Montana Medicaid recipients oppose plan to end continuous coverage

HELENA — Some Montana Medicaid recipients are pushing back against plans to end 12-month continuous coverage for certain people enrolled in public health insurance programs as the state's public comment period on the new policy draws to a close. If successful, the change would likely alter two Medicaid programs in Montana in significant ways, both for enrollees who rely on the state for health care coverage and for officials tasked with operating the new system.

The state will stop accepting public comment on its proposals on Aug. 31.

While the state Department of Public Health and Human Services estimates that ending continuous eligibility, or a year of uninterrupted health care coverage, will save the federal and state governments roughly $22 million a year in the cost of benefits, critics say the change could result in temporary lapses in coverage for more than 20,000 people in a given year.

Inherent to opponents' concerns is the prospect of Montanans losing coverage because of paperwork, communication and bureaucratic errors rather than true income ineligibility, an outcome DPHHS has said it would make every effort to avoid.

The department contends that checking eligibility on a more frequent basis will help ensure that people who don't qualify for the public program won't remain on the rolls, saving the state money in the process.

But vagueness about what might replace the state's current system has sparked anxiety among some residents insured by the impacted programs, including single adults with incomes below 138% of the federal poverty level and people diagnosed with a serious disabling mental illness (SDMI).

"I depend on Medicaid for my mental health problems, and when I have my medicine I feel normal. Please don't make me worry about going without my medicine," said one man in a written comment submitted to the department through the nonprofit Montana Women Vote. "Do not end continuous eligibility."

The Montana Free Press is not publishing the names of quoted commenters, who did not respond to interview requests, in order to protect personal medical information. Montana Women Vote estimated it has helped submit roughly 175 comments from individuals in the past month.

Another woman wrote to the department out of concern for her goddaughter, saying it would be "unfair and cruel to end continuous eligibility," and that the change would make it "difficult or impossible" for her goddaughter to maintain health care coverage.

One recipient told state health officials he depended on Medicaid for "life saving" medicine for diabetes, and urged them not to alter the program's verification process.

"Please don't do this to the people that depend on this," he wrote.

'Under the direction' of the Legislature

Montana and New York are currently the only states that permit continuous eligibility through an agreement with the federal government agency that administers Medicaid and Medicare. Ending continuous eligibility would happen through a waiver submitted to those federal officials, who may accept or reject the proposal.

The draft waiver changes developed by DPHHS contain no details about what would replace Montana's current process of vetting eligibility and income once a year. Department staff said deliberations about program logistics will likely continue between federal and state officials after the waivers are submitted.

The department's move comes in the wake of a legislative session in which lawmakers failed to pass a complex bill, Senate Bill 100, that would have ended continuous eligibility and made several other changes to how Montana verifies Medicaid eligibility.

Late in the session, lawmakers then passed a budget amendment authorizing DPHHS to end continuous eligibility for adults who are covered through the 2015 Medicaid expansion program. That group includes single adults whose income is up to 138% of the federal poverty level. Nearly 10% of Montana's total population, or 101,484 enrollees, were covered by Medicaid expansion as of this July.

"We are implementing this waiver change under the direction of the Montana state Legislature," DPHHS Medicaid and Health Services branch manager Marie Matthews said in an August hearing before lawmakers. "The funding to pay for continuous eligibility was removed from our budget and there was clear language in directing us to pursue this policy."

Though not instructed to do so by the state Legislature, DPHHS has said it will also submit a waiver amendment to the federal government to end continuous eligibility for roughly 20,000 Montanans covered by the WASP (Waiver for Additional Services and Populations) program, which insures low-income families and caretakers as well as people 18 and older who are diagnosed with a serious disabling mental illness (SDMI). The department has said its reason for doing so is to avoid "significant additional administrative burden" if the state continues 12-month continuous eligibility in one program and not the other.

During the August meeting, department officials stressed that a person would be removed from the program only after verification that their permanent monthly income level has exceeded the eligible amount.

"If somebody makes enough income that they're no longer eligible for Medicaid coverage, then the next tier is the subsidized [Affordable Care Act] plans on the exchange," said DPHHS Director Adam Meier, who added that he would expect some residents' health outcomes to eventually improve after leaving Medicaid, based on a presumption that they will have a larger income.

"I would think that as people improve their economic situations, as they're making more income, that would then be their impetus for no longer qualifying [for Medicaid], then we may see a corresponding increase or improvement in health outcomes," Meier said.

The 'human element' to policy change

None of the members of the public who testified before lawmakers in August voiced support for the proposed DPHHS waivers.

Asked how many public comments the department had received so far, and whether those comments supported or opposed the proposals, a DPHHS spokesperson told the Free Press that information will be available after public comment closes on Aug. 31 and the department has submitted its proposals to the federal government.

Democratic lawmakers on the Children, Families, Health, and Human Services Interim Committee in August repeatedly asked members of the department to explain what they consider the benefits of discontinuing continuous eligibility, and how many people would likely be impacted by the change.

"I'm still unclear as to what the outcome is that the department hopes to seek," said Rep. Mary Caferro, D-Helena. "But I am pretty sure that, whether intended or not, the outcome will be a reduction in the rolls."

The department, citing a 2013 study conducted by researchers from George Washington University, estimated that ending continuous eligibility would reduce months of coverage by 2.6%. Caferro said that calculation seems to use "sterile language" to avoid accounting for the impact on real Montanans.

"You know, when you say 2.6% of whatever, we're talking about people," she said. "WASP, for example, covers people who are seriously mentally ill and also the families who live in extreme poverty … we are talking about people's health care and people's lives."

Pinpointing the number of people affected by the waiver change is difficult, said Dr. Leighton Ku of George Washington University, one of the researchers whose work DPHHS cited in its estimate of reduced coverage.

In a written comment submitted to the department and in a later phone interview, Ku said a reduction of 2.6% covered months would likely be distributed across enrollees who would temporarily lose coverage for a short amount of time within a year. If enrollees had their coverage discontinued for roughly two months before they could re-enter the program, Ku said, the number of affected residents could reach as high as 15.6%, or roughly 21,500 people.

Ku said that "churn," the process of people exiting public programs only to re-apply a short time later, can also create administrative strain on public health departments, on top of the increased vetting and communication demands on state employees. In its proposed waiver changes, DPHHS does not estimate the anticipated costs of running the program with more frequent eligibility checks.

If people fall through the cracks because of miscommunication with DPHHS about their income and eligibility, Ku said, their health care may also be more expensive when they come back to a public health insurance program. More importantly, he said, interrupted health care could have serious repercussions for some individuals.

"If you have diabetes, for example, that means that actually you want your insulin and your medications all year round," Ku said. "You don't want to say, OK, insulin for 10 months, two months I'll go without. That's how you end up having problems. Like you go into diabetic coma."

Nationally, health care researchers have encouraged states to enact continuous eligibility policies for particularly vulnerable people with public insurance, such as children, because of improved long-term health outcomes. Ku said he and others are suggesting that states apply that perspective to their Medicaid policies for adults as well.

"There's lots of research that basically shows that by providing people more stable coverage, they end up being healthier. They are able to get primary and preventive care so that they don't have a diabetic coma, so that if they have asthma, they don't end up in the emergency room," Ku said. "If there is someone who has, you know, a mental health problem, that they don't go off their medications, they can still get counseling, so they don't have a psychotic attack."

After the close of public comment next Tuesday, DPHHS has until Sept. 3 to apply changes to the proposed waivers and submit them to the federal government. Before any waivers are approved, federal officials will open another 30-day public comment period and could enter negotiations with state officials on the details of proposed plans.

One other logistical reality hangs over Montana and other states looking to change their enrollment and eligibility processes for Medicaid. Given the federally declared public health emergency in place because of the COVID-19 pandemic, states must keep continuous eligibility in place or risk losing an enhanced federal match rate for Medicaid.

In its presentations on the topic, DPHHS has said it will continue to follow the federal pandemic guideline so as not to sacrifice that boosted rate. The department has said the federal emergency declaration is expected to continue until Dec. 31, and could possibly be extended further, likely pushing the implementation of any changes to Montana's Medicaid programs into 2022.