ALERT: PPACA requires health plans to have internal and external appeal procedures. It is anticipated that the Mississippi Department of Insurance will adopt for use the Uniform External Review Model Act of the National Association of Insurance Commissioners. Your DOI is working hard every day with federal officials and other state insurance departments to implement the sweeping measures of PPACA.
ALERT: HHS has still not issued guidance on Grandfathered Plans. Secretary Sebelius announced it would be out shortly. Brunini will continue to monitor.
Medicaid Expansion Under Health Care Reform
Fly Over View
As part of health care reform, the Patient Protection and Affordable Care Act expands the group of persons eligible for Medicaid coverage beginning in 2014. States may voluntarily extend coverage beginning in 2011. See CMS 4.9.10 “guidance” letter SMDL#10-005,PPACA #1 attached.
The “newly eligible” Medicaid recipient is an individual 19 yrs or older but under the age of 65, not pregnant, not entitled to, or enrolled for, benefits under Part A of Medicaid or Part A and B of Medicare and otherwise not eligible for Medicaid under any other category. In addition, the eligible income is raised to 133% of the Federal Poverty Level [FPL] with a 5% adjustment to bring the effective rate to 138% of FPL. PPACA §2001. Income will be measured using a modified adjusted gross income calculation and asset testing as a means of determining eligibility is prohibited. 133% of FPL for a single person is $14,403.90 and for a family of four is $29,326.50.
If a parent of a child under 19 is a “newly eligible” enrollee, he/she must also enroll all children unless they have other health insurance coverage. Coverage for children in Medicaid and CHIP is required to be maintained through 2019. Current federal funding for CHIP is authorized through 2015. Exchanges would likely absorb CHIP enrollees whose premiums would be paid through government premium assistance, if CHIP funding is not re-authorized. An additional Medicaid extension provision includes mandatory coverage beginning in 2014 for former foster care children between the ages of 19 and 26 who had been in state foster care and enrolled in Medicaid when they reached 18 yrs. Full Medicaid benefits are available for these individuals. PPACA §2004.
Medicaid coverage for the “newly eligible” must include minimum essential benefits referred to as benchmarked or benchmark-equivalent benefits, not full Medicaid benefits. The essential health benefits are set forth in the Act and include such services as mental health and substance abuse [in the same manner as mental health services parity under a group plan], prescription drugs, emergency services, maternity and newborn care.
The Act contemplates a simplified application process which will allow individuals to apply for Medicaid through a website which will be linked to the website mandated for the Exchanges. Thus, individuals [and the state] will be able to determine eligibility for Medicaid or coverage under a Qualified Health Plan with premium assistance. PPACA §2201. In addition, Hospitals that are Medicaid participating providers, beginning in 2014, may request to participate as a qualified entity which will allow it to determine preliminarily whether a patient is eligible for medical assistance under the state’s plan for purposes of providing the medical care. PPACA §2202.
Expansion of the Medicaid rolls necessarily reduces the number of uninsured in Mississippi but increases the cost of the program. The Act provides for a federal cost sharing mechanism which provides for federal payment of 100% of costs for the “newly eligible” in 2015-16, 95% in 2017, 93% in 2019 and 90% for 2020 and thereafter. The Kaiser Commission on Medicaid and the Uninsured estimates that Mississippi’s rolls will increase by 320,748 individuals by 2019 resulting in a 54.9% reduction of uninsured adults and an increase in state spending of $429 million between 2014-19. This estimated increase is based only on the “newly eligible” category and not any other potential increase related to other Act provisions.
Authored by: Cheri D. Green
This Newsletter is a publication of the Health Care Department of the law firm of Brunini, Grantham, Grower & Hewes located in Jackson, Mississippi.. The Newsletter is not designed or intended to provide legal or professional advice, as any such advice requires the consideration of the facts of the specific situation.
