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“Painless”
Administrative Ways for |
 "Painless
" TOC |
Medicaid
Main Page |
| 1. |
Working Spouses |
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While many if not most of those eligible
for Medicaid programs are single, For example, in a survey released in
September,2003, the Kaiser Family Foundation Almost all
state Medicaid programs have HIPP and third party liability program All state Medicaid programs cover
many disabled adults under age 65 (including All federal employee health plans, many
state and local employee plans and Hence, now-grown adults with
disabilities who had onsets (of MR, CMI, childhood |
| 2. | ADAP Only: Health Insurance As Dependent of Working Domestic Partner | |
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For ADAP, but not other
programs, there's still another group of dependents of |
| 3. |
Special Case: Disabled
Medicaid Patients Whose Eligibility Comes From SSI |
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Many of the most costly disabled
Medicaid patients enter the program through
This means that their parents are likely to have employer health coverage,
which
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| 4. |
Special Cases:
Disabled SSDI Beneficiaries Returning to Work Under Ticket to Work Medicaid Buy-in and Disabled Former SSI Recipients Returning to Work with Section 1619(b) Medicaid Coverage |
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| The 1997 Balanced Budget Act (BBA)
and the 1999 Ticket to Work and Work Incentives Improvement Act (TWWIIA) both give states the option of offering Medicaid, at siding scale premiums, to disabled persons on SSDI to return to work with earnings well into the mid-range (states can set allowable income levels as high as $45,000 or even more). And Section 1619(b) of the Social Security Act has long offered SSI recipients continued Medicaid coverage when they return to work and their earnings rise above the SSI eligibility level. State-by-state upper allowable earnings thresholds under Section 1619(b) vary---they’re generally in the high teens up to about $35,000-- but those with extraordinarily high medical are allowed higher earnings. Section 1619(b) continued Medicaid coverage is in effect in all states, while the BBA and TWWIIA Medicaid buy-ins have been implemented in about half the states. Various studies and program statistics show that large majorities of both classes of work returnees consist of those who’ve secured only menial, low-paid, part-time and intermittent work. (Many participants have educations, work experience and disabilities that effectively limit earning capacity---and large numbers of mentally challenged persons have work interruptions linked to their disabilities.) Only a minority (so far) secures the kind of quality full-time, or at least half time, jobs that offer employer- sponsored health insurance more comprehensive acquisitions of offered employer health coverage and Medicare. An important study of the TWWIIA provisions, Medicaid Buy-in Program: Quantitative Measures of Enrollment Trends and Participant Characteristics in 2002 (see the Ticket to Work “professional” Medicaid pages at www.cms.hhs.gov), notes that while at least 70% of TWWIIA buy-in participants have Medicare (which is primary to Medicaid and thus serves to reduce state financial exposure), less than 10% appear to have private health insurance (also primary to Medicaid; this is presumably employer group health coverage acquired during the work attempt although some of this may represent the small minority of married clients being covered as dependents by their healthy, employed spouses). Even a large minority of Section 1619(b) recipients are also Medicare-eligible too because they received SIDE awards below the SSI level (and because Medicare can and does continue indefinitely for still-disabled clients who leave SSDI to return to work), although there’s even less data on the proportion of them that acquire employer insurance. Because ---even before they return to work---the great bulk of TWWIIA participants already consume state Medicaid dollars (on regular Medicaid, via waivers or through on-and-off spend down coverage, with any Medicare being primary to Medicaid) and because Section 1619(b) recipients do too (more often without any primary Medicare coverage reducing state Medicaid payments), any private health coverage acquired through the new employment represents an important, often-overlooked source of significant state Medicaid savings. And Section 1619(b) work attempts have the |added advantage that such employment adds to clients’ FICA-taxed work records--- which can therefore make previously-ineligible clients fully- and currently-insured for SSDI, and therefore, for Medicare, further reducing future state Medicaid expenses. TWWIIA clients apply through state welfare agencies and almost always also have state or contract vocational rehabilitation counselors as well. Hence, they have both state case file information on hand and state workers who manage their eligibility. Section 1619(b) recipients, however, are often serviced only by SSA---with only their names and little more being transmitted electronically to states for Medicaid card issuance in most cases---and thus many of them lack useful state case files and/or caseworkers. All this is important for states if they are to become far more proactive in inquiring about, and fostering enrollment in, potentially available employer health plans. Few states now seem to make much effort in this area---but, to save state funds, they need to adopt for TWWIIA and Section 1619(b) participants the same screening and enrollment measures outlined for spouses in the paragraphs above. States can and should promote work returns for many, many more TWWIIA and Section 1619(b) clients, giving greater attention to targeting those with potential for sustained, full-time employment (and thus the probability an offered employer health plan). For both of them---and in cases where Section 1619(b) work generates a previously unavailable Medicare entitlement for a client once on Medicaid alone--- states can then exercise the kind of vigorous screening and case management that will reduce state Medicaid costs through |
| 5.
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Enrollment/Enrollment Changes
Whenever Requested by State Health Programs |
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| When un-taken-up enrollment of a
dependent who has become a state health program beneficiary is discovered, current provisions in almost all employer plans require the employee to await the next “open season” to enroll or add dependent coverage. Otherwise, enrollment or enrollment changes are only allowed when first employed; upon marriage or the death or divorce of spouse; upon the birth or adoption of a child; and (sometimes) upon moving out of an HMO service area, the loss of Medicaid, becoming Medicare-eligible, or the resumption of full time studies by a child over 18 who is still under the older age (e.g., 22 or even 23) permitted for children in college. As a result, an aggressive state program to identify and foster enrollment in employer health plans will be heavily burdened with labor-intensive filing, diarying, re-verifying information and other bulky red tape if forced to await those next-scheduled, but often differing, open seasons in multiple employer health plans. And, of course, cost avoidances and recoveries will be greatly reduced where necessary enrollment must be delayed for months in most cases (and for nearly a full year in the worst cases). All this can be overcome----and state cost avoidances and recoveries can be immediately put into effect and employers can be least inconvenienced---by enacting a state statute requiring all health insurance, claims payment administration and managed care contracts of employers doing business in the state to honor an additional, unique, special “open season” for enrollment changes: namely, those enrollment changes, whenever requested by, or on behalf of, state health programs. Once such a law takes effect for future new contract years, states will be able to enroll their clients at once in available employer group plans and begin to realize savings. As an important corollary, state legislation needs to include ironclad subrogations and overrides of any private plans’ (or claims administrators’ or benefit administrators’) claims-submission time deadlines or claims format rules; prior authorization or generic substitution requirements (meeting whatever the state rule is should automatically qualify); enrolled or preferred provider participation restrictions (provider enrollment with the state program must be an automatically accepted substitute); and hospital admission authorizations (again, the state’s authorization must be automatically honored) for both first payer and pay-and-chase recovery claims. For a study which only begins to touch upon the need for, and depth of, these necessary reforms, see Medicaid Recovery of Pharmacy Payments from Liable Third Parties (OEI-03-00-00030; August, 2001), Office of the Inspector General, US Department of Health and Human Services at http://www.dhhs.gov/oig. But these recommended reforms to achieve third party liability savings---standing purely alone on their own naked merits---could well attract fatal opposition from pro-business legislators concerned about administrative and cost burdens to be imposed on employers. On the other hand, it is precisely these same reforms which are needed to strengthen the increasingly important medical support component of state child support programs. And fortunately it is those same legislators who are sympathetic to possible burdens on business who are also the most devoted to beefing up child support enforcement not only to aid single, custodial mothers. Even more, they want to prevent and reduce public welfare and Medicaid costs they see as caused by illegitimacy, single-parenthood, family breakup and many parents’ consequent failure to pay child support! State third party liability reforms may well be immunized from being (fatally) seen as burdens to business by presenting them as housekeeping, technical amendments to state child support law. |
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Section D: Electing the Medicaid Eligibility Option to Offer COBRA
Premium Payments to Newly-Disabled and Newly-Unemployed Individuals and Families
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“Painless” Administrative
Ways For States With Budget Shortfalls to Preserve or |
