Proposed Face Lift for Arkansas Medicaid Extension Raises Questions About ‘Equal Access’


For the most part, Arkansas has been successful in navigating state policy and the federal waiver process to expand Medicaid coverage for its residents, although that navigation has resulted in questionable policy choices. Arkansas has intermittently added waiver features such as work and community engagement requirements, bonus obligations for registrants with household incomes above 100% of the federal poverty line, and accounts payable. Health Independence (a quickly discontinued feature that was operationally flawed) to gain the requisite qualified majority voting in both state legislative chambers to continue funding authorization for Medicaid expansion.

However, the major and most innovative feature of the state’s expansion of Medicaid has been the use of “premium assistance” – a long-standing option for Medicaid but made possible by the standardization of essential health benefits. . Instead of enrolling people eligible for the Medicaid fee-for-service program or managed care organizations, Arkansas used Medicaid dollars to purchase qualified individual health plans (QHP) available in the new market. of Affordable Care Act health insurance. In doing so, the state has unmistakably satisfied Medicaid’s “equal access” requirement – the requirement that payments be “sufficient to recruit enough providers for care and services to be available under the plan. at least to the extent that such care and services are available to the general population of the geographic area ”to the expanding population.

The Arkansas expansion program is currently undergoing another facelift with the passage of enabling legislation for Arkansas Health and Opportunity for Me, or ARHOME. This version of the Medicaid expansion still relies on the premium assistance framework, but it incorporates incentives for “full-time work and economic independence” and “encourages the personal responsibility of individuals. demonstrate that they value health care coverage and understand their roles and obligations. in maintaining private insurance coverage. Failure to participate in so-called “economic independence incentives”, including work and community involvement, does not result in the loss of coverage as it previously did. The courts and the Biden administration have closed that door. Instead, as originally proposed in enabling legislation and previously noted by supporters in media remarks, an ARHOME enrollee at a QHP could be transferred to Medicaid for a service charge upon opting out.

Premium support model review

Switching from a QHP program to a Medicaid fee-for-service program could certainly be considered a penalty. After all, the stigma of Medicaid has been documented and is one of the many reasons Arkansas went with a premium assistance model in the first place. The federally-required assessment of the Independence Health Care Program – the first iteration of the Arkansas expansion, also known as the “private option” – showed that those enrolled in Medicaid in QHPs have enjoyed better access – both perceived and real – and better-quality care than fee-for-service. This is not at all surprising: it follows the mantra: “You get what you pay for. The evaluation found that physician pay rates for outpatient services were approximately 95% higher in each of the three years under study for those enrolled in a QHP program compared to their paid Medicaid counterparts. to the act. For inpatient stays, there was a 53 percent difference in payment rates per discharge, including additional payments above base rates.

These cost-related assessment results have been used by some Arkansas lawmakers to argue that the state should save its money by ending the premium assistance approach and moving all enrollees to compensation. to the Medicaid act. In fact, a group of lawmakers have tabled a bill to do just that. Fortunately, the majority of the Arkansas General Assembly was not tempted to move in this direction, believing that the premium assistance approach has not only improved the quality and access for members to expansion, but also benefited the individual insurance market by promoting increased competition and stabilizing premiums. . Equally if not more attractive are the tax breaks for the state budget and providers of higher QHP reimbursement rates, which have bolstered the state’s rural hospitals (only one has closed in Arkansas in recent years, compared to 57 in neighboring states which did not increase).

Premium Medicaid Assistance vs. Fee-for-Service

ARHOME’s waiver request appears to have reversed the “reassignment” of QHP registrants to Medicaid fee-for-service for non-participation in economic independence incentives as originally proposed. The request indicates both a postponement of implementation until 2023 and a regulatory process to define what it means to be an “inactive” beneficiary for the purpose of reallocation. Either way, the waiver function as originally proposed has sparked debate over Medicaid’s “equal access” requirement and whether compliance is at issue.

The assessment of the premium assistance model in Arkansas found that QHPs provide beneficiaries with improved access and quality. Ideally, government officials would have used the results of the assessment to recognize and address what led to disparities in access and quality, i.e. insufficient payments to the government. Medicaid act. Instead, the ARHOME waiver request now proposes to assess “whether beneficiaries enrolled in a QHP program recognize and value health coverage as insurance beyond Medicaid medical assistance”. Federal officials should vigilantly review compliance with Medicaid’s “equal access” requirements before considering any waiver proposals from any state that reassigns a beneficiary to a care delivery strategy with lower provider payments.

To be fair, Arkansas Medicaid officials have launched a systematic review of reimbursement rates in response to a 2019 executive order issued by the governor, and the review must take into account “availability and access to care. in every region of the state “. Prior to the decree, there was no standardized timeline or process for rate reviews, although the state is subject to a consent decree that requires judicial review of rate changes. In place since 1993, the consent decree is the result of a lawsuit brought by groups of providers and, although it aims to ensure sufficient Medicaid payment rates, rates have in fact stagnated under the watchful eye of the public. courts, with some providers not having seen a rate hike for more than a decade.

Consent decrees resulting from “equal access” lawsuits risk being dissolved since the United States Supreme Court ruled in 2015 that health care providers did not have the right to sue for enforce the terms of federal Medicaid law. To date, Arkansas Medicaid officials have not decided to dissolve the consent decree, but recent legislation passed by the Arkansas General Assembly requires the state to seek reconsideration of the consent decree to in light of the 2015 Supreme Court ruling.

Round trip on “equal access” surveillance

Following the 2015 ruling, the Obama administration issued regulations requiring states to regularly submit reports documenting their monitoring of access for Medicaid registrants and to prospectively submit for federal review any proposed reductions or reductions. price changes that could result in reduced access. However, as documented in this Health affairs blog post, in 2019, the Trump administration proposed regulations that would have abandoned efforts to ensure some level of state oversight. What’s more, the proposal has completely withdrawn from the possible federal review of reductions in payment to Medicaid providers. Interestingly, the regulations proposed by the Trump administration were never finalized, which means the Biden administration could overturn the proposed rule and reconsider whether the Obama-era regulations are effective in ensuring access.

Such a review should consider at a minimum the following questions:

Are state assessments of payment rates and access controls sufficiently rigorous to determine compliance with the law?

As has been the case with demonstration override assessments, the administration needs to be clear about the data collection, methodology and measurement expectations for state reporting. It should also consider requiring an independent evaluation.

How do Medicaid rates compare to Medicare and commercial insurance payment rates?

The data allowing this type of comparison are increasingly available. Both states and the federal government have invested in state databases of all payor claims, and they should use them as an available tool to improve assessment.

Should the administration establish a standard methodology for setting tariffs and network adequacy requirements for Medicaid, regardless of the care delivery strategy?

It is clear that Arkansas’ fee-for-service rates do not meet Medicaid’s “equal access” provision, and many other states are reporting similar disparities, despite federal oversight and oversight requirements. access report. While offering the potential for more comprehensive measurement and tighter control over access and contractually, managed care strategies also disappoint on the payment front. State requirements for managed care plans to offer minimum reimbursement to providers – if there are any requirements – are often tied to Medicaid fee-for-service rates. The use of premium Medicaid assistance via QHP by definition meets the “equal access” standard. Shouldn’t we expect more of other Medicaid delivery strategies?

The “equal access” dilemma may not be at the top of the Biden administration’s political priorities, but Arkansas’ proposed waiver is sure to raise questions about how the administration can. possibly gain approval for a reassignment function while advancing broadly applicable equal access regulations. As the administration negotiates with states on ad hoc waiver features, it must be careful not to send conflicting messages and erode long-established, albeit ill-defined and lukewarmly enforced, beneficiary protections entrenched in law. Medicaid.

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