How States are Changing Health Insurance Rules

In an ongoing effort to keep you up to date on the many proposed and approvedhealth insurance
changes to our health care system and how they might impact the cancer community, this week, we bring you updates from around the country. If you don’t live in one of these states, be aware, these changes could come to your state next.

National News:

Two weeks ago, we reported that 11 states have applied for waivers to make some individuals work, in order to get access to health care through Medicaid. Since then, Kentucky and Indiana’s waivers have already been approved by the Center for Medicare and Medicaid Services and those states are moving forward with implementing plans for a Medicaid work requirement. Click here to learn more about the impact of the Medicaid waivers and to see what the states are asking for in their waivers.

In addition to work requirements, five states have also asked the U.S. Department of Health & Human Services if they can place a lifetime cap on how long an individual can receive Medicaid coverage. For example, Arizona, would like to place a 5-year lifetime cap on coverage. Kansas, Utah, Maine and Wisconsin are also seeking to impose lifetime caps.

This would be a substantial change to the Medicaid program, since signed into law under President Truman in 1965.  More than 68 million people receive Medicaid coverage, including children, seniors, and people with disabilities.  HHS has not released any guidance on this issue, to date.

Ohio:

Ohio has now joined Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi (still in process), New Hampshire, North Carolina, Utah, and Wisconsin, in asking for permission to add a work requirement to their Medicaid program. The work requirement would begin July 1, 2018, if approved in time.

Ohio has also asked the federal government for permission to not comply with the individual mandate. This will likely have no actual impact, as Congress reduced the penalty for not purchasing health insurance to $0, in the latest tax bill. The $0 penalty will begin in 2019, which means that those who don’t have health insurance in 2018 will still be responsible for the penalty!

Rhode Island:

Rhode Island is also making cuts to its Medicaid program, which covers more than 300,000 people. Individuals will be required to pay co-pays when receiving health care services or prescription drugs.  However, there will be an annual cap on co-pays equal to 6% of an individual’s income.

Idaho:

Idaho announced last week that they will allow insurance companies to sell plans in violation of the Patient Protection and Affordable Care Act (ACA). The ACA required health insurance plans to meet certain minimum requirements in order to protect consumers from pre-existing condition exclusions and annual and lifetime limits, while ensuring coverage of essential health benefits. Insurers argue that providing this quality coverage is more expensive and that is why plans sold in the Health Insurance Marketplace can be more expensive.

Idaho’s approach to bring down the cost of insurance is to allow plans to offer less coverage and to exclude people with pre-existing conditions. This directly violate the law. It will be up to HHS to enforce the law or allow Idaho to continue offering these illegal plans. There are many other states waiting to see how HHS will react.

Blue Cross of Idaho has already unveiled five new plans that don’t comply with the ACA, including having annual caps on coverage and pre-existing condition exclusions for up to 12 months.

Advocates have three concerns about this approach:

  1. People who are healthier will leave the Marketplace to buy these cheaper plans, which will drive up the costs of plans in the Marketplace
  2. If these healthier individuals are diagnosed with serious medical conditions, they will find they have inadequate coverage
  3. People with pre-existing conditions won’t be able to purchase these cheaper plans, which means they will be stuck in the marketplace with more expensive plans

This turn of events is very concerning for the cancer community, as it allows insurance companies to do an end run around the ACAs protections for people with pre-existing conditions.

Medicaid Work Requirements & the Cancer Community

There has been discussion in the news over the last few weeks about the President’s decision to allow states to require that people “work” in order to receive Medicaid. This is referred to as the Medicaid work requirement. We want to break down these changes for you and how this might impact the cancer community.

If you live in one of the states that is about to make changes to its Medicaid program, you should definitely keep reading.

What is Medicaid?

Medicaid is the federal health insurance program that covers more than 74 million individuals who have a low income, low resources, and meet some other category of eligibility, such as being a senior, a minor child, or having a disability (receiving Supplemental Security Income (SSI)). In 2014, the Affordable Care Act expanded access to Medicaid to all adults with an income level up to 138% of the federal poverty level ($16,753 for an individual in 2018).  Eliminating the low resource requirement and the requirement to be receiving Supplemental Security Income, made it much easier for someone with a cancer diagnosis to get access to Medicaid coverage, and ultimately get access to care.

While Medicaid is a federal program, it is administered by both the federal government and states. Since 2014, 32 states have expanded access to their Medicaid program under the ACA.

There is a lot of discussion about the number of people who receive Medicaid, but don’t work, and whether or not that is fair. Those who are in favor of work requirements for Medicaid believe that “able-bodied” adults should be working if the federal government is going to pay for their health insurance coverage.

Those who are opposed to work requirements are concerned how they might impact people who are unable to work for a variety of reasons or who live in communities where work is difficult to find. Advocates are concerned that the additional administrative requirements will cause people to lose vital coverage, that people will be discouraged from applying for coverage, and that the number of uninsured people will start to rise again.  One of the many benefits of lower numbers of uninsured individuals was that it decreases the amount of uncompensated care that hospitals provide. When hospitals have high levels of uncompensated care, they are more likely to close, which impacts access to care for everyone.

Who Receives Medicaid?

According to an analysis by the Kaiser Family Foundation, most Medicaid and CHIP enrollees would be actually be automatically exempt from the requirement because of their age or disability status.

Medicaid Work Requirements & the Cancer Community

What are the New Medicaid Rules?

In January, the Trump Administration announced its decision to make significant changes to the Medicaid program, by allowing states to apply for waivers to impose work requirements on Medicaid enrollees in their state. The Centers for Medicare and Medicaid Services (CMS) released rules for the states who want to apply for those waivers.

The rules forbids states from imposing work requirements on certain populations, such as the elderly, minor children, individuals who are pregnant, and those receiving SSI.

CMS also requires states to exempt individuals who are “medically-frail.” CMS defines “medically frail” as those who have “disabling mental disorders; chronic substance abuse disorders; serious and complex medical conditions; physical, intellectual, or developmental disabilities that significantly impact the ability to perform one or more activities of daily living; and those who meet Social Security disability criteria.”

While CMS does remind states to consider how some communities have high unemployment rates due to economic factors, it gives states significant flexibility to design their own requirements. CMS also suggested that states could allow for “community engagement” alternatives to work, such as job search, job training, volunteering, community service, or education.

Work requirements are likely to have an impact on everyone receiving Medicaid in a particular state, because everyone will have to document that they meet the requirements. And, the CMS rules allow for states to ask enrollees to certify they are still eligible as often as monthly.

Which States Want Medicaid Work Requirements?

These eleven states have already applied for waivers to add work requirements: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi (still in process), New Hampshire, North Carolina, Utah, and Wisconsin.  Additional states are considering submitting requests.

Medicaid Work Requirements

Since the CMS announcement, Kentucky and Indiana’s waivers have already been approved and those states are moving forward with implementing plans for a Medicaid work requirement.

Click here to learn more about the impact of the Medicaid waivers and to see what the states are asking for in their waivers.

What is in Kentucky’s Waiver?

Kentucky’s waiver requires people to work 80 hours a month, or alternatively to engage in job searching, job training, community service, or education. Drug treatment and caregiving for a non-dependent relative or another person with a disabling medical condition are also considered work activities.

Kentucky Medicaid enrollees can obtain an exception to the work requirement if they can verify one of the following during their month of noncompliance with the work requirement:

  • Disability, hospitalization, or serious illness of enrollee or immediate family member in the home;
  • Birth or death of a family member living with the enrollee;
  • Severe inclement weather including natural disaster; or
  • Family emergency or other life-changing event such as divorce or domestic violence.

A primary caregiver of a dependent minor child or adult with disabilities per household is also exempt.

In addition to the medicaid work requirements, the waiver also establishes premiums, deductibles, benefit restrictions, and six-month coverage lock-outs, while eliminating non-emergency medical transportation.

Also included in Kentucky’s waiver is the elimination of the 3-month retroactive coverage for most adults, including those who are medically frail. This was very useful for someone diagnosed with cancer, so that they could start receiving care while their Medicaid application was being processed.

To read a breakdown of Kentucky’s waiver, click here. These changes are set to begin being phased in on April 1, 2018.

However, advocacy groups in Kentucky have filed a lawsuit to stop the implementation of Kentucky’s waiver. Kentucky Governor Matt Bevin has signed an executive order stating that if the court does stop the work requirements, that the Governor will eliminate the expanded access to Medicaid in Kentucky entirely. This would result in 48,000 people in Kentucky losing access to their health insurance coverage.

What is in Indiana’s Waiver?

Indiana’s waiver was approved on February 2, and requires adult enrollees to work an average of 20 hours a month and it is phased in over time. It also has a long list of exemptions and alternatives to employment. In addition to the work requirement, Indiana will also implement a “lockout” provision.  Medicaid enrollees who fail to submit their paperwork showing that they still qualify for the program, will be blocked from coverage for three months. Click here to read Indiana’s Medicaid waiver.

More Information

Triage Cancer will continue to follow the changes to state programs and how those changes might impact the cancer community and share that information on our blog.  Stay tuned.

ACA ‘Repeal and Replace’ Bill Unveiled

Repeal and Replace BilLate yesterday evening, a bill was introduced in Congress to repeal and replace the
Patient Protection and Affordable Care Act (ACA or Obamacare).  Prior to the actual introduction of this piece of legislation, there was a lot of speculation about what would be included, and although a version was just released, the House of Representatives is expected to begin considering the legislation in the relevant committees this week.  This is very fast moving compared with other legislation.

The bill is significantly shorter than the ACA and has been named “The American Health Care Act.”

If passed, the law would make several significant changes to our health care system.  For example, the bill would:

  • Eliminate the current requirement that most Americans have health insurance or pay a penalty.
  • Eliminate the current requirement for large employers (50+ employees) to pay a penalty if they do not provide adequate and affordable health insurance to their employees.
  • Require that people have “continuous coverage” or else they could be charged a 30% higher premium. Starting with open enrollment for 2019 insurance plans, anyone who has gone more than 63 days without coverage during the previous 12 months will be assessed a 30% late-enrollment surcharge on top of their base premium.
  • Eliminate the current system of financial assistance to purchase individual health insurance that is based on income and household size. Instead the law would provide tax credits based on age, rather than income. Those under 30 would receive $2,000 per year, up to those over 60, who would receive $4,000 per year. Only individuals earning up to $75,000 a year and married couples filing jointly earning up to $150,000 a year for would be eligible for the full credit. It is estimated that many people currently receiving financial assistance would see a 50% cut in the assistance that they receive under this new law.
  • Change the funding structure of the Medicaid system (i.e., to a per capita payment). This means that each state will receive a set amount of money each year. If states run out of money during the year, they will either have to limit enrollment, limit coverage, or both. This system might end up looking like the failed High Risk Pool structure we had prior to the ACA.
  • Increases the amount that insurance companies can charge older Americans for their health insurance from a 3:1 ratio to 5:1 ratio. Currently, insurance companies cannot charge a 64 year old more than 3 times what it charges a 21 year old. This bill would change that to 5 times what a 21 year old is charged, making health care that much more expensive for older Americans.
  • Eliminate several of the taxes (e.g., the medical device tax, the tanning tax, a tax on high earners, etc.) created by the ACA that were designed to help pay for the financial assistance provisions and expansion of coverage.

The bill does not repeal the protections for people with pre-existing conditions and allowing young adults to stay on their parent’s policy until they turn 26, but also doesn’t address some of the gaps in coverage. For example, the bill does not address the cost of prescription drugs or how much insurance companies can increase rates year to year.

So, while some protections from the ACA will survive, it is anticipated that if this bill passes, many of the 20 million Americans that gained coverage under the ACA will be negatively impacted. For the cancer community, passage of this bill could mean an increased likelihood of facing financial ruin due to a diagnosis.

Of course very few bills are ever passed exactly as they are introduced, so there will still likely be more changes.  Additionally, even if this bill is passed by the House of Representatives, it still has to pass the Senate, and be signed by the President.

Stay tuned for more updates.

What You Can Do

We will have to continue to wait and see what happens, but in the meantime, there is something that you can do.

  1. Share your experience and concerns: Call or email your elected officials and share your health insurance concerns. To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources page. You can also find the Facebook and Twitter handles for the current members of Congress here.
  2. Tell your story: Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations that are working to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people. If you feel comfortable doing so, you can share your story at http://familiesusa.org/share-your-storyor at org/blog/share-your-aca-story.

Medi-Cal Coverage for all Children in California

Health4AllKids Triage Cancer Blog

California Senator Ricardo Lara on his #Health4AllKids Tour

The question of whether or not health care is a right or a privilege has been under discussion across the country.  California has taken a step closer to health care being a right.

Under SB 75, authored by California State Senator Ricardo Lara, children under the age of 19 will now be eligible for full-scope Medi-Cal coverage regardless of their immigration status.

Medi-Cal is California’s Medicaid program, which provides free or low-cost health insurance coverage for individuals with a low household income level.

Currently, under federal law, individuals without satisfactory immigration status are only given emergency Medi-Cal, which only provides access to emergency health services.  California is blazing a trail with SB 75, to provide children with full Medi-Cal coverage, which includes benefits such as:

  • Medical Care
  • Dental Care
  • Mental Health Care
  • Vision (Eye) Care
  • Preventive Care

As of May 1, 2016, individuals may begin seeking coverage, as long as they meet the income standards. For those who sign up during May, the coverage will be retroactive back to May 1.

In order to receive Medi-Cal, some individuals will have to pay a monthly premium based on household size and income.  Only those earning more than 160% and less than 266% of the federal poverty level will have to pay a monthly premium.

 Where can people enroll?

In-Person: County Social Services Office
Online: Covered California
Mail:  Medi-Cal Single Streamlined Application

For more information on SB 75: Healthy Kids for All,  visit the California Department of Health Care Services website.