Transcript What is Medicaid? - New Mexico Public Health Association

Medicaid Redesign
Consumer Concerns
by Quela Robinson
Staff Attorney
New Mexico Center on Law and Poverty
December 7, 2011
NM center on law and poverty
Who does Medicaid serve?

Over 550,000 people (or 25% of the New
Mexico population)
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Being low income is not enough to qualify for
Medicaid. You must also fit into specific
eligibility categories.

This means you must also be…
A senior citizen
A person with a disability
A pregnant woman or a child
A low income family
Or fit another specific category

Women needing family planning services, or
treatment for breast or cervical cancer.

People living in institutions (nursing homes)
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“Waiver” programs for certain adults:

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SCI for adults up to 200% FPL ($1815/month for 1 person)
Home and Community Based Services for disabled and seniors
at risk of institutionalization whose income is higher than
traditional Medicaid (DD waiver, D&E waivers)
Budget cuts have frozen these programs, resulting in waitlists of
tens of thousands
What are the income limits?

Low income families: 85% FPL ($1,562/month for family of 4),
but because of income rules, they must often have incomes less
than 30% FPL, or $559 per month for family of four.

Pregnant women: 185% FPL ($2,268/month for family of two)

Children: 235% FPL ($4,379/month for a family of four)
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SSI recipients (elderly, blind, disabled): 75% FPL
($919/month for family of two)

Working Disabled: 250% FPL ($2,269/month for one person)

Institutional Care (Nursing Homes): 225% FPL ($2,022/month
for a single person, plus asset limit of $2,000)
Why is all of this important?
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Over 200,000 more New Mexicans will become eligible
for Medicaid in 2014 (healthcare reform expands
Medicaid to everyone up to 138% FPL).

The federal government will pay 100% of the cost of the
expansion for the first three years.
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Over 50,000 children currently eligible for Medicaid are
not enrolled, and must be by 2014. The state must pay
its regular share to cover these children.

The State wants to “redesign” Medicaid to save money.
We must make sure that the redesign does not
negatively affect access or needed services.
The public has spoken out:

New Mexico has a severe provider shortage

Additional co-payments are unaffordable

Home and community based services cuts
devastate seniors and people with disabilities

End the waiting lists for waiver programs for
people with disabilities, and for SCI

Managed care has too much red tape
HSD’s Redesign Proposals
1. “Personal Responsibility” (premiums,
additional co-pays, deductibles, fees for ER in
non-emergency)
2. Global Waiver
3. Care Coordination
4. Pay for Performance
1. What’s wrong with co-pays?
35 years of research shows that fees and copays prevent low income people from getting
both medically necessary and “unnecessary”
care
A.
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Their conditions worsen, and they need emergency or
more intensive care, driving up costs
Providers and hospitals lose money (can’t collect debt)
Co-pays hit seniors, people with disabilities, and those
with chronic conditions the hardest
Co-pays are a hidden tax on the poor, who already spend
more of their income on food, housing, and transportation
What’s wrong with co-pays?
The state will not save money
B.
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The state does not receive federal matching funds for
money collected through fees and co-pays
Many states have rejected additional cost sharing
because the administrative cost of collection is greater
than what is taken in
When people lose Medicaid coverage because they can’t
afford premiums, they become uninsured, increasing the
cost to local taxpayers to support charity care programs,
and increasing the costs of private health insurance.
MCO’s and providers are burdened with collecting the
debt
What’s wrong with co-pays?
There are few alternatives to the ER in NM
C.
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The Medicaid Act requires that “actually available and
accessible” ER alternatives exist before charging co-pays
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32 of 33 NM counties are federally designated as Health
Professions Shortage Areas, Medically Underserved (NM
Health Policy Commission, Jan. 2011)
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HSD reports the majority of non-emergency use of the ER
occurs in rural and frontier areas on evening and
weekend hours when there is no alternative
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Fees punish sick people for the lack of primary care in NM
What’s wrong with co-pays?
Rather than impose fees, there are better
alternatives:
D.
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Incentives to providers for offering off-hour
access and 24 hour nurse help lines.
Better funding for community health programs
Diversion programs that screens patients who do
not have emergencies and schedules them for
clinic appointments instead (ex: Presbyterian)
2. Global Waiver

12 existing waivers will be combined into 2 or 3

The state must show the federal government that more
federal funds will not be required to do this
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Many states prove this by cutting services
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Current Medicaid waiting lists of people with critical needs
are likely to grow
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Over 20,000 seniors & people w/ disabilities are on waitlist
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Over 40,000 working adults are on waitlist
3. Care Coordination
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Patients benefit from personal contact (care coordinator,
community worker, or navigator)
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New technology can efficiently deliver services and saves
administrative costs to providers and the state
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Create relevant and public reporting standards so that
issues with access and outcomes can be quickly identified
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HSD proposal is to reduce Medicaid MCO’s from 7 to 4 –
we don’t know how this will affect recipients
4. Pay for Performance
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Punitive pay for performance initiatives can
exacerbate health disparities by driving out
already-scarce providers
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Incentives should be positive: higher payments
to providers for expanded hours, encourage
telemedicine and community health workers that
improve health outcomes and save money

Tools for assessing health outcomes must be
relevant and transparent.
In conclusion…
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Successful Medicaid redesign must be patientcentered - focused on healthcare access and
better outcomes. Support at the community level
works!

Imposing fees on low-income recipients,
especially in a bad economy, does not.

Most Medicaid members responsibly take an
active role in managing their own care, but the
system could supply more tools to do so.
Contact Me
Quela Robinson
Staff Attorney
NM Center on Law and Poverty
720 Vassar Dr NE, Albuquerque NM
(505) 255-2840
[email protected]
www.nmpovertylaw.org
NM center on law and poverty