Medicaid Buy-In Workgroup Report - Meeting Summaries
March 14, 2002
Members discussed the reasons for developing a Medicaid Buy-In in Rhode Island. The primary reason is the fear many disabled individuals have regarding the loss of health benefits (Medicare and Medicaid) once they return to work. For many individuals, being on Medicaid has become a life necessity with recovery being thwarted by the fear of losing benefits, most specifically, prescription drugs and personal care assistants.
A discussion took place regarding the potential of Rhode Island applying for a Pharmacy Waiver and the impact this could have on individuals with mental health disabilities. Members were to conduct further research into this matter.
Members briefly discussed a political strategy for getting the issue of a Medicaid Buy-In on the agenda of the gubernatorial candidates. In preparation for a hearing involving individuals with disabilities, it was suggested the candidates be briefed on the Rhodes to Independence grants and the discussions that have occurred on developing a Medicaid Buy-In.
The workgroup began discussing the substance of a potential Buy-In. The following points were highlighted for attention:
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Eligibility connected to the SSA defacto definition of employment is a big concern.
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Initial target group should be SSDI recipients.
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Strong interest in School-to Work being a target population.
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Strong interest in keeping individuals working with current employer if they are seriously injured or contract a chronic illness.
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How will the Buy-In work for self-employed individuals?
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Client providers need training on what benefits are available.
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How will the Buy-In integrate with employer based health insurance coverage? Concerns of small business are different than large employers. If employers contribute to the purchase of the Medicaid product for a group of employees how will this effect the carrier requirement that unless a certain percentage of employees select the group health insurance the group cannot be covered.
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Health insurance carriers in the state need to be brought into this discussion.
APRIL 25, 2002
Douglas Stone, formerly employed with the Oregon Department of Aging and Disability and currently on staff for the APHSA Center for Workers with Disabilities, facilitated a half-day workshop entitled "Designing a Medicaid Buy-In for Rhode Island". The workshop focused on five areas: a) A Brief Overview of Private and Public Health Programs; b) Current Medicaid Availability for People With Disabilities; c) Opportunities to Develop a Medicaid Buy-In Program; and d) Designing Rhode Island's Medicaid Buy-In Program.
A Brief Overview of Private and Public Health Programs
Douglas Stone and Elaina Goldstein briefed the group on existing private and public Health Programs. This area served as a lead in to the next topic of the workshop.
Current Medicaid Availability for People With Disabilities
Dottie Karolyshyn briefed the group on how a disabled person currently gets Medicaid services and benefits in Rhode Island. The discussion focused on the following: a) What is Medicaid; b) Who gets Medicaid, specifically mandatory and optional coverage groups; c) What Medicaid services are covered; and d) How can Medicaid help people with disabilities return to work.
Douglas Stone briefed the group on current Social Security/Medicaid policies relating to persons with disabilities returning to work. The discussion focused on regulations 1619(a) and 1619(b).
Opportunities to Develop a Medicaid Buy-In Program
The discussion, facilitated by Douglas Stone, focused on the intent of the Medicaid Buy-In legislation and the basics of the Balanced Budget Act (BBA) of 1997 and the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999. Following this discussion, Douglas Stone briefed the group on the bare essentials of a Medicaid Buy-In Program.
Designing Rhode Island's Medicaid Buy-In Program
Douglas Stone and Elaina Goldstein discussed policy design options for a comprehensive Medicaid Buy-In Program. The discussion focused on lessons learned from Oregon and decision points regarding the administration of a Medicaid Buy-In Program.
MAY 10, 2002
Members reviewed and discussed several handouts, the "2002 Oregon Income and Medicaid Continuum" and the "2002 Rhode Island Income and Medicaid Continuum". The continuum reflects income points for current Medicaid eligibility categories and compares them with work incentive levels.
The group once again discussed a strategy for disseminating the awareness and understanding of what the Medicaid Buy-In is. It was reiterated that a major effort is necessary to convince people that they can maintain their benefits while returning to work.
Members discussed creating a new eligibility group for people falling through the cracks. There are many issues why people are not returning to work including: health coverage; subsidized housing - rent is adjusted according to income, so returning to work would increase rent; prescription drug benefits; and the cash benefits they currently receive. The current system encourages people not to work and gets them to stop working and move onto public programs.
The group identified four major groups that the Buy-In should be marketed to. The first two are "preventative groups" and the second two are those "on the disability roles or entering the disability roles". The four major groups are: 1) People who have recently become disabled – easier to target this group than those who have been in the system for awhile; 2) Kids who will be entering the workforce – use the School-to-Work Initiative to our advantage; 3) MART (Medical Assistance Review Team) System – this is the system people with disabilities use to get on Medicaid. Currently nothing is done to help these individuals rehab for future employment and independence; and 4) People who are on SSDI/SSI – this is the most complicated group and will be the hardest group to market to because they have been in the system for a long time.
The group requested data on SSI disabled recipients who work. These SSA statistics will be distributed and reviewed at the next meeting.
JUNE 6, 2002
Members reviewed and discussed the most recent SSA statistics (March 2002) on SSI Disabled Recipients who work. In order to develop a premium structure for the Buy-In, critical stats the group must review include those who will be coming into the Buy-In program. The question arose as to whether the MART Issue Workgroup has been established. Elaina Goldstein will speak to Frank Spinelli.
In order to determine how the State can maximize its Voc Rehab dollar and the Medicaid dollar, information is needed on the actual services/benefits provided by Voc Rehab, i.e., Income Standards, Eligibility. Diane Kayala will obtain this information.
Members began discussion on the "Decision Points on Program Design". The discussion focused on BBA versus TWWIIA and how initial eligibility should be constructed.
BBA versus TWWIIA
The group reviewed the overall differences between BBA versus TWWIIA, discussed variables to consider, reviewed what other states have done, and identified the pros/cons of each alternative. TWWIIA gives the states more latitude as to who can be covered under the Buy-In, whereas, BBA has no age restriction and has no conditions in determining the amount of premium/cost share. Regarding the TWWIIA second eligibility group, the Medically Improved Group, the question arose as to whether any of the states that designed their Buy-In under TWWIIA provide coverage for this group. June McLain will research this. The question arose as to what is an Individual Development Account and what is an Employment Account. Elaina Goldstein will speak to Connecticut and New Hampshire regarding this issue.
How Should Initial Eligibility Be Constructed
Members discussed the following: a) How to deal with unearned income; b) How to deal with earned income; c) What will be required as proof of work; d) How will family be defined; and e) Will the income of other family members be counted in the determination of eligibility. In order to discuss these points, the group developed assumptions as to who will be coming into the Buy-In program. The group's determinations regarding these questions were summarized for discussion at the next meeting.
JUNE 27, 2002
The group discussed the key participants that must be present and actively involved in the design of a Medicaid Buy-In. The next Buy-In meeting cannot take place without each essential member present. Due to lack of attendance at this meeting, the following issues were tabled until the next meeting: a) Issue Workgroup – Has the MART Issue Workgroup been established; b) Information on the actual services/benefits provided by Voc Rehab; and c) What is an Individual Development Account and what is an Employment Account.
June McLain presented information regarding the TWWIIA second eligibility group, the Medically Improved Group. Seven states (AZ, CO, CT, IN, KS, PA, and WA) developed their Medicaid Buy-In under TWWIIA and provide coverage for the medically improved group. However, AZ has rescinded funding for the program. No state has begun operating a Medical Improvement Group. Most are awaiting guidance from CMS on defining a "severe medically determinable impairment".
In regards to Outreach, members discussed the necessity of getting the support of the disability community in the establishment of a Medicaid Buy-In. Elaina Goldstein will speak with Bob Cooper regarding outreach at the Disability Forums. John Dupre and John Martinelli will conduct outreach in the mental health and disability communities.
All key participants must be present and actively involved at the next meeting. The group will discuss the decision points and draft a Medicaid Buy-In program.
JULY 25, 2002
Key staff from the Department of Human Service's Policy, Budget, and Medicaid-Adult Health areas reviewed the Decision Points on Program Design document that the Workgroup has been using to design the Buy-In. The key decisions of this meeting were as follows:
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It is critical that we get information on who we assume will participate in the Buy-In. This data will come from various sources. One being the Social Security Administration. We will be looking at the people who are currently on SSDI at various income levels. Another being the people who have applied but have not yet spent enough of their own money in medical expenses to qualify for the Medicaid under the Medically Needy category.
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It is critical that we get information on the assumed cost to the Medicaid program when these people Buy-In. We will look at two sources for this information. One is RI's Linked Medicare/Medicaid database from 1995-1999. We will be able to determine the cost to both Medicare and Medicaid for people who are currently on SSDI. The other source is the current cost to the Medicaid program for people who are 1619 (a) & (b).
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DHS will be able to help us develop a budget article after October 1st which is the date the Department's budget will be sent to the Governor. Once the assumptions of the people and cost of the program are determined the group decided that a more conservative design was in order. Possible premium structures and co-payments will be used as offsets to the cost to the State.
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Regarding design of the program, the group that it was best to look into how New Mexico and Oregon have designed their programs. These two states have taken an approach that promotes work and is incremental. Many of the details of the design will need to be worked out once legislation is passed in the General Assembly.
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Key concerns are: the woodwork effect; what happens if a person can no longer work and we have allowed them to accumulate assets so they are no longer eligible for the regular Medicaid program; what benefit package will we offer; how will we integrate with the employer based system in the state and provide incentives for employers to hire people with disabilities but not significantly increase the costs of the Medicaid program.
SEPTEMBER 13, 2002
The group reviewed the summary of the minutes from all of the meetings thus far. Discussed what had been accomplished and what we still need to be accomplished.
There was a discussion regarding the current budget crisis in the State and the fact that the Department of Human Services is being asked to cut budgets. The current Administration will not be accepting any new budget initiatives that increase costs to the State. Workgroup members discussed the fact that there is current State only programs that if the individuals would become eligible for Medicaid the cost to the State would reduce by over 50%, therefore these programs should be targeted. In addition, maximizing the Vocational Rehabilitation programs benefits to more individuals could bring in more Federal dollars to the State.
The discussion moved into strategies for getting Buy-In legislation on the agenda for the General Assembly this coming session. Together, the group developed both short and long term the recommendations for this process. Elaina was then tasked to draft the Workgroup recommendations.
