The Wyoming basic plan to expand Medicaid has been released late last week. The plan itself is a waiver application for a modified Expansion rather than a straight expansion. However, it is fairly straightforward and logical. It should be quickly approved by the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services. They have approved far wider waivers in the past two years. The major stumbling block is that the plan needs the state legislature to approve it as well. I am a complete naif on Wyoming politics, but I know that the legislature is dominated by Republicans. I don’t know if the plan will be approved, but it should be a significant improvement over non-Expansion.
The short version is the plan is basic Medicaid with a few benefit modifications and restrictions plus premiums for people who make more than 100% FPL. This is an improvement over cost sharing Silver plans for someone making between 100% and 138% FPL.
Here are the major highlights of the plan.
Identification of baseline
individuals and families whose income falls between 100% FPL and 138% FPL will be able to purchase health insurance through the Health Benefit Exchange with great assistance from federal subsidies (they would not pay more than 2% of income towards a premium).
Expansion Medicaid is Medicaid minus a bit:
The SHARE Plan will utilize Wyoming Medicaid’s current provider network in which between 94-99% of Wyoming providers participate (depending on type; only dental providers fall below this)….This coverage will include access to the ten Essential Health Benefits required by the ACA, as well as certain services required by Medicaid regulation. This package will be more limited than the benefits package provided by traditional Medicaid. Because the SHARE Plan will be administered by the State’s Medicaid program, participants will have access to Medicaid’s large provider network.
What does this mean?
There are three major take-aways from this paragraph. The first is that this is Medicaid. It is not premium subsidies for private insurance like Arkansas. It is not reinventing the wheel to recreate Medicaid managed care plans without calling it Medicaid managed care in Pennsylvania. It is not an HSA like the potential Healthy Indiana proposal. It is Medicaid. This straight up expansion will be immediately approved by CMS.
Secondly, there is a proposed income and premium split. People who are in the Subsidy/Medicaid overlap zone will be offered Medicaid plans that will look, smell, and sound a lot like Silver plans with full cost sharing assistance. They will be paying premiums of slightly less than 2% per month which is a slight improvement over the current status quo and will have a maximum out of pocket limit of roughly $575 or 5% of family income. Again, this is a slight improvement over cost sharing Silver plans. The best cost sharing Silver plans have an acturial value of 94% while it seems like the Wyoming expansion plan would have an acturial value of 95% or 96%.
CMS has approved multiple expansion waivers (Michigan, Pennsylvania, Iowa) with some premiums being paid. I don’t see this as a show stopper.
The most interesting thing in the descriptive paragraph is the proposal to have benefit restrictions. Pennsylvania’s Healthy PA expansion has a benefit split proposed but not yet approved. That proposal had a high risk benefit pool with no restrictions on utilization. This would probably cover the Pareto 20% of enrollees who use the most services. There would also be a low risk pool with restricted utilization. People in the low risk pool would only be able to go to the doctor a few times a year, have one or two inpatient stays during the year and have limited rehab services available. For most people, this would result in no change in utilization as most people are low to very low utilizers. But it would be a change in utilization for ten to fifteen percent of the covered population. Pennsylvania’s benefit split has not yet been approved.
There are not too many useful details in the white paper for the Wyoming expansion for the benefit split. I think this is where CMS would push back hard on this matter. There is a decent argument that the moderately high utilizers without concurrent underlying medical conditions are probably one of the easiest spots to achieve cost savings. Benefit restrictions however, are a crude instrument to achieve this goal.
Job linking services
The SHARE Plan connects its participants with work assistance benefits. While the WDH understands not all participants in the SHARE Plan will need these benefits, it would allow those that do to easily access appropriate services.
Something similar to this was originally proposed in the Healthy PA waiver. CMS rejected tying Medicaid benefits and eligibility to work or work search requirements. The final agreement was that the state of Pennsylvania could fund a work force engagement program out of its own funds and tell Medicaid expansion eligible individuals about the program. However participation or non-participation in that state funded program would have absolutely no impact on Medicaid eligibility or individual costs. I think CMS will tell Wyoming it is free to do whatever it wants with state money but work requirements are not germane to Medicaid.
Overall, this is a fairly straightforward and simple Medicaid waiver. There will be a significant conversation about benefit restrictions but everything else should go through quickly. The major stopping point now is approval through the legislature.
Cervantes
It was the Republican legislature that asked the state’s Department of Health to prepare a plan in the first place. While that legislature itself might not have approved any plan that emerged, with the particular Republican individuals newly elected last month it’s even more uncertain.
The plan saves the state money and it helps provide needed care — three strikes against it, I’m guessing.
(You know what the third strike is.)
Yatsuno
Wyoming has the big issue of a provider problem, so anything that helps address that is a positive. I find this development interesting but not terribly surprising. Wyoming has a fairly strong libertarian streak on lands rights issues but when your neighbour is miles away but may be your only help in times of trouble rugged individualism doesn’t pass the smell test. This will also put some pressure on Montana to possibly expand their single payer experiment beyond state workers.
JGabriel
Richard Mayhew:
I don’t know why the Feds would approve any Pennsylvania plan right now. PA just voted out the current gubernatorial GOP asshole (Tom Corbett), and have a new Democratic governor (Tom Wolf) taking office in January.
Isn’t it likely that the Obama administration will just wait to see if they get something better from the new governor? Or is there an approval deadline or something similar that would compel a decision on PA’s current proposal before Wolf takes office?
Barbara
The important point is that the Medicaid expansion includes people whose incomes are between 100% and 138% of the FPL. It is my judgment (and I’m an expert on the legal issues) that the federal government cannot waive Medicaid coverage at the upper thresholds of the FPL. Many states would like their Medicaid expansion benefits to stop at the threshold where exchange coverage begins, but for a host of reasons, the ACA provides for an overlapping population, and there are people who are better served buying on the exchange (young, healthy, working, likely to have increasing wages) and people who are better served by Medicaid (not so young, not so healthy, with spotty employment and enough chronic care needs that ultra low cost sharing offered by Medicaid is clearly the better choice).
richard mayhew
@JGabriel: Healthy PA enrollment started today, and Wolf does not get inaugurated until mid-January. Coverage starts on Jan. 1, 2015 for people who sign up in December. The state and the insurers need to know what is covered at some point. My bet is the feds can slow walk everything until there is policy direction from Wolf et al and then make a decision on benefit changes going forward with all previous visits paid. But that is a minimally informed bet on my part.
Roger Moore
@JGabriel:
It’s a matter of not letting the desire for perfection interfere with implementing an actual improvement. Maybe the new governor will come up with a better plan- or maybe he won’t given that he’s still dealing with a Republican state legislature- but there are people dying today for want of health care. The first goal should be to get those people covered so they can get the care they need. It’s not as if this is an irreversible step, either. If the new governor can put together a better plan, it can be approved for next year.
Chris T.
This has nothing to do with Medicare, Obamacare/ACA, etc., but is just a question I keep wondering about:
Why are teeth and eyes not body parts?
Why do we have a separate dental plan and vision plan, but not a separate knee plan, nose plan, left pinky finger plan, right earlobe plan, and so on?
richard mayhew
@Chris T.: short version, historical legacies. Dentists and Optometrists were mere mechanics compared to the learned doctors. The docs had a hard time accepting surgeons (formerly barbers) into their professional ranks.