“Premium Assistance,” People with Disabilities, and Medicaid Expansion Via Insurance Exchanges. Information Bulletin #379 (4/2013) Do you reside in a State that has not agreed to expand Medicaid under the Affordable Care Act (ACA) to all persons whose incomes are under 138% of the federal poverty level? Has your Governor talked about using Medicaid’s “premium assistance” plan to purchase a health plan via an “Exchange” for people under 138% – the “Arkansas model”? This Information Bulletin attempts to clarify some of these concepts, particularly as they apply to people with disabilities. 1.The normal way most States are implementing the ACA Medicaid expansion is to provide all persons with incomes under 138% with defined Medicaid benefits delivered through one Medicaid system. The “Arkansas model” is different and is the outlier. It uses Medicaid funds as “premium assistance” payments with which a State will purchase a private health plan, through the health insurance exchange being created for each state under the ACA (run either by the state or by the federal government). This private health plan will be limited to specific covered health benefits and services. Based on the proposed federal regulations and guidance from the federal Medicaid agency, CMS, the additional benefits covered under Medicaid, and the cost-sharing protections under Medicaid, must still be provided, these are likely to be very difficult to access. However, absent a special waiver, with premium assistance payments, a State cannot mandate that anyone under 138% receive Medicaid expansion services via the private insurance market; they must all be offered the choice of traditional Medicaid. 2. There is one possible way your State may try to get around this prohibition on mandatory enrollment in premium assistance. The State may apply to CMS for a section 1115 demonstration waiver to provide premium assistance to purchase a health plan on an Exchange and to make participation mandatory. What is critical for people with disabilities to know is that, under such a waiver, “A State may not require an individual to obtain [Medicaid services and health care] benefits through enrollment” with premium assistance payments if the person fits into one of the following five categories. If you are in one of these categories, the State cannot force you into a private health plan even through a 1115 waiver. Instead, the State must provide the traditional Medicaid benefits and services that current Medicaid recipients who are disabled are eligible for and receive, and deliver them in the traditional manner. The exempted categories are: 1. Blind and disabled persons (or persons “being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits …on the basis of being blind or disable. Nationally, we estimated that 2,665,407 people with disabilities are in this category. See Information Bulletin #369 (1/2013) or http://stevegoldada.blogspot.com/ for a State-by-State breakdown. 2. Dual eligibles – i.e., persons who receive both Social Security disability and Supplemental Security Income benefits. 3. Persons institutionalized in a “nursing home, an intermediate care facility for the mentally retarded, or other medical institution, and required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs.” 4. “Medically frail and special medical needs individuals,” (as identified in accordance with regulations of the Secretary). 5. Persons who qualify for long-term care services. “The individual qualifies based on medical condition for medical assistance for long-term care services,” including Home and community-based services furnished under a 1915 waiver. These exempted categories are critical. These people are entitled to all of the Medicaid services and benefits currently available to existing Medicaid recipients who are disabled, through the existing delivery system. 3. Do you reside in a State that is considering using premium assistance payments for people on Medicaid? If you do, please make sure your State is fully aware that it will have to run two separate programs for the Medicaid 138% expansion population, even with a waiver allowing it to force some Medicaid enrollees into premium assistance. One Medicaid program will provide all the components in the State’s existing benefits and services for people in categories ## 1 -5 above, and for others who opt out of premium assistance if there is no waiver. A second and separate Medicaid expansion program will use premium assistance payments for people not exempted under a waiver, or who have not opted out if there is no waiver. We expect that most States using premium assistance without a waiver will try to convince people in categories ## 1-5 to receive services through private insurance in the Exchange paid with the premium assistance. Don’t do it! You are exempted from mandatory enrollment. Why are we so emphatic? There is no way a private insurance company that is paid to provide “Exchange” health services will provide the long-term care Medicaid services that people in categories ##1-5 need to live independent, integrated lives in their homes and apartments. Congress did not even require Exchanges to include long-term care services or benefits, and you can bet they will not. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.