Highlight on Montana: Medicaid copay increases kick in; providers worry about burden

Planned increases for Montana’s Medicaid copayments went into effect on June 1, 2016. The changes set forth a copayment amount for certain Medicaid members, with copayments not to exceed a combined limit of 5 percent of the family’s household income quarterly. Some are concerned that the increases could burden low-income patients.

Copayment increases

Under the changes, which were spurred by a provision in Montana’s Medicaid expansion plan, members will income above 100% of the federal poverty level (FPL) will be responsible for a 10 percent copayment of the provider’s reimbursed amount for any Medicaid-covered service. For members with income at or below 100 percent of the FPL will be responsible for a copay of $4 for preferred brand drugs and an $8 copay for non-preferred brand and specialty drugs; $3-$4 copay for dental, home health, licensed professional counselor, psychologist, licensed clinical social worker, and speech therapy services; $2-$4 copay for audiology, hearing aids, occupational therapy, optician/optometric, and physical therapy services; $1-$4 copay for public health clinic services; and $0-$4 copay for home dialysis attendant, personal assistance, independent lab and x-ray, mental health clinic, chemical dependency, and targeted case management services. Provider preventable healthcare acquired conditions, generic drugs, and approved preventive services no longer require a copayment. Providers may not deny services if the member is at or below 100 percent of the FPL and is unable to pay copayments. The member remains responsible for paying any copayments owed to the provider.

American Indians and Alaska Natives who are eligible for or have received a service from a Tribal health, Urban Indian clinic, or Indian Health Service provider; terminally ill members receiving hospice services; and members who are receiving services under the Medicaid breast and cervical cancer treatment category will no longer have copayments.

Burden to low-income members

Barb Mettler, executive director of the Mental Health Center in Billings, Montana, expressed concern that the increases will affect the poorest and most vulnerable Medicaid members, who may use Medicaid-covered services several times a week. “The way I see it is they have three options. They find an additional way to pay, they don’t pay, or they stop using the services,” Mettler said. Even with caps on the total copay, she worries that clients will choose not to seek the care they need.

The burden on patients translates to a burden on health care providers. Under the new changes, providers cannot and will not turn away people at or below 100 percent of the FPL who are unable to pay the copayments, requiring the facility to make up the costs. According to Mettler, the Mental Health Center had to make up a shortfall of about $500,000 of unpaid patient charges in 2015, after already having to factor charity care and bad debt into its budget.

HHS Deems Insurance Premium Hikes in 9 States Excessive

HHS Secretary Kathleen Sebelius has announced that health insurance premium increases in nine states are “unreasonable” under the rate review authority granted by the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), which requires insurance companies to justify rate increases of 10 percent or higher.

The announcement was made after HHS determined, based on independent expert review, that two insurance companies have proposed unreasonable health insurance premium increases in Arizona, Idaho, Louisiana, Missouri, Montana, Nebraska, Virginia, Wisconsin, and Wyoming. The rate hikes would affect over 42,000 residents across these nine states. Sebelius has called upon these companies to immediately rescind their unreasonable rate hikes, issue refunds to consumers or publicly explain their refusal to do so.

New rate review report issued by HHS

Sebelius also released a new rate review report showing that, six months after HHS began reviewing proposed health insurance rate increases, health insurers have proposed fewer double-digit rate increases and states have begun to take an active role in reducing rate increases. In fact, since March 10, 2012, the justifications and analysis of 186 double-digit rate increases for plans covering 1.3 million people have been posted at HealthCare.gov, resulting in a decline in rate increases. In the last quarter of 2011 alone, according to the report, states have reported that premium increases dropped by 4.5 percent, and in states like Nevada, premiums actually declined.

In these nine states, the insurers have requested rate increases as high as 24 percent. HHS has deemed these increases unreasonable because the insurer would be spending a low percentage of premium dollars on actual medical care and quality improvements and because the justifications of the insurers for the premium increases were based on unreasonable assumptions.

It should be noted that most rates are reviewed by states and many states have the authority to reject unreasonable premium increases. In addition, since the passage of PPACA, the number of states with this authority has increased from 30 to 37, with several states extending existing “prior authority to new markets. The HHS report also shows that:

• Texas, Kentucky, Nevada and Indiana are reporting fewer requests for rate increases over 10 percent;

• California, New York, Oregon, and many others, have proactively lowered rate increases for their residents; and

• the rate review program has made insurance companies explain their increases, and more than 180 have been posted publicly and are open for consumer comment.

Connecticut Proposes Deaf Child Bill of Rights to Address Education Gap

Deaf and hard of hearing (HOH) children generally do not differ cognitively from their peers in a way that would prevent them from learning the same material just as well. So why is it that in Connecticut, as well as other locations, children with hearing disabilities appear to be falling behind hearing children in state tests? In 2011, approximately 71 to 81 percent of children with hearing disabilities failed to reach state standards in Connecticut Mastery Tests (CMTs) and Connecticut Academic Performance Tests (CAPTs). Comparatively, between 35 to 58 percent of hearing students failed to meet the goals.

The answer, according to advocates for deaf and HOH persons, is not the disability itself, but the manner in which the children are being taught.  According to Terry Bedard, president of Hear Here Hartford, a deaf advocacy group, “Their needs are not being addressed in the way they should be, and that’s resulting in this wide achievement gap.” Advocates believe that since there is a relatively “low incidence” of hearing disabilities, they are commonly overlooked. In Connecticut, approximately 700 children are registered with the education department as having a hearing disability; however, the number could be greater since such students are not tracked carefully.

Consequently, the Connecticut General Assembly’s education committee will be considering legislation this term to address the gap. “A Deaf Child Bill of Rights,” introduced by the Connecticut Council of Organizations Serving the Deaf, would focus on an individualized education program (IEP) centered around each student’s communication and language needs. Each student’s IEP would be connected to a formal “Language and Communication Plan” that would address that child’s specific needs. The measure would also require that the team implementing the IEP includes at least one educational professional who specializes in hearing disabilities. The bill would compel the state to execute a more specific tracking system in order to better identify hearing disabled children and chart their academic progress.

If the bill is passed, Connecticut will be the 12th state in the country to implement a deaf child bill of rights, joining California, Colorado, Delaware, Georgia, Louisiana, Montana, New Mexico, Pennsylvania, Rhode Island, South Dakota and Texas.