Arkansas is submitting another round of waivers for their private option Medicaid expansion. There is one thing I don’t see CMS granting, and a couple of fights but the waiver as a whole is fairly straightforward. The biggest problem with the waiver is that it is unnecessarily expensive. Straight up Medicaid expansion would have been cheaper than paying providers Exchange rates but that has never been on the table. As Arkansas needs to pay 5% and then 10% of the total expansion costs, switching back to a straight expansion would get increasingly attractive as a means of reducing the state government cost exposure.
So let’s look at the details:
- Requiring individuals eligible for Medicaid to enroll in employer-sponsored insurance where available, with Medicaid covering employees’ costs that would exceed Medicaid levels
This is straight forward. Medicaid should be the payer of last resort, so if ESI coverage is available, it should be the primary payer. Medicaid will be used as secondary coverage to reduce cost sharing to no more than 5% of total income. Coordination of Benefits is an administrative pain in the ass, but this happens everywhere.
- Requiring premium payments for beneficiaries with incomes above 100% of the federal poverty level, with a consideration of contributions for those with incomes above 50%.
CMS has approved 2% premium requirements for people making more than 100% FPL. This will get approved. Premiums for people making under 100% FPL are solely designed to force people out of the program as the administrative cost of collecting a $3 per person per month premium means there is no net payment by the individual for actual medical care.
- The state would offer enhanced coverage and other incentives for those who comply and meet goals set in Healthy, Active Arkansas, a Hutchinson initiative encouraging wellness.
This is not a big deal, it is a wellness program that CMS has approved in other states. I don’t think it moves the needle all that much on cost or quality outcomes, but it does not hurt as long as participation is not mandatory.
- Care coordination for medically frail individuals
This is a good thing in and of itself.
- Verifying beneficiaries’ incomes through enhanced data matches.
This is an administrative back-end plumbing tweak. It will most likely be used to force marginal cases out of Expansion and onto the Exchanges. The state wants to look at more databases to build an income profile (food stamps, tax records, lottery winnings etc)
Here are some of the areas where I think fights will occur:
- Eliminating the current retroactive eligibility that allows new beneficiaries to be covered for expenses incurred 90 days before they were enrolled.
Medicaid is assumed to be the payer of last resort and there is a presumption of eligibility. Medicaid in most states is not concerned about adverse selection problems as they assume that they are the dumping ground for adverse selection. Medicaid has a bad risk pool. The problem is Arkansas is trying to use an at risk insurance model for Medicaid where presumptive eligibility creates massive adverse selection problems. I could see CMS agree to a 30 day walkback from the date of application but not the elimination of presumptive eligibility.
- Restricting coverage or requiring greater cost sharing by individuals with substantial assets.
Medicaid expansion’s only eligiblity requirements are citizenship (or 5 years of legal residency) and income. There are no asset tests in PPACA. I am having a hard time seeing CMS approving a waiver that institutes asset testing even if the threshold is a million dollars (ie the lottery winner who now does not work and is on Medicaid). If the goal of Expansion is to help the working poor, creating asset tests traps people in a narrow income range as they can’t afford a newer car, or they can not afford to save against expected but unknown shocks.
This is the area of straight up disapproval in my eyes:
- Implementing work training referral requirements with a continued discussion with President Obama’s administration on specific work requirements.
CMS has been vehement against tying eligibility to work requirements. At the most, CMS has told states that they are free to set up and offer voluntary work training programs that are targeted at Medicaid Expansion populations with state money but eligibility is independent of work status.
NeutronFlux
Thanks
MomSense
Work requirements are all the rage but what about people who live where there are no jobs? In Maine the governor has a volunteer option to satisfy the 20 hour per week work requirements for food stamps but people are finding it tough to pay for the gas to get to a volunteer job. It’s just more shame the poor BS that ends up causing real hardship.
Mnemosyne
@MomSense:
Not only that, what about people who can’t work due to their health? My coworker’s sister (who I’ve mentioned before) can’t even get a fast food job because her grand mal seizures are poorly controlled by medication. Subway let her go because she had a seizure on the job and freaked everyone out, and anyplace that has any kind of oven or grill sure as hell isn’t going to take her since she’s a safety risk.
Of course, if you look at her, she *appears* to be healthy, so some idiot somewhere is probably wondering why she’s lounging around on disability and Medicaid.
MomSense
@Mnemosyne:
Absolutely. I hear so many bogus things about disability. It is difficult to get approved and you have to have a work history. Medicaid makes it possible for people to work who would absolutely not be able to without it. Also, too why would you want your meal prepared or served by someone who can’t access basic medical care??
Can we also discuss the need for reliable child care and work schedules that make it possible for parents to plan? Republicans love to shame low income people but they never shame the employers who treat them so callously.