Last year, we reported that voters in three states—Idaho, Nebraska, and Utah—passed ballot initiatives to fully expand Medicaid to individuals up to 138% of the federal poverty level (see Voters In Idaho, Nebraska & Utah Passed Ballot Measures To Expand Medicaid). Despite what appears to be similar initiatives, each state has chosen their own path to implement the Medicaid expansion. And what this means for provider organizations is a continued bifurcation of state Medicaid programs, bringing along its own set of challenges.
What exactly is happening?
Nebraska plans to extend benefits to the Medicaid expansion population beginning in October 2020. Although the state submitted a state plan amendment to the Centers for Medicare & Medicaid Services (CMS) to expand Medicaid, the state also intends to submit a 1115 waiver application. The application will create a non-traditional Medicaid expansion program based around two benefit packages – a Basic benefit package and a Prime benefit package (see Heritage Health Adult Program – Section 1115 Waiver Concept Paper).
The Basic benefit package will include most Medicaid services except vision, dental, and over-the-counter medications. The Prime package will include these services. In order to qualify for Prime after the first year, enrollees will have participated in active care and case management, selected a primary care provider, and had a wellness check-up. In year two, individuals will need to continue to meet these requirements, as well as 80 hours of community engagement activities to retain Prime coverage. Individuals who do not meet the requirements will return to the Basic benefit package (see Medicaid Expansion Briefing).
Idaho also intends to expand Medicaid to individuals up to 138% of the federal poverty level (FPL), but plans to allow the expansion population the choice of financing and delivery systems. The state is in the process of collecting public comments on a 1115 demonstration waiver that will allow individuals with income between 101-138% of the FPL to choose between enrolling in a health insurance marketplace plan and receiving tax credits or enrolling in traditional Medicaid. Medicaid expansion will occur on January 1, 2020 and if the waiver is not approved, everyone will be enrolled in traditional Medicaid (see Idaho Coverage Choice: Section 1115 Medicaid Waiver Demonstration Project Application).
Utah has a multi-step expansion plan that began on April 1, 2019 with the Bridge Plan. The state legislature chose to only expand Medicaid to individuals up to 100% of the FPL instead of the full 138% and if enrollment exceeds the state budget targets, enrollment can be closed. Currently these individuals are receiving full coverage through the fee-for-service (FFS) system. Individuals will be enrolled in the Medicaid health plans where available starting in January 2020. The state is also considering testing the integration of physical and behavioral health financing for this population. In January 2020, the state will also implement community engagement/work requirements.
This month, the state will also submit a 1115 waiver to CMS known as the Per Capita Plan. The plan will continue the expansion of Medicaid coverage to adults up to 100% FPL and will request the following provisions: work/self-sufficiency requirement, authority to cap expansion enrollment, up to 12-month continuous eligibility, required enrollment in employer’s plan with premium reimbursement, lock-out for intentional program violation, use federal funds for housing supports, and use of federal funds limited by per capita cap. If this request is not approved by CMS by January 2020, the state will submit the Fallback plan, which expands coverage up to 138% of the FPL and includes a self-sufficiency requirement, require enrollment in employer’s plan with premium reimbursement, and lock-out provision for intentional program violations. Finally, if this is not approved by July 2020 then the state will implement a traditional expansion (see Utah Implements Limited Medicaid Expansion Plan).
While these approaches may seem disparate what they all have in common is that they put an above average administrative burden on consumers and provider organizations. In Idaho, the onus is put on the consumer to educate themselves and understand the difference between the health insurance marketplace and Medicaid. In Utah and Nebraska, not only do consumers have to apply for and maintain eligibility for services, they have to report meeting work requirements. And in Nebraska, they have to understand the point of participating in care coordination and how it effects their benefits.
Because of this increased complexity, consumer education in the selection of and use of benefit plans is needed. While the state will be required to provide some education, most of the burden will fall on provider organizations. Provider organizations first need to educate staff on these new requirements and then provide coaching and materials to staff to help explain the programs to consumers. We’ve written about the importance of health literacy and consumer engagement before in Less Consumer Education Demands More Consumer Engagement, Is Consumer Engagement A Habit At Your Organization?, and The Dollars & Sense Of Consumer Experience.
Finally, in the case of Utah, we are seeing the first test of a cap on the per person contribution the federal government will take towards Medicaid. Some may even argue, that is the first move towards transitioning Medicaid from an entitlement program. Whether or not the per capita cap will be approved remains to be seen (and its likely to be challenged). But, it represents the increasing bifurcation among state thinking on Medicaid and some states are pressing models that limit spending and enrollment in state Medicaid programs in ways we haven’t seen before. For example, Tennessee is planning to seek federal approval to turn their program into a Medicaid block grant (see Tennessee To Seek Medicaid Block Grant). This will likely increase the uninsured/underinsured population and result in a higher need for safety-net services.
For more on the topic of Medicaid expansion, check out the OPEN MINDS State Profile Series. In addition to an overview of each state’s Medicaid system, the report includes whether or not the state expanded Medicaid, the mechanism used to expand the program, the number of people eligible under the expansion, the benefit plan for this population, and a description of any non-traditional expansion elements such as work requirements and cost-sharing. The State Profile Series is available to all OPEN MINDS Circle Elite members for free. Learn more about becoming an Elite member at https://www.openminds.com/elite/