CT Medicaid wins in health reform reconciliation bill

The reconciliation bill scheduled to be considered this weekend by Congress benefits CT’s Medicaid program, and the state bottom line, in significant ways.

The bill would expand Medicaid coverage to all state residents (except undocumented immigrants) up to 133% of the federal poverty level (FPL) -- $14,620.50 for individuals and $19,669.50 for a family of two – in 2014. CT would receive full funding for all newly eligible residents in 2014, tapering down to 90% after 2019. In 2007/2008 CT had 110,200 uninsured residents living below 133% FPL. In January of this year there were 43,549 members of our state-funded SAGA program; those members would become eligible for Medicaid and, because we do not have a waiver to cover them, they should be eligible for federal funding saving the state $133 million. Because CT does not have a Medicaid SAGA waiver, coverage of SAGA members would qualify for federal funding under the reform bill (sometimes it pays to procrastinate). It is also likely that many of the 6,077 Charter Oak residents in the lowest income band (0 to 150% FPL) as of March 1st will become eligible for Medicaid and full federal funding, saving the state what we spend on their subsidies.

Medicaid primary care providers will benefit under the reconciliation bill which increases their rates to Medicare levels in 2013. In 2008, CT primary care Medicaid rates averaged 0.78 of Medicare levels, according to the Kaiser Family Foundation. The incremental cost will be paid fully by the federal government from 2013 through 2014. In 2008, CT’s rates were better than most other states (weighted average of 1.44 compared to other state’s rates). CT would receive more if our provider rates were closer to the national average, but we will be getting more than we did in the past.

In January, the CT Health Policy Project outlined a list of questions CT’s Medicaid program needs to answer in implementing national health reform.
Ellen Andrews

From the Consumer Helpline

I am working with a consumer who called our helpline to ask for help with medical debt from two hospitals. When he was in Bristol Hospital he applied for financial assistance but he was denied because he didn’t want the Department of Social Services (DSS) to put a lien on his house. It is a requirement of most hospital financial assistance programs that the consumer has to apply for SAGA medical and it is a DSS requirement that if you are a homeowner and you want SAGA medical, they put a lien on your home to recoup the medical costs. I explained this to the consumer who also said he is disabled, although he isn’t currently getting Social Security Disability (SSD). People who are disabled can apply for Medicaid (also through DSS) and a lien is not put on your home. The problem is that since he isn’t currently getting SSD, there is a lot of paperwork for him and his doctor to fill out to determine that he is disabled for the purposes of getting Medicaid. On top of that he will also have to apply for SSD.

The consumer had been paying $10 a month to Bristol Hospital but now they sent him into collections. He said no one from the hospital ever returned his calls to say if $10 a month was acceptable and he thought it was ok since he didn’t hear anything back from them. He also disagrees with the total amount of the Bristol Hospital bill because they are billing him for a CAT scan he didn’t receive. When he called the hospital again to try to straighten this out, they told him to call the collections agency, who told him to call the hospital. I was able to get a name and phone number for the person at the hospital that he needs to talk to look into this. So far, the calls he’s made there haven’t been returned.

The other hospital he has bills from told him he isn’t eligible for financial assistance because he was never admitted to the hospital. He also isn’t eligible for a reduction to pay the “cost” of care (the actual amount that the hospital care costs as opposed to the increased prices the uninsured are usually charged), even though he is below 250% of the federal poverty level, because he didn’t complete the DSS application for SAGA medical.

When he left my office after an appointment, he had a long to-do list, including applying for SSD, applying for Medicaid (which included about 20 pages of medical paperwork for him and his doctor to fill out), contacting the hospital to straighten out the billing error, writing a letter to the collections agency to dispute the bill, and calling his state Senator’s office to see if they could help him. It is a full time job to be without health care when you have health issues and unpaid medical bills. For advice on managing hospital debt see our tip sheet.
Jen Ramirez

Medicaid Managed Care Council update

According to DSS at today’s Medicaid Managed Care Council, the number of dental providers participating in the CT Dental Partnership grew by 20.8% from December to June. There are now 924 dental providers at 541 locations across the state caring for HUSKY and SAGA consumers.

DSS also reported that there were only 366 HUSKY appeals filed in 2007 and even fewer, only 174, in 2008. It is not clear that consumers know that they have the right or know how to appeal treatment denials.

SAGA medical expenses per member per month declined by 0.6% in the fiscal year that ended June 30th after rising 7% in 2008 and 8.2% in 2007, probably because spending in the program is capped and enrollment grew by 12% this year. The average per member per month cost in the program is $424.47. Pharmacy costs decreased by 6.5% because, after carving out pharmacy benefits, drug company rebates rose significantly. Other states have also increased rebate recoveries after carving out pharmacy benefits. The SAGA provider panel has increased by 181 providers this year and utilization of physician services is up 33% from last year. The increase in primary care access may be the reason that ED visits are down by 7% in the program.

Charter Oak enrollment is up to 8,979 as of July 1st, however 824 people stopped paying their premiums in June and dropped out of the program.
Ellen Andrews

Appropriations passes a budget

The budget approved by the Appropriations Committee restores many of Governor Rell’s proposed cuts to health care programs. The committee did not agree to the Governor’s proposed co-pays and premiums on HUSKY families; imposition of premiums would jeopardize significant federal stimulus funding. Also to ensure CT gets new federal funding, the committee rejected the Governor’s proposal to eliminate self-determination of income for HUSKY applicants. The legislature restored HUSKY eligibility for legal immigrants that the Governor proposed to eliminate; the federal SCHIP reauthorization bill grants the state a 65% match on those costs. The committee did not agree to the Governor’s proposal to eliminate prenatal care for undocumented immigrants, eliminate funding for medical interpreters, or to eliminate vision and transportation services for SAGA clients. The committee provided funding for smoking cessation treatment under Medicaid that was not in the Governor’s budget. The committee provided funds to implement the family planning waiver; those funds would be 90% matched by the federal government. The committee did not agree to the Governor’s proposal to eliminate all but emergency dental care for adults in Medicaid and SAGA, however they did implement utilization review for those services. The committee did agree to weaken the Medicaid and SAGA medical necessity definition. The committee agreed to some of the Governor’s proposed pharmacy cuts, but not others. The legislature took money out of the Governor’s proposal for her Charter Oak Plan to reflect lower than expected enrollment. The budget restores funding for the Office of Health Care Advocate. A more detailed analysis will be coming.
Ellen Andrews

Governor’s mitigation plan slashes health programs; 13 better alternatives offered

Yesterday the Governor released her plan to address the $470 million deficit for this fiscal year. This is on top of the cuts made in the budget that passed into law a few months ago. Her proposal includes cuts to the diaper bank, autism pilot, drugs in public coverage programs, new premiums and increases in HUSKY, higher copays in HUSKY and Medicaid, eliminate vision and transportation in SAGA, delay HIV/AIDS waiver, cut lead poisoning programs, genetic disease programs, school based health centers, eliminate adult dental care in Medicaid and SAGA, cut Healthy Start, cuts to community health centers, hospitals and nursing homes. Her proposal also empties all the money out of several funds including stem cell research and the Tobacco and Health Trust Fund.
Sadly, there are alternatives that could save the state money as well as improve health care. We have offered thirteen of them.
Ellen Andrews

Notes from community outreach

Yesterday I did an outreach event for about 25 participants in the STRIVE- New Haven program to let them know about different health insurance options. STRIVE does “employability skills training workshops” for residents of greater New Haven to help them find and keep jobs. STRIVE is a comprehensive job and life-training program with a great record of success.

The purpose of these outreach events is to go out into the community and to provide information and answer questions about health insurance coverage and where to find health insurance in Connecticut. Some of the health insurance options I talked about were individual insurance, employer-based insurance, COBRA, Charter Oak, HUSKY, SAGA, and free bed funds from hospitals. I was impressed by the STRIVE program as well as the professionalism of the participants, who demonstrated what they were learning in the program. They were interested in the different topics and asked questions to get more information (each person would stand and introduce themselves when they had a question). Participants asked questions about HUSKY, community health centers, and SAGA Medical (including spenddowns). All of the men wore ties with dress shirts and pants and the women wore clothes suitable for the workplace. I handed out a lot of our tip sheets, which are a great resource to provide more information about the topics I was covering. The audience was receptive and engaged; it was definitely a successful outreach event.
Jen Ramirez

Medicaid Managed Care Council update

Friday’s Council meeting was relatively uneventful. We started with a wonderful outreach video by CT’s Healthy Start programs describing the important work they do supporting at-risk pregnant women and connecting them to the care they need to ensure healthy births. (Advocates think it would be a good idea to start every Council meeting with babies – it makes it hard to be grumpy.) We then heard about the challenges of keeping families enrolled in HUSKY. A study by CT Voices for Children found that 141,000 people came into HUSKY in 2006 and 2007, but total enrollment grew by only 11,000. However they were unable to determine if people left because they found other coverage or if they became uninsured. DSS noted that they have implemented several improvements to the eligibility system since 2007. PCCM/HSUKY Primary Care enrollment is up to 359 clients and 237 providers. DSS has also agreed with advocates’ concerns and will ask CMS for permission to delay the PCCM evaluation until 2011 when it is hoped enrollment will be high enough to make the study meaningful. DSS described their plans to move all SAGA recipients into Medicaid (as of April 1st) under a new option passed in the recent national health reform act. It is expected that the option will save CT $53 million over the next 15 months. CT is the first in the nation to apply under this provision. However we are eligible because the state never acted on multiple directives from the General Assembly to apply for a waiver to cover SAGA – most other New England states have been covering childless adults under a Medicaid waiver for years. New enrollment numbers from ACS show that about half of all Charter Oak members are over age 50 and that older members have higher incomes than younger members – over half of members paying the full, unsubsidized Charter Oak premium are over age 50.
Ellen Andrews

Governor releases her budget proposal

As promised, the Governor’s state budget proposal for the next two years released today includes painful cuts. Overall, Medicaid would be cut $283 million (6.8%) in the first year and $317 million (7.2%) in the second year. SAGA would be cut $13 m (5%) and $14 m (6.5%) in the two years. Among the proposals are charging copays to Medicaid clients, premiums for HUSKY adults, increasing HUSKY Part B premiums for children, eliminating most dental care for adults, no coverage for legal immigrants living in the US less than five years, eliminating prenatal care for undocumented immigrants, eliminating interpretation services, eliminating vision and transportation services in SAGA, Medicare Part D cuts, pharmacy cuts, cuts to community health centers, school based health centers, local health departments, AIDS programs, nursing loan forgiveness programs, and new barriers to accessing care and applying for HUSKY. She also proposed eliminating the Office of Health Care Advocate (OHA). OHA has returned $5 to consumers in health care services for every dollar spent on the office. OHA is also funded not by the General Fund, but through an assessment on insurers in a fund with a surplus. Cutting the office will do nothing to address the state’s budget crisis. Cutting the office would only return OHA’s $1 million budget back to insurance companies as well as saving them $5 million/year in unpaid consumer bills. For more detail on the health impact of the Governor's proposal, click here.
Ellen Andrews

Governor’s proposed budget adjustments – one major health change

The Governor’s proposals to adjust the current biennial budget include changes to LIA (the former SAGA program). When SAGA was merged into Medicaid in 2010, creating LIA, the asset limit of $1,000 was removed. Since that time enrollment has grown significantly due in part to removing the asset limit (the economy doubtless had something to do with it as well). Because program costs are now matched by the federal government, significant new revenues came into the General Fund. While enrollment growth has moderated, the Governor is proposing re-imposing a more generous $25,000 asset limit, and counting family income for applicants under age 26 living with a parent or claimed as a dependent for taxes. He has also proposed unspecified limits on medical services. The changes would save $22.5 million in the next fiscal year. In 2014, those applicants will become eligible for Medicaid anyway under national reform.

Other proposals include changes to who can administer medications, expanding childhood vaccinations, cost of living increases for private providers, expanding Money Follows the Person, among others.
Ellen Andrews

Who is coming into LIA?

Today’s CT Mirror asks the question – who are the 37,000 new enrollees in the Low Income Adult Program? LIA was created just over a year ago as an option under the Affordable Care Act. CT shifted our fully-state-funded SAGA program into Medicaid, getting a 50% federal match, and re-named it LIA. When the program switched, the SAGA $1,000 asset limit on eligibility was lifted. As more people have signed up for the program than intended (fuzzy policy estimates are hardly new) and costs are higher than expected, the state has asked the feds for permission to re-impose an asset limit of $10,000 for eligibility. The administration has suggested that many new LIA members are able to pay for insurance, but are choosing coverage in a public program. The article notes that we really don’t know who is enrolling, because the state doesn’t ask about assets in applications and no one has surveyed the population. But the reporter spoke to providers who say that’s not what they are seeing in the real world. The article also includes interviews with two new enrollees that do not fit the administration’s picture. Make sure and read down to both stories – important lessons about people working hard doing everything they should and are unlucky enough to have health problems – exactly who safety net programs are built for. In a down economy, it shouldn’t be surprising that numbers are up.

From the helpline

An uninsured consumer called our office looking for help paying bills to two hospitals. He had been placed into collections but he had received no information about financial assistance. He made $17,000 last year; not wealthy by any means but ineligible for SAGA. He has no children, so doesn’t qualify for HUSKY. I called Milford Hospital first on his behalf. The billing person I spoke to was not helpful, stating that information on their financial assistance program was printed on the back of the bill – a provision that she feels complies with CT laws requiring notification. When I pushed the issue, she wanted my name, organization and title. She read the notice from the back of the bill that my client would have received – it was the CT General Statute word-for-word. Anyone who has read CT state law knows that they are not even close to understandable. She informed me that it is hospital policy that they cannot even send a financial assistance application until the patient has applied for HUSKY and SAGA, been denied, and presented the hospital with a denial letter – something that was not explained in the notice she read me. I explained that my client is clearly not eligible for either program and this policy only creates a needless hurdle for him and senseless paperwork for DSS workers who have better uses for their time. She just kept saying that it was hospital policy and that they would have told him the policies if he had called them. I asked her to call him and later got a call back from her to let me know that she’d left him a message. (I’d already called to tell him what he needed to do.) Next I called the Hospital of St. Raphael; they just asked for his address and will send him an application packet right away.
Ellen Andrews

Only CT and DC take early expansion option

To date only CT and the District of Columbia have submitted early option applications to expand Medicaid under the new federal health reform law. CT applied April 15th and DC submitted their application May 13th. CT plans to cover our 45,000 SAGA members under Medicaid, providing expanded coverage and eliminating the SAGA asset test, while bringing in $53 million in new federal matching funds over the next fifteen months. DC expects to save $56 million over the next four years. Twenty nine states, including CT, are also taking advantage of the new federal option to create a temporary high risk pool; eighteen states are going to use the federal high risk program rather than creating their own pool.
Ellen Andrews

Rell administration will not challenge national health reform law

At yesterday’s Health Reform Cabinet meeting, the Rell administration announced that they will not join twelve other states in a lawsuit challenging the Patient Protection and Affordable Care Act. All twelve Republican state senators signed onto a letter urging the state to join the suit. The senators argue that the federal law usurps states’ rights in regulating health care delivery and individual freedoms including the individual mandate. So far the administration has signaled that they will be pursing two opportunities under the new law – the Medicaid early expansion option to bring 43,000 SAGA recipients into Medicaid saving the state over $50 million and another $50 million or more available for CT’s high risk pool to cover people with pre-existing conditions.
Ellen Andrews

Medicaid Managed Care Council update

We ran out of time at Friday’s Council meeting, so we will devote the entire June meeting to discussing how the state plans to implement the new budget provision to self-insure the HUSKY/SAGA/Charter Oak program. Some of the decision points are whether to keep the program capitated but without financial risk (not sure how that works), whether we can continue to allow some providers to be paid more than others, whether to re-bid the contracts for one or more ASOs (or just keep the current HUSKY HMOs as happened last time), and whether we can have (or need) more than one ASO. Other HMOs are interested in applying now that the program does not carry financial risk. Apparently, responses from the current HUSKY HMOs to the RFP to provide non-risk care management services to the current Medicaid fee-for-service population were not cost effective.

In other reports, the Council heard about important work being done by the Women’s Health Subcommittee and Community Health Center, Inc to prevent low birth weight babies and improve breastfeeding rates by getting pregnant women into prenatal care early, ensuring access to dental care, smoking cessation and identifying and treating depression during pregnancy. The committee is planning a prenatal care summit in the fall.

Mercer gave their usual, glowing evaluation of the HMOs. Under questioning, it became clear that their evaluation is only of processes, and does not reflect actual access to care for members. Performance studies were not promising; at best, there was little progress on any health outcome or process measures. The CT Dental Health Partnership continues its impressive progress to enroll more providers and expand access to oral health care. And PCCM enrollment is up to 388 as of May 1st; up from 359 a month before.

And the Council’s name changed to the Council on Medicaid Care Management Oversight.
Ellen Andrews

Medicaid Council meeting update

Friday’s Medicaid Assistance Program Oversight Council meeting was very productive and mainly positive. The main area of discussion was DSS’ implementation of new asset limits required by budget negotiations (bad news) and new spend down tracking processes (good news). This August the enrollment brokers (Xerox, formerly ACS) will handle tracking and evaluation of medical bills as well as information and support for people “spending down” to Medicaid eligibility. This has been a significant barrier to coverage for up to 17,000 people at any time. The new process will move time-consuming documentation to ACS and to electronic formats, providing welcome relief for both frustrated consumers and overwhelmed DSS workers. In bad news, as an outgrowth of negotiated budget cuts, DSS is applying to CMS for a waiver to the LIA program (formerly SAGA) to institute a $10,000 asset test (exempting a home and one car), permission to count parental income and assets for applicants under age 26 who live with parents or are claimed as dependents, and to establish a 90 day limit on nursing home coverage. Spending down to LIA coverage will not be necessary in January 2014 under national health reform. DSS expects that many or most of those with assets will be able to transition to Charter Oak coverage for the interim, which their assets should cover. DSS will also assist anyone needing more than 90 days of nursing home care to apply for disability or other Medicaid coverage. In other news, DSS responded to comments on their dual eligible application and “reserved” the requirement for a behavioral health co-lead in each neighborhood to allow further study and agreed to include incentives in all three years of the pilot for health neighborhoods that improve performance and outcomes, less than if they also achieve savings, but something. DSS also outlined ConnectCT, their plans to improve application, web, customer service and document management/workflow processes. Long overdue and very exciting; hoping for more meetings like this.

Democrats outline three scenarios to save $2.8 billion

Emphasizing that they do not endorse the cuts, the Appropriations Committee described the types of cuts necessary to fill the remaining $2.8 billion budget gap without additional revenues. Across the three budget versions reductions include cutting Medicaid provider rates by 10% for nursing homes and 20% for all others, Medicaid co-pays, eliminating adult pharmacy in Medicaid, eliminating DSH grants to hospitals, eliminating SAGA, eliminating Charter Oak, cutting Alzheimer’s respite care, and eliminating state funded home care. These cuts are in addition to, not instead of, the cuts in the Governor’s budget proposal. Leadership praised the committee for giving a “more accurate picture of what the Governor’s budget would have looked like had she balanced the budget” but was clear that the cuts are “unacceptable.”
Ellen Andrews

From the consumer helpline

A consumer called our helpline about a large bill with Hartford Hospital. Her bill for two hospital stays is about $270,000 and she is uninsured. Her income of about $49,000 doesn’t make her rich but it is over the limit for any of the hospital financial assistance programs. She was making payments on one of the bills but then they all went into collections. The collection agency wants to attach her home. She considered taking out a second mortgage but even that wouldn’t cover the bill. The hospital did offer her a 53% discount if she paid it all right now, in cash. That means she would have to come up with about $126,900.

I called Hartford Hospital because I wanted to be sure the consumer had been screened for all the financial assistance programs and see if the hospital would give her a discount. She had been screened for all of their programs and they had given her a 20% discount on her bill. They were not willing to give a larger discount and seemed to be patting themselves on the back for the discount they did give her.

If her income was under 250% of the federal poverty level ($27,075 for one person) and she had been denied for the SAGA medical program for being over income, the hospital would have charged her “cost”, which is what it costs them to provide the medical care and is generally about half of charges. Since she does not fit this criteria, they can charge her more. If she had health insurance, the insurance company would negotiate a lower rate. She is being charged even more than an insurance company would pay.

I suggested that she call Congressman Chris Murphy’s office to see if they could intervene on her behalf. I also suggested that she contact a local newspaper to see if they would be willing to tell her story. She liked the suggestions and will be contacting her Congressman and the newspaper. I will follow up with her to see what happens.
Jen Ramirez

From the Consumer Helpline

Unfortunately there are times when there aren’t many options for affordable, comprehensive health care for callers to our Consumer Helpline.

One consumer caller, a man in his early 50s is looking into early retirement because of a disability. He is gathering information about his options and his main concern is finding health care for himself and his wife. I have discussed some options for health care with him – but none of them are great. Some are very expensive – like the high-risk pool and COBRA. Some have very low income and asset limits – like SAGA and Medicaid. He most likely won’t be eligible for individual insurance because of pre-existing conditions. Then there’s the Charter Oak program, which will cover pre-existing conditions but doesn’t have a lot of doctors who will take it and he hasn’t been uninsured for six months. His wife is self-employed, part-time and relies on him for health insurance so there’s no option of being added to her insurance. I’ve mailed him some information so he can look into it further.

Another caller works for a non-profit and found out that his health insurance premium for himself and his wife is almost doubling. His wife has stopped working because of a disability and is in the process of applying for social security disability. We talked about Charter Oak for her but she hasn’t been uninsured for six months. I sent them some information about a program through the Department of Social Services for Medicaid for the Employed Disabled – it has higher income and asset limits than regular Medicaid. But there are still not many good options.
Jen Ramirez

New report outlines long term cost of fully funding state retiree health benefits, Gov. Rell aggressively pursuing funding opportunities in national h

An early estimate to the state’s Post Employment Benefits Commission estimated that fully funding health benefits for the state’s 42,000 retired workers would average $1.9 billion over the next 28 years. The state now pays these bills as they arise; just over $490 million is budgeted for these costs in the fiscal year that starts next month. While full funding would cost more now, it would reduce future costs. The Commission includes representatives from the Comptroller’s and Treasurer’s Offices, the administration, and labor and is charged with analyzing long term funding of the state’s health and pension benefits system. The report was prepared by Milliman.

Governor Rell’s administration is aggressively pursuing federal funding opportunities in the new national health reform act, despite criticizing the reforms. The state will not be pursuing any new opportunities to cover Connecticut’s 343,000 uninsured under the act, but is only considering options to replace current state funding including $53 million to move current SAGA recipients into Medicaid and another $50 million to fund our high risk pool. The Comptroller’s Office has also applied for $100 million over the next four years to support coverage for state employee early retirees not yet eligible for Medicare. As funds for early retiree benefits are limited, the Comptroller’s Office responded to the opportunity quickly to apply early.
Ellen Andrews

Universal Health Care Foundation unveils comprehensive health reform plan

The Universal Health Care Foundation of Connecticut released its plan for health care reform on January 13, 2009 at a rally held at Union Station in Hartford. The room was packed with about 1,000 people from advocacy groups, labor unions, religious organizations and other groups. There were also quite a few legislators there, including President of the Senate Don Williams, Speaker of the House Chris Donovan, and Co-chair of the Public Health Committee Jonathan Harris (who all said a few words in support of the plan). It reminded me of the healthcare4every1 rally held in Bushnell Park a few years ago and it was exciting to be in the company of so many like-minded people who believe in health care reform.
The plan, called SustiNet, would eventually be opened to all CT residents but would start by creating a pool with state employees and retirees, and people covered under the HUSKY and SAGA medical programs. Eventually others will be able to buy into the plan, including: people who don’t have access to insurance from an employer, people whose employer-based insurance doesn’t provide affordable access to health care, and employers (starting with small businesses, nonprofits and municipalities and eventually including any CT employer).
SustiNet would offer affordable and comprehensive health coverage as well as coverage for residents without regard to job changes, pre-existing conditions, self employment or divorce. The plan also will have more coordination of patient care, more competitive reimbursement rates for doctors, and extensive use of electronic medical records. The healthcare4every1 Campaign will work this year to raise support for the plan with the legislature and the Governor and urge them to adopt it into law. “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” --Martin Luther King, Jr.
Jen Ramirez