Thursday, May 15, 2014

Federalist misconceptions on HIP 1.0 & 2.0

Okay, I'll give the Federalist this: Medicaid expansion isn't, at its core, a conservative idea. It is a liberal policy goal. The debate, then, has been for conservative states to come up with the most conservative means possible to accomplish at the state level this federal (liberal) policy goal. So it is a conservative means to a liberal end. It is out of that same line of thinking that the HIP 1.0 was created. Liberal Hoosiers wanted to expand coverage. Conservative Hoosiers were still mainstream (reasonable) enough to go along, particularly because they would then be able to influence the outcome, and put controls on both participants and the program itself (to ensure it didn't create a runaway cost in the state budget).

Regarding Arkansas: You can't have it both ways. It was the Republicans in AR that demanded all new enrollees receive private coverage. Now they're complaining that private coverage turns out to be more expensive than public coverage. Yes, when you pay providers more and allow insurers to add a profit margin as well, this does tend to raise overall costs. Most anyone with experience in contracting or budgeting would be aware of this. AR is already pursuing some cost containment strategies. They will restrict new enrollees and those who annually renew to a choice of only a handful of plans deemed most cost effective, and will likely also ensure that if someone selects a plan with optional benefits (dental/vision) that the state will not pay the portion of the premium associated with those options. They will also institute cost sharing for the enrollee, on a sliding scale according to income. A lot will also depend on how the rate setting process for next year's Marketplace goes in AR.

HIP 1.0 really did not expand Medicaid eligibility to 200% FPL because it was capped from the very start to ensure state budget neutrality. The state actually didn't want to cap it, but the (44th) Bush Administration required it. They said that otherwise, the state would be financially at risk for increases in non-caregiver enrollment. So the program usually only served about 50,000 Hoosiers (or less) at any given point in time.

Under HIP 1.0, there was an $1,100 deductible, but, for example, someone who made 100% of the poverty level, $11,670/year, would only be responsible for funding $233.40/year out of the $1,100. The remainder of the $1,100 is funded up front by the state. And, in reality, the entire amount is funded up front, because the enrollee is only responsible for funding 1/12th of the $233.40 each month ($19.45/month). No evidence supports the claim that a current enrollee at 100% FPL would pay $1,100 out of pocket before HIP coverage would take effect. That was only ever the case under original (Gov. Daniels) HIP 1.0, and only for those with higher incomes. Someone who made 200% FPL ($23,340) would have been required to contribute $91.67/mo, but still wouldn't have had to pay the $1,100 annual contribution as a lump sum. It is true, though, that a one-year waiting period was imposed on those who did not pay their contributions.

In HIP 2.0, those who do not contribute are only eligible to keep HIP and move to HIP Basic if they are at or below 100% FPL. That is because federal law and regulation do not allow those below the poverty line to be mandated to pay any up front fees for public health coverage. If those above 100% but at or below 138% do not pay, they have a 60 day grace period to pay up and be fully reinstated. If they do not pay within the 60 days, they are disenrolled for a six month waiting period.

HIP 2.0 Basic copays are not "paid out of the HSA account" they are due at the time of service and expected to be paid out of pocket by the enrollee. For example:
A typical doctor visit bills at the Medicare rate (which is what HIP pays providers) for $66.58. A HIP Basic client would have a copay of $4 for an outpatient service, due at time of service. The HSA account / insurer in this case would pay the remainder $62.58. The enrollee would receive a statement so he/she could see how much was being spent out of the HSA. Under no circumstances can the copay be paid out of HSA dollars under the HIP program. With HIP Plus, assuming that the monthly contribution has been made, any services used other than non-emergency ER are 100% paid either by the HSA or the insurance policy.

Regarding POWER accounts - I cannot find any evidence that suggests that state intends to no longer offer refunds of enrollee contributions when people leave HIP. While they do not explicitly state their intention to continue the practice, they also do not say they will eliminate it. Therefore, to the extent that the HIP 2.0 waiver incorporates previous HIP waivers by reference, it would seem the state retains the option to refund enrollee contributions, just as long as no monies deposited by the state are refunded.

"Enrollees can spend funds on any provider they choose" - incorrect. Enrollees must pick a private health plan (Anthem, MDwise, or MHS) and can only use the doctors/hospitals in the network of the plan they pick. (The only exception is family planning, in which the any willing provider standard applies. Any family planning provider who will accept the HIP/Medicare rate as payment in full can see patients without being in-network and without any prior referral. Patients must be charged in-network copays/contributions.)

"... whatever is unspent will roll over at the end of the year" - incorrect. Rollovers are only available in HIP 1.0, HIP Plus, and HIP Link. In all 3 cases, enrollees receive the maximum possible rollover amounts only if they have completed all recommended preventive care services for their sex and age. (Obviously a 25 year old male needs different preventive care than a 45 year old female.) If they do not complete the preventive care, HIP 1.0 enrollees can only roll over their own funds, but no state dollars. HIP Plus and HIP Link enrollees face a similar situation; completing preventive care will double their rollover amount by adding bonus state dollars, but not completing it will only roll over their own funds.

This is one of the first times that I've heard helping people to buy their employer sponsored insurance will somehow lead to them dropping that employer coverage for Medicaid. While HIP Link is optional, and members have a choice of HIP Plus instead, I can't see why helping people buy their employer's private insurance is bad. HIP Link requires employers to pay at least 50% of the premium, and overall requires that employer coverage must be "cost effective." This is actually a way to save Medicaid dollars; in some cases it is cheaper to use Medicaid funds to cover the out of pocket expenses of a commercial policy, because in this way, Medicaid doesn't bear the entire burden of paying for medical claims. The majority will be paid by the commercial policy and Medicaid may pay much less.

"Sunset" clauses that end Medicaid expansion after a limited time or when Federal funding drops below 90% have been implemented in five states.

HIP 2.0 will pay providers at Medicare rates.

Wednesday, April 16, 2014

This says it all.