Wisconsin: Medicaid Buy-In

Wisconsin: Medicaid Buy-In

Upshot

• A.B. 1118 and S.B. 1089 proposed the creation of a basic health plan, a buy-in option under Medicaid, and the implementation of a state-based Marketplace.

• BadgerCare currently covers all children up to age 18, low-income pregnant women and parents, farm families, and adults with incomes up to the FPL.

• The bills were introduced by Democrats in the Republican-controlled legislature at the very end of the legislative session and died when the legislature adjourned.

Background

Wisconsin is one of 12 states that has not expanded Medicaid under the ACA to adults without dependent children. However, it currently provides Medicaid benefits to a segment of the population that would otherwise benefit from a Medicaid expansion. Through a Section 1115 waiver, Wisconsin operates BadgerCare, which provides Medicaid benefits to childless adults who are not pregnant, disabled, or elderly individuals with incomes of up to and including 100 percent FPL. The waiver allows Wisconsin to expand eligibility criteria and implement additional features, such as charging a monthly premium to beneficiaries with incomes from 50 percent and up to and including 100 percent FPL. Notably, Wisconsin attempted to impose work requirements through its Section 1115 waiver approved by the Trump Administration, though it was ultimately withdrawn by the Biden Administration. BadgerCare is funded through a combination of Medicaid, CHIP, and state-only funds.

Additionally, Wisconsin offers Medicaid Purchase Plan, a Medicaid buy-in for adults with a disability who 1) have a job or are enrolled in the certified Health and Employment Counseling Program, 2) have individual countable assets of $15,000 or less, and 3) have an income of less than 250 percent FPL. Beneficiaries with a gross monthly income at or below 100 percent FPL do not have to pay a monthly premium.

Wisconsin leverages the federally-facilitated Marketplace. In 2022, 14 insurers offered plans on the Marketplace. Overall, average premiums decreased by 0.65 percent from the previous year. The ARP APTC expansion has been particularly impactful in Wisconsin. In 2021, the average monthly premium in Wisconsin was $629 without subsidies and $185 with subsidies. Wisconsin also operates Wisconsin Healthcare Stability Plan, a reinsurance program, through a section 1332 waiver, which lowered premiums by 13.4 percent in 2021.

Summary

The bills would require the Wisconsin Department of Health (DHS) to establish: 1) a basic health plan for individuals with income up to 200 percent FPL and 2) a Medicaid buy-in for individuals with income above 200 percent FPL as well as a limited pathway for employers. In order to facilitate the buy-in option, the bill would also require the establishment and operation of a state-based health insurance Marketplace. Currently, Wisconsin uses the federally-facilitated Marketplace to offer ACA Marketplace plans.

• Basic Health Plan: The bill would require the Wisconsin Department of Health Services (DHS) to request federal approval to create a BHP for individuals with incomes up to 200 percent FPL.

• Medicaid Buy-in: Additionally, the bill would require a purchase option for BadgerCare for individuals with income above 200 percent FPL. There would also be an option for small groups of 50 employees or fewer to purchase coverage for group members. The purchase option must include the following attributes:

  • Establishment of an annual per enrollee premium rate similar to the average rate paid by the state to managed care plan contractors

  • Establishment of a benefit set equal to benefits covered by Medicaid;

  • Annual enrollment that is limited to the same annual open enrollment periods established for Medicaid;

  • The ability for the department to adjust the actuarial value to a value no lower than 87 percent; and

  • Reimbursement mechanisms for addressing potential increased costs to state health programs.

DHS would be required to submit a report with information on the status of receiving a federal waiver and the results of any economic analyses. DHS would also be required to seek any federal waiver and Medicaid plan amendments necessary to allow individuals who buy into BadgerCare to use advanced tax credits and cost-sharing credits.

West Virginia: Medicaid Buy-In Program

West Virginia: Medicaid Buy-In Program

Upshot

• Creating the Affordable Medicaid Buy-In (H.R. 3001 and S.B. 688) would establish a Medicaid buy-in plan in West Virginia for individuals who are above current state Medicaid eligibility levels (138 percent FPL).

• ·The Medicaid buy-in plan would only be available at the platinum metal tier on the individual market outside the Marketplace and require a monthly premium on a sliding scale for individuals under 200 percent FPL.

• The state would have the latitude to offer the Medicaid buy-in plan through Medicaid MCOs, with provider reimbursements rates based on the Medicaid fee schedule.

• Neither bill advanced beyond the committee level during the legislative session. However, the bipartisansupport for the new coverage pathway is relatively unique and signals the willingness of some state legislators to work across the aisle on lowering health care prices.

Background

West Virginia adopted the ACA Medicaid expansion. Therefore, all adults with an income up to 138 percent FPL are eligible for the state Medicaid program. Since 2004, West Virginia has offered Medicaid Work Incentive Network (MWIN), a Medicaid buy-in program for individuals who are disabled and employed with a household income up to 250 percent FPL, as authorized under the federal Ticket to Work and Work Incentives Improvement Act of 1999. Enrollees receive full Medicaid benefits and are required to pay a monthly premium based on a sliding fee scale – $15 to $129.50.

West Virginia leverages the federally-facilitated Marketplace. In 2022, two insurers offered plans on the Marketplace, both of which increased premiums from the previous year – Highmark Blue Cross Blue Shield (11.6 percent) and CareSource (14.9 percent). The ARP APTC expansion has been particularly impactful in West Virginia. In 2021, the average monthly premium in West Virginia was $1,038 without subsidies (the second highest in the country) and $323 with subsidies.

Summary

The bills would require the Department of Health and Human Resources (DHHR) to establish the Affordable Medicaid Buy-In Program by January 1, 2023. The program is defined as a “state-administered, public option, health care coverage plan that leverages the Medicaid coverage structure.” Additional details follow.

• Administration: DHHR would have some flexibility on how to administer the Medicaid buy-in plan. DHHR could rely on existing Medicaid infrastructure and administer the Medicaid buy-in plan through MCOs under contract with the state to provide Medicaid services and benefits. In addition, DHHR could apply the medical loss ratio for Medicaid managed care to the Medicaid buy-in plan, which requires plans to spend at least 85 percent of total payments (per member per month) on covered services and no more than 15 percent on other activities such as plan administration and profit. Since West Virginia uses the federally-facilitated Marketplace, the Medicaid buy-in plan would be available on the individual market outside the Marketplace (i.e., off-Marketplace).

• Eligibility: All people who are ineligible for Medicaid and Medicare and who lack access to employer-sponsored health coverage would be eligible for the new Medicaid buy-in – specifically, adults between 16 and 64 years above 138 percent FPL.

• Covered Services: The plan would only be available in the platinum metal tier, which generally covers 90 percent of all health care costs. The plan would offer EHBs required by the ACA for Marketplace plans. DHHR would be required to establish a standardized benefit and cost sharing design for the plan and establish a method for procuring prescription drugs, which could involve using pharmacy benefit managers to negotiate prices or contracting with other entities for combined purchasing power.

• Payment Rates: DHHR would be required to use the Medicaid fee schedule for provider reimbursement rates. DHHR could increase reimbursement rates if funds are available and doing so would not jeopardize the sustainability of Medicaid or the plan.

• Premiums and Cost-Sharing: Enrollees would pay a monthly premium on a sliding scale based on household income. DHHR would be required to set “fair and reasonable premium rates” based on an actuarial analysis “to ensure maximum access to coverage.” Additionally, DHHR would be required to offer discounted premiums and cost-sharing to residents with household incomes below 200 percent FPL.

• Federal Waiver: DHHR would be required to pursue a Section 1332 waiver to allow individuals who qualify for coverage on the federally-facilitated Marketplace to use their APTC to purchase the Medicaid Buy-In plan. Under current law, APTCs cannot be used to subsidize plans purchased off-Marketplace.

• Advisory Council: DHHR would be required to establish an Affordable Medicaid Buy-In Program advisory council to advise the department on implementation, plan affordability, marketing, enrollment, outreach, and evaluation. The advisory council would consist of the DHHR Secretary, insurance commissioner, three consumer representatives, and a total of four industry representatives and experts appointed by the Governor.

Indiana: Medicaid Buy-In Program

Indiana: Medicaid Buy-In Program

Upshot

• ·S.B. 384  would expand eligibility for and generosity of MED Works, the existing Medicaid buy-in program in Indiana for qualifying individuals with disabilities ages 16-64.

• The proposed limit on the types of assets that the Indiana Family and Social Services Administration (FSSA) considers to determine program eligibility would allow a larger number of applicants to become eligible for MED Works.

• In addition, applicants that previously or currently receive benefits from the federal Social Security Administration (SSA) or the state Medicaid program would not be excluded from MED Works. Beneficiaries of MED Works could also receive home and community-based services to supplement Medicaid buy-in program benefits.

• The bill failed to advance out of the Committee on Health and Provider Services.

Background

Indiana adopted the ACA Medicaid expansion. Therefore, all adults with an income up to 138 percent FPL are eligible for Medicaid. Indiana attempted to impose work requirements through a Section 1115 waiver approved by the Trump Administration, though it was ultimately withdrawn by the Biden Administration.

Since 2002, Indiana has offered MED Works, a Medicaid buy-in program for individuals who are disabled and employed, as authorized under the federal Ticket to Work and Work Incentives Improvement Act of 1999. Individuals eligible for MED Works are enrolled in Hoosier Care Connect, a Medicaid managed care program. Indiana has contracts with three MCOs to deliver Medicaid benefits – Anthem, Managed Health Services, and United Healthcare.

Summary

While the bill would maintain current income limits for MED Works, it would expand eligibility in three ways: 1) permit applicants to have resources (i.e., assets that can be turned into cash) that exceed federal limits; 2) broaden the criteria for what satisfies the employment requirement; and 3) expressly allow applicants to participate in other public programs.

Under the modified MED Works program, all participants would be required to pay a monthly premium. The bill would remove statutory language that currently permits FSSA to exempt participants with an income less than 150 percent FPL from paying a monthly premium. However, the bill would also lower minimum and maximum monthly premiums on a sliding scale. The bill would also add two situations for when FSSA must adjust an individual’s premium across the sliding scale.

Lastly, the bill would allow participants to receive HCBS through a Medicaid waiver program to supplement Medicaid buy-in program benefits. Examples of HCBS services include health care coordination, home delivered meals, and transportation.

Florida: Medicaid Buy-In Program

Florida: Medicaid Buy-In Program

Upshot

• Three identical bills (H.R. 675, S.B 1692, and S.B. 1822) would narrowly expand Medicaid eligibility in Florida to individuals with disabilities ages 16-64 who are above current state Medicaid eligibility levels.

• All three bills died at the committee level during the legislative session. Any efforts to expand Medicaid eligibility appears unlikely to advance under Republican control of the state legislature and governorship. A ballot initiative, though with its own set of challenges, is the more viable path forward to significantly expand Medicaid in Florida.

Background

Florida is one of 12 states that has not expanded Medicaid under the ACA to adults without dependent children. Therefore, most adults without dependent children are not eligible for Medicaid in Florida. The income eligibility limit for parents is 30 percent FPL. Efforts to expand Medicaid through voter initiatives have not been successful in Florida and have been further thwarted by the Florida Legislature. Notably, however, Florida has taken steps over the last several years to expand access to Medicaid for working people with disabilities who are not automatically eligible for Medicaid due to receipt of Supplemental Security Income (SSI) benefits – specifically, people with disabilities with an income above 200 percent FPL, the current income for SSI-related Medicaid benefits.

In 2018, the Florida Legislature directed the Agency for Health Care Administration (AHCA) to evaluate three options to allow individuals with disabilities to work and earn additional income while maintaining their Medicaid coverage. AHCA recommended that Florida pursue a state plan amendment to waive certain income and resource rules for individuals receiving services through home and community-based service waivers, as it would provide “the most direct path” to implementing a Working People with Disabilities program in Florida “while simultaneously imposing a low fiscal impact to the state and the least administrative burden.” AHCA also evaluated, but ultimately did not recommend, the following options:

• Increase utilization of Miller Trusts/Qualified Income Trusts, which would allow eligible individuals to place sufficient income into a special account in order to meet the Medicaid income eligibility limits; and 

• Implement a Medicaid buy-in program to allow eligible individuals with disabilities to pay a premium for Medicaid benefits.

The fiscal year 2019-2020 state budget included funding to implement the Working People with Disabilities program through a state plan amendment. Florida received federal approval to implement this program in 2020. As a result, people in Medicaid can qualify for the program if they are enrolled in one of the following home and community-based services waivers: Development Disabilities Individual Budgeting Waiver (iBudget); the Long-Term Care Waiver; and the Familial Dysautonomia Waiver. The Medicaid monthly income limit is 550 percent of the federal benefit rate (FBR) (previously 300 percent of FBR), and the asset limit to $13,000 for an individual and $24,000 for a couple (previously $2,000 for an individual and $3,000 for a couple). The iBudget and Familial Dysautonomia waivers are fee-for-service programs. The Long-Term Care Waiver is a capitated, managed care program offered by Statewide Medicaid Managed Care Long-term Care plans and Managed Medical Assistance Comprehensive plans.

Summary

The bill would require AHCA to establish and implement a Medicaid buy-in program, as authorized under the federal Ticket to Work and Work Incentives Improvement Act of 1999 and the Balanced Budget Act of 1997, for individuals with disabilities who are between 16 and 64 years and have a household income that exceeds the maximum limit for Medicaid eligibility. Any premium or cost-sharing would be limited to a certain percentage of an individual’s income. Program implementation would necessitate AHCA seek approval of a federal waiver or a state plan amendment.