The Governor’s Work Group on Medicaid Redesign made a new
recommendation on November 14th, 2014 to support a “hybrid” version
of Medicaid expansion. They called this recommendation “Option 3.5”. It
provides Medicaid eligibility for qualifying families below the Federal Poverty
Level (FPL), and uses Medicaid funding to purchase coverage on the state
insurance exchange for qualifying families between 100% and 138% of the FPL.
Implementing this recommendation, or any other option for Medicaid expansion,
will be of significant benefit to many Idahoans with disabilities.
Contrary to popular opinion, not all Idahoans with disabilities, who are living in poverty, are
eligible for Medicaid. Two large groups are currently excluded. Of the
roughly 41,000 Idahoans who have a serious and persistent mental illness
(SPMI), only about 9,000 adults are currently eligible for Medicaid. About
10,000 more get treatment each year from the Department of Health and Welfare, but
only if their illness becomes so severe that that they pose a serious risk to
themselves or others, or if services are ordered by a court. This group (SPMI)
includes only those people whose mental illness is disabling and recurring.
Providing access to health care coverage for families up to 138% of FPL would
include almost all of these people. Medicaid redesign would provide federal
funding for the care and treatment they need and relieve the burden on county
indigent funds and state general funds for both the Catastrophic Health Care
Fund, and the Division of Behavioral Health programs. Currently, most Idahoans
with SPMI have no coverage for mental health treatment, or for the very
expensive prescription drugs needed to control their symptoms.
People who acquire disabilities after a period of
employment, and are unable to work can qualify for Social Security Disability
benefits. However, federal law prevents
these people from obtaining Medicare coverage for two years after the onset of
their disability. If their Social Security benefits exceed $734/month, they
are also excluded from Medicaid coverage. At any given time, there are tens of
thousands of Idahoans with disabilities in this waiting period. A recent study
of Idaho county indigent program claims conducted by Dr. Douglas Dammrose,
revealed that 42% of the claimants fell into this category (http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MoreInformation/08-14-2014%20Medicaid%20Redesign-Idaho%20Doug%20Dammrose.pdf
).
There are other people with disabilities, including many
veterans, who fall into this coverage gap due to individual circumstances. All
of them would benefit from access to affordable health care coverage. Option
3.5” could have different effects depending on its implementation. Some plans
on the exchange have very little coverage for mental health treatment. Some of
the most effective treatments for many people with severe and persistent mental
illness are not included in exchange based plans. People with SPMI need a
robust benefits package to get adequate coverage and to maximize savings from state
general fund programs. This can be provided through Medicaid or through “wrap
around” coverage, but it is necessary to address the needs of people with SPMI.
Many people in the Medicare waiting period may need long term in-home supports
and services to keep them out of expensive nursing home placements. These
services are typically covered under Medicaid but not under exchange policies.
Idaho must insure that people with particular health care issues caused by
disabilities, have access to regular Medicaid coverage or robust “wrap around”
supplemental policies, to meet these needs and prevent higher cost services.
Conclusion:
Any Medicaid redesign
option, which provides access to affordable health care for people in the
“coverage gap”, will benefit Idahoans with disabilities and state and county
budgets. Option 3.5 will be most effective for people with serious and
persistent mental illness and other disabilities if it includes regular
Medicaid coverage for those who need services that are not covered by state
insurance exchange policies.