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Reform Update: Medicaid panel urges Congress to fix coverage gap for pregnant women

By Virgil Dickson
Posted: December 17, 2013 - 4:45 pm ET

Medicaid's congressional advisory panel has urged Congress to make sure pregnant women do not fall between the cracks of Medicaid and subsidized private coverage under the healthcare reform law.

The Medicaid and CHIP Payment and Access Commission (MACPAC) issued seven policy recommendations that it will include in its March 2014 report to Congress addressing little-known coverage dilemmas facing low-income pregnant women and children.

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Most of MACPAC's suggestions address issues that will impact beneficiaries in Medicaid or state Children's Health Insurance Programs (CHIP) both in states that expand Medicaid to adults earning up to 138% of the federal poverty level and those that do not.

The Patient Protection and Affordable Care Act allows states to retain their current Medicaid benefits for pregnant women, even if they expand Medicaid. This has created a little-noticed situation under which women earning above 138% of poverty who would qualify for federal premium subsidies to help them buy private coverage no longer are eligible for the subsidies once they become pregnant, because the state Medicaid program may provide limited benefits to pregnant women earning up to 200% of poverty. Adults who are eligible for Medicaid do not qualify for premium subsidies.

As a result, MACPAC is suggesting two policy changes to Congress that will greatly impact this group.

The first is Congress should require that states provide the same comprehensive benefits to pregnant women who are eligible for Medicaid on the basis of their pregnancy that are furnished to women whose Medicaid eligibility is based on their status as parents of dependent children.

The goal is to address situations where state Medicaid programs cover only pregnancy-related services for Medicaid-enrolled women. Patient advocates say this jeopardizes women's health. A consumer alert sent to MACPAC this past summer detailed instances of pregnant women in California's Medi-Cal program who were not able to get coverage for treatment of broken bones, osteomyelitis, a brain tumor and heart disease.

The alert (PDF) was co-signed by organizations including March of Dimes, Planned Parenthood and American College of Obstetricians and Gynecologists.

As of September, seven states were reported to cover only pregnancy-related services for Medicaid-enrolled pregnant women: Alabama, California, Idaho, Indiana, Nevada, New Mexico and North Carolina, according to MACPAC.

A second pregnancy-related recommendation is that the secretaries of HHS and Treasury should specify that pregnancy-related Medicaid coverage does not constitute minimum essential coverage for women enrolled in private health plans through the insurance exchanges. Having other minimum essential coverage disqualifies a person from receiving a federal premium subsidy to buy coverage on the insurance exchanges.

The back story behind this recommendation is that there are women who have incomes of less than 200% of poverty who are eligible for premium subsidies to buy private overage on the exchanges. But if they become pregnant, they must give up their private insurance plan and switch to Medicaid for the duration of their pregnancy since Medicaid currently is defined as minimum essential coverage. Once they give birth, they are allowed to rejoin a private health plan and receive a premium subsidy.

The MACPAC suggestion “ensures that these pregnant women won't have to bounce back and forth between coverage,” said Jocelyn Guyer, a director at the Washington-based consultant Manatt Health Solutions. “It's a lot disruption when you have to switch plans and work with different providers only then to have to switch again a few months later.”

With regard to children, MACPAC suggested two changes to the CHIP program. These include eliminating waiting periods for CHIP, and eliminating premium payments for children with family incomes below 150% of the poverty level. There are eight states that charge premiums for families with incomes below 150% of poverty: Alabama, Arizona, Delaware, Florida, Georgia, Idaho, Nevada, and Utah, according to MACPAC. These states have a total of 400,000 children whose families have to pay a premium for CHIP coverage. The typical monthly premiums are $10 for families with one child and $15 for families with more than one child.

“Research is clear that asking very low-income families to pay even a modest premium for coverage can be a significant barrier to enrollment and seeking healthcare,” said Elisabeth Wright Burak, senior program director at Georgetown's Center for Children and Families. “Removing premiums for these families ensures that families with multiple sources of coverage are not “double hit” with premiums in the marketplaces as well as in CHIP.”

As for the waiting period, there are now 37 states with CHIP waiting periods. In half of those states, the waiting periods exceed 90 days. When Congress established the CHIP program in 1997, there was concern from lawmakers about the possibility that families would drop employer-based coverage to enroll their children in CHIP, according to Cindy Pellegrini, senior vice president of public policy and government affairs at March of Dimes. To reduce this potential risk, states decided to establish waiting periods for CHIP enrollment. But that concern has been found to be unwarranted, Pellegrini said.

Other suggestions MACPAC plans to make to Congress include: creating a statutory option for 12-month continuous eligibility for adults in Medicaid; eliminating the sunset date for extended Transitional Medical Assistance, while allowing states to opt out of TMA if they expand to the new adult group added under the ACA; and requesting that the HHS secretary collect and make publicly available non-disproportionate share hospital (DSH) payment data at the provider level in a standard format that enables analysis.

Some states dispute that they're getting Medicaid applications

This week, the CMS heralded a technology fix to that's crucial to getting millions of Americans enrolled in Medicaid after the online enrollment portal deems them potentially eligible for coverage. Some states are disputing the accomplishment.

According to the Obama administration, 10 states began getting complete Medicaid applications from this past weekend: Alabama, Delaware, Idaho, Nebraska, New Hampshire, New Mexico, Montana, Pennsylvania, Tennessee and West Virginia.

They are among 36 states that are not operating health insurance exchanges and are relying on the federal marketplace to screen applicants for Medicaid eligibility. The website, however, has not been able to transmit applications to state agencies.

Representatives from Alabama, Delaware, New Mexico and Pennsylvania said they are still waiting.

Asked why the CMS would claim otherwise, New Mexico Department of Human Services spokesman Matt Kennicott said: “That's a very good question, we're trying to figure that out ourselves.”

New Mexico, Kennicott said, has been ready from a technical standpoint for weeks.

A representative from Tennessee said applications started to trickle in Tuesday—three of them. Montana officials received five transmissions Tuesday and said they expect more Wednesday. A spokesman for the Idaho agency said three Medicaid files were transmitted from the federal data hub on Tuesday morning and that officials expected 200 on Wednesday.

The CMS did not respond to a request for comment.

Follow Virgil Dickson on Twitter: @MHvdickson

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