Medicaid Premium Assistance Programs: What Information is Available About Benefit and Cost-Sharing Wrap-Around Coverage?

Introduction
  1. See generally Kaiser Commission on Medicaid and the Uninsured, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/; Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion Through Marketplace Premium Assistance (Sept. 2013), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-through-marketplace-premium-assistance/; Kaiser Commission on Medicaid and the Uninsured, Premium Assistance in Medicaid and CHIP: An Overview of Current Options and Implications of the Affordable Care Act (March 2013), https://www.kff.org/medicaid/issue-brief/premium-assistance-in-medicaid-and-chip-an-overview-of-current-options-and-implications-of-the-affordable-care-act/.

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  2. United States Government Accountability Office, Medicaid and CHIP: Enrollment, Benefits, Expenditures, and Other Characteristics of State Premium Assistance Programs (Washington, DC: United States Government Accountability Office, Jan. 19, 2010), http://www.gao.gov/new.items/d10258r.pdf.

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  3. There also are statutory authorities for states to use premium assistance in CHIP programs. See Kaiser Commission on Medicaid and the Uninsured, Premium Assistance in Medicaid and CHIP: An Overview of Current Options and Implications of the Affordable Care Act (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2013), https://www.kff.org/medicaid/issue-brief/premium-assistance-in-medicaid-and-chip-an-overview-of-current-options-and-implications-of-the-affordable-care-act/.

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  4. 42 U.S.C. § 1396e, https://www.law.cornell.edu/uscode/text/42/1396e. States also have the Section 1906A option to use premium assistance for Medicaid beneficiaries with access to employer-sponsored insurance with a minimum 40% employer contribution to premium costs. Section 1906A was limited to children and their parents when first effective in 2009, and extended to all Medicaid beneficiaries as of 2014. Unlike Section 1906 programs, beneficiaries cannot be required to enroll in premium assistance under Section 1906A. 42 U.S.C. § 1396e-1, as amended by ACA § § 2003 and 10203(b)(2)(B), http://www.ssa.gov/OP_Home/ssact/title19/1906A.htm#ft118.

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  5. The top two challenges in implementing and operating premium assistance programs identified by states surveyed by the GAO in 2009 include the limited number of individuals with access to private health insurance and difficulty identifying those individuals. GAO at 11.

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  6. 42 U.S.C. § 1396d(a) (medical assistance payments “may include. . . other insurance premiums for medical or any other type of remedial care or the cost thereof”), https://www.law.cornell.edu/uscode/text/42/1396d. Only six states reported using Section 1905(a) authority in 2009. GAO at 15-16, Table 3.

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  7. 42 C.F.R. § 435.1015; CMS, Medicaid and the Affordable Care Act: Premium Assistance Frequently Asked Questions (March 2013), http://medicaid.gov/Federal-Policy-Guidance/Downloads/FAQ-03-29-13-Premium-Assistance.pdf.

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  8. 42 C.F.R. § 435.1015(b); CMS, Medicaid and the Affordable Care Act: Premium Assistance Frequently Asked Questions at 2 (March 2013), http://medicaid.gov/Federal-Policy-Guidance/Downloads/FAQ-03-29-13-Premium-Assistance.pdf.

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  9. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Oct. 2014), https://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.

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  10. 42 U.S.C. § 1396d(r)(5), https://www.law.cornell.edu/uscode/text/42/1396d.

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  11. 42 U.S.C. § 1396o, https://www.law.cornell.edu/uscode/text/42/1396o.  

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  12. See, e.g., L. Dague, “The effect of Medicaid premiums on enrollment: A regression discontinuity approach,” Journal of Health Economics 37, (Sept. 2014): 1-12, http://www.sciencedirect.com/science/article/pii/S0167629614000642; Kaiser Commission on Medicaid and the Uninsured, Premiums and Cost-Sharing in Medicaid: A Review of Research Findings, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb., 2013), https://www.kff.org/medicaid/issue-brief/premiums-and-cost-sharing-in-medicaid-a-review-of-research-findings/.

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  13. 42 C.F.R. § 435.1015(b); CMS, Medicaid and the Affordable Care Act: Premium Assistance Frequently Asked Questions at 2 (March 2013), http://medicaid.gov/Federal-Policy-Guidance/Downloads/FAQ-03-29-13-Premium-Assistance.pdf.

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  14. 42 CFR § 435.1015(a)(2) and (3) (making premium assistance subject to the conditions that, inter alia, “[t]he agency furnishes all benefits for which the individual is covered under the State plan that are not available through the individual health plan” and that “[t]he individual does not incur any cost-sharing charges in excess of any amounts imposed by the agency under subpart A of part 447”).

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  15. 78 Fed. Reg.42159, 42184 (July 15, 2013), https://www.federalregister.gov/articles/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit .

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  16. CMS, Medicaid and the Affordable Care Act: Premium Assistance Frequently Asked Questions at 2 (March 2013), http://medicaid.gov/Federal-Policy-Guidance/Downloads/FAQ-03-29-13-Premium-Assistance.pdf.

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  17. 78 Fed. Reg. 42184.

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  18. 42 C.F.R. § 435.1015(a)(4).

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  19. 42 C.F.R. § 435.1015(a)(4).

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  20. GAO at 2-3. Not all programs responded to all survey questions. All 45 programs offered premium assistance for group coverage, and 21 offered premium assistance for individual market coverage. GAO at 7. Less than half (20 programs) required beneficiaries to enroll in premium assistance. GAO at 8.

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  21. GAO at 8.

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  22. GAO at 2.

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  23. GAO at 2.

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  24. GAO at 9, 10, n.22. An additional three states reported $0.00 in spending.

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  25. GAO at 6.

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  26. GAO at 10, n.22. An additional four states reported $0.00 in spending.

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Issue Brief
  1. Kaiser Family Foundation, Total Monthly Medicaid and CHIP Enrollment (Washington DC: Kaiser Family Foundation, Aug. 2015), https://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/; Kaiser Family Foundation, Total Monthly Medicaid Enrollment (Washington DC: Kaiser Family Foundation, Dec. 2013), https://www.kff.org/medicaid/state-indicator/monthly-medicaid-enrollment-in-thousands/.

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  2. Kaiser Commission on Medicaid and the Uninsured, Serving Low-income Families Through Premium Assistance: A Look at Recent State Activity (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Oct. 2003), https://www.kff.org/medicaid/issue-brief/serving-low-income-families-through-premium-assistance/.

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  3. For more information, see Utah Dep’t of Health, UPP for Health insurance Frequently Asked Questions, http://health.utah.gov/upp/faqs.htm#15; Utah Dep’t of Health, UPP for Health Insurance Comparison Chart, http://health.utah.gov/upp/PDF/Comparison%20Chart2014%20-%20eng%20.pdf.

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  4. We did not receive written materials from Vermont, although we did receive a limited response to our survey on some of the spending questions. We were not able to analyze Vermont’s materials as it discontinued its program in 2014.

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  5. 42 C.F.R. § 441.56(a).

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  6. 42 U.S.C. § 1396d(r)(5).

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  7. Rhode Island Department of Human Services, Rite Share Health Insurance Premium Assistance Program Brochure (Feb. 2011), http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/rs_booklet_eng.pdf.

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  8. Texas Medicaid and CHIP Health Insurance Premium Payment program web description, http://www.hhsc.state.tx.us/Medicaid/hipp/.

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  9. Alabama Health Insurance Premium Payment Program FAQs, http://myalhipp.com/faqs/.

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  10. Alabama Health Insurance Premium Payment Program Brochure, http://myalhipp.com/faqs/.

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  11. State of Nevada Division of Health Care Financing and Policy Health Insurance Premium Payment Program Brochure, dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Pgms/CPT/HIPPEnglishBrochure.pdf.

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  12. See “Frequently Asked Questions” Utah Department of Health Utah Premium Partnership website, health.utah.gov/upp/faqs.htm.

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  13. Louisiana HIPP application and flyer on file with authors.

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  14. In Utah where families only receive a monthly contribution towards the cost of dental coverage cost-sharing is not addressed at all.

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  15. Rhode Island Department of Human Services, Rite Share Health Insurance Premium Assistance Program Brochure (February 2011), http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/rs_booklet_eng.pdf.

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  16. Alabama Health Insurance Premium Payment Program, Fact Sheet, http://www.myalhipp.com/wp-content/uploads/2012/02/Fact-Sheet.pdf .

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  17. Texas Health and Human Services Commission, “Your Guide to HIPP,” (on file with authors).

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  18. The state’s response to our survey indicated that this is Louisiana’s policy on wrap-around cost-sharing.

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  19. Louisiana Health Insurance Premium Payment Program, “Pregnant and on Medicaid,” http://new.dhh.louisiana.gov/assets/medicaid/lahipp/docs/LaHIPP_pregnancy_onepager.pdf.

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  20. Alabama Health Insurance Premium Payment Program Brochure and website materials available as noted above.

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  21. Wisconsin’s member booklet “ForwardHealth: Your Connection to Health Care Coverage and Nutrition Benefits” https://www.dhs.wisconsin.gov/publications/p0/p00079.pdf. Also see a state factsheet describing the program which does not clarify that providers must be Medicaid providers to be reimbursed, https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf.

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  22. See generally Kaiser Commission on Medicaid and the Uninsured, The ACA and Medicaid Expansion Waivers (Feb. 2015), available at https://www.kff.org/medicaid/issue-brief/the-aca-and-medicaid-expansion-waivers/. As of this writing, 31 states (including DC) have implemented the ACA’s Medicaid expansion to nearly all adults up to 138% of the federal poverty level (FPL, $16,243 for an individual in 2015), and most states have done so as Congress envisioned in the ACA. Kaiser Family Foundation State Health Facts, Status of State Action on the Medicaid Expansion Decision. Data Source: KCMU tracking and analysis of state executive activity (Nov. 2, 2015), https://www.kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. As a result of the Supreme Court decision in National Federation of Independent Business v. Sebelius, states may now choose whether they wish to expand Medicaid. Kaiser Family Foundation, A Guide to the Supreme Court’s Affordable Care Act Decision (Washington, DC: Kaiser Family Foundation, June 2012), https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-affordable/.

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  23. Kaiser Commission on Medicaid and the Uninsured, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/; Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-arkansas/.

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  24. New Hampshire initially implemented the Medicaid expansion using its existing Medicaid delivery system. Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in New Hampshire (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-new-hampshire/.

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  25. Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Iowa (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-iowa/.

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  26. Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Indiana (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-indiana/.

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  27. For example the proposal advanced by the Florida Senate (Florida Health Insurance Affordability Exchange Program) included a premium subsidy model that would potentially subsidize employer-sponsored insurance, www.ahealthyfloridaworks.com.

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  28. Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Tennessee (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Jan. 2015), https://www.kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in-tennessee/.

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  29. Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Utah (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Jan. 2015), https://www.kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in-utah/.

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  30. Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Iowa (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-iowa/.

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  31. Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Indiana (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-indiana/.

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  32. Data was obtained via personal communication with the Arkansas Department of Human Services, Division of Medical Services, Coordination of Coverage Unit, April 2014, on file with authors.

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  33. Kaiser Commission on Medicaid and the Uninsured, A Look at the Private Option in Arkansas at 11 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/.

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