Proposed changes to Medicaid eligibility in MT receive pushback in interim hearing

Missoula Current

Healthcare advocacy organizations in a legislative hearing on Tuesday railed against proposed language amending state Medicaid law that will end 12-month continuous eligibility for Medicaid expansion members, warning that the policy change could result in vulnerable Montanans losing their healthcare due to added regulation.

The language, part of an amendment to an existing application the state had already submitted to waive certain Medicaid requirements under the U.S. Social Security Act, comes at the direction of House Bill 2, the main state budget legislation, which Republican lawmakers modified late in the last session to cut funding for continuous eligibility.

With the legislature out of session, the state Department of Health and Human Services is required to present its waiver application to the Children and Families Interim Committee, which heard public comment on the proposal Tuesday.

In essence, continuous eligibility allows people on Medicaid expansion to retain access to care year-round, even if their income level or other life circumstances change. Already, Medicaid members are expected to report these changes — but under continuous eligibility, which is only on the books in Montana and New York, the state doesn’t have to act on them.

Rather, they stay on their coverage through the end of the year even if, perhaps, they no longer meet the income threshold. Under the amendment, the Department of Public Health and Human Services would review these changes, request information from the member in question and then make a decision as to their eligibility.

Rehashing arguments against a slate of failed legislative proposals with similar aims from the last session, advocates said Tuesday that regardless of the state’s intentions, the new language could result in gaps of Medicaid coverage — especially for those with serious mental illnesses — due to the increased scrutiny and paperwork requirements.

They also raised issue with the fact that DPHHS told lawmakers on the interim committee that the department was submitting these proposals at the behest of the Legislature.

“We do not need another layer of red tape that puts another barrier to continued access to care for folks needing the services provided through these waivers,” testified Kristin Page-Nei, a lobbyist for the American Cancer Society Cancer Action Network, who spoke to the committee based on her experiences caring for an older brother that has struggled with serious mental illness and addiction. “I am basing my concerns about the elimination from my observations and trying to work with the system.” 

Republican lawmakers made several attempts during the session to end continuous eligibility, namely through SB100, which was marketed as an effort to crack down on welfare fraud and would have increased the frequency of eligibility checks to six months.

Those proposals were defeated, but the general concept lived on in narrative language added by legislative Republicans to the budget directing the department to end the policy of 12-month continuous eligibility. The change, they argued, would save the state money while ensuring that only those who are eligible receive Medicaid coverage.

But Page-Nei told the committee Tuesday these objectives are based on faulty assumptions. Her brother receives coverage for behavioral health treatment thanks to a Medicaid waiver intended for people with severe and disabling mental illness. Last year, she took charge of her brother’s welfare.

“There’s an assumption that recipients aren’t already in crisis,” she said. “When they’re in crisis, they’re not paying attention to their mail. They’re just trying to survive.”

And there’s another assumption that there will be enough case managers to help Medicaid recipients “defend from being bumped off a waiver,” she said. Her brother regularly rotated through case managers, she said, and sometimes, he didn’t have one at all. Plus, if a person gets kicked off Medicaid, they lose access to wraparound services that might help them avoid costly stays in the ER, she said.

“I just think we have to look at all of these different scenarios and understand it’s not just about the specific amendment, it’s about how it impacts this already fractured system,” Page-Nei said. 

Others pointed out that the changes could harm those with seasonal jobs whose incomes often fluctuate — while there’s state statute saying that a person can’t lose Medicaid coverage due to short-term pay increases from overtime or bonuses, the amended language could kick agricultural or tourism workers off their insurance depending on how their income changes, said Heather O’Loughlin with the Montana Budget and Policy Center.

“It is really important for this committee to see the details of what eligibility redetermination plans are moving forward,” she said.

DPHHS is actually seeking to remove continuous eligibility for two programs: Medicaid expansion, known as the HELP extension, and the Waiver for Additional Services and Populations, or WASP, which specifically covers Montanans over 18 with serious mental illness.

The department estimates the change will result in a roughly 2.6% loss of “coverage months” for each program, and will save the state $22 million in administrative costs for the former program and around $1 million for the latter. (On average Medicaid would be covering 2.6% fewer months due to people leaving the program from churn.)

But the department couldn’t provide to lawmakers an estimate of how many people that loss in coverage months will impact — for Medicaid expansion, DPHHS forecasted 29,083 fewer Medicaid expansion coverage months under the amendment.

“We were very aware that we could not calculate how many people the member months loss would impact,” said Marie Matthews, the state Medicaid director with the department. 

And while the state budget indeed directed DPHHS to eliminate continuous eligibility for Medicaid expansion, it made no mention of the WASP program. In a presentation to the committee, the department said it would cause undue administrative burden to eliminate continuous eligibility in one program and not the other.

“It was not the Legislature’s intent to remove continuous eligibility for WASP waiver,” said Mary Windecker, the executive director of the Behavioral Health Alliance of Montana. “People living with an SDMI are often trying to juggle numerous balls, including acquiring safe housing, managing family relationships, finding and keeping employment” and so on.

The new policy, she said, “will result in them dropping one or all of those balls.”

Opponents of the changes and the committee’s Democrats questioned the presumption that the department was just following legislative intent. For one, they said, the fact that lawmakers defeated legislation with a similar effect seems to express legislative intent in itself.

“To the extent that does provide legislative intent, so do the three bills that were defeated that would have tried to do the same thing, including the companion bill to HB2,” said Rep. Ed Stafman, D-Bozeman, who chairs the interim committee. “The legislative intent in my view is ambiguous at best.”

Lawmakers on the committee have the opportunity to submit comment on the proposals until the end of August, by which time the department will begin preparing the amendments for submission to CMS. However, they have no actual authority over the fate of the amendments themselves, meaning that calls to action Tuesday were limited essentially to requests for DPHHS to drop the application.

“The loss of continuous eligibility is reflected in more than the sterile statement of some savings received through less coverage months,” said Katherine Buckley-Patton, who sits on the Beaverhead County Mental Health local advisory council. “It is the loss of security, stability and benefits for Montanans in need.