CMS to evaluate Montana's Medicaid expansion

The CMS will evaluate Montana's Medicaid expansion program despite past protests from key Trump administration officials against similar audits.

In 2015, the state received CMS approval for a waiver to expand Medicaid coverage to individuals who earn up to 138% of the poverty line starting Jan 1, 2016. The initiative, known as the Montana Health and Economic Livelihood Partnership, or HELP, was expected to provide coverage to approximately 70,000 people.

The CMS is now collecting comments through May 8 on the survey for program beneficiaries. Once it reviews and incorporates those comments, the agency will submit a formal request to the Office of Management and Budget to begin its evaluation.

Under Montana's waiver, which expires at the end of 2020, the state received permission from the CMS to charge beneficiaries up to 2% of their income as program premiums, as long as the individuals earned at least 50% of the federal poverty line. Beneficiaries would lose coverage for up to three months if they fail to pay their premiums, except for those living below the poverty level. For those individuals, the unpaid premiums would become debt that could be taken out of future state income tax returns.

Montana also was granted permission to charge beneficiaries co-pays. Collectively, the co-payments and premiums could not exceed 5% of a family's household income.

The CMS' evaluation will include surveys and associated focus groups, and informational interviews with beneficiaries. The agency hopes the audit will show whether premiums and co-payments encouraged HELP enrollees to seek care in appropriate settings instead of the emergency room. The assessment will also evaluate whether the premiums and co-pays ended up being a barrier to receiving care.

When Vice President Mike Pence served as governor of Indiana, he pushed back against the CMS' attempts to conduct a similar evaluation of his Medicaid expansion program, Healthy Indiana Plan 2.0, because the state had already contracted with the independent consultancy Lewin Group to look at the program. CMS Administrator Seema Verma, who helped create the program, also balked at the audit when she was a consultant for the state, as she felt the contractors chosen by the CMS would be biased.

The Obama administration sought to evaluate the waiver because other states had started to model their Medicaid expansions off Indiana's program.

It's unclear whether the federal review of Indiana's program ever happened, even though Social & Scientific Systems, the lead federal contractor on the evaluation, has been paid more than $7 million to date to perform one, according to federal records.

Paul Gorrell, a vice president at the company said Social & Scientific Systems is still under contract to evaluate Indiana's waiver but declined to provide further details.

Indiana's waiver has been the subject of controversy after reports in February said the state's application used misleading and inaccurate information to justify extending HIP 2.0. Staffers at the left-leaning National Health Law Program and Center on Budget and Policy Priorities reviewed the data and found it flawed.

Despite Verma's prior reservations, Social & Scientific Systems developed the surveys that will be given to Montana enrollees, according to a CMS notice.

Unlike Indiana, Montana has yet to hire its own independent contractor to evaluate its program. The state ceded the responsibility to Blue Cross and Blue Shield of Montana, which it hired to oversee the HELP program as a third-party administrator.

A spokesman for the insurance company said it would hire a contractor this year, but it is unclear when an initial report may be released.

The Montana Healthcare Foundation, a not-for-profit that advocates on healthcare matters in the state, said in a March report that over 30,000 newly insured adults accessed preventive services such as cancer and diabetes screening and dental visits in the first year of the program and that Montana's hospitals experienced a 25% decline in bad debt and charity care.

The report, which was created by Manatt Phelps & Philips on the foundation's behalf, did not examine the impact premiums and copays have had on access to care.