The CMS has renewed conservative Medicaid waiver proposals from Indiana and Iowa that will extend into President-elect Donald Trump's incoming administration.
Both states have gained permission to continue not covering nonemergency transportation services. Iowa can opt of the expense through December 2019, and Indiana can do so through January 2018, according to CMS letters from last week.
Federal law usually requires coverage of necessary transportation to and from doctors. But when both Indiana and Iowa expanded Medicaid under the Affordable Care Act, they used the opportunity to get permission to waive the requirement for nonemergency medical transportation.
Advocates and lawmakers have been nervous about states gaining this permission over fears it could prevent beneficiaries from getting to dialysis, chronic-care visits or mental-health appointments.
There has been limited evidence the waivers have caused harm. For instance, a February 2016 report from the Lewin Group said the impact of the transportation benefit waiver in Indiana has been minimal. Of the 286 beneficiaries interviewed, 11% cited lack of transportation as their reason for missing appointments.
But the National Health Law Program noted that those results only focused on scheduled visits and did not track instances where a person decided not to seek care because they didn't have a ride.
“An individual who knows she has no way of getting to a doctor is unlikely to even schedule an appointment,” the National Health Law Program said in a comment letter. “The state's evaluation does not capture or even consider such individuals and so is not an adequate measure of the impact of waiving" nonemergency transportation.
In 2015, a survey in Iowa showed some beneficiaries with incomes under the poverty level did not have transportation to or from a healthcare visit. Others said a lack of transportation could prevent them from getting a physical exam in the coming year. But it was unclear if these instances were statistically significant.
In addition to opting out of the nonemergency transportation benefit, Iowa received the go-ahead to continue charging monthly premiums for beneficiaries who make less than 138% of the federal poverty level. The amount will not exceed $5 for people between 50% and 100% of poverty and $10 for those above. The obligation will be reduced or eliminated for beneficiaries who complete a wellness exam and a health-risk assessment.
Iowa can't revoke coverage for the poorest beneficiaries for failing to pay the premium. But the state can terminate coverage for anyone in the higher income category who fails to pay for 90 days, and the debt will be subject to collections. Only 710 people out of 144,000 Iowans that have gained coverage under expansion have been disenrolled as of June 2016, according to a state evaluation.