On July 14, WHA submitted comments to the Centers for Medicare & Medicaid Services (CMS) on Wisconsin’s draft waiver amendment to the state’s Medicaid childless adult demonstration project. WHA recommends CMS consider enhanced funding for Wisconsin’s program and suggests modifications to proposed emergency department copayments, premiums, work requirements and drug testing. The DHS proposal also includes a change to the federal policy that limits services in Institutes for Mental Disease (IMD).
The Wisconsin Department of Health Services (DHS) submitted the waiver amendment proposal to CMS in June after receiving stakeholder feedback on an earlier draft. In order to implement the changes, DHS needs CMS approval. In May, WHA submitted comments to the State and was pleased DHS made some modifications to the earlier draft. Nevertheless, WHA calls for additional modifications, particularly to the funding and the emergency department copayment provisions.
The original waiver for providing services to the childless adult population was approved in late 2013 and allowed the state to expand eligibility to childless adults with income up to the poverty line (100 percent FPL). This was considered a "partial expansion" by the previous federal administration, and thus Wisconsin was not eligible for the higher level of federal funding available to states that expanded coverage to adults with income up to 133 percent of the federal poverty level (FPL). WHA has been advocating for equitable funding for Wisconsin’s partial Medicaid expansion compared to states that fully expanded Medicaid under the Affordable Care Act.
In its comments, WHA recommends that CMS consider and approve enhanced federal matching funds for the partial expansion. In doing so, WHA describes Wisconsin as a model for avoiding gaps in coverage and notes other states are now considering changes to their programs that align with Wisconsin. In Arkansas, for example, recently passed legislation that requires the state modify its current Medicaid waiver to reduce the income threshold for coverage from 133 percent FPL to 100 percent FPL, like Wisconsin’s program. Arkansas is an expansion state and is expected to ask the federal government to maintain the higher match it currently receives.
"As states seek flexibility for their programs, including as expansion states seek ways to reform their programs and reduce costs for their Medicaid programs, the principle that Medicaid should be a safety net for all in poverty can resonate if states are assured of enhanced funding," wrote Eric Borgerding, WHA president/CEO.
In addition to the funding question, WHA also provided comments about the implementation of other policies included in the waiver proposal. WHA noted in particular the state’s commitment to increasing treatment options for individuals with substance use disorders. WHA also expressed support for the intention of the overall proposal to engage participants in maintaining and improving their overall health and incenting the efficient use of health care resources.
At the same time, WHA expressed concern about some provisions that would result in a person’s disenrollment from the Medicaid program. The imposition of premiums is an example.
"WHA’s members are the health care safety net," wrote Borgerding. "Individuals who fail to pay their premium and are disenrolled will still seek care at their doors, and our members will continue to serve them. Unfortunately, this will mean more uncompensated care."
The draft waiver proposal also includes copayments for emergency department utilization. The copayment would be $8 for all emergency visits, with providers being responsible for collecting the copayments. In its comments, WHA notes individuals with income below poverty likely will not be able to pay, and this will essentially result in a provider rate cut, increasing the Medicaid shortfall even more. Instead, WHA recommends the copayment be collected directly by DHS. WHA also believes the proposal as drafted could discourage appropriate use of the emergency room and recommends the proposal be narrowed to non-emergent use only.
The waiver proposal includes a 48-month time limit and work requirements. Any month in which the participant does not meet the work requirement would apply to the 48-month limit, and once a person meets the 48-month limit he/she would be disenrolled for six months. DHS proposes to limit the application of these policies to people age 19-49, and would allow for exemptions for individuals with mental illness, disabilities and other circumstances. WHA encourages CMS to consider additional exemptions for people with medical conditions that might prevent them from being able to meet the work requirement.
WHA believes health risk screenings are a positive practice and helpful if used appropriately to address care needs. WHA also supports the provision to waive the current limits on services provided by IMDs. With respect to the substance use provisions, WHA remains concerned about significant gaps in availability of treatment. While Wisconsin has made gains in the past several years in expanding substance abuse treatment resources, considerable additional investments are still needed. WHA has been and will continue to partner with and support efforts to combat substance abuse and increase access to and the availability of substance abuse treatment for individuals suffering from addiction.