Feds want to know what you think about Bevin plan to overhaul Medicaid
Deborah Yetter, Louisville Courier Journal Published 3:05 p.m. ET July 20, 2018
The federal government, once again, wants to know what people think about Gov. Matt Bevin’s plan to overhaul Kentucky’s Medicaid.
Less than a month after a federal judge struck down Bevin’s plan that includes work requirements and premiums for some Kentuckians who get health coverage through Medicaid, the U.S. Centers for Medicare and Medicaid Services (CMS) is seeking public comments on the exact same plan, known as a “waiver.”
The public comment period began July 19 and ends Aug. 18.
Health advocates who are concerned about the changes say it’s important that people take advantage of the public comment period, as they did last year when CMS previously reviewed Bevin’s plan before approving it in January.
“It really matters that people speak up,” said Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of organizations. “This is the exact same waiver.”
During the previous public comment period, about 3,000 people responded, the majority opposed to the waiver, Beauregard said.
It’s not clear why CMS is seeking comments on the same plan that was rejected June 29 by U.S. District Judge James Boasberg, of Washington D.C. The judge vacated CMS’ previous approval of the plan and sent it back to the agency for further review, finding among deficiencies that the agency did not fully consider previous public comments.
A CMS statement said the agency is seeking more comments “to ensure that interested stakeholders have an opportunity to comment on issues raised in the litigation and the court’s decision.”
Some health advocates have speculated it’s part of an effort by the Trump administration to push through work requirements for people enrolled in Medicaid, following public comments by CMS administrator Seema Verma at a July 17 Politico event.
“We are very committed to this,” Verma said, according to Politico. “We are looking at what the court said. We want to be respectful of the court’s decision while also wanting to push ahead with our policy initiatives and our goals. … We are trying to figure out a path forward.”
Adam Meier, secretary of the Cabinet for Health and Family Services, told a legislative committee Wednesday that Kentucky Medicaid officials are working with CMS to enact the plan.
“Our position is that we’d like to gain re-approval as quickly as possible,” he said.
Health law advocates who successfully challenged Kentucky’s plan in federal court said they intend to argue that, as the judge found, the plan does not conform with the federal Medicaid law, which is to improve access to health care for vulnerable citizens.
Medicaid is a federal state health plan for low-income and disabled individuals.
“We continue to take the position that work requirements are illegal because they are inconsistent with the Medicaid Act,” said Jane Perkins, legal director of the National Health Law Program in Washington. “We will certainly be commenting during this re-opened period.”
Kentucky was the first state to win CMS approval of Medicaid work requirements.
They have already been approved in Arkansas, Indiana and New Hampshire, while Arizona, Maine, Wisconsin and Utah are waiting to hear from CMS, Politico reported.
Under Bevin’s plan, “able-bodied adults” among the about a half-million people added to Medicaid under the Affordable Care Act would be subject to “community engagement” requirements that they work or volunteer at least 20 hours a week. They also would pay premiums of $1 to $15 per month and could be subject to a “lock-out” of coverage up to six months for failing to meet requirements.
Basic vision and dental benefits would be eliminated for that group though they could earn points to purchase such services through a “My Rewards” account through activities such as volunteering or taking online self-improvement classes.
Kentucky officials said in a statement Thursday that the Cabinet for Health and Family Services has “been working with CMS on details of the re-approval process, including the status of dental and vision benefits.”
The abrupt decision of the Bevin administration to cut dental, vision and non-emergency transportation benefits July 1, two days after the judge rejected the plan, sparked an uproar among patients and health care providers across Kentucky.
On Thursday, the state announced it was reinstating the benefits while it works toward federal approval of its plan.
Here is a link to the public comment page on the CMS website: https://public.medicaid.gov/connect.ti/public.comments/viewQuestionnaire?qid=1897699.
Beauregard said Kentucky Voices for Health will also begin collecting comments on its website, https://www.kyvoicesforhealth.org/, starting July 23 that it will forward to state and federal officials.
Kentucky makes Medicaid copays mandatory ‘under the cover of darkness’
Deborah Yetter, Louisville Courier Journal Published 1:43 p.m. ET July 27, 2018 | Updated 1:48 p.m. ET July 27, 2018
After three weeks of turmoil in Kentucky’s Medicaid program, a new complication — the state’s abrupt enactment of copays ranging from $1 to $50 for medical services — has triggered more confusion among patients, some afraid they can’t afford items such as essential medication for diabetes and asthma.
“It seemed to have been slipped in under the cover of darkness,” said Bill Wagner, CEO of Family Health Centers, a network of community clinics in Louisville. “Even though this went into effect July 1, the instructions have not come out.”
At the University of Louisville medical school, Dr. Barbara Casper, an internist, worries state officials didn’t consider the impact of the new copays on the very poor patients she treats in an outpatient clinic, many of them seriously ill.
“Some of our patients can’t even pay $1,” said Casper, who credits Kentucky’s 2014 expansion of Medicaid under the Affordable Care Act for providing health coverage for many of the low-income patients U of L sees at its clinics.
“This was a problem before we had the Medicaid expansion,” she said. “We had a $2 copay for our patients to be seen and some of them couldn’t even come up with that.”
The clinic does not turn away patients who can’t pay, she said.
While small copays have long been allowed by Medicaid, Kentucky hasn’t required them in recent years. The sudden announcement that copays were mandatory July 1 caught many health providers and advocates off guard.
“Complete confusion,” is how Sheila Schuster, a longtime mental health advocate described it. “It’s not entirely clear what copays are charged for certain services.”
Adam Meier, secretary of the Cabinet for Health and Family Services, speaking at a legislative committee meeting July 18, said his agency is “still clarifying” some aspects of the copays. The cabinet did not respond to a request for information for this story.
Health providers say they aren’t sure who has to pay, who is exempt, how to collect the copays and what to do when patients can’t pay.
For example, pregnant women and children generally have been exempt from such requirements. But several health providers say it appears that children covered through Children’s Health Insurance Program, a Medicaid program for children of low-income parents, must now pay copays.
In Kentucky, about 90,000 children are covered by CHIP.
Some health providers are reassuring patients they will still get care if they can’t pay, including Bridgehaven, a day program in Louisville for people with serious, disabling mental illnesses.
“I worry about it causing them additional stress and anxiety when they’re already trying to cope with mental illness and trying to live on an extremely limited income,” Bridgehaven CEO Ramona Johnson said.
The copays come in the midst of upheaval in the Kentucky Medicaid program, which covers about 1.4 million people, including more than 600,000 children.
The state launched the copays on the same day it had planned to launch Gov. Matt Bevin’s sweeping plan to overhaul Medicaid, adding work requirements, premiums and other new rules aimed at “able-bodied” adults.
But a federal judge struck down the plan June 29, forcing the state to abruptly halt the changes that could affect nearly half a million Kentuckians.
Meanwhile, in a separate move effective July 1, the Bevin administration abruptly announced it had eliminated basic dental and vision coverage for up to 460,000 Kentuckians, creating an uproar particularly among patients who arrived at dentists’ offices only to discover they had no Medicaid coverage.
The administration quickly backtracked and on July 19 said it was rescinding the cuts to dental and vision benefits for now.
But the copays remain in place, leaving bewildered health providers trying to figure out with little guidance how to apply them. If the patient can’t pay, it comes out of the Medicaid reimbursement and the provider takes the loss.
“It could become a big issue for providers that operate with a very slim margin,” Johnson said.
She said that includes her organization, Bridgehaven, whose clients typically visit the center three times a week and may receive three or more services per day, such as a visit with a therapist, a support group and a peer counseling session.
The state says providers must charge $3 per office visit for a service, so that means clients could end up owing $9 a day, Johnson said.
“Three times a day, three times a week, that’s $27 a week,” Johnson said. In addition, Bridgehaven clients will have to pay $3 for visits to a primary care physician or psychiatrist and copays for medication of up to $8 per prescription — medication she said is essential for people with mental illness to remain stable.
“Of course they don’t have that kind of money,” she said. “They struggle to pay their rent, their utilities, buy their groceries.”
Johnson said Bridgehaven will still provide services for clients for now regardless of ability to pay the copay, but the organization could lose up to $100,000 a year from an already tight budget by doing so.
She’s also worried copays will discourage people from seeking treatment.
And in the mental health area, if people don’t get regular services, they wind up homeless, in jail or in far more costly psychiatric hospitals — at state expense, according to mental health advocates.
Casper, the U of L physician, said that also holds true for patients she sees with serious conditions including diabetes, high blood pressure, congestive heart failure, asthma and emphysema.
She worries the patients will wind up in the emergency room or hospital if they skip office visits or cut back on medication because they can’t afford a copay. Copays for Medicaid range from $1 for generics to $4 or $8 for some name brand drugs.
And while physicians try to prescribe generic drugs, some medications — such as insulin for diabetes and inhalers for asthma or other breathing disorders — mostly are available only as name brand drugs, she said.
“It’s not uncommon for some of our patients to be on 10 different medications,” Casper said. “They’re going to be back in the circumstances they were in previously. Do they eat, pay rent, their electric bill, take care of children or get their medicine?”
Casper said the new copays are especially frustrating because they come as patients now receiving regular care through Medicaid are beginning to make important changes in their lifestyles, losing weight, monitoring blood pressure and getting treatment for chronic illnesses.
“It kind of breaks my heart,” she said. “I’ve seen a lot more engagement in their health care by our patients. They’re doing all we want them to to stay healthy.”
Health providers said they are trying to explain the changes to patients and let them know what to expect but are having a hard time doing so absent clear guidance from state Medicaid officials.
“There’s no rhyme or reason as to how co-pays are coming through,” said Michael Lin, pharmacy director for Family Health Centers. “They’re so inconsistent.”
The state has sent out information to people on Medicaid but several providers say patients have brought it to them, unable to understand the complicated, bureaucratic language.
At the Family Health Centers pharmacy in Portland, patients are worried about whether they can afford new Medicaid copays, especially if they have multiple prescriptions for essential medications such as inhalers for asthma or insulin for diabetes.
“They worry about what’s going to happen if they don’t have the money,” Lin said.
Lin and Wagner said the Family Health Centers won’t turn away people who can’t pay, because as a federally recognized “safety net” health service, their agency is able to get other funding to try to defray the costs.
But they said health care providers in private practice don’t have the ability to sustain losses from patients who can’t pay the copay.
And Wagner said making up the difference will still be a hit to the budget at Family Health Centers and other health care providers.
“It’s going to come off the bottom line,” he said.
Here are some of the new copays some people covered by Medicaid are being charged, effective July 1.
>> Office visits for physician, dentist, vision care, behavioral health or other health provider: $3
>> Prescription drugs: $1 for generic drugs, $4 to $8 for name-brand medication.
>> Outpatient hospital service: $4
>> Emergency room visit for non-emergency: $8
>> Hospital admission: $50
>> Durable medical equipment: $4
>> Laboratory or X-ray services: $3
>> Physical, speech or occupational therapy: $3
>> Chiropractor: $3
>> Podiatrist: $3
Source: Kentucky Cabinet for Health and Family Services