Proposed MassHealth changes -comments due June 12

On May 12, MassHealth posted notice of its intent to ask CMS for 3 amendments to the 1115 waiver.  It will accept public comments until June 12.

The public notice, summary of the proposed amendments, and draft amendment request are posted here: https://www.mass.gov/service-details/masshealth-health-care-reform

Two of the 3 amendments propose restrictions affecting non-emergency medical transportation and provisional eligibility, the 3d is a technical amendment required to continue an existing policy.

The two proposed negative changes in policy are:

1. Non-emergency medical transportation. MassHealth proposes to eliminate non-emergency medical transportation for adults (21-64) in the CarePlus program except for travel to substance use disorder services. (The proposal does not affect adults enrolled in MassHealth Standard or CommonHealth)

MassHealth estimates that eliminating this service for the Medicaid expansion adults  will affect about 14,000 people who now use this service for other than SUD services.  The rationale for the change is to align CarePlus with ConnectorCare and commercial insurance which do not cover non-emergency transportation. The costs of services in CarePlus are reimbursed at an enhanced matching rate (89.6% in 2018). Thus, cost savings are not the main driver of this proposal.

In a letter to Governors, the new HHS Secretary & CMS administrator stated that the Medicaid expansion was "a clear departure" from the mission of Medicaid, and invited states to seek waivers "to help working age, non-pregnant, non-disabled adults prepare for private coverage", specifically including waiver of the non-emergency medical transportation requirement.

Currently MassHealth arranges rides for people who have no other means to get to a MassHealth covered service because no public transportation is available or they cannot use public transportation for medical reasons. MassHealth will also reimburse members for the costs of travel to a covered service using public transportation. The adults in CarePlus are under 65, not otherwise eligible for MassHealth as parents or people with disabilities, not on Medicare, and have income at or under 133% of the poverty level ($16,040 for one person).

In 2006, the National Academy of Sciences issued a "Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation." The study looked at 12 specific preventive services and chronic conditions and found the costs of transportation for the target population resulted in reduced health care spending in for four conditions, was highly effective in improving morbidity and mortality for six conditions, and moderately effective in the remaining two.

2. Provisional Eligibility for adults. For adults under 65,  MassHealth is proposing a change from the current practice of providing coverage during a temporary period pending receipt of paper documentation of income. Instead, eligible adults who need to verify income on paper will have to wait until MassHealth workers manually process the paperwork before they can be found eligible.

The current practice enables MassHealth to make a real-time eligibility determination based on self-declared income. When income cannot be verified electronically, applicants are temporarily enrolled pending submission of paper documentation of income. The proposed change will apply to parents and adults with disabilities as well as the Medicaid expansion adults applying for CarePlus. It will not apply to children and youth under 21, or adults eligible based on pregnancy, HIV positive status or treatment for breast or cervical cancer. Under the proposal, affected adults will not receive an eligibility determination until they have submitted proof of income and the proof is manually processed by MassHealth.

According to MassHealth about 140,000 adults were provisionally eligible based on income last year, and about 25 percent (35,000) were ultimately found ineligible. MassHealth has not supplied information on how many of those found ineligible were later reinstated after supplying the missing documents.

Under the terms of the current 1115, MassHealth receives federal reimbursement at the 50% federal matching rate for those terminated at the end of the provisional period as ineligible. This restriction is expected to save $31 million gross in FY 18 --$12.4 million in state dollars net of federal matching revenue.

This change means that instead of real-time determinations for eligible applicants, determinations will be delayed until paperwork is processed. Paperwork delays will be exacerbated by problems related to lengthy telephone call wait times, outdated technology for document submission, lost documents, and delays processing documents once they are received. The HIX computer system’s inability to “stop the clock” on benefit termination when required documents are submitted by a deadline but not yet processed means enrolled members with outstanding documents will be competing with uninsured applicants for processing priority.

3. The third change continues coverage for young adults who age out of foster care. MassHealth explains that CMS clarified in late 2016 that states must use 1115 authority rather than state plan authority to extend this protection to state residents who "aged out" while living in another state. This amendment does not change current MassHealth policy and will benefit a group of about 200 young adults.

Next steps:

EOHHS first announced its plans to make these changes to nonemergency transportation and provisional eligibility in January, and has not been dissuaded by anything it has heard to date. Comments to EOHHS are due by June 12.

We need examples of people who will be harmed by these changes including:

1. Patients/clients in CarePlus who are now getting rides to medical appointments from MassHealth (other than for SUD services which will remain available) or getting reimbursed for the costs of public transportation

2. Adults who could not get care until MassHealth made an eligibility decision and who experienced paperwork delays getting a timely decision

Please let Vicky or Neil at MLRI know of your examples and/or file your own comments by June 12.