states to a block grant with no entitlement and capped funding. Such proposals would grant states additional flexibility to design and administer their programs and potentially include an option to allow states to impose a work requirement for Medicaid beneficiaries, which is not allowed under current law.  This issue brief examines the work status of non-elderly, non-disabled adults with Medicaid coverage to understand the potential implications of work requirement proposals in Medicaid.

Key Takeaways
This brief provides an overview of work status of non-disabled, adult Medicaid enrollees and examines some of the policy proposals around tying Medicaid coverage to work.

  • Among non-disabled, non-elderly Medicaid adults (including parents and childless adults — the group targeted by the Medicaid expansion) nearly 8 in 10 live in working families, and a majority are working themselves. However, nearly half of working Medicaid enrollees are employed by small firms, and many work in industries with low ESI offer rates.
  • Among the non-disabled, non-elderly adult Medicaid enrollees who were not working, most report major impediments to their ability to work.
  • Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states have sought to impose a work requirement for the Medicaid expansion population through waivers; the prior administration did not approve these requests.  The issue of work requirements may be re-examined by the new administration and may be debated in Congress as part of broader efforts to restructure Medicaid financing and core federal requirements.

 

Rolling Back the ACA’s Medicaid Expansion: What Are the Costs for States?

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

http://www.commonwealthfund.org/publications/blog/2017/feb/states-roll-back-aca-medicaid-expansion

Millions of people have gained health insurance coverage though the Affordable Care Act’s (ACA) Medicaid eligibility expansion, adopted by 31 states and Washington, D.C., over the past three years. Should Congress decide to eliminate or reduce federal funding for this coverage as part of ACA repeal, states that expanded will be faced with the prospect of either maintaining coverage out of their own funds or dropping the new beneficiaries from the program. Along with the loss of coverage or the creation of large budget holes, rolling back Medicaid benefits would present states with expensive and complex administrative challenges.

Were Congress to repeal federal funding for the expansion group, coverage for these newly eligible enrollees—estimated at 11 million as of 2015—inevitably would disappear. No state is in a position to support this population without considerable federal funding. For example, were ACA Medicaid expansion funding to disappear, California would lose more than 27 percent of the total federal Medicaid funding the state is projected to receive over the 2019 to 2028 time period; federal funding would drop from $364 billion to $265 billion, a $99 billion loss.

If a repeal bill retains the Medicaid expansion but reduces federal funding for the expansion group to traditional Medicaid funding levels,1  some states might seek flexibility to roll back coverage to a lower level such as 75 percent of poverty, rather than the eligibility standard used under the expansion (138 percent of poverty). Rather than terminate insurance eligibility altogether for populations without an alternative source of coverage, states also might try to trim benefits or reduce or freeze provider payments.

But even if funding is eliminated completely, federal laws place important brakes on the process. For example, federal Medicaid rules dating back decades require states to determine if there is another basis of eligibility prior to terminating coverage. At least some of the people covered as part of the expansion population may qualify for Medicaid on other grounds such as pregnancy, being the parent of a minor child, or disability.

What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , , • Leave a comment

http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaid-block-grants

ABSTRACT

Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans.

Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee.

Methods: Review of existing policy proposals and other documents.

Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting “per capita caps” would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.