CONCORD — Requiring eligible recipients to be covered by private insurers will need a waiver from federal health and human service officials, a committee studying Medicaid expansion in New Hampshire was told.
The Committee to Study Expansion of Medicaid Eligibility heard Tuesday from representatives of the National Governors Association and the National Conference of State Legislatures discuss how other states are expanding Medicaid and alternative programs being proposed.
Gov. Maggie Hassan and the Democratically controlled House both included expanding Medicaid eligibility in their budgets, but the Republican-controlled Senate balked, asking for more information. As a result, the committee was created with a deadline of Oct. 15 for issuing recommendations.
Under the Affordable Care Act, the federal government will pay 100 percent of the cost of expanding eligibility from 100 to 138 percent of the federal poverty level for the first three years and then gradually reduce its share to 90 percent.
About 49,000 people would be added to the Medicaid program if it were expanded in New Hampshire.
Brian Osberg, health division program director for the governors association, told the committee there is not a lot of flexibility without a federal waiver from the Center of Medicaid Services.
He said programs where states help those eligible pay premiums for private health insurance coverage from an employer are allowed now, but have to be cost-effective, with cost-sharing comparable to regular Medicaid. And he said the programs cannot cost the federal government additional money.
The state is responsible for Medicaid services such as emergency transportation not covered under private insurance, he said.
Several states have proposed requiring individuals between 100 and 138 percent of poverty to purchase private insurance through their state electronic exchanges paid for by Medicaid.
Iowa would require all new enrollees to participate in the electronic health insurance exchange, and would require recipients to pay a $20 monthly premium. Iowa would not provide Medicaid services not offered in the private insurance plans, Osberg said. He predicted Iowa would have a difficult time winning a waiver from federal officials.
“This administration is very reluctant to approve any cost-sharing or enrollment or eligibility restrictions,” Osberg said.
Arkansas’ plan is more straight-forward, he said, requiring all newly eligible enrollees to use private insurance through the electronic marketplace, but does not require co-pays or premiums. He said Arkansas would provide Medicaid services not offered in private insurance plans.
He noted Vermont is proposing a single-payer system for all new enrollees.
Osberg said while waivers are difficult to obtain and require significant discussions with the CMS, most states have them for some aspect of their Medicaid program. But he noted amendments to already approved state Medicaid plans are much easier to obtain.
Commission member Sen. Andy Sanborn, R-Bedford, warned “the probability is exceptionally high that the majority of the Senate will not consider any Medicaid expansion without a waiver in it.”
Joy Johnson Wilson, health policy director at the National Conference of State Legislatures, said there are seven other states studying whether to expand Medicaid.
She said Michigan is about to vote on several proposals developed by a study committee; Ohio will report Dec. 1. She said Indiana is looking at something similar to Arkansas and Iowa.
While 18 states have said no to Medicaid expansion, some of those states continue to explore their options, but others like Louisiana and Texas are definitely not expanding Medicaid, she said.
Wilson said 15 states have approved expansion, including Arkansas and Iowa, although that approval is contingent on a waiver. Eight others are expanding their programs under the governor’s authority.
Only Tennessee is undecided.
Several states want to limit the time someone can be on Medicaid, Wilson said, but so far none have approved such a requirement.
She said in the past, waivers often were done without much public scrutiny but that changed under the Affordable Care Act, which requires public hearings and feedback.
“Now a waiver requires some Kumbaya moments between a state and the CMS (Center of Medicaid Services),” Wilson said.
Aug. 27 public hearing
Next week, the commission will hear from state experts on Medicaid expansion.
A public hearing for the public and other stakeholders will be held Aug. 27.
After the hearing, committee Chair Jim Varnum said the commission’s consultant should be able to begin drafting the report due by Oct. 15.